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The Glasgow coma scale is used frequently to assess trauma victims in the field, through the EMS system, through the emergency department, oftentimes to the anesthetic suite if the patient is at all awake, and into the ICU. It is nice because it is relatively simple, it’s relatively consistent between observers and it provides a numerical scale that can be followed between multiple different people who are assuming and maybe passing on care to another team. If consists of three different systems; eye-opening, you get a total of four points, verbal you can get five points, and motor you can get six points, for a total of 15 points. In your handout they have the complete Glasgow coma score. Of some note is that if someone calls you to admit a patient to you or transport a patient, and they tell you that the Glasgow coma score is zero, they’ve told you two things. One is that the child is probably pretty sick, and two that they don’t know what the Glasgow coma scale is all about, because as you can see, dead people and inanimate objects have three points. The table in front of you gets a Glasgow coma score of three, so if someone gives one of your patients a lower score, you know they are in a heap of trouble.
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Okay, you’ve stabilized your patient, you’ve done your primary survey. As you’ve discovered problems, such as a pneumothorax, hemothorax, respiratory arrest, you’ve dealt with it, you’ve moved on. Now you are going to go back for a secondary survey and look for a little bit more subtle findings, generally in a head-to-toe approach. You are going to look at the head, palpate it, look for hematomas, other signs that may lead you to suspect emerging intracranial pathology. Cranial nerves. Repeat your primary survey, that is, make sure they are moving both sides of their body. Neck; you are going to look for tenderness. Consider the cervical spine unstable until it has been evaluated. Chest; look for subcutaneous emphysema as perhaps a more subtle sign of pneumothoraces underlying it. Abdomen; tenderness, presence of bowel sounds, distention. Perineum and rectum; looking for perhaps a spinal cord injury where you have lost all erectile tone. And certainly you are going to be looking at your musculoskeletal injuries that, until now, someone has been putting pressure on with the bone sticking out of the leg, and now you are going to be able to really take a better look at it.
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Trauma radiology; the C-spine and the spine itself are very controversial as to the best ways of evaluating them, and how extensive it needs to be. Some institutions relying only on an AP and a lateral x-ray of the cervical spine. Most centers require, especially in the unresponsive patient, further investigation which may be a CT of the spine, may go as far as a flexion/extension MRI in a patient who is not cooperative with examination. A head CT; indications, I think as head CT’s have become more prevalent with more rapid turnaround times, and there have been evidence of significant intracranial injuries with apparently more trivial injuries, the indications for head CT’s have diminished. That is, anybody who has any alteration in their Glasgow coma score, that is 14 out of 15, should be scanned. Anybody with a loss of consciousness of five minutes or greater should be scanned. And if the patient is going to be in an environment where they are going to lose your ability to examine them – like they are going in for an acute abdomen, traumatic, and they are going to disappear into anesthesia for awhile – you’d like to make sure there is not an evolving epidural hematoma that is going to be unrecognized under anesthesia. So if for some reason you are going to lose the ability to examine them, CT their head. Chest; at least an AP. Abdominal CTF is evidence of abdominal trauma and they are stable. If they are unstable with an enlarging abdomen and clinical intraabdominal catastrophe, they are in all likelihood going to go to the operating room straight-away rather than having an abdominal CT scan. If they are stabilized, you may want to give them an abdominal CT scan. The findings of pathology on the CT scan do not indicate the need for surgery. You can have significant splenic and hepatic lacerations, but if the patient stabilizes they will generally be managed non-operatively. Musculoskeletal; that bone sticking out of that leg, now you can get some pictures of it and see exactly what’s going on.