Evaluation of the Obtunded Patient

First Things First (assess & treat for the following)

ABCs

• Airway assessment
  • Altered mental status may indicate compromised ability to protect airway.
  • GCS 8 or less requires airway protection (eg, ETT).

Glasgow Coma Scale

• Motor
  • 6 = Appropriate
  • 5 = Localizes to pain
  • 4 = Nonpurposeful
  • 3 = Decorticate posturing: upper extremities flex, lower extremities extend
  • 2 = Decerebrate posturing: fully extends
  • 1 = No movement
• Eye Opening
  • 4 = Spontaneous opening
  • 3 = Opens to stimulation
  • 2 = Opens to strong stimulation
  • 1 = Does not open
• Speech
  • 5 = Appropriate
  • 4 = Confused
  • 3 = Inappropriate words
  • 2 = Incomprehensible sounds
  • 1 = No response
• Breathing
  • Alterations in breathing pattern may indicate site of lesion.
  • Mechanical support may be required to maintain adequate ventilation & oxygenation.
  • Circulation (see Circulation)
    • Goal is to maintain cerebral perfusion pressure (CPP) at least 60 mmHg.
    • If ICP is unknown, then goal of MAP >90 mmHg until ICP can be determined
    • General physical exam
  • Other clinical exams as directed by clinical suspicion
  • Focused history & general medical exam
  • ICU neuro exam
    • This MUST be performed w/ attention to detail!
  • Treat immediate conditions.
    • Seizures, herniation, malignant hypertension, etc.
  • Appropriate diagnostic tests
    • Neuroimaging (eg, CT or MRI), EEG, labs, etc.