Learning Objectives

• ABCDE assessment in critically unwell patient
• GCS assessment
• Airway management
• NICE head injury guidelines
• Anticoagulants reversal
• Case escalation

Background 

• Patient brought in as standby with head injury

• On DOAC therapy

• Low GCS

• Airway compromise

• Patient is immediately managed in Resus

• cABCDE assessment

• Airway management - intubation

• Interpretation of investigations:   CT / bloods

• Escalation 

Case

Patient self-presents to ED

62-year-old male: Maurice

In Resus

PC: Head injury

HPC: Slipped on wet surface at home and sustained head injury.

LOC for few minutes.

Confused and drowsy since.

Fall witnessed by wife.

PMH: Hypertension / Hyperlipidaemia / IHD / AF

DH: NKDA

Atorvastatin / Bisoprolol / Apixaban / GTN spray

FH: Father died of colon ca – age 56 years / Mother had hyperthyroidism

SH: Civil servant / ex-smoker / independent / lives with wife

Observation & Examination

Maurice is snoring despite nasopharyngeal airway inserted by paramedics

GCS 6 (E1V1M4) T 36.7°C CRT  < 2 secs

BP 195/84 HR 108 RR 8

SpO2  98% on 15L

HS I + II + nil

Chest clear with bilateral air entry

Abdomen soft / non tender

Abnormal flexion of arms / left gaze deviation / pupils sluggish with sizes: R-3 L-5