Approach to low GCS
Etiologies
Low GCS with lateralising signs
vascular
- stroke - ischaemic/embolic, bleeds
- Embolic:
- vasculitis
- IE
- AF
- Embolic:
no lateralising signs?
Surgical sieve it!
Vascular
- haemorrhagic/ischaemic stroke - especially brainstem
Infective, Immunological
- raised ICP
- intracranial infection
Trauma (physical, chemical, thermal, radiological) / Toxic
- sedatives, benzodiazepines,
- recreational drugs - GHB, alcohol...
Autoimmune
- autoimmune encephalitis
Metabolic
- hypoglycaemia
- hyponatraemia
- uraemia
- hepatic encephalopathy
Iatrogenic, Idiopathic
- epilepsy - status epilepticus
- hypoactive delirium???
Neoplastic
Congenital
examination
initial approach
- control the airway
- normalise resp physiology
- give glucose/thiamine
- common antidotes - naloxone?
- examine motor response + pupils
- treat raised ICP if present or suspected
- no tube ties, nurse head up
- normocapnia
- hypertonic saline?
when the dust settles:
resp pattern
- ataxic, cheyne stokes...
neurological
- Eye signs
- 'blown pupil' - suggests CN3/4/6, i.e. third nerve palsy ... herniation?
- Cranial nerve reflexes
- Posturing
- decorticate → above red nucleus (see Midbrain)/diencephalon
- decerebrate → progression midbrain/upper pons
- any kind of posturing associated with worse outcomes
- Motor
- myoclonus
- choreas
- clonus