Central Venous Line or Catheter

A central venous catheter is a special IV line that is inserted into a large vein in the body. Several veins are used for central venous catheters including those located in the shoulder (subclavian vein), neck (jugular vein), and groin (femoral vein)

Common sites for central venous

catheter insertion

1

PROCEDURE

The most common used

method is seldinger

technique.

In some patients, a central venous

catheter may be inserted into the

elbow vein (anticubital vein) and

advanced into the subclavian vein.

PURPOSE

These special IVs are used when the

patient either does not have adequate

veins in the arms or needs special

medications and/or nutrition that cannot

be given through the smaller arm veins.

Serve as a guide of fluid balance in

critically ill patients.

Determine the function of the right side

of the heart

complication

Bleeding and infection are complications

associated with IV catheters. As previously

mentioned, collapse of a lung is a rare

complication of central venous catheters.

If this occurs, a chest tube (thoracostomy

tube) may be required to re-expand the

lung.

Arterial puncture, cardiac puncture

Pneumothorax, Hemomothorax

Air emboli, Thrombosis

Cardiac temponade

Cardiac arrhythmias

Carotid Artery Puncture

Perforation of SVC or R. Atrium/Ventricle

Pleural Effusion

NURSES ROLE

Monitor for the signs of complications.

Assess for patency of the CVP line.

Sterile dressing should be done to

prevent infection( CVP care per the

hospital protocol)

The length of the indwelling catheter

should be recorded and regularly

monitored.

ICP monitor

ICU patients who have sustained head

trauma, brain hemorrhage, brain surgery,

or conditions in which the brain may

swell might require intracranial pressure

monitoring.

PURPOSE

The purpose of ICP monitoring is to

continuously measure the pressure

surrounding the brain. If the pressure

surrounding the brain gets too high, it can

cause decreased blood flow to the brain

and potentially lead to brain damage.

The ICP monitor is usually inserted by a

neurosurgeon while the patient is in the

ICU or operating room. After using

numbing medicine (local anesthetics), the

neurosurgeon makes a skin incision and

inserts the ICP monitor into the brain

through a very small hole created in the

skull.

The ICP monitor is usually inserted in the

left or right top-front part of the brain.

Some ICP monitors can drain spinal fluid if

necessary.

complication

Potential complications associated with

ICP monitoring include infection and brain

hemorrhage, which are very infrequent.

Nurses role

Optimizing cerebral tissue perfusion.

Preventing infection.

Maintaining patient airway.

Maintaining negative fluid balance.

Prevent infection( dressing)

PULSE OXIMETER

A pulse oximeter is the device that

measures and displays the oxygen arterial

saturation. The study is called pulse

oxymetry.

The pulse oximeter is a small device that

has to be in contact with the skin to detect

the oxygen saturation.

The device is usually place on the

patient's finger, earlobe, toe or nose. The

pulse oximeter gives off light that

determines the oxygen saturation of the

blood.

Breathing Machine (Mechanical

Ventilator

A breathing machine

helps the patient

breathe. It is designed

to help patients who

cannot breathe

adequately on their

own. The breathing

machine does not fix

any problems of the

lungs.

It is a device that simply pushes air and

oxygen into the lungs and withdraws

carbon dioxide from the lungs. The lungs

must function in order for the breathing

machine to be effective.

PURPOSE

A breathing machine is used whenever a patient cannot breathe without assistance. Doctors, nurses and respiratory therapists all work to make sure a breathing machine is not used any longer than necessary.

The goal when a breathing machine is

first used is to get the patient to be able

to breathe on their own, so that the

breathing machine can be removed.

complications

Patients who require breathing machine

support are at increased risk to develop

pneumonia. Occasionally, patients may

develop a collapsed lung. Both of these

complications require treatment

NURSES ROLE

Promoting effective airway clearance.

preventing trauma and infection.

Check

Ventilator functioning properly

Blockage of air passage

Too much sputum, secretions

When sedation drugs are used

ABG, hypoxia

b. Suction periodically as per need

c. Change the mode setup as adviced.

d. Give sedatives as adviced.

INFUSION PUMP

An intravenous (IV) infusion pump is a

machine that carefully controls the rate at

which IV fluids and/or IV medications are

given.

PURPOSE

Under some circumstances, the rate at

which IV fluids and/or IV medications are

given needs to be closely controlled.

These pumps are very reliable. Mechanical

problems are possible, but very rare. If the

IV infusion pump does not work correctly,

an alarm will sound.

NURSES ROLE

Using aseptic technique and universal

precautions, iv infusion should be set.

Set the flow rate as prescribed calculating

the amount of fluid.

Observe for the signs of infiltration or

other complications such as

thrombophlebitis. Fluid or electrolyte

overload and embolism before

administration.

Resuscitation Cart (Crash Cart)

The resuscitation cart

contains all of the

equipment and

medications needed

for advanced life

support and CPR

(cardiopulmonary

resuscitation).

purpose

This emergency equipment is used only if

the patient's heart or lungs stop working.

The cart is brought to the patient's

bedside when the patient's heart or lungs

are failing or have failed.

NURSES ROLE

Keep the resuscitation cart ready all the

time.

Check the devices and ensure that the

devices are kept in charging.

Check for the emergency (life saving)

medication for their expiry date.

DEFIBRILLATOR

A defibrillator is a device that is designed

to pass electrical current through a

patient’s heart. The passing of electrical

current through the heart is called

defibrillation. A defibrillation is done

through pads placed on the patient’s chest.

purpose

A defibrillation is used to restore a

patient’s heart rhythm to normal.

Abnormal heart rhythms may be treated

with medications while other rhythms

need to be treated with defibrillation.

Life threatening heart rhythms need

defibrillation immediately while other heart

rhythms may be defibrillated in a scheduled

fashion.

Defibrillation may be done using the manual

defibrillator or the automatic external

defibrillator (AED).

Complication

The defibrillator pads may cause a skin

irritation and leave a temporary redden

area where they contacted the chest.

Unfortunately defibrillation does not

always return the patient’s heart rhythm

back to normal.

NURSES ROLE

Keep the patient in comfortable position

and obtain 12 lead ECG.

Give the patient 100 % oxygen by

inhalation.

Apply electrode paste on the DC paddle,

rub it and apply the paste at the patient’s

chest in the second intercostal space at the

right side of breast line and at the apex of

the heart.

TURN OFF the oxygen to the patient as a

spark from paddle could blow the oxygen

on the fire.

Be sure to say “ ALL CLEAR”. No one

should touch the patient or the bed during

cardioversion.

Check the rhythm on ECG monitor.

Keep the patient in comfortable position

and give 100% oxygen by inhalation.

Report and record the procedure and

clean the paddle area with spirit swab.

Keep the difibrilator on continue electrical

charging.

MAINTENANCE OF ICU

EQUIPMENTS

Since ICU equipment is used continuously

on critically ill patients, it is essential that

equipment be properly maintained,

particularly devices that are used for life

support and resuscitation.

Contd…

Staff in the ICU should perform daily checks on equipment and inform biomedical engineering staff when equipment needs maintenance, repair, or replacement.

For mechanically complex devices, service and preventive maintenance contracts are available from the manufacturer or third-party servicing companies, and should be kept current at all times.

Health care team roles

Equipment in the ICU is used by a team

specialized in their use. The team usually

comprises a critical care attending

physician (also called an intensivist), critical

care nurses, an infectious disease team,

critical care respiratory therapists,

pharmacologists, physical therapists, and

dietitians.

Radiologic technologists perform mobile x

ray examinations (bedside radiography).

Either nurses or clinical laboratory

personnel perform point-of-care blood

analysis. Equipment in the ICU is

maintained and repaired by hospital

biomedical engineering staff and/or the

equipment manufacturer.

Thank you

INTRODUCTION

Intensive care unit (ICU) equipment

includes patient monitoring, respiratory

and cardiac support, pain management ,

emergency resuscitation devices, and

other life support equipment designed

to care for patients who have a critical

or life-threatening illness, thereby

requiring 24-hour care and monitoring.

45

PURPOSE

An ICU may be designed and equipped to

provide care to patients with a range of

conditions, or it may be designed and

equipped to provide specialized care to

patients with specific conditions.

46

ICU BED

Comfy ICU Bed (7 function) with

electrically operated back rest tilting 0-80°,

knee rest tilting 0-35°, trendelenburg tilting

0-20°, Reverse trendelenburg tilting 0-20°,

mattress base tilting to the left up to 40°,

tilting to the right up to 40°.

Size: 2155 x 940 x 630 / 1030 mm.

All functions controlled with Power Device

.

47

Contd….

Four easy lifting guardrails (2 on each

side), which are safe and reliable, and can

be fixed upward and downward.

Easy to operate built-in Control Panel on

both sides of guard rails.

48

Contd….

Foot Step Control Panel under the bed

frame.

Removable & interchangeable high quality

ABS engineering plastic head panel and

foot panel.

Head panel and foot panel equipped with

safety lock and roller bumpers.

49

Contd…

Epoxy coated mild steel frame work and

4 section perforated top.

125mm dia noiseless castors with

simultaneous braking system which locks

/ unlocks 2 castors with single pedal

press.

Provision for I.V. Rod on both sides of the

bed.

50

51

MONITORED PHYSIOLIGIC

VARIABLES Arterial blood pressure

Heart rate

Temperature

Hemoglobin and hematocrit

concentration

Urine output

Electrocardiogram(ECG)

52

Contd….

Serum electrolytes and blood chemistries

Central venous pressure

Arterial blood gases

Respiratory volume

Blood volume , plasma volume

Elecroencephalography

Intracranial pressure

53

Contd….

Pulmonary capillary and pre capillary

wedge pressure

54

TYPES OF DEVICES

Intensive care unit equipment includes:

Patient monitoring devices

Life support and emergency

resuscitation devices, and

Diagnostic devices.

55

PATIENT MONITORING

EQUIPMENT

Vascular access techniques

Bed side monitor

Blood pressure monitor

Electrocardiograph(ECG or EKG machine)

Electroencephalograph(EEG machine)

Intracranial pressure monitor

Pulse Oxymetry

Glucometer

56

LIFE SUPPORT AND EMERGENCY

RESUSCITATION DEVICES

Mechanical Ventilator

Laryngoscope

Airway

Infusion pump

Crash cart(Resuscitation cart)

Intra aortic balloon pump

Cardiac pacing

Defibrillator

57

DIAGNOSTIC EQUIPMENT

Mobile x-ray units

Portable clinical laboratory devices,

Bronchoscope

Colonoscope

Endoscope

Gastroscope

58

OTHER ICU EQUIPMENT

Disposable ICU equipment

includes

• Urinary catheter

• Urinary drainage collector

• Suction catheter

• Nasogastric (NG) tube

• Intravenous(IV) line or catheter

• Feeding tube

• Breathing tube( Endotracheal tube) 59

Patient Monitoring Techniques

Vascular catheterization

Electroencephalography

Pulse oximetry

ICP monitor

Bedside Monitor

60

3.CARDIAC PACING

Cardiac Pacing is

the repetitive

delivery of very

low electrical

energies to the

heart to initiate

and maintain

cardiac rhythm.

63

METHODS

Percussive pacing

Transcutaneous

Epicardial

Transvenous

Permanent pacing

64

CVP, PCWP AND GCS

CENTRAL VENOUS

PRESSURE

WHAT IS CENTRAL VENOUS

PRESSURE

• Is the pressure within the superior vena cava or the right atrium

• The CVP catheter is an important tool used to assess right ventricular function and systemic fluid status.

• Helps to determine the venous return and intravascular volume of the right atrium.

• The normal value is 5-10cm H2O

Purposes of CVP

measurement To serve as a guide of fluid balance in critically ill

patients

To estimate the circulating blood volume

To determine the function of the right side of the heart

To assist in monitoring circulatory failure

Indication to measure CVP

• Hypovolemic patients

( trauma patient, severe diarrhoea, dehydration, hypovolemic shock)

• Myocardial dysfunction

(myocardial failure, MI, cardiac temponade, pulmonary failure)

WHAT IS A CENTRAL LINE

It is a catheter that provides venous access via the superior vena cava or right atrium

CENTRAL LINES

• purposes of CVP lines are:

-Fluid resuscitation – Parenteral feeding

–Measurement of central venous pressure

– Poor venous access

– For transfusion

– For chemotherapy

–To give ionotropes

– For sampling blood

INDICATION OF CVC i) Major operative procedures involving large fluid shifts

and / or blood loss

ii) Intravascular volume assessment when urine output is less or not present(e.g renal failure)

iii) Major trauma

iv) Surgical procedures with a high risk of air embolism, such as craniotomies.

v)To aspirate intracardiac air.

vi) Special Uses as insertion of PA catheters ,haemodialysis/ plasmapheresis

vii) Hypovolemic shock

viii) Myocardial dysfunction

COMMON SITES OF CVP LINE

INSERTION

CENTRAL SITE

Right internal jugular

Left internal jugular

Right subclavian

Left subclavian

PERIPHERALLY

INSERTED CENTRAL

CATHETERS (PICC)

antecubital veins

basilic vein

Cephalic vein

Femoral artery

10

8

INTERNAL JUGULAR 10-12 cm

Better for CVC

Easy to pass, less chance

of pneumothorax, in direct

contact with right atrium

Difficult to maintain as it is

mobile and chance of

infection

Commonly done in

BPKIHS,ICU.

SUBCLAVIAN

• 8-10cm

• In hypovolemia subclavian remains dilated so best route

• Less mobile

• Can be kept for larger period (6 months, 3 months for chemotherapy)

PERIPHERAL ROUTE

• Easy to cannulate, less chance of severe complication, no chance of pneumothorax

• Long catheter is required so flow rate of IV fluids and drugs is slow.

TYPES OF CENTRAL LINE

SINGLE LUMEN

DOUBLE LUMEN

TRIPLE LUMEN

QUADRUPLE LUMEN

Right position to keep the tip

of catheter

At the junction of

superior venacava

and right atrium.

Seldinger technique

is used in CVP Cannulation

Patient is kept in trendenleberg position

The cannula with stylet is inserted at the tip of

triangle formed by 2 heads of sternomatoid and

clavicle. The direction of needle is slightly lateral

Once internal jugular is punctured stylet is

removed and guide wire is passed and catheter is

inserted.

Head turned to left, Trendelenberg position, two heads of

sternocleidomastoid

Post-Catheter Placement

Aspirate blood from each port

Flush with saline or sterile water

Secure catheter with sutures

Cover with sterile dressing (tega-derm)

Obtain chest x-ray for IJ and SC lines

Write a procedure note

Catheterization Kits

Injection Cap

Pigtail or

lumen luer

connector

Individual lumens or pigtails

Catheter juncture

hub

Pigtail or

lumen slide

clamp

METHODS OF CVP

MONITORING

• There are two methods of CVP monitoring

–manometer system: enables intermittent readings and is less accurate than the transducer system

–transducer system: enables continuous readings which are displayed on a monitor.

CVP MONITORING USING MANOMETER

• The CVP catheter is connected to water filled

water manometer column via a 3 way cannula.

• Find out the zero reference point(phlebostatic axis) from midaxillary line at 4th intercoastal space.

• Flush the CVP line

• Flush the manometer

• Close the heparin flush line and open CVP line and manometer

• Where the fluid get stabilised ,count from the zero reference

MONITORING WITH TRANSDUCERS

• Transducers enable the pressure readings from invasive monitoring to be displayed on a monitor.

• To maintain patency of the cannula a bag of normal saline or heparinised saline should be connected to the transducer tubing and kept under continuous pressure of 300mmHg thus facilitating a continuous flush of 3mls/hr

PROCEDURE FOR CVP

MEASUREMENT USING A

TRANSDUCER

explain the procedure to the patient

ensure the line is patent

position the patient supine (if possible) and align the

transducer with the mid axilla (level with the right

atrium)

zero the monitor

observe the CVP trace

document the reading and report any changes or

abnormalities

THE CVP WAVEFORM The CVP waveform reflects

changes in right atrial

pressure during the cardiac

cycle

Mechanical events during the

cardiac cycle are responsible

for the sequence of waves

seen in a typical CVP trace.

The CVP waveform consists

of five phasic events, three

peaks (a, c, v) and two

descents (x, y)

The normal CVP waveform

1. The ‘a’ wave : right atrial contraction

2. The ‘c’ wave : ventricular contraction.

3. X descent: Decrease in the pressure within the RA with right ventricular ejection.

4. V wave : Filling of RA during late ventricular systole

5. The Y descent :Empyting of RA into the RV during early diastole.

CENTRAL

VENOUS

PRESSURE(CVP)

BLOOD VOLUME

(INCREASED VENOUS RETURN RAISES CVP

CARDIAC COMPETENCE (REDUCED VENTRICULAR FUNCTION RAISES CVP)

INTRATHORACIC AND INTRAPERITONEAL PRESSURE (RAISES CVP)

SYSTEMIC VASCULAR RESISTENCE (INCREASED TONE RAISES CVP)

CVP is elevated by :

◦ Overhydration, Hypervolemia which increases venous return

◦ Heart failure or PA stenosis,

◦ forced exhalation

◦ Pneumothorax

◦ Heart failure

◦ Pleural effusion

◦ Decreased cardiac output

◦ Cardiac tamponade

CVP decreases with:

Hypovolemia, hypovolemic shock from

hemorrhage, fluid shift, dehydration

◦ Deep inhalation

Contraindications

Infection at the site of insertion

Coagulopathies

Newly inserted pacemaker wires

Presence of carotid disease

Recent cannulation of the internal jugular vein

Contra lateral diaphragmatic dysfunction

Thyromegaly or prior neck surgery:

MANAGEMENT OF A PATIENT WITH A CVP LINE

Monitor the patient for signs of complications

Label CVP lines with drugs/fluids etc. being

infused in order to minimise the risk of

accidental bolus injection

If not in use, flush the cannula regularly to help

prevent thrombosis.

Sterile dressing should be done to prevent

infection.

Cont…

Ensure all connections are secure to prevent

dislodgement, introduction of infection and air

emboli

Observe the insertion site frequently for signs of

infection.

The length of the indwelling catheter should be

recorded and regularly monitored.

CVP lines should be removed when clinically

indicated

Nursing and Catheter Care Equipment:

Sterile dressing tray

Sterile cotton-tipped applicators

Cleansing swabs

Cleansing solution (Use of commercially available

chlorhexidine impregnated sponge dressing may be used)

Wound adhesive tapes (Steri Strips)

Clear tape

Non-sterile gloves

Sterile gloves

Procedure: •Wash hands. •Prepare tray and supplies. •Put on non-sterile gloves. •Remove dressing. •Remove gloves. •Wash hands. •Put on sterile gloves. •Remove steri strips and wings using forceps. •Inspect the catheter site. If there is any sign of infection, swab the site for C&S and notify the physician. •Cleanse around and under catheter using cotton-tipped applicators.

Cont...

Cleanse the insertion site starting at the catheter and

working outwards in a circular motion to a radius of 10

cm. Avoid crossing over the catheter. Repeat twice using

a new swab each time.

Cleanse the top and underside of the catheter, starting

at the exit site. Allow to dry.

Cleanse wings with cleansing solution. Allow to dry

prior to replacing.

Re-apply wings by squeezing the wing together so that it

splits open. Place wings on catheter. Ensure that catheter is

within the channel under the wings. Cleanse catheter and

insertion site with applicators/gauze soaked in cleansing

solution.

Apply steri strips to secure wings. Tuck steri strips under

wings and catheter so that catheter is supported off skin, but

secure.

Apply sterile dressing to site. Create a loose loop so that the

catheter is not twisted or kinked under the dressing

COMPLICATIONS FOLLOWING CVP

LINE INSERTION

Malposition of the catheter Haematoma Arterial puncture, cardiac puncture Pneumothorax, Hemomothorax Haemorrhage Air emboli, Thrombosis Cardiac temponade Cardiac arrhythmias

.

Cont…

Sepsis

Carotid Artery Puncture

Perforation of SVC or R. Atrium/Ventricle

Pleural Effusion

Allergic reaction to catheter material

Thrombophlebities

Cardiac puncture

PULMONARY CAPILLARY

WEDGE PRESSURE

PCWP

Pulmonary capillary wedge pressure

(PCWP) provides an indirect estimate of

left atrial pressure (LAP).

Normal PCWP 8-10mm Hg

How is it measured?

PCWP is measured by inserting balloon-tipped, multi-lumen catheter (Swan-Ganz catheter) into a peripheral vein, then advancing the catheter into the right atrium, right ventricle, pulmonary artery, and then into a branch of the pulmonary artery.

Just behind the tip of the catheter is a small balloon that can be inflated with air (~1 cc). The catheter has one opening (port) at the tip (distal to the balloon) and a second port several centimeters proximal to the balloon. These ports are connected to pressure transducers.

Cont…

• The balloon is then inflated, which occludes

the branch of the pulmonary artery. The

pressure rapidly falls and reaches a stable

lower value that is very similar to left atrial

pressure (normally about 8-10 mmHg). The

balloon is then deflated.

Why is it measured?

• to diagnose the severity of left ventricular failure

• to quantify the degree of mitral valve stenosis. Aortic valve stenosis and regurgitation, and mitral regurgitation also elevate LAP(above 20 mmHg) causing pulmonary edema which is a life-threatening condition.

• PCWP is also useful in evaluating blood volume status when fluids are administered during hypovloemic shock.

Cont…

It is necessary to measure when evaluating

pulmonary hypertension(due to increase in

pulmonary vascular resistance)

To titrate the dose of diuretic drugs and other drugs

that are used to reduce pulmonary venous and

capillary pressure, and reduce the pulmonary edema.

Indications For PCWP

Monitoring:

A. Cardiac cause: Recent MI Complications of MI eg. MR, VSD, ventricular aneurysm. Combined lesions eg. CAD+MR or CAD+AS

B. Non-cardiac situations: Shock of any cause Severe pulmonary disease Complicated surgical procedure Massive trauma Hepatic transplantation

COMPLICATION OF PCWP

Pulmonary infection

Pulmonary artery rupture

Pulmonary infraction

Catheter kinking

Dysarrythmias

Air embolism

Glasgow Coma Scale

GCS

• Glasgow Coma Scale or GCS, sometimes also known as the Glasgow Coma Score is a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person, for initial as well as continuing assessment.

• The scale was published in 1974 by Graham

Teasdale and Bryan J. Jennett, professors of neurosurgery at the University of Glasgow.

Components of the GCS

• There are three components to the GCS: • Best eye opening • Best motor response • Best verbal response Each is evaluated independently of the other two

components.

ALWAYS SCORE THE BEST RESPONSE FOR THE PATIENT

Cont…

The three values separately as well as their

sum are considered. The lowest possible

GCS (the sum) is 3 (deep coma or death),

while the highest is 15 (fully awake

person).

• Scoring

– Eye Opening

• Spontaneous: 4

• To speech: 3

• To pain: 2

• No Response: 1

– Best Verbal Response

• Oriented (Infant coos or babbles): 5

• Confused (Infant irritable cries): 4

• Inappropriate words (Infant Cries to pain): 3

• Incomprehensible sounds (Infant Moans to pain): 2

• No Response: 1

– Best Motor Response

• Obeys (Infant moves spontaneous/purposefully): 6

• Localizes (infant withdraws to touch): 5

• Withdraws to pain: 4

• Abnormal Flexion to pain (Decorticate): 3

• Extensor Response to pain (Decerebrate): 2

• No Response: 1

Best eye response (E) If there is damage to the occulomotor nerve from trauma, the

patient may not be able to open his or her eye. :

1=No eye opening (regardless of any stimuli)

2=Eye opening in response to pain. (Patient responds to

pressure on the patient’s fingernailbed supraorbital and sternal

pressure)

3=Eye opening to speech. (either spoken or shouted verbal

response)

4=Eyes opening spontaneously (when a person approaches

bedside)

Best Verbal Response (5 - 1)

Verbal response assesses consciousness by

determining whether a person is aware of

him/herself and the environment.

Best verbal response (V)

1=No verbal response

2=Incomprehensible sounds.

3=Inappropriate words

4=Confused.

5=Oriented.

Orientation

There are six specific questions in the original GCS

• What is your name?

• Where are you?

• Why are you here?

• What month are we in?

• What year are we in?

• What season are we in?

Confusion (4)

A patient may be able to hold a conversation

with the observer but responses are

inappropriate or disoriented.

Inappropriate Speech (3)

Does not carry on conversation, poor

attention span, uses inappropriate words

and phrases.

Random/confused/repetitive.

Incomprehensible Speech (2)

Patients are less aware of their environment

and their verbal response is in the form of incomprehensible sounds.

• Moan or cry

• The observer may now have to use both a painful and verbal stimulus to get a response.

Best Motor Response (6 – 1)

6= Obeys commands

5= Localises to pain

4= Withdraws from pain

3= Abnormal flexion

2= Extension

1= No response

Obeys Commands (6)

Patients are aware of their environment, have understood the observer's instructions, and are to carry them out. • Examples of possible commands are 'lift up your

arms' or 'hold up your thumb'.

• If patients are asked to 'squeeze my hands', they must also be asked to release their grip.

Localises to Pain (5)

• This is a response to a central painful stimulus.

• It involves the higher centres of the brain, the

cerebral hemispheres or cerebrum.

• usually a motor response such as moving an

arm towards the source of the pain in order

to remove it and stop the pain from

continuing pain stimuli

Withdraws from pain (4)

Patients flex or bend their arm towards

the source of the pain, but do not actually

localise or try to remove the source of the

pain

Abnormal Flexion (3)

• Patients flex or bend the arm at the elbow and rotate the wrist, resulting in a spastic posture in response to a central painful stimulus.

• It is an abnormal response and indicates severe cerebral damage and an interruption of nerve pathways from the brain's cortex to the spine.

Abnormal Flexion

Extension (2)

• In response to a central painful stimulus, patients will extend or straighten an arm at the elbow, or may rotate the arm inwards.

• Abnormal response due to damage to the brain stem by which information to and from the cerebrum are not tranmitted.

Extension

Severe, with GCS ≤ 8 - that is also a

generally accepted definition of a coma

Moderate, GCS 9 - 12

Minor, GCS ≥ 13.

• The motor component of the GCS score is a powerful predictor of outcome and contains most of the predictive power of the score.

• There are two circumstances in which the motor-only model is unreliable: in patients with pharmacologic (therapeutic) paralysis and in patients with traumatic paralysis (i.e., high spinal cord injuries). In these cases, the motor score is simply not a measure of consciousness and cannot be used as one.

Others methods: AVPU Scale

A-alertness

V-verbal response

P- response to pain

U-unresponsive

3 GCS components

3-point scores

a) simplified verbal score: oriented=2, confused conversation=1,

inappropriate words or less=0

b) simplified motor score: obeys commands=2, localizes pain=1,

withdrawal to pain or less=0).

We then compared the test performance of each of these 5 to the total

GCS score using a priori thresholds for clinically important differences.

ANY QUERIES???

THANK YOU!!!