A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body weight, height; further:
- Inspection (viewing).
- Skin [swelling of skin due to hives?, blistering if any?, necrosis if any (death of cells/cell death)]Note: The length of the welts on the skin caused by the tentacles provides information about the degree of poisoning.
- Neck veins
- Congested? (→ cardiogenic shock/ shock caused by pumping failure of the heart).
- Angioedema due toanaphylactic shock (bulging elastic swellings (eg, in the facial area: lip, cheeks, forehead) that appear suddenly and disfigure the appearance)]
- Auscultation (listening) of the heart.
- Auscultation of the lungs [bronchospasm/cramping of the muscles surrounding the airways].
- Inspection (viewing).
Square brackets [ ] indicate possible pathological (pathological) physical findings.
Glasgow Coma Scale (GCS) – scale for the estimation of a disorder of consciousness.
Criterion | Score | |
Eye opening | spontaneous | 4 |
on request | 3 | |
on pain stimulus | 2 | |
no reaction | 1 | |
Verbal communication | conversational, oriented | 5 |
conversational, disoriented (confused) | 4 | |
incoherent words | 3 | |
unintelligible sounds | 2 | |
no verbal reaction | 1 | |
Motor response | Follows prompts | 6 |
Targeted pain defense | 5 | |
untargeted pain defense | 4 | |
on pain stimulus flexion synergisms | 3 | |
on pain stimulus stretching synergisms | 2 | |
No response to pain stimulus | 1 |
Assessment
- Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
- If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
- With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.