Disabilitizz

A 23-year-old man presents to the emergency department following a road traffic collision. He is unresponsive to verbal commands but opens his eyes in response to painful stimuli when a trapezius squeeze is applied. He exhibits purposeful movements by reaching up and attempting to remove your hand during the procedure, with his hand reaching his clavicle. Additionally, he is making groaning sounds, although his speech is not intelligible.

What is this patient's Glasgow Coma Scale score?

Answer explanation

Analysing this patient's GCS score:

• - open their eyes in response to a painful stimulus: eye-opening score of 2 out of 4

• - vocalisations are limited to groans: verbal response score of 2 out of 5

• - exhibits localising behaviour by moving their hand toward the clavicle level in response to pain: motor response score of 5 out of 6

• - GCS =9, E2 V2 M5, at 12:00.

A patient is brought in to resus by paramedics after being involved in a road traffic collision. The patient is wearing a hard-neck collar and currently has an oropharyngeal airway in place. He does not respond to voice or pain, his eyes are closed and he exhibits a decorticate motor response. What should be done regarding the patient's airway?

Answer explanation

Intubate if the GCS is less than 8

A 34-year-old man is brought into the emergency department after a road traffic accident. He was thrown from the car and has sustained multiple injuries to his neck, head, and left arm.

The man's eyes open to voice, but he does not respond to commands. You apply supraorbital pressure, and his left arm bends slightly, his right arm bends up to rest on his sternum, and his head doesn't move. You apply nail bed pressure to the patient's right arms and legs contract but he does not try to pull away from the stimulus. When you speak to the man, he responds only in grunts.

What is his GCS?

Answer explanation

The correct answer is GCS 8 ( E3 V2 M3). His eyes open to the voice, which is E3. He is making grunts but no words, so he is V2, and he is flexing to pain which is M3. To differentiate between flexion and withdrawing you need to apply nail bed pressure to see if the patient pulls away from the stimulus or remains flexed. In this case, he flexed and didn't pull away from the stimulus and therefore was not withdrawing, so was classified as M3

A 28-year-old woman is brought into the emergency department after a road traffic accident. She sustained multiple injuries to her neck, head, and left arm.

Her left eye is swollen shut, but her right eye opens to pain. She does not respond to commands or a trapezius squeeze. You apply supraorbital pressure, and her left arm extends, but her right arm reaches to her eye and tries to pull your hand away.

During the exam, she says no words but makes various noises to indicate she's in pain.

What is her GCS?

Answer explanation

She is E2 V2 M5 making her GCS 9. the critical part to note about this case is when measuring GCS, you should always take the best response. The patient tried to pull your hand away when pressure was applied, so she scored M5 (localising). She opened an eye to pain which is E2, and she made noises which is V2.

It is important to remember that a trapezius squeeze is not always reliable. Patients may have spinal cord injuries, but regardless of whether there is an injury, you should always take the patient's best result

A 25-year-old motorcyclist post-crash, GCS 10.​
Pupils: Unequal — right 6 mm fixed, left 3 mm reactive.

Answer explanation

Right-sided uncal herniation from intracranial bleed.​
Next step: Neuroprotective measures, urgent CT head, neurosurgical review.

A 62-year-old woman presents with gradual loss ofvision in her left eye and discomfort on eye movement.You perform the swinging flashlight test.​

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Findings:​

• When you shine the light into the right eye, bothpupils constrict normally.​

• When you swing the light to the left eye, both pupilsdilate slightly instead of constricting.

Answer explanation

Left Relative Afferent Pupillary Defect (RAPD) dueto optic nerve (CN II) pathology, e.g. optic neuritis(often MS) or severe retinal disease.​

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Next step:​

• Arrange urgent ophthalmology review and MRI

You are doing your A-E assessment on Mr Example, an 84-year-old male. He has COPD and had recently beenacting very agitated. You have completed A-C of the A-E assessment. Mr example’s notable findings are a patentairway, tachyponea and fluctuating blood pressure. Blood glucose is 6.0mmol. However, you note that MrExample has new onset confusion and not orientated to time or place. He has marked muscle ridigity (GCS 14).He is also pyrexic (39.C) You open Mr Example’s drug chart and see the following drugs: Clexane, andhaloperidol.​

What is the most likely cause of Mr Example’s change in consciousness.​

• A. Hypoglycemia​

• B. Delerium​

• C. Serotonin Syndrome​

• D. Neuroleptic malignant syndrome​

• E. Sepsis

You are called to see Ms. Placeholder, a 76-year-old female who had recently had a left hemicolectomy for colorectal cancer. You begin your A-E assessment. Her airway is patent as she can talk to you. She is slightly tachypoenic. BP 127/86. Blood glucose 5.6mmol/L. When you talk to Ms. Placeholder, she is drowsy and canonly respond to voice (GCS 13). She has pinpoint pupils that are barely reactive. Her temperature is 36.4. Her medication is morphine for analgesia, ondansetron, temazepam for insomnia, cyclizine, and several regular drugs.​

What is the most likely cause of Ms. Placeholder’s altered consciousness and what is the recommended treatment?​

• A. Sepsis → Start Sepsis 6​

• B. Opioid toxicity → Naloxone​

• C. Opioid toxicity → Flumazenil​

• D. Anticholinergic toxicity → Supportive care​

• E. Benzodiazepine overdose → flumazenil​

You are called to see Mr. Insert Name Here, a 54-year-old male who is now 3 days post-right-sided hemicolectomy for colorectal cancer. he has been recovering well. During visiting hours, his husband informed the nursing staff that he started getting increasingly drowsy and they agree. On assessment, his airway ispatent, and he can respond to voice (GCS 13). He is tachypnoeic, HR 112, BP 94/62 mmHg, and temperature 38.6°C. His oxygen saturations are 93% on OA and his glucose is 6.1 mmol/L. His pupils are small but reactive. His medication chart includes morphine for pain, ondansetron and cyclizine​

What is the most likely cause of his reduced level of consciousness, and what is the recommended treatment?​

• A. Opioid toxicity → Naloxone​

• B. Sepsis → Start Sepsis 6​

• C. Anticholinergic toxicity → Supportive treatment​

• D. Anticholinergic toxicity → Fomepizole​