1.2d Resucitation (D - Disability)

Question 1

What is altered LOC?

Answer 1

Any alteration in level of consciousness (decrease) which is less than normal for the patient.

Question 2

Define some terms used to describe ALOC.

Answer 2

1. Lethargy - mildly decreased, easily rousable
2. Obtunded - more depressed, cannot be fully aroused
3. Stuporous - not able to be aroused from a sleep-like state
4. Coma - inability to make any purposeful response

These are subjective, hence in 1974, Teasdale and Jennett developed the GCS scale.

Question 3

What are the 3 domains of the GCS scale?

Answer 3

1. Eyes
2. Verbal
3. Movement

Question 4

Explain how you would assess for eye score in GCS.

Answer 4

4 = Pt. has eyes open as you approach them.

3 = “Open your eyes, open your eyes,” Patient opens their eyes. (Open to voice.)

2 = Painful stimulus applied, patient opens their eyes.

• Pen to nailbed
• Trapezius squeeze
• Sternal rub - try to avoid as can cause damage

1 = No eyes opening.

Question 5

Explain how you would assess for ‘verbal’ score in GCS.

Answer 5

5 = Normal. Pt. is speaking to you and makes sense.

4 = Confused. Not oriented to time or place, speaking sentences, but not making sense.

3 = Inappropriate words. No clear sentences, but formed words.

2 = Incomprehensible sounds. Sounds or grunts, e.g. “URrrrRggh…”

1 = No response.

Question 6

Explain how you would assess motor function.

Answer 6

6 = Obeying commands.

• Squeeze my fingers, let go
• Show me 2 fingers, 3 fingers, 4 fingers

5 = Localising to pain.

• Trapezius squeeze –> Patient moves hand across midline to localise to pain, reaching above the clavicle to where you are squeezing

4 = Withdrawing from pain. (Normal flexor response)

• Nailbed pinch - withdrawal from pain

3 = Abnormal flexor response, i.e. decorticate posturing.

2 = Extensor posturing, i.e. decerebrate posturing.

1 = None

Question 7

Describe the suite of basic reflexes you could test for in assessing disability.

Answer 7

1. Pupillary reflexes
   
   • They should both be responsive
   • Sometimes aniscoria can be normal
   • Is there a relative afferent pupillary defect?
2. Doll’s eyes
   
   • Normal response - eyes continue to look upwards
   • Abnormal response - eyes turn with head from side to side
3. Lateralising signs
   
   • Biceps, brachioradialis, triceps
   • Patellar, ankle
4. Babinski
   
   • Upgoing - UMN lesion

Question 8

Explain 5 categories of differentials to consider for decreased LOC.

Answer 8

1. Airway
2. Respiratory
3. Cardiovascular
4. CNS & Trauma, e.g. stroke, trauma, infection
5. Other

Question 9

Describe airway causes of decreased LOC.

Answer 9

1. Intraluminal - FB, bleeding
2. Intramural - Swelling, anaphylaxis, burns, infection
3. Extramural - Haematoma, decreased LOC

Question 10

Describe the respiratory causes of decreased LOC.

Answer 10

1. Hypoxia (Type 1 Failure)
   
   • Obstructed airway
   • V/Q mismatch, e.g. pneumonia, PE
2. Hypercarbia (Type 2 Failure, is +Hypoxia)
   
   • Reduced respiratory drive, e.g. drugs, chronic airway disease

Question 11

Describe the ‘other’ causes of ALOC you would see in the emergency department.

Answer 11

1. Toxins, e.g. narcotics, benzos, anticholinergic, anti-histamine, GHB, alcohol.
2. Environmental, e.g. heat stroke, envenomation, lightning strike (causes ferning).
3. Endocrine & metabolic (do a VBG early!), e.g. adrenal, glucose, thyroid, electrolytes, Wernicke-Korsakoff, hepatic encephalopathy,
4. Mental health, e.g. psychosis, catatonia, malingering, depression.

Question 12

How do you do a rapid neurological assessment and what managements?

Answer 12

Sort ABCs, do a Bsl.

1. GCS
2. Pupils
3. Motor assessment

ECG and telemetry.

Consider CT head for trauma/ICH.

I&V, arterial line, vasopressors, regular medications.

Question 13

How to roll a patient into recovery position.

Answer 13

See image.