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.
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STAGE |
EVENTS |
OBSERVATIONS / AVAILABLE RESULTS |
EXPECTED ACTIONS |
PROMPTS |
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Initial assessment
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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.
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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.
|
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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
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*Nurse can prompt – “He isn’t looking any better doctor, he looks worse”. |
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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?” |
*.