1. ALTERED CONSCIOUSNESS: AN F1 GUIDE Tammy Clark (T&O academic F1) Jason Appleton (Neurology SpR)

2. What is altered consciousness?  Any state of arousal that isn’t ‘normal’  How do we measure consciousness?  AVPU  GCS  ACDU  Grady Coma Scale

4. Use the ABCDE assessment

5. 31 year old male walked into Rugby Urgent Care with lacerations to his hands. He had fallen over a fence several hours ago, hit his head, neck and vomited several times. He was called to the treatment room when he suddenly collapsed.

6.  A  OP not tolerated. NP inserted  C-spine stabilised- collar, blocks, spinal board  B  Bilateral AE. No added sounds  SpO2 100% on 15L  RR 14  C  Cool and clammy; temp 35.4  BP 100/60  Pulse 90bpm; regular  CRT 2 seconds  UO- catheterised to monitor D GCS: E 3 V 1 M6 = 10 Pupils initially equal; unreactive BM 6.7 E Initially could not get patient to move legs- reduced tone. Arms mobile. Pantars down going Abdo- unremarkable Lacerations to hands bilaterally. No further injury

7. PLAN:  Call for help but don’t leave patient  Anaesthetist  Bloods- including paracetamol and salicylate levels  IVI  ABG  ECG  CT head and neck as part of trauma series

8. Criteria for CT head  GCS <13  GCS <15 2hr post-injury  Suspect open or depressed skull #  Signs of basal skull #  Post-traumatic seizure  Focal neuro deficit  >1 episode of vomiting  Amnesia >30min before injury  LOC or amnesia since injury PLUS one of following:  >65yrs old  Coagulopathy  Mechanism of injury ++ NICE head injury guidance, Selection of adults for CT scannign of the head. NICE clinical guidline 56; 2007 [https:// guidance.nice.org.uk/CG56 accessed 27/07/2015]

9. Seizures  All about the timing 15l O2 Remove surrounding potential dangers Recovery position Full set of obs ECG BM IV access Bloods FBC, U&E, LFTs, BCM, Ca2+, anti- convulsant levels Call for help Protect airway IV lorazepam 4mg OR PR diazepam 10mg Repeat at 10 min if need be If still seizing, help WILL be there by now and anaesthetist/ ICU involvement required 0 mins 5 mins15/20 mins

10. Delirium  Acute, fluctuating, altered cognitive function Hypoactive hyperactive mixed  HYPOACTIVE- Drowsy, quiet, withdrawn  Consider risk factors  Hip fracture  Increased age  Cognitive impairment  Severe illness/ infection  Dehydration  Constipation  Pain  Electrolyte dysfunction  Poly-pharmacy  Withdrawal

11. Management  Side room, family presence, photos, clock  Drug kardex  Stool chart and urine output  Address dehydration or constipation  Pain control  Maximise SpO2  Bloods inc FBC, B12 and folate, TFT, U&Es, LFTs, clotting, CRP and BM  Septic screen Sources of sepsis eg wound, canula sites, urine, chest  Good communication with family NICE delirium guidance: Delirium: Diagnosis, prevention and management; NCIE CG103 [http://www.nice.org.uk/guidance/cg103/chapter/1-recommendations accessed 27/07/2015]

12. Alcoholic withdrawal What would you prescribe?

15. Practical tips  Escalating  Own ward- call SHO, SpR, inform consultant  Crash call ‘2222’ Medical assistance Peri- arrest Arrest  Switchboard ‘0’ eg. Med spR  Bleeping- 66 wait for tone 4 digit bleep 5 digit extension on phone # (optional)

16. Practical tips II  Tips for phone calls to seniors  Have everything to hand Drug kardex Latest obs and trend Recent bloods or gases Recent scans or ECGs  Introduce yourself  Give an idea why your calling eg. For advice; for a review  Start with age and a brief PMH (thinking time) and current problem  Concise  Then summarise with your question

17. Practical tips III  Documentation  Date, time  Review by X  Issue list  ABCDE  Impression and plan  Sign, bleep, print name, GMC number, job title- get a stamp  NB: Phone calls or meetings with relatives etc Name and designation/role eg. Spoke to SpR Appleton (neuro); Meeting with Mrs A (daughter)

18. Any questions?