Name of the Condition

• Coma scale, eyes open, to sound, in the field [EMT or ambulance]
• Technical term: R40.2131

Summary

This condition refers to an assessment of a patient's level of consciousness specifically in response to auditory stimuli, used primarily in emergency medical settings. The Glasgow Coma Scale (GCS) is a common tool for measuring this, where a specific score is given based on the patient's ability to open their eyes to sound.

Causes

• Severe head trauma
• Neurological disorders
• Stroke or brain hemorrhage
• Drug or alcohol intoxication
• Metabolic disturbances

Risk Factors

• Participating in high-risk activities (e.g., contact sports, extreme sports)
• Pre-existing neurological conditions
• Advanced age
• History of substance abuse

Symptoms

• Lack of spontaneous eye-opening
• Eye-opening only in response to auditory stimuli

Diagnosis

• Performed using the Glasgow Coma Scale in the field
• Assessment of eye, verbal, and motor responses to determine consciousness level

Treatment Options

• Immediate stabilization in the field by EMT personnel (e.g., ensuring an open airway, proper ventilation)
• Hospital transport for further evaluation and treatment
• Treatments may vary widely depending on underlying cause, such as surgery for traumatic injuries, medication for intoxication, or intensive monitoring for neurological conditions

Prognosis and Follow-Up

• Prognosis depends on the underlying cause and severity of the initial condition
• Regular follow-up and monitoring for improvement or deterioration in consciousness

Complications

• Risk of further brain injury if unmanaged
• Potential for persistent vegetative state or extended loss of consciousness
• Risk of secondary complications such as pressure sores or infections if immobilized for long periods

Lifestyle & Prevention

• Use protective gear in high-risk situations (e.g., helmets in sports, seatbelts in vehicles)
• Avoid substance abuse
• Early management of health conditions that could increase risk, such as hypertension or diabetes

When to Seek Professional Help

• Any incident involving head trauma
• Sudden confusion or inability to respond normally
• Any indication of severe neurological compromise

Additional Resources

• Brain Injury Association of America (www.biausa.org)
• Centers for Disease Control and Prevention (www.cdc.gov/traumaticbraininjury)

Tips for Medical Coders

• Ensure clear documentation of patient response to auditory stimuli
• Avoid confusion with other GCS scores related to different stimuli (e.g., verbal commands, pain)
• Confirm the setting (field assessment by EMT or ambulance) is documented, aligning with R40.2131 requirements