A return to GCS and intoxication

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Here is a prehospital scenario....

45 yo NAM, bystanders state pt was sitting in a chair and just went limp =
with head falling back, not responding. I find avpU, GCS=3D3, =
normopneic, SPO2=3D100%, tachycardic, skin PWM, sinus tach no ectopy, BP =
slightly elevated, D-stick=3D127mg/dl. Start a line, begin infusing =
fluid & hi flow O2, with no response to treatment. Narcan 2mg with no =
response, Thiamine 100mg again no response, Dextrose 12.5g with no =
response. This pt is someone we know as a homeless person who is =
normally intoxicated. No strong odor of ETOH is present, unusually.

Now comes the extrication from the small upstairs apartment via =
LBB/straps.  Attempt to place an OPA, noting stiff jaw and some oral =
resistance (indicating possibly a gag reflex), so that attempt is DCd =
and an NPA is placed without complication. On the way to the ED a second =
IV is established and 700cc are infused enroute. At ED no changes. Dr =
considers intubation but decides to wait, with suction on standby. =
Romazicon was also considered but decided against barring positive Tox =
results.

A 'little' while later labs come back indicating negative TOX screen =
findings and ETOH level +400. DDx, alcohol toxicity. It took a couple =
hours and several liters of fluid to wake him up...

Enroute, I have absolutely no way of knowing if this person has had 0, =
1, or 100 drinks. I can only indicate that his GCS=3D3 so he is avpU. I =
cannot rule out stroke, cardiac complications, hypoxic conditions, =
diabetic complications or trauma. Is not this what GCS is for? Other =
then just describing the s/s of the pt (which you can do for anyone- who =
really needs the GCS?) I gave the appropriate GCS for this pt.=20

It is now up to the Dr to make a diagnosis as to what has actually =
happened. ANY Dr or Nurse or Paramedic who relies on someone else's =
assessment of a patient for their direct treatment should take =
responsibility for this action (IMHO).

Nick



____
Nick Nudell, NREMT-P
Glacier County EMS
www.glacierems.com
Northern Rockies Medical Center
Cut Bank, MT
nick@glacierems.com



  ----- Original Message -----=20
  From: canes=20
  To: trauma-list@trauma.org=20
  Sent: Thursday, February 28, 2002 1:32 AM
  Subject: A return to GCS and intoxication



  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".  =


  (... 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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charset=3Diso-8859-1">
<META content=3D"MSHTML 6.00.2600.0" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DTahoma size=3D2>Here is a prehospital =
scenario....</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>45 yo NAM, bystanders state pt was =
sitting in a=20
chair and just went limp with head falling back, not responding. I find =
avpU,=20
GCS=3D3, normopneic, SPO2=3D100%, tachycardic, skin PWM, sinus tach no =
ectopy, BP=20
slightly elevated, D-stick=3D127mg/dl. Start a line, begin infusing =
fluid=20
&amp;&nbsp;hi flow O2, with no response to treatment. Narcan =
2mg&nbsp;with no=20
response, Thiamine 100mg again no response, Dextrose 12.5g with no =
response.=20
This pt is someone we know as a homeless person who is normally =
intoxicated. No=20
strong odor of ETOH is present, unusually.</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>Now comes the extrication from the =
small upstairs=20
apartment via LBB/straps.&nbsp; Attempt to place an OPA, noting stiff =
jaw and=20
some oral resistance (indicating possibly a gag reflex), so that attempt =
is DCd=20
and an NPA is placed without complication. On the way to the ED a second =
IV is=20
established and 700cc are infused enroute. At ED no changes. Dr =
considers=20
intubation but decides to wait, with suction on standby. Romazicon was =
also=20
considered but decided against barring positive Tox =
results.</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>A 'little' while later labs come back =
indicating=20
negative TOX screen findings and ETOH level +400. DDx, alcohol toxicity. =
It took=20
a couple hours and several liters of fluid to wake him =
up...</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>Enroute, I have absolutely no way of =
knowing if=20
this person has had 0, 1, or 100 drinks. I can only indicate that his=20
GCS=3D3&nbsp;so he is avpU. I cannot rule out stroke, cardiac =
complications,=20
hypoxic&nbsp;conditions, diabetic complications or trauma. Is not this =
what GCS=20
is for? Other then just describing the s/s of the pt (which you can do =
for=20
anyone- who really needs the GCS?) I gave the appropriate GCS for this =
pt.=20
</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>It is now up to the Dr to make a =
diagnosis as to=20
what has actually happened. ANY Dr or Nurse or Paramedic&nbsp;who relies =
on=20
someone else's assessment of a patient for their direct treatment should =
take=20
responsibility for this action (IMHO).</FONT></DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2>Nick</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DTahoma size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>____<BR>Nick Nudell, NREMT-P<BR>Glacier =
County=20
EMS<BR><A =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002/3D"http://www.glacierems.com">www.glacierems.com</A><BR>Northern=20
Rockies Medical Center<BR>Cut Bank, MT<BR><A=20
href=3D"mailto:nick@glacierems.com">nick@glacierems.com</A></FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2><BR></FONT>&nbsp;</DIV>
<BLOCKQUOTE dir=3Dltr=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3Dcanes@xtra.co.nz href=3D"mailto:canes@xtra.co.nz">canes</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Thursday, February 28, =
2002 1:32=20
  AM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> A return to GCS and=20
  intoxication</DIV>
  <DIV><BR></DIV>
  <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=20
  Joyce wrote:</FONT><BR>Is it possible to complete a comprehensive GCS =
on a pt=20
  who is chemically<BR>paralysed??</FONT><BR><BR>And Pret=20
  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 and/or paralysis.&nbsp; It's<BR>very useful for the receiving =

  physician to know whether or not the patient<BR>was comatose, had =
airway=20
  jeopardy, or was simply too combative to =
treat<BR>otherwise.<BR>Pret<BR><FONT=20
  face=3DArial 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=20
  intubation, before someone points this out) &nbsp;they are often so =
flacid as=20
  to render the motor part of the assessment meaningless. Their =
cognitive=20
  responses are affected by the chemical CNS depressants in their =
system, so it=20
  is impossible to properly assess any&nbsp;change in head injury =
status, (not=20
  even going&nbsp;into those who&nbsp;simply don't want to =
cooperate)&nbsp;and=20
  of course none of them open their eyes spontaneously. Basic&nbsp;BP =
(I'll=20
  explain the systolic/diastolic thing to you another time Pret!!!) may =
show the=20
  pulse widening evident in an expanding subdural haematoma, but in =
theory, in a=20
  level 3 care facility a CT will already have been done which will have =
proved=20
  or ruled out significant head injury. So, given all this, how do we, =
as=20
  nurses, accurately keep a tab on the patients evolving condition in a=20
  meaningful way? The medical answer at the place I work is to=20
  require&nbsp;nurses to continue half to one hourly GCS recordings, =
despite the=20
  above problems with this. I just wondered if anyone else had any =
revolutionary=20
  new ways of treatment or assessment that would help us manage =
intoxicated=20
  patients who have the possibility of underlying head injury. (which, =
as=20
  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 size=3D+0><FONT face=3DArial size=3D2>JL Holmes=20
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=20
  for....)</DIV>
  <DIV>&nbsp;</DIV>
  <DIV>In the heat of battle the occasional user struggles.&nbsp; I have =
to=20
  admit that I get rather annoyed<BR>when I am presented a patient who =
is said=20
  to have a 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=20
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=20
  before anyone else claims that their nursing or medical staff are =
unable to=20
  learn how to do an accurate GCS recording, I would like to point out =
that=20
  gives the rest of us a very low opinion of the caliber of staff whom =
you=20
  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=20
  intubate?&nbsp; I hear<BR>this quite often.<BR>&gt; Daryl Eustace, =
EMT-P<BR>I=20
  agree. Strictly of the neurological point of view, a patient who does=20
  not<BR>attend to a simple verbal command should be intubated. I need =
not=20
  the<BR>Glasgow's Scale for this.<BR>Hermeto, MV<BR>Coordinator -=20
  Physician<BR>SAMU - Betim<BR>Brazil<BR><FONT face=3DArial =
size=3D2>(...The use of=20
  GCS before intubation is to give an accurate picture of the patient's=20
  condition, and it goes with all the other evaluations&nbsp;and =
recordings=20
  taken&nbsp; to&nbsp;acheive an accurate baseline. You might as well =
say that=20
  you don't need a blood pressure to tell that a patient is =
exanguinating=20
  through femoral wound )... this completely misses the point of doing =
the BP or=20
  any recording at all. With this attitude, we might just as well all go =
home=20
  and let the patients treat themselves)</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>Enough from me,</FONT></DIV>
  <DIV><FONT face=3DArial size=3D2>Ali Cane=20
(RCpN)</FONT>&nbsp;</DIV></BLOCKQUOTE></BODY></HTML>

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