EKG case: Patient with reduced consciousness, neck rigidity

What's your assessment and care for a patient who had a headache the night before and now has a GCS of 9?


Article updated August 3, 2017

Your morning unit inspection is interrupted by the pager alerting Medic 1 to the scene of a 41-year-old female with an altered level of consciousness. You arrive to find a female lying supine on a bed. According to her husband, she has been minimally responsive since the early morning after failing to wake up. The husband called 9-1-1 and continued to monitor his wife until you arrived.

Patient presentation: Minimally responsive female

The patient has an open airway and does not have labored breathing. The skin is warm and not diaphoretic. There is no evidence of trauma.

A quick neurological exam reveals a Glasgow Coma Scale of 9 based on spontaneous eye opening, withdrawal to pain and no verbal response. 

The husband tells you that she only complained of a headache the night before, for which she took 1g of acetaminophen and went to bed. He denies that she has any recent history of illness, fever or trauma. A quick blood glucose test reveals 96 mg/dL of glucose.

Pupils are equal but slowly reactive. There is no evidence of track marks suggestive of drug abuse, no history of alcohol or drug intake.

Patient's vital signs:

Heart Rate: 57 bpm
Respirations: 24 rpm
Blood Pressure: 160/100 mm Hg
SpO2: 97 percent

Past Medical History: 

None

Allergies: 

None

Meds: 

None

Initial EKG (click for larger image):

The following EKG is obtained:

This is the EKG that you are given. The computed interpretation is not available. Make sure to follow a standarized process for 12-lead EKG interpretation.

Patient treatment considerations and questions

As the patient is moved to the stretcher, you note the patient’s reaction to pain upon eliciting flexion of the neck and some resistance and rigidity. Nonetheless, you move the patient to the stretcher. You start an IV. Medical command is contacted and the EKG is transmitted for review.

Consider these questions about the patient's condition and best course of treatment.

  • Why would a patient with a diminished level of consciousness present with neck rigidity?
  • What could be a probable differential diagnosis for this patient?

Patient follow-up: Use a 12-lead EKG to determine causes of reduce LOC

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