Management of the Unconscious Patient

Question 1

What is a rapid assessment tool for consciousness?

Answer 1

“AVPU” mnemonic

• A = alert
• V = (response to) verbal stimuli
• P = (response to) painful stimuli
• U = unresponsive

Question 2

What is the Glasgow coma scale designed for?

Answer 2

Blunt head trauma

Not prognostic for non-traumatic LoC

Question 3

What does the Glasgow coma scale do?

Answer 3

Gross estimate of cerebral function

Point estimate less specific than change over time > falling GCS mandates investigation and intervention

Question 4

What are the categories for the Glasgow coma scale?

Answer 4

Eye opening
Best verbal response
Best motor response

Question 5

What is the scale for eye opening?

Answer 5

4 = spontaneous
3 = to verbal command
2 = to pain
1 = nil

Question 6

What is the scale for best verbal response?

Answer 6

5 = orientated
4 = confused
3 = uses inappropriate words
2 = incomprehensible
1 = nil

Question 7

What is the scale for best motor response?

Answer 7

6 = obeys commands
5 = localises to pain
4 = withdraws to pain
3 = abnormal flexion to pain
2 = abnormal extension to pain
1 = no response

Question 8

What does abnormal flexion to pain mean?

Answer 8

Press on finger > flex wrists and arms

Question 9

What does abnormal extension to pain mean?

Answer 9

Press on finger > extend arms and wrists

Question 10

At what GCS score would a person be intubated in a trauma situation?

Answer 10

10 or less

Question 11

What are the differential diagnoses for an unresponsive dilated pupil in a trauma setting?

Answer 11

Direct ocular trauma

Ipsilateral cerebral herniation

Question 12

Along with an unresponsive dilated pupil, what other symptoms are present in the case of an ipsilateral cerebral herniation?

Answer 12

Decreased conscious state
Hypertension
Bradycardia

Question 13

What are the urgent interventions for coning of the brainstem?

Answer 13

Elevate head > improves venous sinus drainage
Mannitol = osmotic diuretic
Hyperventilation > decrease pCO2 > vasoconstriction
Definitive treatment

Question 14

What is the ongoing management for the stable unconscious patient?

Answer 14

Maintain vital signs in normal range
- O2 saturation
- BP
- CO2
Prevent aspiration
Adequate hydration
Manage pressure areas
- DVT prophylaxis
- Stress ulcer prophylaxis
May need sedation
Nutritional support over medium term
Appropriate monitoring