Evaluation of the Obtunded Patient
First Things First (assess & treat for the following)
- Airway assessment
- Altered mental status may indicate compromised ability to protect airway.
- GCS 8 or less requires airway protection (eg, ETT).
Glasgow Coma Scale
- 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
- 5 = Appropriate
- 4 = Confused
- 3 = Inappropriate words
- 2 = Incomprehensible sounds
- 1 = No response
- 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.
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