Management of the Semi-Conscious/Unconscious Patient

Question 1

What are the three components of the GCS?

Answer 1

Motor (6)
Verbal (5)
Eye opening (4)

Question 2

What are the different levels of motor response w/i the GCS?

Answer 2

6 - obeys commands
5 - localises to pain, any purposeful movement towards stimuli
4 - withdraws from pain, pulls limb away
3 - flexor response to pain, decorticate response, arms flexed onto chest
2 - extensor response to pain, stimulus causes limb extension
1 - no response

Question 3

What are the different levels of verbal response w/i the GCS?

Answer 3

5 - orientated
4 - confused conversation, responds to qs, disorientation
3 - inappropriate speech, random, no conversation
2 - incomprehensible speech, moaning w/ no words
1 - no speech

Question 4

What are the different levels of eye opening w/i the GCS?

Answer 4

4 - spontaneous
3 - in response to speech
2 - in response to pain
1 - no eye opening

Question 5

How should the GSC be recorded?

Answer 5

Best response of any limb/best speech

Question 6

What is the best prognostic indicator w/i the GCS?

Answer 6

Motor response

Question 7

What does a GCS 13-15 indicate?

Answer 7

Mild injury

Question 8

What does a GCS 9-12 indicate?

Answer 8

Moderate injury

Question 9

What does a GCS 8/<8 indicate

Answer 9

Severe injury

Consider airway protection

Question 10

What is the vascular ddx for an unconscious patient?

Answer 10

Stroke
Shock
Haematoma
SAH

Question 11

What is the infective/inflammatory ddx for an unconscious patient?

Answer 11

Sepsis
Meningitis
Encephalitis
Abscess

Question 12

What is the traumatic ddx for an unconscious patient?

Answer 12

Traumatic brain injury

Question 13

What is the autoimmune ddx for an unconscious patient?

Answer 13

Brainstem demyelination

Question 14

What is the metabolic ddx for an unconscious patient?

Answer 14

Hypo/hyper - glycaemia, calcaemia, natraemia
Hypo - adrenalism, thyroidism
Severe uraemia
Wernicke-Korsakoff syndrome

Question 15

What is the neoplastic ddx for an unconscious patient?

Answer 15

Cerebral tumour

Question 16

What are the key features to identify on examination of an unconscious patient?

Answer 16

Temp - infection/hypothermia?
Breath - ketones/alcohol?
Trauma
Resp - Cheyne-Stokes/Kussmaul?
Pupil signs

Question 17

What is Cheyne-Stokes respiration?

Answer 17

Alternating apnoea/hyperpnoea

Sign of initial coning (cerebral herniation w/ brainstem compression)

Question 18

What is Kussmaul respiration?

Answer 18

Deep & laboured

Seen in uraemia/acidosis

Question 19

What pupil signs may be present in an unconscious patient?

Answer 19

Unilateral, dilated - raised ICP
Bilateral, dilated, fixed - brainstem death/deep coma
Pinpoint - opiate od, pontine lesions

Question 20

What investigations are appropriate in an unconscious patient?

Answer 20

FBCs, U&Es, LFTs etc.
Metabolic/endocrine studies
Drugs screen
Blood cultures
Head CT/MRI
LP (if no raised ICP/mass lesions)

Question 21

What is the management of an unconscious patient?

Answer 21

A-E resuscitation

Identifying/treating cause