A 16-year old female who was thrown from a horse arrives by private car to your emergency department. You are the only registered nurse on duty and the only emergency physician has left for a meeting. Assessment reveals a deteriorating mental status GCS=6, ventilation 8 per min. with sonorous respirations and a strong radial pulse of 78 beats/min. Which is the most appropriate treatment at this time?
a. Oropharyngeal airway placement and bag-valve mask ventilation
b. Supplemental oxygen via nonrebreather mask at 12 to 15 L/min.
c. Nasopharyngeal airway with nonrebreather mask at 15 liters per min.
d. Mouth-to-mouth resuscitation.
serious answers please I would choose (a), here's why:
Suspected head injury (low GCS) -- best GCS of 6 is E3 (eyes open to speech) + V2 (e.g. grunting to noxious stim.) + M1 (no motor response to painful stimuli, which could be caused by spinal shock -- reversible in best case scenario).
ABCs:
Airway and breathing obviously come first -- with a true GCS of 6, the patient is unable to clear secretions -- sonorous resps indicate the tongue is obstructing the airway, so answers (b), and (d) are out; 12 - 15 LPM O2 assumes no airway obstruction (but there is -- sonorous resps); also, *never* do mouth-to -mouth in a healthcare setting (for many reasons).
Some would argue the possibility of a basal skull # would contraindicae the use of a nasopharyngeal airway (but see http://emj.bmj.com/cgi/content/abstract/... A NPA is *OK!* ... but *not* with a 'plain old' NRB mask (at any flow rate ... 15 LPM or @ "flush" for that matter) because the patient needs to be *ventilated* to reduce the PaCO2 (recall the Monro-Kellie hypothesisand the fact that intracranial blood vessels dilate with increased PaCO2). There is no knowledge of what this patient's ICP is (or CPP ... CPP = MAP - ICP).
The only correct answer is therefore (a) -- OPA with BVM ventilation. The OPA pushes down on the tongue, leaving a patent airway. Bag-valve-mask ventilation (with "death grip") allows the nurse to bag the patient and control the pt's ventilation depth & rate (RR of 8 is too low -- I'd bag at 10-12 (i.e. slowly) with a tidal volume approximating 15-20cc/kg or about twice what you'd think a pt of her size requires, but I have big hands -- "practice makes permanent" -- know the minute volume you can deliver with different sized baggers beforehand -- if you have small hands and no help, you'll have to bag more frequently with one hand ... or improvize) until someone can establish a secure airway (e.g. combivent or ETT) and set vent. parameters to target the ABG to normal pH and PaCO2 (PO2 doesn't matter much -- could be 10 mmHg, or 100 ... or 300, as long as it's adequate (anything over 80 at sea-level)).
After A-B-C (C = get a baseline BP & monitor BP frequently, start at least one line and run NS *not* D5W for a suspected head injury) ... D (doctor: make sure s/he is en route; disability -- frequent pupil checks: assess GCS Q5 min while bagging to check for response to reduced PaCO2) ... E = Exposure/environment (clothes cut off, measure temp; don't treat mild hypothermia; don't cover with a heated blanket if T > 37.5C unless shivering).
Other things I'd do: place an orogastric (cf. NG -- don't want to intubate the brain with ?basal skull #) tube to low-intermittent suction, observe C-T-L- spine precautions as best as possible for a pt. brought in by private car. Prepare for RSI -- GCS of 6 is a 100% indication to intubate if pt's GCS remains < 8). The answer is C
oxygen is the main treatment for respiratory difficulty. Use a nasopharyngeal airway with nonrebreather mask at 12-15 liters per minute Based upon that assessment information, the best and most appropriate course of action would be choice A. The reason for that is
1. This patient has an obviously deteriorating LOC, and with a GCS of 6 and respiratory rate of 8/min and snoring respirations, she needs definitive airway management with oxygen and assisted ventilation. The best thing would be to intubate the patient and assist resps with the BVM, but that is not one of the choices (the saying is "GCS less than 8, intubate). But, intubation is not an option in this question.
Choice B is not appropriate because the patient is only breathing at a rate of 8 per minute. She needs 100 % Oxygen AND she needs to have her respirations assisted...that part is missing from choice B.
Choice C....same issue as choice B.
Choice D...no definitive airway control,
So, my opinion only, choice A is the best choice. In real life, you would put in an oral airway, ventilate with 100 percent O2, intubate as soon as possible, take spinal immobilization precautions, IV access, cardiac monitor, etc.
I hope that helped. Let me know if you need further help. john_r820@yahoo.com |
