Presentation on theme: "Care of the Unconscious Patient Acute Care Day"— Presentation transcript:
1 Care of the Unconscious Patient Acute Care Day Case StudiesAssessing GCSLooking after the Unconscious Patient
2 Assessing Consciousness Using GCSPrevention of secondary complications of ComaSafely managing comatose patientsThere are many ways to assess neurological status in the comatose patient. The aim of this tutorial is to make sure that the GCS is used and recorded properly and is used as part of the assessment and acute resuscitation of the patient who has decreased conscious level. By the end the students should be able to chart and record an accurate GCS in addition to realising some of the practical care of the unconscious patient.
3 Principles of assessing Consciousness Glasgow Coma Scale Eye ResponseEyes open spontaneously3 Eyes open to verbal Command2 Eyes open to Pain1 No eye openingMotor Response6 Obeys Commands5 Localises to Pain4 Withdraws to pain3 Flexes to pain2 Extension to pain1 No Motor ResponseVerbal Response5 Orientated4 Confused3 Inappropriate Words2 Incomprehensible Sounds1 No Verbal ResponseGo through the GCS and how it is scored.Explain how to obtain the responses with a supraclavicular stimulus and even on the face if necessary,Explain that localising is crossing midline compared to flexing
4 This is a typical chart for putting coma scale on. Please explain the any score less than GCS 8 is classified as Coma.
5 Assessing GCSScore should always be documented as the 3 components and not just a totalNeeds to be re-assessed regularlyMake sure stimulus is applied above the clavicle when assessing – in case there is a high spinal lesion
6 Acute Respiratory Care Day Case 1Acute Respiratory Care DayAll 3 cases are to scored by students.6
7 Case 130 year oldFound by shopkeeper when opening up shop sleeping in shop doorway, when asked to move on seemed a bit confused,Became progressively more drowsy and refused to move from doorway so ambulance called.You are called to assess him in A&E
10 AssessmentABCDEABCDE approach to be reiterated10
11 Respiratory rate 20 breaths per minute Oxygen saturations 97% on air A and BTalking (confused)Respiratory rate 20 breaths per minuteOxygen saturations 97% on airTrachea centralNormal Breath sounds11
13 Assess GCS (Chart on your chart) D and EAssess GCS (Chart on your chart)Nothing else found on exposureSpecifically no signs of traumaSweaty13
14 Case 1 D and EGet the students to chart the GCS and swap charts with each other so that they can see whether they have charted consistently, emphasise to them the fact that the stimulus was supraclavicular so that potential spinal injury does not affect the assessment.Encourage a bit of discussion about the actual scoring and clarify the issues raised – especially that it is the best response obtained.Discuss AVPU as an alternative quick assessment in triage or an emergency.A-alertV-responds to voiceP- responds to painU-unresponsive14
16 Further Investigations? Further Management? Case 1 What Now?Further examination?Further Investigations?Further Management?SweatyBlood glucose <1U&E otherwise normalAllow them to give sweet drink, glucose infusion or glucagonCT would probably depend on response to treatment. Ie don’t ever forget the glucose.
17 Case 1Nurse calls you back to see him because she is concerned about his conditionAsk them what kind of things they should be doing now?Emphasise the necessity for re-assessment and Encourage ABC againShow the video on the next slide.
21 Case 1 What is his coma scale now? Chart his coma scale now on your paper chartWhat further assessment do you need to do?A – slight snoring, but has he still got protective reflexesB- SaO2 95% on air, Air entry still OKCpulse 115Bp 140/85What further investigations does he need?Potential causes for his acute change?Get them to discuss how they should change the emphasis their management,The idea is to get them to recognise that this is now a dynamic situation, his condition is deteriorating, they will have to consider protecting his airway now and also finding out why his condition has deteriorated. The reason is actually that he has taken a slow release insulin injection and that is now having more of an effect.His hypoglycaemia has recurred, and his conscious level has decreased.They are now dealing with an unconscious patient and need to focus on that as well as treating hypoglycaemia i.e. ABC and go on to discuss the following slides about dealing safely with a comatose patient who has no protective reflexes.
22 Preventing pressure sores Protecting neck and limbs from injury What Measures do you need to take to ensure safety of unconscious patient?Airway protectionPositioningPreventing pressure soresProtecting neck and limbs from injuryCorneal protection
23 Clinical Decisions in the Unconscious patient Combination of diagnostic steps and treatment decisionsPragmatic assessment of adequacy of medical supportFind treatable disorderInitial care, diagnosis and treatment of reversible pathologyThink about safety for transfer of patientsConsent for treatment / Incapacity FormsBriefly refer to the fact that any patient who is comatose is not competent to give consent for procedures and that an incapacity certificate would be appropriate for any consent for further treatment required.I.e. surgery or invasive investigations, monitoring or ICU care or withdrawal of treatment. (obviously not appropriate in this actual case, but principles need a bit of emphasis)
25 Case 233 year old man, has been found at bottom of flight of stairs in his close,He has blood on the back of his head, and the ambulance crew have said that there was some blood coming from his left ear when they arrived at the sceneCLICK ON PICTURE TO PLAY VIDEOGet students to score GCS before going to next slide.
26 Get the students to score on their sheet and compare with this
27 Where is the Lesion likely to be? Case 2 – Chart his GCSWhere is the Lesion likely to be?Note Fixed dilated left pupilFlexing on rightLocalising on leftThe presence of a unilateral fixed dilated pupil is due to an oculomotor lesion. It can be from compression of midbrain oculomotor complex, traction of the oculomotor nerve, or pressure of nerve against the clivus. Or hernia ion of the uncal hippocampus directly compressing the third nerve at the edge of the tentorium.The next slide (on the day will be a CT of possible brain lesion)
28 Case 3: Presentation18 year old3 week history of dental abscess on left upper molarToo afraid to go to dentist so took his mother’s co-codamol tabletsFever for 1 week,Found by mother in bedroom, could not wake him up this morning, called ambulance.
29 Case 3: Initial Assessment: Airway Clear (how do you test for that?)No cough or gag reflexBSaO2 96% on air,Air entry both sidesCP 130 Sinus rhythmBp 85/32Warm, vasodilated,This is the results of the ABC assessmentThe next slide is a video of coma score – get the students to score again on their sheets.
30 What is his GCS? Case 3 D and E 30 Get the students to chart on their chart what the GCS is now30
31 Case 3 GCSThere may be a bit of variation of scoring on this, encourage discussion. Emphasise that the score is the best obtained.Note each side is different due to localisation of lesionThe last slide will be the CT showing the lesion.
33 How are you going to transport him safely to CT? Case 3: What next?Any investigations?Temp 40.5 CWCC 25CRP 450CT -How are you going to transport him safely to CT?Requires Intubation call anaesthetist.