DERMATOMES & GLASGOW COMA SCALE

QUESTION:
Name the dermatome for the following anatomical landmarks:

Nipple line

Xiphoid

Umbilicus

Inguinal

Groin

Thumb

Pinkie

Clavicle

Anal sphincter

Anterior thighs

Posterior thighs

Anterior calf

Posterior calf

Occiput

Feet

ANSWER:

Nipple line - T4

Xiphoid - T6

Umbilicus - T10

Inguinal - L1

Groin - S2-S3

Thumb - C6

Pinkie - C8

Clavicle - C4-C5

Anal sphincter - S5

Anterior thighs - L2, L3, L4

Posterior thighs - S1, S2

Anterior calf - L4, L5

Posterior calf - S1, S2

Occiput - C2

Feet - L4, L5, S4

How many did you get right?

GLASGOW COMA SCALE

The GCS is a neurological scale to assess level of consciousness of a person for initial and subsequent assessments.  If the patient has a variety of responses during the exam, the clinician should always take the absolute BEST response he or she can elicit from the patient. The scale goes from 3-15 (There is no zero!). With a score of 8 or less, intubate!

QUESTION:

You walk into the room and your patient appears to be asleep breathing very slow and shallow at 6 breaths per minute.  He only opens his eyes when you start calling his name.  When you ask him if he knows where he is at he says "apple, baseball, woof woof".  He won't follow commands for a neurological exam but will try to grab you if you pinch him.  What is his GCS?

ANSWER:

His GCS is an 11.  He is opening his eyes to speech only (3). He is having inappropriate conversation and just stating random words that don't form a sentence (3).  He localizes to pain (5).  Realistically, you wouldn't pinch him if he is moving all of his extremities but not following commands, you would just give him the next score down.

QUESTION:

Your patient has a HR of 56 and RR of 8.  He appears to be unconscious.  No matter how loud you scream his name he doesn't open his eyes.  When you give him nailbed pressure to his hands and feet, he doesn't move any of his extremities but does moan.  What is his GCS? Would you intubate this patient?

ANSWER:

His GCS is a 4.  He has no eye opening response (1).  He makes incomprehensible sounds (2). He has no motor response (1).  According to the GCS criteria, you would intubate this patient.  Realistically, however, it depends.  Is the patient protecting his airway regardless of being unconscious?  Is he ventilating adequately to maintain proper O2 and CO2 levels?  Or can a person with such a low score on eye opening, verbal and motor response even maintain a patent airway?

Glasgow Coma Scale

BEST EYE OPENING RESPONSE:

• 4 - Spontaneous  (as soon as you walk into the room without yet speaking)
• 3 - To speech (only after you call the person's name)
• 2 - To pain (only after painful stimuli such as nailbed pressure)
• 1 - No response

BEST VERBAL RESPONSE:

• 5 - Oriented (Knows name, date/time, location)
• 4 - Confused conversation (May know name but confused on location or situation)
• 3 - Inappropriate words (Stating some words but not forming sentences)
• 2 - Incomprehensible sounds (moaning, making few sounds but no words)
• 1 - No response

BEST MOTOR RESPONSE:

• 6 - Obeys commands
• 5 - Localizes to pain (Moves extremities towards painful stimuli in attempts to stop it)
• 4 - Withdraws from pain (Moves extremities or body away from painful stimuli in attempts to get away from it)
• 3 - Flexes to pain --> decorticate
• 2 - Extends to pain --> decerebrate
• 1 - No response

Remember, 4 eyes, 5 verbal, 6 motor.