Contraindications and Critical Thinking: NTG/CPAP

NUEMT said:
I am referring to how she presented her score. If you use GCS, this is how you do it. And my ED stopped asking for GCS a while ago. Being that so many EMS providers calculate it poorly it really wasn't of any use.
Click to expand...

So you guys were so bad at using GCS that the your ED had to give up on it altogether? And yet you are lecturing me on how to use the GCS? Seems legit.

I still don't see what any of this has to do with the discussion at hand.

I've never really bought the "GCS of 8, intubate" mantra, but the reason that came to be is that anyone with a GCS at that level is neurologically depressed enough that their CN function is considered unreliable, REGARDLESS of which combination of scores exist to add up to 8. On a very gross level it makes sense, so even though it is imperfect and should not dictate clinical decisions, it is a decent rule of thumb to keep in mind. Mix in uncontrolled positive pressure and a non-NPO patient, and you are asking for trouble.
 
Remi said:
So you guys were so bad at using GCS that the your ED had to give up on it altogether? And yet you are lecturing me on how to use the GCS? Seems legit.

I still don't see what any of this has to do with the discussion at hand.

I've never really bought the "GCS of 8, intubate" mantra, but the reason that came to be is that anyone with a GCS at that level is neurologically depressed enough that their CN function is considered unreliable, REGARDLESS of which combination of scores exist to add up to 8. On a very gross level it makes sense, so even though it is imperfect and should not dictate clinical decisions, it is a decent rule of thumb to keep in mind. Mix in uncontrolled positive pressure and a non-NPO patient, and you are asking for trouble.
Click to expand...


Really? Irony doesn't really register with you does it. REMI, sometimes you give me hope. Then you totally drive off the cliff.

Remi said:
So you guys were so bad at using GCS that the your ED had to give up on it altogether? And yet you are lecturing me on how to use the GCS? Seems legit.
Click to expand...

Nope. Our docs just follow the latest evidence. Hardly feel like that was a lecture. Where do you practice again?
 
NUEMT said:
Really? Irony doesn't really register with you does it. REMI, sometimes you give me hope. Then you totally drive off the cliff.



Nope. Our docs just follow the latest evidence. Hardly feel like that was a lecture. Where do you practice again?
Click to expand...

Look, you do not know what you are talking about. Just stop.
 
NUEMT said:
I am referring to how she presented her score. If you use GCS, this is how you do it. And my ED stopped asking for GCS a while ago. Being that so many EMS providers calculate it poorly it really wasn't of any use.
Click to expand...
Sounds like a problem with your system...


Sent from my iPhone using Tapatalk
 
The GCS was created to assess neuro function in a traumatic brain injury. It was not designed for any other purpose although it has been widely accepted and used for other purposes. In fact, the new ICD 10 codes (for those who follow the stupidity of medicine) require documentation of a GCS on any pt who is diagnosed as AMS, even if there is no trauma. I don't believe it has ever been validated for any other purpose, although someone could google it to be sure. I don't believe in the GCS of 8 mantra. If they can't protect their airway, they get the tube regardless of their GCS. It was designed as a test to look for a change in status over time.
 
ERDoc said:
The GCS was created to assess neuro function in a traumatic brain injury. It was not designed for any other purpose although it has been widely accepted and used for other purposes. In fact, the new ICD 10 codes (for those who follow the stupidity of medicine) require documentation of a GCS on any pt who is diagnosed as AMS, even if there is no trauma. I don't believe it has ever been validated for any other purpose, although someone could google it to be sure. I don't believe in the GCS of 8 mantra. If they can't protect their airway, they get the tube regardless of their GCS. It was designed as a test to look for a change in status over time.
Click to expand...


Thanks doc.
 
GCS is a piss poor surrogate for actual level of neuro function following an acute event, it wasn't ever intended to be added together and used the way we do. That said....

It's just about all we've got physical exam wise. I know for a fact that if I have a patient who I can assume was formerly conscious and now has a GCS <8 there's been a fairly devastating neurologic event that needs my attention and very likely the airway managed as a result. I probably end up doing tubes on deteriorating mental status far more often than just "less than 8, intubate", however, it's not a terrible rule of thumb.

If your docs have stopped using GCS completely, they're almost certainly not an ACS Level I or II trauma facility.
 
usalsfyre said:
If your docs have stopped using GCS completely, they're almost certainly not an ACS Level I or II trauma facility.
Click to expand...

Good point. On the wall in our trauma bay we have a huge poster with the GCS criteria with pictures. It is an easy test (in theory) that gives some information, especially if used for serial exams but was never designed for its current use. This is especially true when it is used in pts who have other causes of altered mental status such as EtOH, drugs, etc.
 
ERDoc said:
Good point. On the wall in our trauma bay we have a huge poster with the GCS criteria with pictures. It is an easy test (in theory) that gives some information, especially if used for serial exams but was never designed for its current use. This is especially true when it is used in pts who have other causes of altered mental status such as EtOH, drugs, etc.
Click to expand...

Docs still use. Consideration of the EMS gcs score not so much. 7 level ones.
 
We've been required to document the GCS on every patient, period. It's in the same part of my ePCR as airway patency, lung sounds, skin signs, pupils etc, and is coded as a critical field (must be filled out otherwise it won't let me upload the form).

While there's a second GCS chart right below it to document any changes to GCS that occurred (last time I used that was for a diabetic with low blood sugar who was like a 9 on arrival and then a 15 after some D50).

But now they've put out a memo saying that second GCS is now mandatory on loddy-dotty-everybody as part of the transfer of care vitals (that also HAS to be within 5 min of our documented available time because....reasons?) Doesn't matter if the Chief Complaint/Reason for Transport was a major trauma with altered mental status or flu like symptoms or a scheduled transfer (and if there was a change in GCS, they want all 3 documented). So safe to say GCS is still alive and well here. And is apparently as important to constantly monitor as blood pressure and pulse rates.
 
On a personal note, I have an issue with any scale that gives a dead person a score of 3 and not 0.
 
Jim37F said:
We've been required to document the GCS on every patient, period. It's in the same part of my ePCR as airway patency, lung sounds, skin signs, pupils etc, and is coded as a critical field (must be filled out otherwise it won't let me upload the form).

While there's a second GCS chart right below it to document any changes to GCS that occurred (last time I used that was for a diabetic with low blood sugar who was like a 9 on arrival and then a 15 after some D50).

But now they've put out a memo saying that second GCS is now mandatory on loddy-dotty-everybody as part of the transfer of care vitals (that also HAS to be within 5 min of our documented available time because....reasons?) Doesn't matter if the Chief Complaint/Reason for Transport was a major trauma with altered mental status or flu like symptoms or a scheduled transfer (and if there was a change in GCS, they want all 3 documented). So safe to say GCS is still alive and well here. And is apparently as important to constantly monitor as blood pressure and pulse rates.
Click to expand...
Because documenting a 14 or lower throughout transport helps justify ambulance billing.
 
You must log in or register to reply here.
Back
Top