Unconscious patient

Question 1

Define what is meant by an unconscious patient

Answer 1

An unconscious patient is unresponsive to voice or painful stimulus. A GCS of 8 or less.

Note - it is possible for a patient to be conscious but incapable of speech or movement (eg in “locked in” syndrome, or in anaesthetic practice it is possible for a patient to be conscious but unable to respond due to the action of muscle-blocking drugs)

Question 2

List the different causes of unconscious patients

Answer 2

• Drugs (eg overdose, alcohol)
• Neurological disease (eg stroke, subarachnoid haemorrhage, cerebral tumour, post-ictal)
• Trauma (eg head injury)
• Metabolic disorders (eg hypoglycaemia in diabetes, hypothyroidism, carbonmonoxide poisoning)
• Cardiovascular disease (eg dysrythmias, shock)
• Infection (eg meningitis, encephalitis, cerebral malaria)
• Hypoxia or Hypercarbia (eg pneumonitis, airways obstruction)
• Hypothermia
• A induced state during anaesthesia

Question 3

List the general management steps of an unconcscious patient

Answer 3

• Rapid assessment and management of ABCDE. This may include oxygen, securing the airway with an ET tube, ventilation, IV access and fluids, cervical spine protection. Assessment and monitoring of neurological status is clearly important but D comes after AB&C. Students should be familiar with AVPU and GCS scoring.
• A rapid history should be taken once ABC are secured.
• Initiation of appropriate monitoring.
• Initiation of appropriate investigations. These may include: Radiology: chest, c-spine, CT head, Blood (ABG’s, FBC, U&E’s), glucose, drug levels, G&S or cross match. 12-lead ECG, Microbiology: Samples for microscopy and culture.
• Specific treatments may include drug reversal, antibiotics, surgery, and treatment of metabolic conditions or hypothermia.
• Management of the patient in an appropriate setting such as a High Dependency Unit, or Intensive Care. GCS, Pupil size and reactivity should be documented regularly.