WBR1084

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Author PageAuthor::Chetan Lokhande
Exam Type ExamType::USMLE Step 3
Main Category MainCategory::Emergency Room
Sub Category SubCategory::Cardiovascular, SubCategory::Respiratory, SubCategory::Surgery
Prompt [[Prompt::A 75-year-old male is brought to the emergecny room in an unconscious state. He has been brought to your hospital for a neurosurgical consultation after X-ray reports at an outside hospital showed a fracture of his left temporal bone after a fall on his head. Definitive reports are still not available. Relatives say he was normal after the fall. Soon after, he had 2 episodes of vomiting and gradually lost consciousness over a period of 4 hours. His vital signs are maintained within normal range. Glasgow coma scale - is 8/15 and breathing spontaneously without effort. What is the next best step in management?]]
Answer A AnswerA::Repeat X-ray
Answer A Explanation AnswerAExp::X-ray should be repeated since the quality of the previous X-ray is doubted . The next best step in this case should be intubation as the GCS is 8.
Answer B AnswerB::CT
Answer B Explanation AnswerBExp::CT can be performed later to visualize the effect of the fall. The next best step in this case should be intubation as the GCS is 8.
Answer C AnswerC::Steroids
Answer C Explanation AnswerCExp::Steroids play no important role in treatment of falls or respiratory failure
Answer D AnswerD::Intubation
Answer D Explanation [[AnswerDExp::A GCS < 8 is an indication to intubate the patient as the patient is in respiratory failure and unconscious.]]
Answer E AnswerE::Mannitol
Answer E Explanation AnswerEExp::Mannitol may be used to treat cerebral edema but in this case it is not the next best step .
Right Answer RightAnswer::D
Explanation [[Explanation::The Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

The scale is composed of three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). Eye response (E)

There are four grades starting with the most severe:

  1. No eye opening
  2. Eye opening in response to pain stimulus. (a peripheral pain stimulus, such as squeezing the lunula area of the patient's fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect).
  3. Eye opening to speech. (Not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3.)
  4. Eyes opening spontaneously

Verbal response (V)

There are five grades starting with the most severe:

  1. No verbal response
  2. Incomprehensible sounds. (Moaning but no words.)
  3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
  4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
  5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Motor response (M)

There are six grades:

  1. No motor response
  2. Extension to pain (extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
  3. Abnormal flexion to pain (flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
  4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
  5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
  6. Obeys commands. (The patient does simple things as asked.)

Interpretation

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".

Generally, brain injury is classified as:

  • Severe, with GCS < 9
  • Moderate, GCS 9–12 (controversial)
  • Minor, GCS ≥ 13.

Tracheal intubation and severe facial/eye swelling or damage make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. "E1c" where "c" = closed, or "V1t" where t = tube. A composite might be "GCS 5tc". This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal flexion". Often the 1 is left out, so the scale reads Ec or Vt.

Education Objective A score of <9 is a sign of impending respiratory failure and all patients must be intubated first before starting any treatment
Educational Objective:
References: ]]

Approved Approved::Yes
Keyword WBRKeyword::GCS, WBRKeyword::Intubation, WBRKeyword::Head trauma
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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