A A A
 

Management of the Unconscious Patient

Management of the Patient with Reduced Consciousness

Primary topic:

Initial management of the patient with reduced consciousness

Secondary topics:

Differential diagnosis
Management of DKA

Curriculum mapping

Foundation programme 7.1 (Core skills in relation to acute illness)

Knowledge

Common presenting symptoms and signs of acute illness
Manages patients with impaired consciousness including those with convulsions
Clinical interpretation of acutely abnormal physiology
Safe oxygen therapy

Competencies

Promptly assesses the acutely ill or collapsed patient
Protects airway in an unconscious patient
Responds appropriately to abnormal physiology
Reassesses appropriately

 

Foundation programme 7.2 (Resuscitation)

Knowledge

Contents of advanced life support

Competencies

Able to initiate resuscitation at advanced life support level

 

Foundation programme 7.3 (Management of the “take”)

Knowledge

Indications for urgent investigations and therapy
When to seek help and from whom

Competencies

Able to prioritise
Interacts effectively with other health care professionals
Keeps patients and relatives informed
Receives and makes referrals appropriately
Delegates effectively and safely
Performs safe handover

Learning Objectives

At the end of this session the doctors should be able to:
In scenario role;
Confidently assess an acutely ill patient using the ABCDE approach
Protect the airway of the unconscious patient
Formulate a differential diagnosis
Initiate appropriate initial management
Reassess after intervention
Appropriately handover to a colleague

In observation role;
Critique colleague performance

In debrief;
Discuss different approaches to the clinical problem

Discussion topics

Airway management
Differential diagnosis for patient admitted unconscious
Triggers of DKA
Management of DKA

Scenario

A male in his early twenties is brought to the ED resuscitation room by police. He was initially picked up by the police as he was thought to be ‘drunk and disorderly’ in the street, vomiting and they thought he smelt of alcohol. He collapsed in the police car and therefore they came to the ED.

 

STAGE

EVENTS

OBSERVATIONS / AVAILABLE RESULTS

EXPECTED ACTIONS

PROMPTS

Initial assessment

 

 

F1 arrives to see the patient.  A nurse is available and has applied monitoring.

 

Patient has reduced consciousness.

Obstructed sounding airway on back with no airway support.

 

Sats: 93% on air

Pulse: 130

BP: 90/50

RR: 30

Temp: 38

 

AVPU = V/P

 

GCS = 10

Eyes open to pain (2)

Localises to pain (5)

Incomprehensible sounds (3)

 

Drowsy and confused

Normal pupils

Doesn’t tolerate oropharyngeal airway.

 

Introduces self

Takes focused but adequate history from the police/nursing staff.

 

Airway:

Asks for high flow oxygen.

Notes ketotic smell.

Assesses airway as partially obstructed but improved with airway opening manoeuvres and suction. 

 

Asks for help with airway.

 

 

Breathing:

Assesses respiratory rate and SaO2

Palpates, percusses and auscultates.

Notes increased RR and low sats.

Notes focal creps.

 

Circulation:

Notes observations.

Asks for cap refill time (6).

 

Disability:

Assesses GCS

Assesses pupils

Assesses for obvious signs of head injury

Asks for BM

 

Encourage to talk to police and nurse and treat as would usually, if doesn’t take much history or hesitant.

 

 

 

 

 

 

 

 

 

 

Initial management

Patient is unconscious.

Sats: 95% on high flow 02

Pulse: 130

BP: 90/50

RR: 30

Temp: 38.1

 

GCS

Eyes open to pain (2)

Localises to pain (5)

Incomprehensible sounds (3)

 

ABG on high flow 02

P02 – 15.5

PC02 – 2.8

HC03 – 13

BE - -10

Hb 14

Lactate 3.8

Optimises airway

 

Applies high flow oxygen

 

Gains IV access

 

Gives IV fluid (N/Saline) over 30 mins and states plans for further fluids

 

Recognises high BM and commences insulin

 

Takes ABG

 

Takes blood for other tests: glucose, renal function, electrolytes, LFTs, clotting, G+S

 

Orders ECG (sinus tachy)

 

 

 

 

 

 

If not done patient becomes more drowsy and hypotensive.

Reassessment

 

 

 

 

 

 

 

 

*if appropriate treatment not given during initial management patient will continue to become more hypotensive and will drop GCS accordingly

Patient more responsive and confused.

 

 

 

 

 

 

 

*patient less responsive

Airway noisier again

BP 100/60

P 120

Sa02 97% on high flow 02

RR 26

Temp 36.8

 

 

 

*BP 85/40

P 130

Sa02 94% on high flow 02

RR 30

Recognises improvement

 

Reassesses ABCDE

 

Looks for potential trigger for DKA (orders CXR, blood cultures, MSU, blood alcohol)

 

*Recognises deterioration

Recognises airway obstruction and continues airway opening manoeuvres which help.

If GCS has dropped below 7 may tolerate oropharyngeal.

Reassesses ABCDE

 

 

 

 

 

 

 

 

 

 

*Nurse can prompt – “He isn’t looking any better doctor, he looks worse”.

Management after reassessment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*if patient deteriorating

Patient more responsive and confused.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*patient unconscious

BP 100/60

P 120

Sa02 97% on high flow 02

RR 26

Temp 36.8

 

 

 

 

 

 

 

 

 

 

 

 

 

*BP 85/40

P 130

Sa02 92% on high flow 02

RR 30

 

Continues high flow oxygen.

 

Gives clear update of situation to seniors.

 

Makes plan for continued insulin, fluids, potassium.

 

Recognises chest infection as trigger and starts appropriate antibiotics for community acquired chest infection

 

Communicates with patient to help their orientation.

 

*Calls for help

Protects airway

Gives high flow oxygen

Gives IV n/saline

Commences insulin

Nurse can prompt “What is the plan Doctor, can he go to the ward?”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Nurse can prompt “Would you like me to give some fluids?”

“Would you like to give anything for this fit?”

“What shall we do about this high BM?”

*.