「清醒程度字母湯」: AMS, LOC, GCS, AVPU, DDx, STOPEATS, AEIOU TIPS

Jackwabbit

「清醒程度字母湯」
LOC Level of consciousness: 清醒程度, 意識水平;
AMS Altered Mental Status: 意識有變、意識不清，"altered" 雖然是譯做"有變",  通常 AMS 是描述精神狀態變差 ( ↓LOC  ), 但是從來不會用來形容從壞變好 ; 但是也可以用來描述因為精神藥物而引至的 hyperactive state.
前期 AMS 的徵狀是清醒  A/AVPU 或 A&Ox4 ，但包括一些不明顯的行為: withdrawal 回避、lethargic 無生氣 / 遲鈍、anxious 焦慮、cannot concentrate 精神不能集中、confuse 迷亂、combative 好鬥...。

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We won't teach GCS or AVPU here, this reference bank is to clarify some of the key points or confusion of these techniques.

Glasgow Coma Score (GCS) 格拉斯哥昏迷指數
格拉斯哥昏迷指數: http://imsp206.netvigator.com/~norme/Main/IS/Pathology/ComaScale.pdf

Sir Graham Teasdale speaks... the proper way of doing it.
  GCS-Part 1 (Leedsneurosurgery, July 2013): http://www.youtube.com/watch?feature=player_embedded&v=T93Ah9ZkurI
  GCS-Part 2 (Leedsneurosurgery, July 2013): http://www.youtube.com/watch?v=_jTTPjZ_ruE
  
Glasgow Coma Scale at 40:
  The new approach to Glasgow Coma Scale assessment : https://www.youtube.com/watch?v=v6qpEQxJQO4
  THE GLASGOW STRUCTURED APPROACH to ASSESSMENT of the GLASGOW COMA SCALE : http://www.glasgowcomascale.org/
  http://www.glasgowcomascale.org/downloads/GCS-Assessment-Aid.pdf

The differences between GCS-M3去皮質 和 GCS-M2去大腦:
   GCS-M3 去皮質姿勢 decorticate posturing (模擬):
    http://www.youtube.com/watch?v=HbUh3B8RCqg
   GCS-M2 去大腦姿勢 decerebrate posturing (模擬):
    http://www.youtube.com/watch?v=xJ_JclMx-D4
Decerebrate vs. Decorticate Posturing https://www.youtube.com/watch?v=yZUE2Dvf1Q4

記憶口訣:
1.  GCS-M3 去皮質姿勢: “Decorticate” rhymes with “Caught a Cat” – inward movement as in holding the cat tight; 屈曲 or hands "in". (sources ?)
2.  GCS-M2 去大腦姿勢: “Decerebrate” is phonetically similar to “celebrate” – you throw your hands up in the air, extending them; 伸展 or hands "out". (sources ?)
3.  "GCS 8, intubate." is suggested.

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Pain stimulations

在急救的名詞中,  trapezius squeeze (or trap squeeze 斜方肌擠壓法) 有兩個解釋, 請讀者們不要混淆這兩個用法:
1.  在檢查患者的清醒程度時, 用痛楚去刺激患者 P/AVPU, 例如用手指加壓或擰斜方肌... "the trapezius squeeze - which involves gripping and twisting a portion of the trapezius muscle in the patient's shoulder"。  參考: http://en.wikipedia.org/wiki/Pain_stimulus
2.  在限制患者的脊椎移動時, 用雙手按著兩邊的斜方肌, 見下文發表於 2013-8-26:「檢查脊椎受傷」Focused Spine Assessment   http://www.hkcvst.org/forum/forum.php?mod=viewthread&tid=102

Neurological Assessment (Palmer & Knight): http://www.slideserve.com/albert/neurological-assessment-neurological-assessment
OR http://www.authorstream.com/Presentation/heylide-1593845-chapter20/
Slide 18 Pain/Noxious Stimuli: Central / Peripheral stimuli
Slide 19 Painful stimuli: 1. Trapezius muscle squeeze
Slide 20 2. Peripheral pain stimulus: Apply pressure to the edge of the finger, just below the interpharngeal joint.  Do not apply pressure directly over the nail bed.
  
Misinterpreting the Results of a Sternal Rub (J Mistovich, June 2008):
  http://www.ems1.com/ems-products/education/articles/403668-Misinterpreting-the-Results-of-a-Sternal-Rub/
Interpreting a Peripheral Painful Stimulus Response (J Mistovich, Aug 2008):
  http://www.ems1.com/ems-products/education/articles/423367-Interpreting-a-Peripheral-Painful-Stimulus-Response/
Pinching and Sternal Rub: A Cautionary Tale (Larry Mellic, 2013):
  http://www.youtube.com/watch?v=hQRFQEwvMS4&list=UU_yjveGdyx6mqqHkHaD-_bg

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AVPU, 英文讀做 "a-pu", 中文翻譯是「醒, 聲, 痛 , 否/無」。 我們在這裡只會澄清 A 的解釋, VPU 通常不會有太多誤解。
(仲需要少少裝修)
A+Ox4 = Awake, Oriented to Person, Place, Time, Events. 對「人、地、時、事」有認知。
A+Ox3 = Awake, Oriented to Person, Place, and Time.
A+Ox2 = Awake, Oriented to Person and Place.
A+Ox1 = Awake, Oriented to Person.
A+Ox0 = Awake, not oriented.
V = Not awake. Responds to verbal stimulus.
P = Not awake. Responds only to pain stimulus.
U = Does not respond to any stimuli.
Source: https://www.facebook.com/notes/nols-wilderness-medicine-institute/vital-signs-note-the-time-the-vital-signs-are-measured/10150469539811331

AVPU  references 參考資料:
1. The Outward Bound Wilderness First-Aid Handbook, Revised and Updated (Jeffrey Isaac,pg51):  http://books.google.com.hk/books?id=SSPhzelgdKEC&pg=PA52&lpg=PA52&dq=STOPEATS&source=bl&ots=yQB5IwQ_wR&sig=fZCxIryr31MA3X8ZUQUVSuKQ7XY&hl=zh-TW&sa=X&ei=TGsMU7rkBa2IiQfmhYGYAQ&ved=0CEsQ6AEwBA#v=onepage&q=AVPU&f=false
2. Patient Assessment: The Key to Making Critical Wilderness Medicine Decisions (T Schimelpfenig, 2002):
  http://www.nols.edu/alumni/leader/02summer/patientassessment.shtml

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GCS 本來是用來量度在創傷後的 LOC 清醒程度, 但是很難量度在創傷後 ICP 顱內壓 增加的先兆。例如... GCS15, 有頭痛和嘔吐, 及輕微或不易察覺的 "AMS 意識有變"。所以有時話 "Treat the patient, not the number.", 如果只是睇 GCS15, 話係無事就會漏左野。
Here are two famous  "TBI, walk and die" cases..., acutually one died, one still in a coma.  Schumacher ski accident similar to one that killed Natasha Richardson:  http://globalnews.ca/news/1054259/schumacher-ski-accident-similar-to-one-that-killed-natasha-richardson/

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How is AVPU = GCS ?
雖然有下列研究, 但是據筆者所以知, 現時是沒有一個公認的 AVPU 去 GCS 的變換。
1.  Practical use of the Glasgow Coma Scale; acomprehensive narrative review of GCS methodology (Middleton, 2012):
  http://www.researchgate.net/publication/230796635_Practical_use_of_the_Glasgow_Coma_Scale_a_comprehensive_narrative_review_of_GCS_methodology/file/9fcfd50b84f41b8eac.pdf
   A ~ GCS 15     V ~ GCS 13      P ~ GCS 8     U ~ GCS 3

2. Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the GCS (Mcnarry & Goldhill, 2004):
   A ~ GCS 15     V ~ GCS 13      P ~ GCS 8     U ~ GCS 6

3.  According to ATLS: mild 輕度受傷：13-15 分;     moderate 中度受傷：9-12 分;     severe 重度受傷：3-8 分

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Controversies 有爭議性的文章
T Schimelpfenig (2012), Decision Making Tools: Illusions of Objectivity:  http://rendezvous.nols.edu//content/view/2523/964/
Glasgow Coma Scale Must Go, At Least in the ED (ACEP 2011):
   http://www.emsworld.com/news/10335426/glasgow-coma-scale-must-go-at-least-in-the-ed
Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale (SM Green, 2011):
   http://dallenfarmer.com/wp-content/uploads/2012/04/1-s2.0-S019606441100655X-main.pdf

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References 參考資料 (英文)
Life in the Fast Lane: GCS: http://lifeinthefastlane.com/education/ccc/glasgow-coma-scale-gcs/
Altered Mental Status (R Patwari, 2012): http://www.youtube.com/watch?v=2Xiz9ovBMMw

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Jackwabbit

嚴格來說，「診斷」diagnosis 並不屬於急救和救護的「實踐/作業範圍 」Scope of Practice，但是或多或少我們都會做一些「現場診斷」 field diagnosis 去區別出一些我們可以做到的患者處理。  EMS Doesn't "Diagnose"... or Do We?  (WA Maggiore, 2014): http://www.jems.com/article/patient-care/ems-doesn-t-diagnose-or-do-we

DDx differential diagnosis「鑑別診斷 」是有系統地用一個清單去逐步排除不同病患的一種方法。
在荒蕪偏遠的地方 (包括在飛機上或航海旅程), 如果出左事, 就可能要幾個鐘或幾日才能夠送患者到醫院。在這段時間我們希望能夠用這個 DDx 去幫一個 ↓ LOC 的患者。
DDx of AMS or ↓ LOC 清醒程度下降 (Altered Mental Status, 意識不清、意識有變) 的鑑別診斷清單/口訣為: STOPEATS 或 AEIOUTIPS。
DDx 通常是寫 SOAP notes 中 Assessment 的一部份。

有追"怪醫 House" 劇集的朋友們都會對 DDx 的程序有多少認識。
我們可以用劇集的情節公式去解釋一下 DDx 的大致用法:
(a)  Brainstorm 一個可能病患的清單
     ( 我們已經有 STOPEATS / AEIOUTIPS  )
(b)  用臨床徵狀和化驗報告去排除清單中不可能或較少機會的病患
     ( 我們可以用 現場和患者評估, 包括維生指數 / 全身檢查 / SAMPLE 病歷 去排除某一些病患的可能性 )
(c)  從余下的清單中選擇出最容易致死或最有可能的病患 + 對症下藥
     ( 要留意ABC, 我們的藥物 / 處治可以是糖、鹽、水、氧氣、下山 / 加壓包、適當的體溫 ...等等 )
(d)  如無好轉或轉差, 就要選擇清單中下一個最有可能的病患 + 再對症下藥
     ( 如果不能排除可能性, 就可能會幾個病患同時處治。後送或撤離送院也是一個很好的處治方法 )

STOPEATS and AEIOU TIPS are first aid acronyms that lists possible reasons for a patient's changes in mental status, or decreased level of consciousness.  Try to eliminate some of these reasons during scene survey and patient exam/SAMPLE Hx.  The rest will have to remain on your treatment list until you can confirm or rule them out base on the treatment result.  So treat what you can and evacuate as needed.  Evacuate (urgently ?) if you cannot treat the patient,  if there is no improvement after treatment, or if the condition is getting worst .

Sugar 糖- 血糖 blood sugar low or high

Temperature 溫度 - extreme temperatures and/or altered body temperature; hypo or hyperthermia

Oxygen  氧氣 - abnormaly lowl levels of oxygen, hypoxia from suffocation

Pressure 壓力 - increased ICP 顱內壓上升, TBI 創傷性腦損傷, hemorrhagic stroke 出血性中風

Electricity 電 - electric current or lightning, or seizure

Altitude 高海拔 - hypoxia from HAPE, pressure from HACE, or underwater can result innitrogen nacrosis

Toxins 毒素 - drugs (overdose/ think underdose), alcohol/intoxicants, poisons

Salts 鹽 - electrolyte imbalance 電解質不平衡, low sodium or potassium levels, or exertional hyponatremia

Alcohol 醉酒
Epilepsy 腦癇 / seizure
Insulin 胰島素 - 糖尿病聯想至低血糖
Overdose 藥物過量 / Oxygen
Underdose 藥量不足
Trauma 創傷
Infection 感染 - 腦膜炎, 敗血症...
Poisoning 中毒 / Psychogenic 精神因素  
Stroke 中風 / Shock 休克

參考資料:
1. The Outward Bound Wilderness First-Aid Handbook, Revised and Updated (Jeffrey Isaac,pg52):   http://books.google.com.hk/books?id=SSPhzelgdKEC&pg=PA52&lpg=PA52&dq=STOPEATS&source=bl&ots=yQB5IwQ_wR&sig=fZCxIryr31MA3X8ZUQUVSuKQ7XY&hl=zh-TW&sa=X&ei=TGsMU7rkBa2IiQfmhYGYAQ&ved=0CEsQ6AEwBA#v=onepage&q=STOPEATS&f=false
2.  新晉講師趙偉：作為急救醫生獲益匪淺 (2012): http://news.sina.com.tw/article/20140211/11743323.html
3.  Using AEIOUTIPS For Altered Mental States (EMTSpot, 2011): http://theemtspot.com/2011/04/09/using-aeioutips-for-altered-mental-states/
4.  Altered Mental Status (R Patwari, 2012; time 6:40): http://www.youtube.com/watch?v=2Xiz9ovBMMw
5.  EMS Providers Use DDx in Pt Care (Burnett & Page 2012): http://m.jems.com/article/patient-care/ems-providers-use-differential-diagnoses
6.  Advanced Assessment: Critical Thinking Skills (OBHG 2007): http://www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/002-CriticalDecisionMaking11-06.pdf
7.  Paramedic Differential Diagnosis Flowchart ( CSowerbrower, 2009): http://www.naemse.org/Educator-Update/397689/

ACLS Hs & Ts references 參考資料:
高級生命支援術 ACLS 的 Hs & Ts 是超越了野外急救的論題, 有興趣的朋友們請自行查閱這些資料。
5H&5T: 冰酸容鉀氧 – 毒氣填心肺
冰(低溫)  酸(pH)    容(低血容量)   鉀(高/低血鉀)  氧(缺氧)
毒(毒素)  氣(氣胸)  填(心包填塞)  心(心肌梗塞)    肺(肺栓塞)
ACLS Part 3 - 6 H's and 5 T's; presented by Dr. Gallagher's Neighborhood (2011): http://www.youtube.com/watch?v=923lXP4e9Zs

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