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Q1: What is the most likely cause of deterioration of GCS in this case?
Hypoxia is the most important preventable cause of obtunded sensorium in a trauma patient. It may manifest in the form of non-purposeful motor responses, and, therefore, is a strong indication for the need for definitive airway. 1 Hypoxia and hypotension are to be ruled out before incriminating intracranial events or drugs (alcohol) as a cause of deterioration in GCS score.
Q2: What should be the next step?
Extubate the patient because the tube is blocked. Oxygenate him with mask, and establish a definitive airway once again.
The cuff of the endotracheal tube was immediately deflated and the patient was extubated. The oral cavity and pharynx were cleaned and he was put on an oxygen mask. He was reintubated with another endotracheal tube and ventilated. Immediately thereafter, a bottle of saline (500 ml) was infused over 15 minutes. After 30 minutes of reintubation his blood pressure improved to 105 mm Hg systolic. Two hours after reintubation and ventilation, his arterial blood gases were: oxygen tension 13.6 kPa, carbon dioxide tension 5.6 kPa, and pH 7.32. About five hours after admission his blood pressure was...