FOUR Score for the Evaluation of the Comatose Patient

This post was peer reviewed.
Click to learn more.

Image Credit: MaxPixel

Authors: Justin Rafael De la Fuente, MSII
Medical Student
University of Miami Miller School of Medicine

Tim Montrief, MD MPH
Emergency Medicine Resident Physician
Jackson Memorial Health System
AAEM/RSA Publications & Social Media Committee

Jeffrey M Scott, DO
Attending Physician
Jackson Memorial Health System

Case
A 63-year-old man is brought in to the emergency department by ambulance after being found unresponsive at home by his family. He was last seen normal about four hours prior to arrival. En route, the patient was exhibiting irregular respirations with an oxygen saturation of 85% and was intubated by paramedics. On arrival, he is unresponsive with an oxygen saturation of 92%, bradycardic at 55 beats per minute, and hypertensive with a blood pressure of 160/95 mmHg.

Pre-intubation Optimization of the Neurocritical Care Patient

This post was peer reviewed.
Click to learn more.

Image Credit: Wikimedia

Author: Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

The catastrophic neurologic emergency remains one of the most challenging presentations managed by emergency physicians. Stress, diagnostic uncertainty, and time-sensitive nature lead to challenging management decisions. Likewise, the intubation of the neurocritical care patient provides many challenges, and requires a modified technique to avoid the harmful consequences of intubation, including an exaggerated reflex sympathetic response to laryngoscopy, hypotension due to induction agents, and exacerbation of elevated intracranial pressure (ICP). Additionally, maximizing first past success and minimizing hypoxia is especially important in patients with central nervous system (CNS) pathology, in particular, unsecured aneurysmal subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and stroke. Optimization of the neurocritical care patient is of upmost importance, and many of the techniques are familiar to the emergency physician. For instance, apneic oxygenation via a nasal cannula on the patient at 15 L/min maximizes oxygenation prior to intubation. Additionally, one may raise the head of the bed, which decreases ICP and has a ben­eficial effect on oxygenation. While ninety degrees is the ideal angle, elevation of the head of bed to thirty degrees is also an option. Finally, if faced with an agitated, combative patient, delayed sequence intubation (read more about it here) may be an option to optimize preoxygenation.