The Unconscious Patient: A Comprehensive Guide for Junior Doctors

Introduction

Encountering an unconscious patient can be one of the most challenging situations in emergency medicine. As a junior doctor, it's crucial to approach this scenario methodically, ensuring that no critical detail is overlooked. This blog post will guide you through the essential steps in managing an unconscious patient, focusing on history-taking, examination, investigations, and management, with insights drawn from leading resources.

History-Taking:  Questions to Ask                                            

In cases where the patient is unconscious, obtaining a history can be difficult. However, history from bystanders, family members, or emergency services is invaluable. Key questions to consider include:

Onset and Duration:

·       When was the patient last seen conscious?

·       Was the onset of unconsciousness sudden or gradual?

Preceding Events:

·       Did the patient complain of any symptoms before losing consciousness, such as chest pain, headache, or palpitations?

·       Was there any witnessed seizure activity?

Past Medical History:

·       Does the patient have a history of diabetes, epilepsy, stroke, or cardiac disease?

·       Are there any known psychiatric conditions or history of substance abuse?

Medications and Allergies:

·       What medications is the patient currently taking?

·       Could they have taken an overdose?

·       Are there any known allergies, particularly to medications?

Social and Family History:

·       Does the patient live alone? Any recent significant life events?

·       Is there any family history of sudden death or hereditary conditions?

Examination: What to Look For                        

Thorough and systematic examination is critical in assessing an unconscious patient. The examination should be approached using the ABCDE method:

A - Airway:

·       Ensure the airway is patent. Look for signs of obstruction, such as blood, vomit, or foreign bodies.

B - Breathing:

·       Assess the rate, rhythm, and depth of breathing.

·       Listen for abnormal breath sounds, and check for chest symmetry.

C - Circulation:

·       Measure blood pressure, heart rate, and capillary refill time.

·       Check for signs of hypo perfusion such as pale, clammy skin or cyanosis.

D - Disability (Neurological Status):

·       Use the Glasgow Coma Scale (GCS) to assess the level of consciousness.

·       Examine pupil size and reaction to light. Look for lateralizing signs or neck stiffness.

E - Exposure:

·       Fully expose the patient to look for any signs of trauma, rashes, or needle marks.

·       Check the temperature, as hyperthermia or hypothermia may be contributing factors.

Investigations: What to Order                                  

Choice of investigations should be guided by the history and examination findings. Essential investigations include:

Blood Tests:

·       Glucose: Hypoglycemia is a reversible cause of unconsciousness.

·       Full Blood Count (FBC): To check for infection or anemia.

·       Electrolytes and Renal Function: To assess for metabolic disturbances.

·       Toxicology Screen: If overdose or poisoning is suspected.

·       Liver Function Tests: To assess for hepatic encephalopathy.

Imaging:

·       CT Head: Indicated if there is suspicion of intracranial pathology such as hemorrhage or stroke.

·       CXR: To rule out aspiration pneumonia, pneumothorax, or other thoracic pathology.

Other Tests:

·       ECG: To identify any arrhythmias or ischemic changes.

·       Urine Analysis: To check for infection, ketones (diabetes), or toxins.

Management Plan:                                                                                                                        Steps to Take Management should be tailored to the underlying cause, but general principles include:

Stabilization:

·       Secure the airway, support breathing with oxygen, and maintain circulation with IV fluids or vasopressors if needed.

·       Correct hypoglycemia with IV glucose.

Specific Treatments:

·       If opioid overdose is suspected, administer naloxone.

·       Treat seizures with IV benzodiazepines.

·       Manage elevated intracranial pressure with head elevation, controlled ventilation, and osmotic agents like mannitol.

Monitoring:

·       Continuous monitoring of vital signs, GCS, and pupillary response is crucial.

·       Repeat imaging or investigations as needed based on clinical progression.

Consultation:

·       Early involvement of relevant specialties such as neurology, cardiology, or toxicology may be necessary.

·       Consider ICU admission if the patient remains unstable despite initial management.