Oriot D
Presse Med. 1994 Feb 26;23(8):360-1.
Clinical assessment is an essential fundamental element in the evaluation of comatose states, particularly in children. Paediatricians quickly recognized that the early Glasgow Coma Scale, used for over 20 years in adults, is inadapted for children because it lacks brain stem criteria, involves interpretation of motor response (particularly difficult in infants) and uses verbal response which is of little value before language acquisition. The first attempt at standardized coma assessment in children was the Paediatric Coma Scale, developed in Australia in 1982. This scale improved on the Glasgow scale, removing the motor retraction response, modifying the verbal response scale (normal, words, sounds, crying, or none) and quantifying the best possible score as a function of age. In 1983 a fundamental modification was proposed in the Jacob scale. Besides removing the motor retraction response, this scale replaced the verbal scale with one based on ocular behaviour, thus evaluating consciousness of presence or stimulation. The vestibular response and pupil reactions were also included to assess brain stem activity. In 1987, we introduced the Bicêtre scale which uses ocular behaviour instead of verbal response and separates ocular diameter as a specific criteria. Assessment of four reflexes (mimic, photomotor, cornea and cough) provides precise information on the activities of the different levels of the brain stem. Several comparative studies have been conducted to determine the positive predictive value and interpersonal variability of these scales. In a prospective multicentric study of 277 comatose children aged 6 months to 15 years, we found that the Bicêtre scale had a positive predictive value of 94% for good outcome at 24 hours and that interpersonal disagreement occurred in only 10.1% of 65 cases studied (compared with 13.5% for the Glasgow scale which was studied simultaneously). Paediatricians now have reliable clinical scales for assessing the conscious level in children.
临床评估是昏迷状态评估中必不可少的基本要素，在儿童中尤为如此。儿科医生很快意识到，在成人中使用了20多年的早期格拉斯哥昏迷量表不适用于儿童，因为它缺乏脑干标准，涉及对运动反应的解读（在婴儿中尤其困难），并且使用的言语反应在语言习得之前价值不大。1982年在澳大利亚制定的儿科昏迷量表是儿童标准化昏迷评估的首次尝试。该量表在格拉斯哥量表的基础上进行了改进，去除了运动回缩反应，修改了言语反应量表（正常、单词、声音、哭泣或无反应），并根据年龄对最佳可能分数进行了量化。1983年，雅各布量表提出了一项根本性修改。除了去除运动回缩反应外，该量表还用基于眼部行为的量表取代了言语量表，从而评估对存在或刺激的意识。还包括前庭反应和瞳孔反应以评估脑干活动。1987年，我们引入了比塞特尔量表，该量表使用眼部行为而非言语反应，并将眼径作为一个特定标准单独列出。对四种反射（模仿、光运动、角膜和咳嗽）的评估提供了关于脑干不同水平活动的精确信息。已经进行了几项比较研究，以确定这些量表的阳性预测价值和人际变异性。在一项对277名6个月至15岁昏迷儿童的前瞻性多中心研究中，我们发现比塞特尔量表对24小时良好预后的阳性预测价值为94%，在所研究的65例病例中，人际分歧仅发生在10.1%（相比之下，同时研究的格拉斯哥量表为13.5%）。儿科医生现在有了可靠的临床量表来评估儿童的意识水平。
