The next goals in the primary survey are to identify neurologic abnormalities in the child. Level of consciousness is assessed by either the Glasgow Coma Score (GCS) or the AVPU system wherein the child's consciousness is rated as (presesnt or absent): ^lert, responds to Verbal stimuli, responds to Painful stimuli, or Unresponsive. The GCS is commonly used in trauma databases, and lower scores have been associated with increased mortality rate. An arbitrary cutoff of 8 is often quoted as the score that should prompt endotracheal intubation in trauma patients. This point has been chosen because mortality rate is greatly increased with GCSs below this level. The AVPU system is recommended by the American Heart Association as an easier system to use.7
A pupillary exam is used to recognize early signs of increased intracranial pressure and herniation. Several case reports can be found of children with a high level of consciousness who had a dilated pupil and then rapidly developed a herniation syndrome.
Examination of the motor strength of each limb concludes the disability exam. Gross strength is all that is noted during the primary survey, so that paralysis from a spinal cord or central neurologic event is recognized. If a spinal cord injury is strongly suspected, then IV steroids are started immediately 10 (see discussion below).
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