Emergency Management of an Unconscious Patient

Introduction:

Unconscious patients do not have control over themselves or the environment. Unconsciousness can be caused by temporary or permanent impairment of the brainstem and cerebral hemispheres. Patients can have an altered mental status which includes confusion and disorientation. It can be fatal if the patient falls into a coma and is not given desired treatment on time. Measures to resuscitate, stabilize and support an unconscious patient must be performed soon.

What Is the Pathophysiology of Unconsciousness?

The causes can be differentiated into structural pathology or systemic pathology. A coma is an unresponsive state of a patient defined by no eye-opening stimulation, absent speech, and a failure to obey commands.

The mechanism for coma can be of different types:

1. The first is a diffuse abuse to both cerebral hemispheres of the brain.

2. The second is the disruption of the reticular activating system (regulates sleep-wake transitions) in the midbrain and pons.

3. Most rarely could be a psychiatric disorder.

The thalamus maintains arousal. The thalamus and the ascending reticular activating system can be injured by direct insult or problems arising within the brainstem.

What Are the Causes of Unconsciousness?

Different reasons can cause unconsciousness. The causes can be divided into three categories; these are as follows:

1. Systemic Causes: Seizures, meningitis, hypoglycemia, hyperglycemia, sepsis, malaria, anesthesia, and excess alcohol intake are some of the systemic causes of unconsciousness.

2. Structural Causes: Structural causes such as stroke, thrombosis, inflammation, brain injury, and trauma may lead to unconsciousness

3. Psychiatric Causes: Depression, agitation, confusion.

Unconsciousness or fainting can result from dehydration, decreased blood sugar levels, or temporary low blood pressure in the body.

An unconscious patient can be affected by damage to three main areas of the brain:

1. Bilateral Hemispheric Damage: Brain trauma, and hypoxia, can occur with damage to the bilateral cerebral cortex. It can also result in neuron deaths and an abnormal physiological environment. This is a reversible pattern if systemic abnormalities are corrected on time.

2. Diencephalic or Thalamic Injury: Bilateral thalamic lesions can mimic the result of a bilateral cortical injury as they have nuclei that direct inputs to the brain (cortex).

3. Upper Brainstem Injury: Lesions in the pons and midbrain can result in a coma state as they supervise the activating system.

What Are the Signs and Symptoms of Unconsciousness?

An unconscious person may show the following signs:

• Motionless.

• May come in and out of a coma state.

• Disoriented.

• Confused.

• Inability to respond.

• Unclear speech.

How Is an Unconscious Patient Evaluated?

There are certain things to keep in mind and follow if someone is unconscious. Primary care, history, examination, investigation, and treatment are the four components that should occur concomitantly in case of unconsciousness. The approach employed by the caregiver for unconscious patients is known as the ABCDE (airway, breathing, circulation, disability, exposure) approach.

• Always check for the patient's airway, breathing, and circulation and put the person in a recovery position.

• Turn the person's face up and position them on their back.

• Support the head and tilt it back for air to move freely in and out of the mouth.

The following steps are taken to recover the patient and manage the situation:

1. Taking History: History taking is essential. A patient's previous medical history may provide a diagnostic clue and help in decision-making. Paramedics should watch out for clues, such as drugs, alcohol, or suicide notes near the victim.

2. Examination: The level of consciousness is measured using the Glasgow Coma Scale (GCS). Motor response to a stimulus is assessed in a stepwise approach:

• Verbal Stimulus: Questioning, 'can you hear me?' loudly.

• Tactile Stimulus: Tap or shake hands and face.

• Noxious Stimulus: It should not cause intense injury, like pressure on the nail bed.

A patient is considered to have slipped into a coma when the GCS (Glasgow coma score) is less than eight.

1. Pupil Examination:

• Small pupils less than two millimeters may be opioid toxicity.

• Mid Sized pupils four to six millimeters dilated and unresponsive to light indicate midbrain lesion.

• Pupils dilated more than eight mm indicate drug toxicity or drug overdose.

2. Breathing and Respiratory Examination :

• Deep, difficult breathing indicates severe metabolic acidosis and is commonly associated with diabetic ketoacidosis.

• In the case of an Opiate overdose, shallow with a highly depressed respiratory rate is seen.

• Quick, shallow inspirations, along with regular or irregular periods of cessation of breath during sleep, suggest a lesion in the lower pons of the brain.

• Profound and rapid breaths at a rate of at least twenty-five breaths per minute indicate a lesion in the midbrain.

3. Motor Function: Motor function is examined by muscle tone, movement, patterns, and reflexes.

What Investigations Are Done for Unconscious Patients?

Investigations help in the diagnosis and management of the situation. Before further examination, a bedside blood glucose test is done to exclude hypoglycemia cases. Tests such as complete blood tests, liver function tests, and kidney function tests are done to check the proper functioning of the organs. Brain imaging is vital if the reason for unconsciousness is not known. Computed tomography (CT) is done to assess brain function rapidly.

Electroencephalography (EEG) is performed in suspected cases of non-convulsive status (prolonged seizures that alter mental status) epilepticus, which is more common in older patients. MRI (magnetic resonance imaging) is used as primary diagnostic imaging.

How Is an Unconscious Patient Managed?

Until the cause of the unconsciousness is not clear and known, primary treatment should be started:

• Maintain the oxygen level of the patient.

• Circulation is monitored and maintained.

• Seizures should be treated if patients have any seizure attacks.

• Blood glucose levels are maintained and monitored.

• Respiratory rates are regulated.

What Are the Complications?

The inability to execute emergency treatment in an unconscious patient may result in fatalities such as permanent brain damage, brain injury, coma, pneumonia (infection that inflames the air sacs), and skin ulcer (round open pores that restrict the blood flow).

Conclusion :

A systematic and logical approach is required with the unconscious patient as they are very challenging in immediate care, diagnosis, treatment, and prognosis. Prevention is better than late interventions. Certain conditions that may lead to unconsciousness may need therapeutic interventions to prevent complications. Counseling may prevent complications for patients with drug or alcohol overdoses and suicidal thoughts.