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Neurological Assessment & Artificial Airway Management

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Neurological Assessment & Artificial Airway Management

  1. 1. Neurological Assessment
  2. 2. Glasco Coma Scale
  3. 3. Glasco Coma Scale The Glasgow Coma Scale (GCS) is used to assess level of consciousness in a wide variety of clinical settings, particularly for patients with head injuries.
  4. 4. Glasco Coma Scale • named for Glasgow Scotland • a simple way that physicians communicate the severity and depth of coma in a patient who has suffered traumatic brain injury
  5. 5. Glasco Coma Scale Mental alertness varies from fully alert to lethargic and stuporous all the way to deep coma, where a patient is minimally responsive or unresponsive to external stimuli. The GCS grades this level of consciousness on a scale from 3 (worst, deep coma) to 15 (normal, alert).
  6. 6. Glasco Coma Scale • The GCS assesses the two aspects of consciousness: – Arousal or wakefulness: being aware of the environment; – Awareness: demonstrating an understanding of what has been said.
  7. 7. Glasco Coma Scale • The 15-point scale assesses the patient's level of consciousness by evaluating three behavioural responses: • Eye opening; • Verbal response; • Motor response.
  8. 8. Glasco Coma Scale Eye opening • Assessment of eye opening involves the evaluation of arousal (being aware of the environment):
  9. 9. Glasco Coma Scale • Score 4: eyes open spontaneously; • Score 3: eyes open to speech; • Score 2: eyes open in response to pain only, for example trapezium squeeze (caution if applying a painful stimulus); • Score 1: eyes do not open to verbal or painful stimuli.
  10. 10. Glasco Coma Scale Record 'C' if the patient is unable to open her or his eyes because of swelling, ptosis (drooping of the upper eye lid) or a dressing.
  11. 11. Glasco Coma Scale Verbal response • Assessment involves evaluating awareness:
  12. 12. Glasco Coma Scale • Score 5: orientated; • Score 4: confused; • Score 3: inappropriate words; • Score 2: incomprehensible sounds; • Score 1: no response. This is despite both verbal and physical stimuli.
  13. 13. Glasco Coma Scale Record 'D' if the patient is dysphasic and 'T' if the patient has a tracheal or tracheostomy tube in situ.
  14. 14. Glasco Coma Scale Motor response • Assessment of motor response is designed to determine the patient's ability to obey a command and to localise, and to withdraw or assume abnormal body positions, in response to a painful stimulus:
  15. 15. Glasco Coma Scale • Score 6: obeys commands. The patient can perform two different movements; • Score 5: localises to central pain. The patient does not respond to a verbal stimulus but purposely moves an arm to remove the cause of a central painful stimulus;
  16. 16. Glasco Coma Scale • Score 4: withdraws from pain. The patient flexes or bends the arm towards the source of the pain but fails to locate the source of the pain (no wrist rotation); • Score 3: flexion to pain. The patient flexes or bends the arm; characterised by internal rotation and adduction of the shoulder and flexion of the elbow, much slower than normal flexion;
  17. 17. Glasco Coma Scale • Score 2: extension to pain. The patient extends the arm by straightening the elbow and may be associated with internal shoulder and wrist rotation; • Score 1: no response to painful stimuli.
  18. 18. Glasco Coma Scale Painful stimulus • A true localising response to pain involves the patient bringing an arm up to chin level.
  19. 19. Glasco Coma Scale • Painful stimuli that can elicit this response include trapezium squeeze.
  20. 20. Glasco Coma Scale • suborbital ridge pressure (not recommended if there is a suspected/confirmed facial fracture)
  21. 21. Glasco Coma Scale • sternal rub (caution, not recommended in some organisations)
  22. 22. Glasco Coma Scale • In general, head injury is classified as mild, moderate or severe based on the Glasgow Coma Scale as such: – Mild: GCS ≥ 13 – Moderate: GCS 9 - 12 – Severe: GCS ≤ 8
  23. 23. Glasco Coma Scale • Mild (13-15): – Loss of consciousness and/or confusion and disorientation is shorter than 30 minutes.
  24. 24. Glasco Coma Scale • Moderate Disability (9-12): – Loss of consciousness greater than 30 minutes – Physical or cognitive impairments which may or may resolve – Benefit from Rehabilitation
  25. 25. Glasco Coma Scale • Severe Disability (3-8): – Coma: unconscious state. No meaningful response, no voluntary activities
  26. 26. Glasco Coma Scale • Vegetative State (Less Than 3): – Sleep wake cycles – Arousal, but no interaction with environment – No localized response to pain
  27. 27. Glasco Coma Scale • Persistent Vegetative State: – Vegetative state lasting longer than one month • Brain Death: – No brain function – Specific criteria needed for making this diagnosis
  28. 28.
  29. 29. Pupillary Assessment
  30. 30. Pupillary Assessment • Evaluation of pupillary reaction is effectively an assessment of the third cranial nerve (oculomotor nerve), which controls constriction of the pupil. Compression of this nerve will result in fixed dilated pupils.
  31. 31. Pupillary Assessment • Evaluation of pupillary reaction is effectively an assessment of the third cranial nerve (oculomotor nerve), which controls constriction of the pupil. Compression of this nerve will result in fixed dilated pupils.
  32. 32. Pupillary Assessment • Any changes in the patient’s pupil reaction, size or shape, together with other neurological signs, are an indication of raised intracranial pressure (ICP) and compression of the optic nerve.
  33. 33. Pupillary Assessment Pupil size and shape • Pupil size should be measured, ideally with reference to a neurological observation chart or similar. • The average size is 2-5mm (Bersten et al, 2003). The pupils should be equal in size.
  34. 34.
  35. 35. Pupillary Assessment Pupil size and shape • Pupil shape should be ascertained. It should be round; abnormal shapes may indicate cerebral damage; oval shape could indicate intracranial hypertension (Fairley, 2005). The pupils should be identical in shape.
  36. 36. Pupillary Assessment Reaction to a bright light • brisk and after removal of the light source, the pupil should return to its original size • consensual reaction to the light source • documented as per local policy, for example B (brisk), S (sluggish) or N (no reaction). • Both pupils should react equally to light.
  37. 37. Pupillary Assessment • Unreactive pupils can be caused by an expanding mass, for example a blood clot exerting pressure on the third cranial nerve; • a fixed and dilated pupil may be due to herniation of the medial temporal lobe.
  38. 38. Artificial Airway Management
  39. 39. Indications • Loss of consciousness • Facial or oral trauma • Copious respiratory secretions • Respiratory distress • Need for mechanical ventilator
  40. 40. Types of Airways 1. Oropharyngeal airway
  41. 41. Types of Airways 2. Nasopharyngeal airway (nasal trumpet)
  42. 42. Types of Airways 3. Endotracheal tube - flexible tube inserted through the mouth or nose and into the trachea beyond the vocal cords that acts as artificial airways.
  43. 43. Types of Airways 3. Endotracheal tube • allows for deep tracheal suction and removal of secretions • permits mechanical ventilator • inflated balloon seals off trachea so aspiration from the G.I tract cannot occur. • generally easy to insert in an emergency, but maintaining placement is more difficult so this is not for long term use.
  44. 44. Types of Airways 4. Tracheostomy tube
  45. 45. Mallampati Score In anesthesiology, the Mallampati score, also Mallampati classification, is used to predict the ease of intubation. It is determined by looking at the anatomy of the oral cavity; specifically, it is based on the visibility of the base of uvula, faucial pillars (the arches in front of and behind the tonsils) and soft palate.
  46. 46. Mallampati Score Scoring may be done with or without phonation. A high Mallampati score (class 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea
  47. 47. Mallampati Score • Modified Mallampati Scoring is as follows: Class 1: Full visibility of tonsils, uvula and soft palate Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula Class 3: Soft and hard palate and base of the uvula are visible Class 4: Only Hard Palate visible Class 0: visibility of Epiglottis
  48. 48. Mallampati Score
  49. 49. INTUBATION • An introduction of a tube into a hollow organ (as the trachea).
  50. 50. Indications • Failure to protect the airway • Institution of controlled ventilation • Suctioning of secretions
  51. 51. Types of Intubation 1. Endotracheal Intubation - maybe inserted through the nose or the mouth.
  52. 52. Types of Intubation 1. Endotracheal Intubation a. Orotracheal Disadvantages:  increased oral secretions  decreased patient comfort  difficulty with stabilization  inability of patient to use lip movement as a communication means
  53. 53.
  54. 54.
  55. 55. Types of Intubation 1. Endotracheal Intubation b. Nasotracheal Disadvantages:  blind insertion is required  possible development of pressure necrosis of nasal airway  sinusitis  otitis media
  56. 56.
  57. 57.
  58. 58.
  59. 59.
  60. 60. Types of Intubation 1. Endotracheal Intubation c. Tube Types Sizes:  Usual in adult are 6.0, 7.0, 8.0, 9.0 mm
  61. 61.
  62. 62. Types of Intubation 1. Endotracheal Intubation c. Tube Types Cuffs:  High volume  Low preassure  With self sealing inflation valves  Foam rubber (fome-cuff)
  63. 63.
  64. 64. Types of Intubation 1. Endotracheal Intubation c. Tube Types Lumens:  Single Lumen  Dual Lumen
  65. 65.
  66. 66. Types of Intubation 1. Endotracheal Intubation d. Contraindications  glottis is obscured by vomitus, bleeding, foreign body  trauma  cervical spine injury or deformity
  67. 67. Types of Intubation 2. Tracheostomy - inserted into the trachea via incision created at the level at the second or third cartilage ring.
  68. 68. Indications of ET intubation / Tracheostomy Acute respiratory failure CNS depression neuromuscular disease pulmonary disease chest wall injury
  69. 69. Indications of ET intubation / Tracheostomy Upper airway obstruction tumor inflammation foreign body laryngeal spasm
  70. 70. Indications of ET intubation / Tracheostomy Anticipated upper airway obstruction from edema or soft tissue swelling due to head and neck trauma some past-operative head and neck procedures involving the airway facial or airway burns decreased level of consciousness
  71. 71. Indications of ET intubation / Tracheostomy Aspiration Prophylaxis Fracture of cervical vertebrae with spinal cord injury (SCI) requiring ventilator assistance.
  72. 72. Endotracheal Intubation Equipments
  73. 73. Endotracheal Intubation • Laryngoscope with curved or straight blade and working light source (check batteries and bulb regularly)
  74. 74. Endotracheal Intubation
  75. 75. Endotracheal Intubation • Endotracheal tube with low-pressure cuff and adapter to connect tube to ventilator or resuscitation bag
  76. 76. Endotracheal Intubation • Stylet to guide the endotracheal tube • Oral airway (assorted sizes) or bite block to keep patient from biting into and occluding the endotracheal tube • Adhesive tape or tube fixation system • Sterile anesthetic lubricant jelly (water- soluble) • 10 mL syringe
  77. 77. Endotracheal Intubation
  78. 78. Endotracheal Intubation
  79. 79. Endotracheal Intubation • Suction source • Suction catheter and tonsil suction • Resuscitation bag and mask connected to oxygen source • Sterile towel • Gloves • Face shield • End tidal CO2 detector
  80. 80. Endotracheal Intubation
  81. 81. Endotracheal Intubation
  82. 82. Endotracheal Intubation Procedure
  83. 83. Endotracheal Intubation • PREPARATORY PHASE • Assess the patient’s heart rate, level of consciousness, and respiratory status
  84. 84. Endotracheal Intubation • PERFORMANCE PHASE 1.Remove the patient’s dental bridgework and plates. 2.Remove headboard of bed (optional).
  85. 85. Endotracheal Intubation • PERFORMANCE PHASE 3. Prepare equipment. a) Ensure function of resuscitation bag with mask and suction b) Assemble the laryngoscope. Make sure the light bulb is tightly attached and functional c) Select an endotracheal tube of the appropriate size (6.0 to 9.0 mm for average adult).
  86. 86. Endotracheal Intubation • PERFORMANCE PHASE 3. Prepare equipment. d.) Place the endotracheal tube on a sterile towel. e.) Inflate the cuff to make sure it assumes a symmetric shape and holds volume without leakage. Then deflate maximally. f.) Lubricate the distal end of the tube liberally with the sterile anesthetic water-soluble jelly. g.) Insert the stylet into the tube (if oral intubation is planned). Nasal intubation does not employ use of the stylet.
  87. 87. Endotracheal Intubation 4. Aspirate stomach contents if nasogastric tube is in place. 5. If time allows, inform the patient of impending inability to talk and discuss alternative means of communication. 6. If the patient is confused, it may be necessary to apply soft wrist restraints. 7. Put on gloves and face shield.
  88. 88. Endotracheal Intubation 8. During oral intubation if cervical spine is not injured, place patient’s head in a “sniffing” position (ie, extended at the junction of the neck and thorax and flexed at the junction of the spine and skull). 9. Spray the back of the patient’s throat with anesthetic spray if time is available. 10.Ventilate and oxygenate the patient with the resuscitation bag and mask before intubation. 11.Hold the handle of the laryngoscope in the left hand and hold the patient’s mouth open with the right hand by placing crossed fingers on the teeth.
  89. 89. Endotracheal Intubation 12.Insert the curved blade of the laryngoscope along the right side of the tongue, push the tongue to the left, and use right thumb and index finger to pull patient’s lower lip away from lower teeth. 13.Lift laryngoscope forward (toward ceiling) to expose the epiglottis. 14.Lift laryngoscope upward and forward at 45-degree angle to expose glottis and visual vocal cords. 15.As the epiglottis is lifted forward (toward ceiling), the vertical opening of the larynx between the vocal cords will come into view
  90. 90. Endotracheal Intubation 16.Once vocal cords are visualized, insert tube into the right corner of the mouth and pass the tube while keeping vocal cords in constant view. 17.Gently push the tube through the triangular space formed by the vocal cords and back wall of trachea. 18.Stop insertion just after the tube cuff has disappeared from view beyond the cords. 19.Withdraw laryngoscope while holding endotracheal tube in place. Disassemble mask from the resuscitation bag, attach bag to ET tube, and ventilate the patient.
  91. 91. Endotracheal Intubation 20. Inflate cuff with the minimal amount of air required to occlude the trachea. 21. Insert bite block if necessary. 22. Ascertain expansion of both sides of the chest by observation and auscultation of breath sounds. 23. Record distance from proximal end of tube to the point where the tube reaches the teeth. 24. Secure tube to the patient’s face with adhesive tape or apply a commercially available endotracheal tube stabilization device. 25. Obtain chest x-ray to verify tube position.
  92. 92. Endotracheal Intubation • FOLLOW-UP PHASE 1.Record tube type and size, cuff pressure, and patient tolerance of the procedure. Auscultate breath sounds every 2 hours or if signs and symptoms of respiratory distress occur. Assess ABGs after intubation if requested by the health care provider.
  93. 93. Endotracheal Intubation • ABGs may be prescribed to ensure adequacy of ventilation and oxygenation. Tube displacement may result in extubation (cuff above vocal cords), tube touching carina (causing paroxysmal coughing), or intubation of a mainstem bronchus (resulting in collapse of the unventilated lung).
  94. 94. Endotracheal Intubation 2. Measure cuff pressure with manometer; adjust pressure. Make adjustment in tube placement on the basis of the chest x-ray results. • The tube may be advanced or removed several centimeters for proper placement on the basis of the chest x-ray results.
  95. 95. Complications of ET or tracheostomy tubes Laryngeal or tracheal injury 1. Sore throat, tracheal injury 2. Glottic edema 3. Ulceration or necrosis of tracheal mucosa 4. Vocal cord ulceration, granuloma or polyps 5. Vocal cord paralysis
  96. 96. Complications of ET or tracheostomy tubes Laryngeal or tracheal injury 6. Past extubation tracheal stenosis 7. Tracheal dilation 8. Formation of tracheal-esophageal fistula 9. Formation of tracheal-arterial fistula 10.Innominate artery erosion
  97. 97. Complications of ET or tracheostomy tubes Pulmonary infection and sepsis Dependence on artificial airway
  98. 98. Specialist Group Hospital and Trauma Center Intensive Care Unit Department Presentation Louie Ray Roldan, R.N. SGHTC – ICU Senior Staff Nurse