Unconscious Patient

Question 1

Outline the ‘motor response’ section of the Glasgow Coma Scale

Answer 1

6: Obeying commands
5: Localising to pain
4: Withdrawing to pain
3: Flexor response to pain
2: Extensor response to pain
1: None

Question 2

Outline the ‘verbal response’ section of the Glasgow Coma Scale

Answer 2

5: Orientated to time, place, person
4: Confused conversation
3: Inappropriate speech
2: Incomprehensible sounds
1: None

Question 3

Outline the ‘eye opening’ section of the Glasgow Coma Scale

Answer 3

4: Spontaneous
3: In response to speech
2: In response to pain
1: None

Question 4

What is a minor, moderate, and severe GCS injury?

Answer 4

Minor: 13-15
Moderate: 9-12
Severe: <8 (airway protection needed)

Question 5

What is decorticate and decerebrate posturing?

Answer 5

Decorticate: arms flexed inwards, legs extended
Implies damage above the level of the red nucleus in the midbrain

Decerebrate: adduction and internal rotation of the shoulder, pronation of the forearm
Implies damage below the level of the red nucleus

Question 6

According to NICE guidelines, following head injury which patients require a CT head IMMEDIATELY?

Answer 6

GCS <13 on arrival
GCS <15 after two hours post-injury
Suspected open or depressed skull fracture
Any signs of basal skull fracture
Post-traumatic seizure
Focal neurological deficit
>1 episode vomiting

Question 7

What are the signs of a basal skull fracture?

Answer 7

Haemotympanum
Panda eyes
CSF leakage from ears or nose
Battle’s sign

Question 8

According to NICE guidelines, following head injury which patients require a CT head within 8 hours?

Answer 8

If adults have minor LOC/amnesia since the injury AND either:
>65
History of bleeding or clotting disorders
Dangerous mechanism of injury
>30min retrograde amnesia

Question 9

What are the features of an extradural haematoma?

Answer 9

Often results from acceleration-deceleration trauma or blows to the side of the head

Features: raised ICP, some patients may have a lucid interval

Question 10

What are the features of a subdural haematoma?

Answer 10

Most commonly occur in the frontal or parietal lobes
Bleeding into outermost meningeal layer

Risk factors: old age and alcoholism

Slower onset than extradural haematoma

Question 11

For patients who are warfarinsed and had a head injury but have no signs or symptoms of a head injury, what is the management?

Answer 11

CT Head in 8 hours

Question 12

What are the in hospital monitoring requirements of patients with a head injury?

Answer 12

Obs half hourly until GCS is 15

Half hourly for two hours
1 hourly for 4 hours

Question 13

When is ICP monitoring required?

Answer 13

Appropriate if: GCS 3-8 and normal CT scan

Mandatory if: GCS 3-8 and abnormal CT scan

Question 14

What head injury pathology presents with a unilateral dilated, sluggish pupil?

Answer 14

3rd nerve compression secondary to tentorial herniation

Question 15

What head injury pathology presents with bilateral dilated sluggish pupils?

Answer 15

Poor CNS perfusion

bilateral third nerve compression

Question 16

What pathologies present with bilaterally constricted pupils?

Answer 16

Opiates
Pontine lesions
Metabolic encephalopathy

Question 17

What are the risk factors for a CT cervical spine within an hour?

Answer 17

GCS <13
Patient has been intubated
Plain X-Rays are abnormal/inadequate
Clinical suspicion and either >65, focal neurological deficit, paraesthesia, dangerous mechanism of injury

Question 18

Which head injury patients should you intubate and ventilate?

Answer 18

GCS <8
Copious bleeding into mouth
Irregular respirations
Hypoxaemia/hypercapnea
Unstable fractures of the face
Head injury with seizure

Question 19

What is the immediate management of a coma?

Answer 19

ABC
IV access
Stabilise cervical spine
Blood glucose (give 200mL 10% glucose IV stat if hypoglycaemia)
Control possible seizures
Brief collateral history
Investigations: ABG, FBC, ethanol, CXR, toxin screen, drug levels, urine culture, blood cultures, CT head