Brain Injury and Coma

Question 1

In an unconscious patient with an airway obstruction, what can you do to relieve the obstruction?

Answer 1

Head tilt chin lift

Jaw thrust

Question 2

Give some signs of an airway obstruction

Answer 2

Gurgling and snoring
See-saw breathing
Absence of breath when felt but chest moving

Question 3

In an unconscious patient with an unclear history and/or a history of trauma, which airway manoeuvre would you want to use and why?

Answer 3

Jaw thrust

If unclear history or trauma, concerns about c-spine and so head tilt chin lift is likely to cause more problems

Question 4

What are the indications for an oropharyngeal or nasopharyngeal airway?

Answer 4

Obstructed airway

Semi-conscious/unconscious patient

Question 5

What is a relative contraindication to an oropharyngeal airway?

Answer 5

Gag-reflex

Patient must have a low enough consciousness level to tolerate the OPA.

Question 6

What is a contraindication to an nasopharyngeal airway? Why?

Answer 6

Suspected or confirmed base of skull fracture.

There is a risk of the airway entering the cranium from the nose if fractured.

Question 7

When is endotracheal intubation indicated?

Answer 7

Only in a patient who is under general anaesthetic or in cardiac arrest

Question 8

What signs might indicate a base of skull fracture?

Answer 8

Racoon sign (bruising round the eyes)
Battles sign (bruising over the mastoid)
CSF leakage from the ears or nose
Blood leakage from the ears or nose

Question 9

In the unconscious patient with unclear history or signs of base of skull fracture, with airway obstruction, an oropharyngeal airway should be the first thing used. If it isn’t tolerated, what is your next step?

Answer 9

Can’t use NPA due to risk of base of skull #
Not tolerating OPA.
Need to call anaesthetics as will need intubated.

Question 10

Once you’ve cleared the airway in an unconscious patient with trauma or unclear history, what should you do now?

Answer 10

C-spine control and all spinal precautions should be implemented; collar and blocks.

Question 11

Your patient now has a very high BP (250/140) and profound bradycardia (35BPM). What is the likely cause?

Answer 11

Likely cushing reflex.
ICP is raised so CPP is lowered. CPP = MAP - ICP. Therefore when ICP goes up, MAP goes up to try to compensate and maintain cerebral profusion. Now you’d worry about something taking up space in the brain.

Question 12

When you get to E of assessing the patient, it is important you look at his back too - this patient is in spinal precautions how do you do this?

Answer 12

Log roll him, using a minimum of 4 people, to maintain strict alignment of the spine.

Question 13

The patient is opening eyes to pain, making groaning noises to pain and is flexing to pain. What’s his GCS?

Answer 13

E2
V2
M4
GCS 8 total

Question 14

GCS equal to or less than 8 is worrying. Why?

Answer 14

Below this you have lost the ability to maintain your own airway. he’ll need to be intubated so call your reg/consultant/anaesthetist now if you haven’t already.

Question 15

Give suggestions as to how you would raise body temperature in a hypothermic patient?

Answer 15

Bear hugger

Warmed fluids

Question 16

Why do we obstruct our airway when unconscious?

Answer 16

You lose a lot of tone in the muscles, especially tour tongue and airway.

Question 17

Why does a head tilt chin lift/jaw thrust relieve obstruction?

Answer 17

Tongue is attached to the jaw by ligaments, when you pull the jaw forwards, the tongue is pulled forward and out of the airway

Question 18

How do oropharyngeal and nasopharyngeal airways relieve obstructions respectively?

Answer 18

OPA - slips around the back of the tongue to allow air to flow in and out past the tongue
NPA - bypasses the mouth completely and comes round the back to the tongue to give a channel through which air can move.

Question 19

Why is a nasopharyngeal airway high risk in a base of skull fracture?

Answer 19

Skull is very thin behind the nose and there is a high risk of broken of the tube entering the cranium

Question 20

How is GCS scored?

Answer 20

Your best score in 3 domains?

Question 21

What are the criteria for Eyes in GCS?

Answer 21

4 - spontaneously open
3 - open to voice
2 - open to pain
1 - don’t open

Question 22

What are the criteria for voice in GCS?

Answer 22

5 - orientated to time and place
4 - disorientated 
3 - inappropriate words 
2 - inappropriate sounds 
1 - no sound

Question 23

What are the criteria for movement in GCS?

Answer 23

6 - obeys commands
5 - localises to pain
4 - flexes to pain
3 - abnormal flexion to pain
2 - extension to pain
1 - no response to pain

Question 24

At what level of GCS is coma defined?

Answer 24

less than 8