Unconscious Patient Flashcards
Outline the ‘motor response’ section of the Glasgow Coma Scale
6: Obeying commands
5: Localising to pain
4: Withdrawing to pain
3: Flexor response to pain
2: Extensor response to pain
1: None
Outline the ‘verbal response’ section of the Glasgow Coma Scale
5: Orientated to time, place, person
4: Confused conversation
3: Inappropriate speech
2: Incomprehensible sounds
1: None
Outline the ‘eye opening’ section of the Glasgow Coma Scale
4: Spontaneous
3: In response to speech
2: In response to pain
1: None
What is a minor, moderate, and severe GCS injury?
Minor: 13-15
Moderate: 9-12
Severe: <8 (airway protection needed)
What is decorticate and decerebrate posturing?
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
According to NICE guidelines, following head injury which patients require a CT head IMMEDIATELY?
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
What are the signs of a basal skull fracture?
Haemotympanum
Panda eyes
CSF leakage from ears or nose
Battle’s sign
According to NICE guidelines, following head injury which patients require a CT head within 8 hours?
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
What are the features of an extradural haematoma?
Often results from acceleration-deceleration trauma or blows to the side of the head
Features: raised ICP, some patients may have a lucid interval
What are the features of a subdural haematoma?
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
For patients who are warfarinsed and had a head injury but have no signs or symptoms of a head injury, what is the management?
CT Head in 8 hours
What are the in hospital monitoring requirements of patients with a head injury?
Obs half hourly until GCS is 15
Half hourly for two hours
1 hourly for 4 hours
When is ICP monitoring required?
Appropriate if: GCS 3-8 and normal CT scan
Mandatory if: GCS 3-8 and abnormal CT scan
What head injury pathology presents with a unilateral dilated, sluggish pupil?
3rd nerve compression secondary to tentorial herniation
What head injury pathology presents with bilateral dilated sluggish pupils?
Poor CNS perfusion
bilateral third nerve compression
What pathologies present with bilaterally constricted pupils?
Opiates
Pontine lesions
Metabolic encephalopathy
What are the risk factors for a CT cervical spine within an hour?
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
Which head injury patients should you intubate and ventilate?
GCS <8 Copious bleeding into mouth Irregular respirations Hypoxaemia/hypercapnea Unstable fractures of the face Head injury with seizure
What is the immediate management of a coma?
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
