care of the unconscious patient acute care dayclinical decisions in the unconscious patient •...
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Care of the Unconscious Patient Acute Care Day
Case Studies Assessing GCS Looking after the Unconscious Patient
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Assessing Consciousness
• Using GCS • Prevention of secondary complications of
Coma • Safely managing comatose patients
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Principles of assessing Consciousness Glasgow Coma Scale
Eye Response 4 Eyes open spontaneously
3 Eyes open to verbal Command 2 Eyes open to Pain 1 No eye opening
Motor Response 6 Obeys Commands 5 Localises to Pain 4 Withdraws to pain 3 Flexes to pain 2 Extension to pain 1 No Motor Response
Verbal Response 5 Orientated 4 Confused 3 Inappropriate Words 2 Incomprehensible Sounds 1 No Verbal Response
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Assessing GCS
• Score should always be documented as the 3 components and not just a total
• Needs to be re-assessed regularly • Make sure stimulus is applied above the
clavicle when assessing – in case there is a high spinal lesion
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Case 1
Acute Respiratory Care Day
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Case 1
• 30 year old • Found 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
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Case 1 (1)
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What are you going to do?
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Assessment
• A • B • C • D • E
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A and B
• Talking (confused) • Respiratory rate 20 breaths per minute • Oxygen saturations 97% on air • Trachea central • Normal Breath sounds
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C
• Good Capillary return • Pulse 120bpm • BP 110/65 mmHg
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D and E
• Assess GCS (Chart on your chart)
• Nothing else found on exposure
• Specifically no signs of trauma
• Sweaty
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Case 1 D and E
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Case 1 What Now?
• Further examination? • Further Investigations? • Further Management?
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Case 1
• Nurse calls you back to see him because she is concerned about his condition
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Case 1 (2)
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Case 1 (2nd set obs)
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Case 1 What is his coma scale now?
• Chart his coma scale now on your paper chart
• What further assessment do you need to do? – A – slight snoring, but has he still got protective
reflexes – B- SaO2 95% on air, Air entry still OK – C
• pulse 115 • Bp 140/85
• What further investigations does he need? • Potential causes for his acute change?
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What Measures do you need to take to ensure safety of unconscious patient?
• Airway protection • Positioning • Preventing pressure sores • Protecting neck and limbs from injury • Corneal protection
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Clinical Decisions in the Unconscious patient
• Combination of diagnostic steps and treatment decisions
• Pragmatic assessment of adequacy of medical support
• Find treatable disorder • Initial care, diagnosis and treatment of
reversible pathology • Think about safety for transfer of patients • Consent for treatment / Incapacity Forms
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Prevent complications
• Aspiration • Pressure Sores • Dehydration • Malnutrition • Secondary brain injury • Nosocomial infections • Eye and mouth care • DVT/PE • Rhabdomyolysis
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Case 2
• 33 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 scene
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Case 2 – Chart his GCS
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Case 3: Presentation
• 18 year old • 3 week history of dental abscess on left
upper molar • Too afraid to go to dentist so took his
mother’s co-codamol tablets • Fever for 1 week, • Found by mother in bedroom, could not
wake him up this morning, called ambulance.
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Case 3: Initial Assessment:
• A – Airway Clear (how do you test for that?) – No cough or gag reflex
• B – SaO2 96% on air, – Air entry both sides
• C – P 130 Sinus rhythm – Bp 85/32 – Warm, vasodilated,
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Case 3 D and E
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Case 3 GCS
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What next?
Any investigations?
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Case 3: What next?
• Any investigations? • Temp 40.5 C • WCC 25 • CRP 450
• CT -
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Questions?