I have not read each post, but briefly disagree with some interpretations and treatment.
Simplistic enough that it either has to be traumatic or cerebral bleed. Decorticate posturing is a lower response on the pons but not as dramatic as decerebrate posturing. As well, since the pupils are at 3mm and fixed ? Administering Narcan should not be considered as the "coma cocktail" has been outdated for several years. Lortab and other opioid derivatives would produce pinpoint type pupillary response not dilated and fixed. In regards to the posturing type response after Narcan, I truly doubt it was decorticate posturing. Rather I believe it was due to improper administration and dosage of Narcan in a patient with history of analgesics. Again, a foolish treatment regime.
In one of the responses I read where the GCS was 8 and the patient had "snoring respirations". Perform a quick detailed neuro assessment (brachial cephalic response, Babinski reflexes, cornea reflex, uvula mid-line?, cold water tympanic response? ) and prepare the patient for RSI. Sorry, this patient exhibits the inability to maintain airway and intubation should be performed. Maintaining ICP (exhibition of decorticate posturing?) can also assist by sedating the patient and maintaining oxygenation. As well, ICP patients have a bad habit of projectile vomiting. Etiology at this time is really irrelevant at this time, (it would be nice) but realistically it will be assumed a closed head injury (CHI) no matter what (trauma or medically) induced. A CT will verify the true injury and assist in deduction of the cause.
Not having a "large cuff" is not good enough answer not to get a blood pressure. It only comes from those that do not know how to assess patients. Take a forearm, calf, etc blood pressure. Use your brain.
If trauma was suspected, one should see a scalp laceration or hematoma within a few minutes. Scalp injuries are one of the fastest areas to swell and bleed due to the vast circulation.
At this time all the focus should be on airway control and monitoring changes. Neuro changes would not be noted since RSI has occurred, but along with the usual continuation of ECG, EtCo2 (which would change in ICP as well) and changes in variation of pressure and heart rate (Beck's Triad).
If one cannot RSI, then intubation should still be attempted by facilitation of medications (Versed, Valium) etc. Alike above a very detailed neuro examination prior to administration. Continuation of neuro changes and again vital sign changes.
As many like to point out, maintain the ABC's. Due to the obvious signs of obesity, this patient has multiple causes of < LOC. Anything from HTN/head bleed to P.E. ... who knows?
R/r 911
