Cvp line

CVP Line

1. 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)

3. Common sites for central venous
catheter insertion

1

4. PROCEDURE
The most common used
method is seldinger
technique.

5.  In some patients, a central venous
catheter may be inserted into the
elbow vein (anticubital vein) and
advanced into the subclavian vein.

7. 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

8. 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.

9. 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

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. complication
Potential complications associated with
ICP monitoring include infection and brain
hemorrhage, which are very infrequent.

16. Nurses role
Optimizing cerebral tissue perfusion.
Preventing infection.
Maintaining patient airway.
Maintaining negative fluid balance.
Prevent infection( dressing)

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22.  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.

23. 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

24. 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

25. b.Suction periodically as per need
c.Change the mode setup as adviced.
d.Give sedatives as adviced.

26. 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.

27. PURPOSE
Under some circumstances, the rate at
which IV fluids and/or IV medications are
given needs to be closely controlled.

28. 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.

29. 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.

30. Resuscitation Cart (Crash Cart)

The resuscitation cart
contains all of the
equipment and
medications needed
for advanced life
support and CPR
(cardiopulmonary
resuscitation).

31. 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.

32. 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.

33. 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.

34. 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.

35. 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).

36. 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.

37. 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.

38. 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.

39. Report and record the procedure and
clean the paddle area with spirit swab.
Keep the difibrilator on continue electrical
charging.

40. 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.

41. 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.

42. 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.

43.  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.

44. Thank you

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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. 51

52. MONITORED PHYSIOLIGIC
VARIABLES
 Arterial blood pressure
 Heart rate
 Temperature
 Hemoglobin and hematocrit
concentration
 Urine output
 Electrocardiogram(ECG)

52

53. Contd….
 Serum electrolytes and blood chemistries
 Central venous pressure
 Arterial blood gases
 Respiratory volume
 Blood volume , plasma volume
 Elecroencephalography
 Intracranial pressure

53

54. Contd….
 Pulmonary capillary and pre capillary
wedge pressure

54

55. TYPES OF DEVICES
Intensive care unit equipment includes:
 Patient monitoring devices
 Life support and emergency
resuscitation devices, and
 Diagnostic devices.


55

56. 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

57. LIFE SUPPORT AND EMERGENCY
RESUSCITATION DEVICES
 Mechanical Ventilator
 Laryngoscope
 Airway
 Infusion pump
 Crash cart(Resuscitation cart)
 Intra aortic balloon pump
 Cardiac pacing
 Defibrillator
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58. DIAGNOSTIC EQUIPMEN T

 Mobile x-ray units
 Portable clinical laboratory devices,
 Bronchoscope
 Colonoscope
 Endoscope
 Gastroscope


58

59. 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

60. Patient Monitoring Techniques
Vascular catheterization
Electroencephalography
Pulse oximetry
ICP monitor
Bedside Monitor



60

63. 3.CARDIAC PACING
Cardiac Pacing is
the repetitive
delivery of very
low electrical
energies to the
heart to initiate
and maintain
cardiac rhythm.

63

64. METHODS
Percussive pacing
Transcutaneous
Epicardial
Transvenous
Permanent pacing
64

65. CVP, PCWP AND GCS

66. CENTRAL VENOUS
PRESSURE

67. 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

68. 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

69. Indication to measure CVP
•Hypovolemic patients
( trauma patient, severe diarrhoea, dehydration,
hypovolemic shock)


•Myocardial dysfunction
(myocardial failure, MI, cardiac temponade,
pulmonary failure)

70. WHAT IS A CENTRAL LINE
It is a catheter that
provides venous
access via the superior
vena cava or right
atrium

71. 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

72. 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

73. 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

74. 10
8

77. 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.

79. 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)

80. 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.

81. TYPES OF CENTRAL LINE
SINGLE LUMEN

DOUBLE LUMEN

TRIPLE LUMEN

QUADRUPLE LUMEN

82. Right position to keep the tip
of catheter
At the junction of
superior venacava
and right atrium.
Seldinger technique
is used in CVP Cannulation

83. 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.

84. Head turned to left,
Trendelenberg
position, two heads
of
sternocleidomastoid

87. 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

88. Catheterization Kits

89. Injection Cap
Pigtail or
lumen luer
connector
Individual lumens or pigtails
Catheter juncture
hub
Pigtail or
lumen slide
clamp

90. 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.

91. 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 4
th
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

93. 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

94. 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

95. 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)

96. 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.

98. 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)

99. 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

100. CVP decreases with:
Hypovolemia, hypovolemic shock from
hemorrhage, fluid shift, dehydration
◦Deep inhalation

101. 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:

102. 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.

103. 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

104. 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

105. 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.

106. 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.

107.  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

108. COMPLICATIONS FOLLOWING CVP
LINE INSERTION
Malposition of the catheter
Haematoma
Arterial puncture, cardiac puncture
Pneumothorax, Hemomothorax
Haemorrhage
Air emboli, Thrombosis
Cardiac temponade
Cardiac arrhythmias


.

109. Cont…
Sepsis
Carotid Artery Puncture
Perforation of SVC or R. Atrium/Ventricle
Pleural Effusion
Allergic reaction to catheter material
Thrombophlebities
Cardiac puncture

110. PULMONARY CAPILLARY

WEDGE PRESSURE

112. PCWP
Pulmonary capillary wedge pressure
(PCWP) provides an indirect estimate of
left atrial pressure (LAP).

Normal PCWP 8-10mm Hg

113. 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.

114. 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.

116. 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.

117. 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.

118. 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

121. COMPLICATION OF PCWP
Pulmonary infection
Pulmonary artery rupture
Pulmonary infraction
Catheter kinking
Dysarrythmias
Air embolism

122. Glasgow Coma Scale

123. 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.

124. 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

125. 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).

126. •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

127. 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)

128. Best Verbal Response (5 - 1)

Verbal response assesses consciousness by
determining whether a person is aware of
him/herself and the environment.

129. Best verbal response (V)


1=No verbal response
2=Incomprehensible sounds.
3=Inappropriate words
4=Confused.
5=Oriented.

130. 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?

131. Confusion (4)

A patient may be able to hold a conversation
with the observer but responses are
inappropriate or disoriented.

132. Inappropriate Speech (3)


Does not carry on conversation, poor
attention span, uses inappropriate words
and phrases.
 Random/confused/repetitive.

133. 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.

134. Best Motor Response (6 – 1)

6= Obeys commands
5= Localises to pain
4= Withdraws from pain
3= Abnormal flexion
2= Extension
1= No response

135. 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.

136. 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

137. 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

138. 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.

139. Abnormal Flexion

140. 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.

141. Extension

142. Severe, with GCS ≤ 8 - that is also a
generally accepted definition of a coma
Moderate, GCS 9 - 12
Minor, GCS ≥ 13.

143. •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.

144. 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.

145. ANY QUERIES???

146. THANK YOU!!!