Management of unconscious patient

Question 1

Describe outline of management of unconscious patient (of unknown cause)

Answer 1

Upon approach: Check for danger, check responsiveness - shout, sternal rub

1. Maintain airways –> DR ABC –> check airways clear, listen for breathing. Provide O2 via face mask. Intubate if vomiting / laboured breathing.
2. Ensure circulation stable –> chest compressions (CPR) if necessary
3. Ensure airways and circulation stable. Check vitals - pulse, temperature, BP
4. Hx from witness, or examine patient for evidence of medical condition bands (e.g. diabetes, epilepsy, etc.)
5. Examine patient: Rate / rhythm of breathing. Pupillary constriction/dilation. Neck stiffness. Rashes. Skin turgor / mucous membranes (dehydration). Heart / lung auscultation. Limb responsiveness. Look for IVDU injections, DM injections. Reflexes.
6. Consider Coma Cocktail - “TONG”
   
   • Thiamine 100mg IM or IV
   • Oxygenation
   • Naloxone 0.1-0.2mg IM or IV
   • Glucose –> 50ml of 50% dextrose IV (or as per guidelines)

Question 2

Management of known opioid overdose (e.g. heroin)

Answer 2

Pt will be hypoventilating and pupils constrictred

1. Check responsiveness - sternal run
2. Check airways open
3. Give O2 via face mask, intubate if necessary (probably is). Provide positive airway pressure with O2 delivery bag if no pt respiratory effort.
4. Naloxone 0.4mg IV STAT –> repeat after 3 mins if necessary
   + Naloxone 0.4mg IM (to aintain cover)

Question 3

Management of benzodiazepine overdose

Answer 3

1. Responsive? sternal rub
2. Check airways, respiratory effort, cardiovascular integrity
3. Face mask high-flow O2, and intubate if needed
4. FLUMAZENIL 0.2 mg IV
   Followed by 0.3-0.5mg boluses every 1-2 minutes (with caution) until response is observed

Question 4

Important key areas for examining a patient after a ‘funny turn’

Answer 4

Evaluate mental state - especially anxiety

Evidence of anaemia (eyes), alcohol or other drug use

Signs of infection (temperature), rashes, general illness symptoms

If suspect TIA (or other cerebrovascular event) –> Listen for carotid bruits, feel carotid arteries, inspect ocular fudus

General CV examination: pulses, BP (lying, sitting, standing), heart sounds (elicit aortic regurgitation murmur with dynamic manouvre)

Question 5

Investigations & what you’re looking for after a ‘funny turn’

Answer 5

Temp - Infection?

Pulses - cardiovascular status?

BP lyding, siting & standing - postural hypotension? hypotensive (blood loss?)

FBC - anaemia? Polycythemia? Infection?

BSL - diabetes? hypoglycemia?

PTT, APTT, INR - increased coagulability?

U&E - electrolyte disturbances? high urea in dehydration?

ECG - arrhythmias? Ischemic damage?

24-ambulatory ECG - to find any arrhythmias

Imaging:
Carotic doppler scan - carotid artery stenosis?
CT scan
MRI scan - both to show any signs of haemorrhage, ischemic damage
CT angiography - stensosis of vessels
Cervical x-ray - cervical spondylitis impinging on vertebral vessels?

EEG - sleep disorders, e.g. narcolepsy

PET brain scan (waaaay down the line if necessary) – Can show localised brain dysfunction where other scans do not

Question 6

Likely causes of ‘funny turn’ or blackout in children?

Answer 6

Febrile seizures – temperature, infection.

Absence epilepsy – unresponsive, vaguing out, often noted by teachers, multiple attacks per day possible

Complex partial seizures (disturbed consciousness and perception. Can involve lip-smacking, unresponsive to commands, pacing around, absence, hallucinations, affective feelings - fear, anxiety, anger – usually 1-3 mins)

Tonic clonic seizures

Infantile spasms (implications for cognitive development)

Benign rolandic epilepsy (gluging sound due to face and mouth/throat dysfunction during sleep. Peaks at 5-8 years, may progress to tonic-clonic epilepsy later in adolescence or remission in adolesence. Diagnosis best with EEG, Treat with carbamezapine)

Question 7

Diagnostic dillemmas when considering a child with ‘funny turns’?

Answer 7

Night terrors

Tics of tourettes

Breath holding syncopal episodes - often after episodes of crying

Early signs of neurological problems - e.g. cerebral palsy

Question 8

Important causes of convulsive seizures?

Answer 8

Epilepsy
Cerebral hypoxia
Hypoglycemia
Infection - CNS
Poor cerebral perfusion
Neurotrauma
Toxins
Alcohol excess
Hyperthermia
Metabolic disorders
Drugs
Anaphylaxis
Brain lesions - expanding - neoplasm, haematoma