A return to GCS and intoxication

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Right, here go my thoughts, after reading yours with amusement and =
amazement for several days: (mine are the bits in brackets)

Sheree Joyce wrote:
Is it possible to complete a comprehensive GCS on a pt who is chemically
paralysed??

And Pret replied:
No.  And "7T" or "3P" is useless, diagnostically, prognostically, and
descriptively.  These terms have identical meaning: "all bets are off."

For acute care purposes, it should suffice to inform clinicians that the
patient is chemically disqualified from coma assessment: they'll have to
assume the worst, or prove otherwise by discontinuing the paralysis.  As =
has
been discussed, however, it is important for the 'upstream' clinician to
carefully observe and record a GCS prior to sedation and/or paralysis.  =
It's
very useful for the receiving physician to know whether or not the =
patient
was comatose, had airway jeopardy, or was simply too combative to treat
otherwise.
Pret

(.....Well, this all brings me back to my question about nursing =
management of self-medicated people who possibly have a head injury. =
Those who have taken an overdose, either of ETOH, or some other sedating =
medication, are effectively CHEMICALLY PARALYSED. If they do not =
actually have respiratory impairment, (which would obviously require =
intubation, before someone points this out)  they are often so flacid as =
to render the motor part of the assessment meaningless. Their cognitive =
responses are affected by the chemical CNS depressants in their system, =
so it is impossible to properly assess any change in head injury status, =
(not even going into those who simply don't want to cooperate) and of =
course none of them open their eyes spontaneously. Basic BP (I'll =
explain the systolic/diastolic thing to you another time Pret!!!) may =
show the pulse widening evident in an expanding subdural haematoma, but =
in theory, in a level 3 care facility a CT will already have been done =
which will have proved or ruled out significant head injury. So, given =
all this, how do we, as nurses, accurately keep a tab on the patients =
evolving condition in a meaningful way? The medical answer at the place =
I work is to require nurses to continue half to one hourly GCS =
recordings, despite the above problems with this. I just wondered if =
anyone else had any revolutionary new ways of treatment or assessment =
that would help us manage intoxicated patients who have the possibility =
of underlying head injury. (which, as someone pointed out, could be all =
of them, due to the inherent difficulties in the initial assessment. I'm =
sorry to be a little long-winded, but having read what some of you =
write, I don't want to be misinterpreted!)

JL Holmes wrote:
The problem with GCS is that, as with all scoring systems, the details
become forgotten unless one is using it frequently. =20

(....Very true, but that is what the posters on the wall are for....)

In the heat of battle the occasional user struggles.  I have to admit =
that I get rather annoyed
when I am presented a patient who is said to have a GCS of "about 7". =20

(... what about the difficult to asses patient whose GCS changes from =
minute to minute due to the action of drugs and or alcohol on their =
state of consciousness and their cooperativeness...?)

A GCS is an absolute score or it's not been properly assessed.=20

(...Hmmm...)

 Further - an inaccurate GCS (or vaguely guessed at GCS) has great =
potential for harm if
it is relied upon when looking for trends.
(... yes, but that is what staff education is for, and before anyone =
else claims that their nursing or medical staff are unable to learn how =
to do an accurate GCS recording, I would like to point out that gives =
the rest of us a very low opinion of the caliber of staff whom you =
employ)

Finally:
 Is it really necessary to have a GCS to know when to intubate?  I hear
this quite often.
> Daryl Eustace, EMT-P
I agree. Strictly of the neurological point of view, a patient who does =
not
attend to a simple verbal command should be intubated. I need not the
Glasgow's Scale for this.
Hermeto, MV
Coordinator - Physician
SAMU - Betim
Brazil
(...The use of GCS before intubation is to give an accurate picture of =
the patient's condition, and it goes with all the other evaluations and =
recordings taken  to acheive an accurate baseline. You might as well say =
that you don't need a blood pressure to tell that a patient is =
exanguinating through femoral wound )... this completely misses the =
point of doing the BP or any recording at all. With this attitude, we =
might just as well all go home and let the patients treat themselves)
Enough from me,
Ali Cane (RCpN)=20

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<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2><FONT face=3D"Times New Roman" =
size=3D3><FONT=20
face=3D"Times New Roman" size=3D3><BR><FONT face=3DArial size=3D2>Right, =
here go my=20
thoughts, after reading yours with amusement and amazement for several =
days:=20
(mine are the bits in brackets)</FONT><BR></FONT></FONT></FONT></DIV>
<DIV align=3Dleft><FONT face=3DArial size=3D2><FONT face=3D"Times New =
Roman"=20
size=3D3><FONT face=3D"Times New Roman" size=3D3><FONT face=3DArial =
size=3D2>Sheree Joyce=20
wrote:</FONT><BR>Is it possible to complete a comprehensive GCS on a pt =
who is=20
chemically<BR>paralysed??</FONT><BR><BR>And Pret =
replied:</FONT></FONT></DIV>
<DIV><FONT face=3DArial size=3D2><FONT face=3D"Times New Roman" =
size=3D3>No.&nbsp; And=20
"7T" or "3P" is useless, diagnostically, prognostically,=20
and<BR>descriptively.&nbsp; These terms have identical meaning: "all =
bets are=20
off."<BR><BR>For acute care purposes, it should suffice to inform =
clinicians=20
that the<BR>patient is chemically disqualified from coma assessment: =
they'll=20
have to<BR>assume the worst, or prove otherwise by discontinuing the=20
paralysis.&nbsp; As has<BR>been discussed, however, it is important for =
the=20
'upstream' clinician to<BR>carefully observe and record a GCS prior to =
sedation=20
and/or paralysis.&nbsp; It's<BR>very useful for the receiving physician =
to know=20
whether or not the patient<BR>was comatose, had airway jeopardy, or was =
simply=20
too combative to treat<BR>otherwise.<BR>Pret<BR><FONT face=3DArial=20
size=3D2></FONT></FONT></FONT></DIV>
<DIV><FONT face=3DArial size=3D2><FONT face=3D"Times New Roman" =
size=3D3><FONT=20
face=3DArial size=3D2>(.....Well, this all brings me back to my question =
about=20
<EM>nursing</EM> management of self-medicated people who possibly have a =
head=20
injury.&nbsp;Those who have taken an overdose, either of ETOH, or some =
other=20
sedating medication, are effectively CHEMICALLY PARALYSED. If they do =
not=20
actually have respiratory impairment, (which would obviously require =
intubation,=20
before someone points this out) &nbsp;they are often so flacid as to =
render the=20
motor part of the assessment meaningless. Their cognitive responses are =
affected=20
by the chemical CNS depressants in their system, so it is impossible to =
properly=20
assess any&nbsp;change in head injury status, (not even going&nbsp;into =
those=20
who&nbsp;simply don't want to cooperate)&nbsp;and of course none of them =
open=20
their eyes spontaneously. Basic&nbsp;BP (I'll explain the =
systolic/diastolic=20
thing to you another time Pret!!!) may show the pulse widening evident =
in an=20
expanding subdural haematoma, but in theory, in a level 3 care facility =
a CT=20
will already have been done which will have proved or ruled out =
significant head=20
injury. So, given all this, how do we, as nurses, accurately keep a tab =
on the=20
patients evolving condition in a meaningful way? The medical answer at =
the place=20
I work is to require&nbsp;nurses to continue half to one hourly GCS =
recordings,=20
despite the above problems with this. I just wondered if anyone else had =
any=20
revolutionary new ways of treatment or assessment that would help us =
manage=20
intoxicated patients who have the possibility of underlying head injury. =
(which,=20
as someone pointed out, <EM>could</EM> be all of them, due to the =
inherent=20
difficulties in the initial assessment. I'm sorry to be a little =
long-winded,=20
but having read what some of you write, I don't want to be=20
misinterpreted!)</FONT></FONT></FONT></DIV>
<DIV><FONT face=3DArial size=3D2><FONT face=3D"Times New Roman"=20
size=3D3></FONT></FONT>&nbsp;</DIV>
<DIV><FONT><FONT face=3DArial size=3D2>JL Holmes =
wrote:</FONT></FONT></DIV>
<DIV>The problem with GCS is that, as with all scoring systems, the=20
details<BR>become forgotten unless one is using it frequently.&nbsp; =
</DIV>
<DIV>&nbsp;</DIV>
<DIV>(....Very true, but that is what the posters on the wall are =
for....)</DIV>
<DIV>&nbsp;</DIV>
<DIV>In the heat of battle the occasional user struggles.&nbsp; I have =
to admit=20
that I get rather annoyed<BR>when I am presented a patient who is said =
to have a=20
GCS of "about 7".&nbsp; </DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>(... what about the difficult to asses =
patient=20
whose GCS changes from minute to minute due to the action of drugs and =
or=20
alcohol on their state of consciousness and their=20
cooperativeness...?)</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV>A GCS is an absolute score or it's not been properly =
assessed.&nbsp;</DIV>
<DIV>&nbsp;</DIV>
<DIV>(...Hmmm...)</DIV>
<DIV>&nbsp;</DIV>
<DIV>&nbsp;Further - an inaccurate GCS (or vaguely guessed at GCS) has =
great=20
potential for harm if<BR>it is relied upon when looking for =
trends.<BR><FONT=20
face=3DArial size=3D2>(... yes, but that is what staff education is for, =
and before=20
anyone else claims that their nursing or medical staff are unable to =
learn how=20
to do an accurate GCS recording, I would like to point out that gives =
the rest=20
of us a very low opinion of the caliber of staff whom you =
employ)</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Finally:</FONT></DIV>
<DIV>&nbsp;Is it really necessary to have a GCS to know when to =
intubate?&nbsp;=20
I hear<BR>this quite often.<BR>&gt; Daryl Eustace, EMT-P<BR>I agree. =
Strictly of=20
the neurological point of view, a patient who does not<BR>attend to a =
simple=20
verbal command should be intubated. I need not the<BR>Glasgow's Scale =
for=20
this.<BR>Hermeto, MV<BR>Coordinator - Physician<BR>SAMU -=20
Betim<BR>Brazil<BR><FONT face=3DArial size=3D2>(...The use of GCS before =
intubation=20
is to give an accurate picture of the patient's condition, and it goes =
with all=20
the other evaluations&nbsp;and recordings taken&nbsp; to&nbsp;acheive an =

accurate baseline. You might as well say that you don't need a blood =
pressure to=20
tell that a patient is exanguinating through femoral wound )... this =
completely=20
misses the point of doing the BP or any recording at all. With this =
attitude, we=20
might just as well all go home and let the patients treat=20
themselves)</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Enough from me,</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Ali Cane =
(RCpN)</FONT>&nbsp;</DIV></BODY></HTML>

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