Welcome to Talk EM, brought to you by the Emergency Medicine Institute where our goal is promoting clinical excellence. Our focus is for the advanced emergency medicine practitioners, nurse practitioners and physician assistants who work in the field, taking care of people who are really sick.
Progression of disease is a classic concept of medicine. In emergency medicine, the progression of a disease is something we have to constantly monitor for. While people are with us, diseases get worse; therefore, we have to continuously assess.
If someone comes in with a chief complaint and we do one assessment, and it happens to be a disease that could rapidly progress over the couple hours that they’re with us, we look quite negligent if we don’t do a repeat exam.
If someone comes in with reactive airway disease exacerbation, the optimal way to do repeat assessments would be peak flows. You would monitor how response therapy is changing over the course of time that you’re with them. The same is true of abdominal pain or chest pain. You really want to document serial exams, regardless of what that exam is.
Head injuries also require repeat assessments. We need to monitor with at least two different neuro exams. Now, this is not evidence-based medicine, but it is my experience as an advanced practitioner.
There are two types of people I scan with the slightest trauma. You could be hit in the head with a marshmallow, but if you are one of these two types of people, I’m going to scan you. Those two types of people are those on anticoagulants and alcoholics.
Anticoagulants speak for themselves. If someone is on a blood thinner, I want to scan them. One of the cool things about medicine is compensation and how the body will compensate for itself. If someone has increased intracranial pressure, their body is going to say, “Holy cow, we have too much pressure on the brain. We have to get rid of pressure ASAP.” The body compensates by vomiting.
Anybody who has a head injury and vomiting should make you think they’re compensating for increased intracranial pressure. It’s the same thing in the eye with glaucoma. If someone has acute angle closure glaucoma, they’re going to vomit. It’s an attempt by the body to decrease pressure in the head.
Here’s my problem with anticoagulation: as people get older, the brain atrophies and, therefore, they can have bleeding in the brain with no neurological problems. I’m hesitant about anybody on anticoagulants. If they bump their head and that’s their chief complaint, I will scan them 100% of the time. I don’t feel as strongly about antiplatelets.
With alcoholics, their brain is atrophied and their bridging veins are like pigtails. We have shock absorbers in those pigtails, but when you’re an alcoholic, your brain is constantly sunk because of the atrophy and chronic dehydration. Therefore, they are more prone to yanking on one of the bridging veins and getting a subdural. I will scan them at a very, very low threshold.
Glasgow Coma Scale
Using the Glasgow Coma Scale to monitor a patient allows us to communicate to the next clinician, the supervising doc or the trauma center you’re sending them to. I’ll be honest with you, I almost always have to look up the Glasgow Coma Scale when I have an abnormal patient.
The Scale goes from three to 15, and you score three different body systems (motor, verbal, eye). Use the mnemonic Miami Vice to remember the order. If someone is fully obeying commands, they’re oriented to verbal response and they spontaneously open their eyes, they get a Glasgow Coma Scale of 15. That’s normal; it’s what I expect from most people. When your Glasgow Coma Scale is less than eight, the patient is at a very real risk of losing their airway. You need to intubate them.
Motor is most important, so it gets a total of six points. If I were to pinch your arm, you will go to your arm and rub the area. Rubbing the area is a physiologic response to stimulate the nerve fibers and decrease pain.
If someone is sleeping and I pinch their arm, they may not fully wake up, but they localize the pain. If the patient localizes the pain, they lose a point. If you pinch your patient and they actually withdraw from the pain, they don’t go towards the pain but actually away from it, that’s more sinister. That would be four points.
Patients who flex to pain (decerebrate posturing) receive three points. Extension to pain is decorticate posturing, and that gets two points. If the patient has no response whatsoever, they get one point.
Verbal is second most important and it gets five points. If the patient is confused, they get four points. If they’re using inappropriate words, that’s three points. Making guttural sounds (“ooh,” “aah”) warrants two points. A patient gets one point if there’s no verbal response at all.
Eye movement gets four points. Spontaneously opening their eyes gets four points. If they only open to a verbal command, that’s three points. If you give them painful stimuli and they open their eyes, that’s a two and if they’re not opening their eyes at all, that’s one point.
The Glasgow Coma Scale is a way to quickly communicate a patient’s mental status after a head injury. It’s also a good way to document serial exams. If you document a time and a score of 15, then you document a time 45 minutes later with a score of 15 and add a little detail each time, that’s a pretty darn good chart that demonstrates you did serial neurological exams on your patient.