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A return to GCS and intoxication
Nick Nudell trauma-list@trauma.orgThu, 28 Feb 2002 22:05:49 -0700
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This is a multi-part message in MIME format. ------=_NextPart_000_0074_01C1C0A4.148F7500 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Good question. I believe that only 500 was infused PRIOR to arrival and = the other 200 happened between arrival and anyone in the ED actually = making an effort to adjust the rate... 300-500 is a standard fluid bolus = in our system. In considering the possible etiologies, a fluid bolus = should not hurt and may be helpful (ok, let 'em rip).... (I was not monitoring the fluid but I believe this to be the case) 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: P. Hoffman=20 To: trauma-list@trauma.org=20 Sent: Thursday, February 28, 2002 1:05 PM Subject: RE: A return to GCS and intoxication 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=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 =20 ----- 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". =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 ------=_NextPart_000_0074_01C1C0A4.148F7500 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 6.00.2600.0" name=3DGENERATOR> <STYLE></STYLE> </HEAD> <BODY bgColor=3D#ffffff> <DIV><FONT face=3DTahoma size=3D2>Good question. I believe that only 500 = was infused=20 PRIOR to arrival and the other 200 happened between arrival and anyone = in the ED=20 actually making an effort to adjust the rate... 300-500 is a standard = fluid=20 bolus in our system. In considering the possible etiologies, a = fluid bolus=20 should not hurt and may be helpful (ok, let 'em rip)....</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV><FONT face=3DTahoma size=3D2>(I was not monitoring the fluid but I = believe this=20 to be the case)</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV><FONT face=3DTahoma size=3D2>Nick</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV>____<BR>Nick Nudell, NREMT-P<BR>Glacier County EMS<BR><A=20 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 = Rockies=20 Medical Center<BR>Cut Bank, MT<BR><A=20 href=3D"mailto:nick@glacierems.com">nick@glacierems.com</A></DIV> <DIV> </DIV> <DIV><BR> </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=3Dphoffman@freeway.net = href=3D"mailto:phoffman@freeway.net">P.=20 Hoffman</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 1:05=20 PM</DIV> <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> RE: A return to GCS = and=20 intoxication</DIV> <DIV><BR></DIV> <DIV><SPAN class=3D720160420-28022002><FONT face=3DArial = color=3D#0000ff size=3D2>At=20 the 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=20 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=20 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> <A=20 = href=3D"mailto:trauma-list-admin@trauma.org">trauma-list-admin@trauma.org= </A>=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> <A=20 = href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A><BR><B>S= ubject:</B>=20 Re: A return to GCS and intoxication<BR><BR></FONT></DIV> <DIV><FONT face=3DTahoma size=3D2>Here is a prehospital=20 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=20 a chair and just went limp with head falling back, not responding. I = find=20 avpU, GCS=3D3, normopneic, SPO2=3D100%, tachycardic, skin PWM, sinus = tach no=20 ectopy, BP slightly elevated, D-stick=3D127mg/dl. Start a line, = begin infusing=20 fluid & hi flow O2, with no response to treatment. Narcan=20 2mg with no response, Thiamine 100mg again no response, = Dextrose 12.5g=20 with no response. This pt is someone we know as a homeless person = who is=20 normally intoxicated. No strong odor of ETOH is present,=20 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=20 stiff jaw and some oral resistance (indicating possibly a gag = reflex), so=20 that attempt is DCd and an NPA is placed without complication. On = the way to=20 the ED a second IV is established and 700cc are infused enroute. At = ED no=20 changes. Dr considers intubation but decides to wait, with suction = on=20 standby. Romazicon was also considered but decided against barring = positive=20 Tox results.</FONT></DIV> <DIV><FONT face=3DTahoma size=3D2></FONT> </DIV> <DIV><FONT face=3DTahoma size=3D2>A 'little' while later labs come = back=20 indicating negative TOX screen findings and ETOH level +400. DDx, = alcohol=20 toxicity. It took a couple hours and several liters of fluid to wake = him=20 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=20 if 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=20 for anyone- who really needs the GCS?) I gave the appropriate GCS = for this=20 pt. </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=20 to what has actually happened. ANY Dr or Nurse or Paramedic who = relies=20 on someone else's assessment of a patient for their direct treatment = should=20 take 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=20 = 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 = Rockies=20 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=20 1:32 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=20 my thoughts, after reading yours with amusement and amazement for = several=20 days: (mine are the bits in=20 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=20 is important for the 'upstream' clinician to<BR>carefully observe = and=20 record a GCS prior to sedation and/or paralysis. = It's<BR>very useful=20 for the receiving physician to know whether or not the = patient<BR>was=20 comatose, had 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=20 some other sedating medication, are effectively CHEMICALLY = PARALYSED. If=20 they do not actually have respiratory impairment, (which would = obviously=20 require intubation, before someone points this out) they are = often=20 so flacid as to render the motor part of the assessment = meaningless. Their=20 cognitive responses are affected by the chemical CNS depressants = in their=20 system, so it is impossible to properly assess any change in = head=20 injury status, (not even going into those who simply = don't want=20 to cooperate) and of course none of them open their eyes=20 spontaneously. Basic BP (I'll explain the systolic/diastolic = thing to=20 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=20 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=20 way? The medical answer at the place I work is to = require nurses to=20 continue half to one hourly GCS recordings, despite the above = problems=20 with this. I just wondered if anyone else had any revolutionary = new ways=20 of treatment or assessment that would help us manage intoxicated = patients=20 who have the possibility of underlying head injury. (which, as = someone=20 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=20 long-winded, 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> </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. =20 </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=20 said 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=20 patient whose GCS changes from minute to minute due to the action = of drugs=20 and or 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=20 great potential for harm if<BR>it is relied upon when looking for=20 trends.<BR><FONT face=3DArial size=3D2>(... yes, but that is what = staff=20 education is for, and before anyone else claims that their nursing = or=20 medical staff are unable to learn how to do an accurate GCS = recording, I=20 would like to point out that gives the rest of us a very low = opinion of=20 the caliber of staff whom you 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, = EMT-P<BR>I agree. Strictly of the neurological point of view, a = patient=20 who does not<BR>attend to a simple verbal command should be = intubated. I=20 need not 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=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=20 that you don't need a blood pressure to tell that a patient is=20 exanguinating through femoral wound )... this completely misses = the point=20 of doing the BP or any recording at all. With this attitude, we = might just=20 as well all go 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></BLOCKQUOTE></BODY></= HTML> ------=_NextPart_000_0074_01C1C0A4.148F7500--
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