Neurological Assessment & Artificial Airway Management

Neurological
Assessment
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Glasco Coma
Scale

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.


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


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).


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.


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.


Glasco Coma Scale
Eye opening

• Assessment of eye opening involves the
evaluation of arousal (being aware of the
environment):


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.


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.


Glasco Coma Scale
Verbal response

• Assessment involves evaluating
awareness:


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.


Glasco Coma Scale

Record 'D' if the patient is dysphasic
and 'T' if the patient has a tracheal or
tracheostomy tube in situ.


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:


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;


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;

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.


Glasco Coma Scale
Painful stimulus

• A true localising response to pain involves
the patient bringing an arm up to chin
level.


Glasco Coma Scale
• Painful stimuli that can
elicit this response
include trapezium
squeeze.


Glasco Coma Scale
• suborbital ridge
pressure (not
recommended if there
is a
suspected/confirmed
facial fracture)


Glasco Coma Scale
• sternal rub (caution,
not recommended in
some organisations)


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


Glasco Coma Scale

• Mild (13-15):

– Loss of consciousness and/or confusion and
disorientation is shorter than 30 minutes.


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


Glasco Coma Scale

• Severe Disability (3-8):

– Coma: unconscious state. No meaningful
response, no voluntary activities


Glasco Coma Scale

• Vegetative State (Less Than 3):

– Sleep wake cycles
– Arousal, but no interaction with environment
– No localized response to pain


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


Pupillary
Assessment

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.


• 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.


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.


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.


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.


• 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.


Artificial Airway
Management

Indications

• Loss of consciousness
• Facial or oral trauma
• Copious respiratory secretions
• Respiratory distress
• Need for mechanical ventilator


Types of Airways

1. Oropharyngeal airway


Types of Airways

2. Nasopharyngeal airway (nasal trumpet)


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.


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.


Types of Airways

4. Tracheostomy tube


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.


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


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


Mallampati Score


INTUBATION
• An introduction of a tube into a hollow
organ (as the trachea).


Indications
• Failure to protect the airway
• Institution of controlled ventilation
• Suctioning of secretions


Types of Intubation
1. Endotracheal Intubation
- maybe inserted through the nose or
the mouth.


Types of Intubation
a. Orotracheal
Disadvantages:
 increased oral secretions
 decreased patient comfort
 difficulty with stabilization
 inability of patient to use lip
movement as a communication
means


Types of Intubation

b. Nasotracheal
Disadvantages:
 blind insertion is required
 possible development of pressure
necrosis of nasal airway
 sinusitis
 otitis media


Types of Intubation

c. Tube Types
Sizes:
 Usual in adult are
6.0, 7.0, 8.0, 9.0 mm


Types of Intubation

c. Tube Types
Cuffs:
 High volume
 Low preassure
 With self sealing inflation valves
 Foam rubber (fome-cuff)


Types of Intubation

c. Tube Types
Lumens:
 Single Lumen
 Dual Lumen


Types of Intubation

d. Contraindications
 glottis is obscured by
vomitus, bleeding, foreign body
 trauma
 cervical spine injury or deformity


Types of Intubation
2. Tracheostomy
- inserted into the
trachea via incision
created at the level at
the second or third
cartilage ring.


Indications of
ET intubation / Tracheostomy

Acute respiratory failure
CNS depression
neuromuscular disease
pulmonary disease
chest wall injury


Indications of

Upper airway obstruction
tumor
inflammation
foreign body
laryngeal spasm


Indications of

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


Indications of

Aspiration Prophylaxis

Fracture of cervical vertebrae with spinal
cord injury (SCI) requiring ventilator
assistance.


Endotracheal Intubation

Equipments

• Laryngoscope with curved or straight
blade and working light source (check
batteries and bulb regularly)


• Endotracheal tube with low-pressure cuff
and adapter to connect tube to ventilator
or resuscitation bag


• 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


• Suction source
• Suction catheter and tonsil suction
• Resuscitation bag and mask connected to
oxygen source
• Sterile towel
• Gloves
• Face shield
• End tidal CO2 detector


Procedure

• PREPARATORY PHASE

• Assess the patient’s heart rate, level of
consciousness, and respiratory status


• PERFORMANCE PHASE

1.Remove the patient’s dental bridgework
and plates.

2.Remove headboard of bed (optional).


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).


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.

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.


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.


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


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.


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.


• 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.


• 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).


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.


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


Complications of
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


Complications of

Pulmonary infection and sepsis

Dependence on artificial airway


Specialist Group Hospital and
Trauma Center
Intensive Care Unit Department

Presentation
Louie Ray Roldan, R.N.
SGHTC – ICU Senior Staff Nurse


Neurological Assessment & Artificial Airway Management

Neurological Assessment & Artificial Airway Management

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