Neuro Obs in ICU

[Ian Seppelt]

A topic close to my heart. GCS is often very poorly assessed, and
interindividual difference can be spectacular. It fascinates me to see a
previously stable GCS suddenly change by a number of units at the time
of a nursing shift handover!

A. Central pain needs to be central and specific. By far the best is
the supraorbital nerve. Another reasonable site is a trapezius squeeze.
The 'sternal rub' is useless, non specific and also disfiguring (how
many times have you seen bruising after too many people have done
misguided, violent sternal rubs). I threaten to break the arms of any of
my own staff I see doing it. Attached find a picture of a patient who
had one too many vigorous sternal rubs.

The supraorbital nerve is also the only specific way to distinguish
between appropriate (M4) and inappropriate flexion (M3) and localisation
(M5), depending on whether the hand comes ABOVE the clavicle [need to
come above the clavicle to score a 5]

B. It is part of your overall neurological assessment of a patient,
which includes an examination to rule out spinal cord injury. I have
attached the original description of the motor response from Teasdale
and Jennett.

C. Hourly / 4th hourly GCS is of much less value in a sedated patient.
One of the standard 'errors' in APACHE II scoring is to assign a GCS3 to
someone deeply sedated and unresponsive (=12 points instantly!). A great
way to dishonestly bring down your SMR and one thing I specifically look
at when assessing a unit's data during training accreditation
inspections.

I note your question refers to ongoing GCS assessments in ICU - that is
a different animal to a one off assessment in the emergency department,
and the reproducibility of ICU observations is paramount (rather than
the 'best' response per se)

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Senior Staff Specialist
Dept of Intensive Care Medicine
The Nepean Hospital, PO Box 63 Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> comascora at hotmail.com 13/09/2006 7:40pm >>>
I am a General ICU nurse with just over six years experience in 
predominately Trauma/neuro intensive care both in Australia and the UK.
I am 
after opinion, current practice/guidelines, or relevant
references/evidence 
for assessment using the Glasgow Coma Score in order to facilitate best

practice at my current workplace.

Most specifically,

A) What is the best site for giving central pain stimulus?

B) Is there any true relevance to assessing using peripheral stimulus?
Or is 
it impossible distinguish it from purely a spinal reflex?

C) Is it necessary to assess using the GCS (ie give painful stimulus
etc, 
hourly/4th hourly etc), to a sedated patient? Or is pupil assessment
the 
only guide to deterioration once sedation is commenced?

Any information is greatly appreciated

Brenton

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