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A return to GCS and intoxication
P. Hoffman trauma-list@trauma.orgThu, 28 Feb 2002 15:05:04 -0500
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This is a multi-part message in MIME format. ------=_NextPart_000_0008_01C1C069.4D537A20 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 7bit At the risk of exposing my ignorance, what was the purpose of so much fluid pre-hospital? Phil Hoffman EMTP -----Original Message----- From: trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org]On Behalf Of Nick Nudell Sent: Thursday, February 28, 2002 12:27 PM To: trauma-list@trauma.org Subject: Re: A return to GCS and intoxication 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=3, normopneic, SPO2=100%, tachycardic, skin PWM, sinus tach no ectopy, BP slightly elevated, D-stick=127mg/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=3 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. 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 ----- From: canes To: trauma-list@trauma.org 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. (....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. (...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) ------=_NextPart_000_0008_01C1C069.4D537A20 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <HTML><HEAD> <META http-equiv=3DContent-Type content=3D"text/html; = charset=3Diso-8859-1"> <META content=3D"MSHTML 6.00.2713.1100" name=3DGENERATOR> <STYLE></STYLE> </HEAD> <BODY bgColor=3D#ffffff> <DIV><SPAN class=3D720160420-28022002><FONT face=3DArial color=3D#0000ff = size=3D2>At the=20 risk of exposing my ignorance, what was the purpose of so much fluid=20 pre-hospital?</FONT></SPAN></DIV> <DIV><SPAN class=3D720160420-28022002><FONT face=3DArial color=3D#0000ff = size=3D2></FONT></SPAN> </DIV> <DIV><SPAN class=3D720160420-28022002><FONT face=3DArial color=3D#0000ff = size=3D2>Phil=20 Hoffman</FONT></SPAN></DIV> <DIV><SPAN class=3D720160420-28022002><FONT face=3DArial color=3D#0000ff = size=3D2>EMTP</FONT></SPAN></DIV> <BLOCKQUOTE dir=3Dltr style=3D"MARGIN-RIGHT: 0px"> <DIV class=3DOutlookMessageHeader dir=3Dltr align=3Dleft><FONT = face=3DTahoma=20 size=3D2>-----Original Message-----<BR><B>From:</B> = trauma-list-admin@trauma.org=20 [mailto:trauma-list-admin@trauma.org]<B>On Behalf Of </B>Nick=20 Nudell<BR><B>Sent:</B> Thursday, February 28, 2002 12:27 = PM<BR><B>To:</B>=20 trauma-list@trauma.org<BR><B>Subject:</B> Re: A return to GCS and=20 intoxication<BR><BR></FONT></DIV> <DIV><FONT face=3DTahoma size=3D2>Here is a prehospital = scenario....</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </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 & hi flow O2, with no response to treatment. Narcan = 2mg 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.=20 No strong odor of ETOH is present, unusually.</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV><FONT face=3DTahoma size=3D2>Now comes the extrication from the = small=20 upstairs apartment via LBB/straps. Attempt to place an OPA, = noting stiff=20 jaw and some oral resistance (indicating possibly a gag reflex), so = that=20 attempt is DCd and an NPA is placed without complication. On the way = to the ED=20 a second IV is established and 700cc are infused enroute. At ED no = changes. Dr=20 considers intubation but decides to wait, with suction on standby. = Romazicon=20 was also considered but decided against barring positive Tox=20 results.</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </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=20 took a couple hours and several liters of fluid to wake him = up...</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </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 so he is avpU. I cannot rule out stroke, cardiac = complications,=20 hypoxic conditions, diabetic complications or trauma. Is not this = what=20 GCS 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> </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 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> </DIV> <DIV><FONT face=3DTahoma size=3D2>Nick</FONT></DIV> <DIV> </DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </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> </DIV> <DIV><FONT face=3DArial size=3D2><BR></FONT> </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=20 pt 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. =20 And "7T" or "3P" is useless, diagnostically, prognostically,=20 and<BR>descriptively. These terms have identical meaning: "all = bets=20 are off."<BR><BR>For acute care purposes, it should suffice to = inform=20 clinicians that the<BR>patient is chemically disqualified from coma=20 assessment: they'll have to<BR>assume the worst, or prove otherwise = by=20 discontinuing the paralysis. As has<BR>been discussed, = however, it is=20 important for the 'upstream' clinician to<BR>carefully observe and = record a=20 GCS prior to sedation and/or paralysis. It's<BR>very useful = for the=20 receiving physician to know whether or not the patient<BR>was = comatose, had=20 airway jeopardy, or was simply too combative to=20 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=20 head injury. Those who have taken an overdose, either of ETOH, = or some=20 other sedating medication, are effectively CHEMICALLY PARALYSED. If = they do=20 not actually have respiratory impairment, (which would obviously = require=20 intubation, before someone points this out) they are often so = flacid=20 as to render the motor part of the assessment meaningless. Their = cognitive=20 responses are affected by the chemical CNS depressants in their = system, so=20 it is impossible to properly assess any change in head injury = status,=20 (not even going into those who simply don't want to=20 cooperate) and of course none of them open their eyes = spontaneously.=20 Basic BP (I'll explain the systolic/diastolic thing to you = another time=20 Pret!!!) may show the pulse widening evident in an expanding = subdural=20 haematoma, but in theory, in a level 3 care facility a CT will = already have=20 been done which will have proved or ruled out significant head = injury. So,=20 given all this, how do we, as nurses, accurately keep a tab on the = patients=20 evolving condition in a meaningful way? The medical answer at the = place I=20 work is to require nurses to continue half to one hourly GCS=20 recordings, despite the above problems with this. I just wondered if = anyone=20 else had any revolutionary new ways of treatment or assessment that = would=20 help us manage intoxicated patients who have the possibility of = underlying=20 head injury. (which, as someone pointed out, <EM>could</EM> be all = of them,=20 due to the inherent difficulties in the initial assessment. I'm = sorry to be=20 a little long-winded, but having read what some of you write, I = don't want=20 to be misinterpreted!)</FONT></FONT></FONT></DIV> <DIV><FONT face=3DArial size=3D2><FONT face=3D"Times New Roman"=20 size=3D3></FONT></FONT> </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. = </DIV> <DIV> </DIV> <DIV>(....Very true, but that is what the posters on the wall are=20 for....)</DIV> <DIV> </DIV> <DIV>In the heat of battle the occasional user struggles. 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". </DIV> <DIV><FONT face=3DArial size=3D2></FONT> </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> </DIV> <DIV>A GCS is an absolute score or it's not been properly=20 assessed. </DIV> <DIV> </DIV> <DIV>(...Hmmm...)</DIV> <DIV> </DIV> <DIV> 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> </DIV> <DIV><FONT face=3DArial size=3D2>Finally:</FONT></DIV> <DIV> Is it really necessary to have a GCS to know when to=20 intubate? I hear<BR>this quite often.<BR>> Daryl Eustace,=20 EMT-P<BR>I agree. Strictly of the neurological point of view, a = patient who=20 does not<BR>attend to a simple verbal command should be intubated. I = need=20 not the<BR>Glasgow's Scale for this.<BR>Hermeto, MV<BR>Coordinator - = Physician<BR>SAMU - Betim<BR>Brazil<BR><FONT face=3DArial = size=3D2>(...The use=20 of GCS before intubation is to give an accurate picture of the = patient's=20 condition, and it goes with all the other evaluations and = recordings=20 taken to 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=20 or any recording at all. With this attitude, we might just as well = all go=20 home 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> </DIV></BLOCKQUOTE></BLOCKQUOTE></BODY></HTML> ------=_NextPart_000_0008_01C1C069.4D537A20--
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