• Assess neurological state using GCS (Table 5.1) and AVPU.
• Prevent further neurological injury treat seizures and hyperglycaemia.
• Prevent hyperthermia.
• Maintain ICP <20-25 mmHg (if monitoring available).
• Evidence of raised ICP - pupillary dilatation, motor posturing, progressive neurological deficit, consider mannitol (0.25-0.5 g/kg). Ensure adequate sedation.
• Nurse 30° head up, do not obstruct venous return. m External examination
• Exclude extracranial injuries.
Table 5.1 The GCS is scored between 3 and 15 (maximum score 15, minimum 3). It is composed of three parameters
Best eye response (4)
Spontaneous eye opening Eye opening to speech Eye opening to pain No eye opening
Best motor response (6)
Obeys commands Localises to pain Withdraws from pain Abnormal flexion to pain Extension to pain (decerebrate) No movement
Verbal response (5)
Orientated (able to give name and age) Confused (still answers questions) Inappropriate words
Incomprehensible sounds (grunts, no actual words) None
It is helpful to breakdown the component score of the GCS, e.g. E4V3M4 = GCS 11 A coma score of 13 or higher correlates with mild brain injury, 9-12 with moderate brain injury and 8 or below with a severe brain injury.
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