Agree with most correspondents so far. The only real justification for
waiting is if you strongly suspect an ictal origin or poisoning (which you
don't, unless you're thinking of eclampsia but I'm sure that risk has
diminished by two weeks post partum). Intracranial causes (apoplectic,
traumatic and infective) surely top the list. Violent struggling/sedation
are not an excuse to avoid imaging, and, in fact, are positive indications
for imaging, ideal world or not! That said, the struggling confused patient
is at very low risk for aspiration, and I assume she is well oxygenated
although you haven't confirmed this. The other thing about the agitated
patient is that GCS is slightly misleading: they usually have open eyes;
they often verbalise; and it's difficult to assess limb movements
accurately. The agitation itself, rather than any perceived GCS, should form
the basis for any decision to scan. Of course, intubation and ventilation
per se are unlikely to do this particular patient much good, but at least
they will allow you to reach a diagnosis, and to carry out basic
interventions including bloods, ECG, CXR, oxygenation etc. Finally I'd be
careful about being too prescriptive about the age of bruises. Some people
can have remarkably "established" bruises within several hours of injury, so
most likely they relate to her restless struggling at home, rather than an
"assault" from the previous evening.

Adrian Fogarty

----- Original Message -----
From: "Scott, Charles" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, March 02, 2004 10:58 AM
Subject: Case presentation - acute confusion

> 24 year old local woman brought to Emergency Unit by husband who had come
> home from work in the afternoon to find her lying on the floor confused
and
> very restless.   Been doubly incontinent .  Last seen by husband that
> morning as she left the house to take children to school.  Has 5 week old
> baby, normal delivery.
> No known other medical Hx, no known drug or alcohol abuse.
>
> O/E
> Restless++
> Not talking, moaning.  Fights off any touch.   Bruises (?24+ hrs old) on
> both upper arms and sides of head and ear lobes.  Not petechial.  No neck
> stiffness.
> Pulse 125, BP 119/70, resps 24, Temp 37.0; Cap refill <2 secs.  BM 6.4
> Pupils 5mm react to light equally.
> Bloods, ECG, Xray or CT scan unobtainable without violent
struggle/sedation
> so decide to wait and see.
>
> What should I have done?