Unconcious patient question

[DwayneEMTP]

Man, great question.

Once again I got to learn something I had no idea I wanted to know, because I had no idea I didn't know it...Know what I mean?

Pretty cool...

Dwayne

[Asysin2leads]

Not to stray off topic here, but I think your patient is a good example of why many of us don't like the concept of protocol driven medicine. I wish patient's always fell into a set pattern, but god bless it, there are those who just don't know how to be sick.

In a good system, it should be left to the medic's discretion when to start an IO. Restrictions like "in an unconscious patient" or "in a cardiac arrest" bring up situations where considerations that should not affect patient care decisions end up being the driving force.

IO's should be started on patients who need them, and those are IMHO, unstable to critical patients where other means of access are not available.

To further stray off topic, I recently had a man who presented with a chief complaint of feeling weak and dizzy for a few days. He had a long list of medical problems, including a-fib and CHF, and was taking lasix. He admitted to poor fluid and nutrition intake. He was sitting upright, AOx3, pale, but warm and dry, lungs clear, with a BP of 80/50. His EKG showed a rapid A-fib of around 160 with runs of V-tach occasionally.

Okay, so basically this guy is sick, probably dehydrated, and with obvious cardiac irritabilty. My game plan was to try to bring his BP up with a fluid challenge and then administer amiodarone to bring his rate an rhythm under control.

My telemetry physician saw it differently. As per protocol, a BP under 80 sys means an unstable patient, so he was an unstable a-fib patient and needed to be sedated and cardioverted. IMHO, he wasn't unstable, but I got trumped. This is why protocol medicine is not a good idea.

[KAThomas]

Did the child respond to any noxious stimuli, or any stimuli. Did he withdraw from the IV sticks??

I still think the child was most likely unconscious. To answer your question, unconscious patients can cry, moan, and grimace from pain...if the brain senses it.

That would be negative response... I was monitoring for changes on each attempt and zero change there was unchanged grimace with eyes closed and the constant mewling without any tearing at all.

[KAThomas]

Use the PGCS (Pediatric Glasgow Coma Score) to figure the LOC of the child. This is used for children 2 years old and younger.

Best eye response: (E)

1. No eye opening

Best verbal response: (V)

2. Infant moans to pain

1. No verbal response

Best motor responses: (M)

2. Extension to pain (decerebrate response)

1. No motor response

A child can be crying AND have a significant decrease in their normal level of consciousness. I would have treated the child aggressively with IO/IV, RSI, and rapid transport. To answer your question, YES this child is "unconscious" enough for the IO.

Thank you there is the answer I'm looking for but can you recall where is it cited directly? & the PMC was hot that there was no line whatsoever when we rolled in.

[Dustdevil]

My telemetry physician saw it differently. As per protocol, a BP under 80 sys means an unstable patient, so he was an unstable a-fib patient and needed to be sedated and cardioverted. IMHO, he wasn't unstable, but I got trumped. This is why protocol medicine is not a good idea.

:shock:

Bro, if you ever have to treat me for anything, I BEG of you to PLEASE pull the old, "Sorry doc, I couldn't hear you. You're cutting out!" routine if he does anything that stupid!

[medic_texas]

http://www.fpnotebook.com/Neuro/Exam/GlsgwCmScl.htm

http://trauma.ucsd.edu/Portals/0/47%20GCS.pdf

The second one is a better reference as it has infant, child, and the regular GCS scale to compare.

[bullmedic]

We have the ability to IO patients if we are unable to gain IV access and the patient needs meds immediately. The LOC matters not.

[snakemedic]

I have to agree with Dust, I like Ais thought process. A little off topic but I heard it said once "now that we are getting away from Dr's teaching us, we have to dumb 'it' down to the lowest common denominator". (it referring to education) Now that being said, I disagree, I think medics should be able to use their best judgement and make a decision based on their education...however, you need to accept the fact you may be wrong which happens in the ER enough. There is too much teaching of pink box, purple box, yellowish box and then when the patient enters the gray zone medics fall back to "well, it didn't say that in the protocols" Protocols be damned...you are a patient advocate...and sometimes you need to do what needs to be done and take the flack. Protocols are ambiguous at best and definitions in them, as well as the medical world are also perceived differently by different folks. A simple rule of thumb I go by is "sick, not sick". CCDoc is right, the pt may present with a number of responses while not being"conscious" and these would be called decreased level of consciousness. I know, I'm rambling....suffice it to say, the medic made a descision based on numerous factors at the time and you got him from point a to point b...that's a good thing.

snake