unconscious patient in the scenariosscenarios · 2019. 7. 17. · unconscious patient in the...

Unconscious patient in the Unconscious patient in the scenariosscenarios

Craig UrquhartCraig Urquhart

December 2011December 2011

ObjectivesObjectives

Understand the management of the Understand the management of the unconscious patient (ABCDE)unconscious patient (ABCDE)

Appreciate that correction of the underlying Appreciate that correction of the underlying cause is important but the basic cause is important but the basic management is the samemanagement is the same

Know the common causes of reduced Know the common causes of reduced conscious levelconscious level

Causes of Unconscious PatientCauses of Unconscious Patient

TraumaTraumaNonNon-- TraumaticTraumaticHaemorrhageHaemorrhageInfectionInfectionInfarctionInfarctionMetabolic / ToxicMetabolic / ToxicSeizureSeizureOtherOther

What is the What is the commonest cause of commonest cause of Airway obstruction?Airway obstruction?

UNCONSCIOUSNESSUNCONSCIOUSNESS

The RulesThe Rules

There can be little or no historyThere can be little or no history

Keeping the patient alive is more important than the Keeping the patient alive is more important than the underlying diagnosisunderlying diagnosis

Every unconscious patient should be approached the Every unconscious patient should be approached the same way same way –– ABCDE ABCDE

Try to find cause and correct itTry to find cause and correct it

Why ABCDE?Why ABCDE?

Problems with the Problems with the AIRWAYAIRWAY will kill you beforewill kill you before

Problems with Problems with BREATHINGBREATHING which will kill you which will kill you before before

Problems with Problems with CIRCULATIONCIRCULATION

With little history, you With little history, you must be the detective must be the detective through examinationthrough examination

The clues are in the ABCDEThe clues are in the ABCDE

AirwayAirway

How do you know if an airway is obstructed?How do you know if an airway is obstructed?

GurglingGurgling

SnoringSnoring

StridorStridor

ApnoeaApnoea

Treatment of Airway obstructionTreatment of Airway obstruction

Airway manoeuvresAirway manoeuvres

Head tilt, chin lift, jaw thrustHead tilt, chin lift, jaw thrust

Airway AdjunctsAirway Adjuncts

SIMPLE ADJUNCTSSIMPLE ADJUNCTSOPA OPA

NPA (unless NPA (unless hxhx ? Basal skull Fracture )? Basal skull Fracture )

ADVANCED ADJUNCTSADVANCED ADJUNCTSLMALMA

ETT ETT

BreathingBreathing

Is the patient breathing?Is the patient breathing?

What is the respiratory rate?What is the respiratory rate?

What is the respiratory pattern?What is the respiratory pattern?

What is the respiratory effort?What is the respiratory effort?

What is the oxygen saturation and is it on or off What is the oxygen saturation and is it on or off oxygen?oxygen?

BreathingBreathing

What causes a high respiratory rate?What causes a high respiratory rate?

What causes a low respiratory rate?What causes a low respiratory rate?

CirculationCirculation

Heart rateHeart rate

Blood PressureBlood Pressure

Capillary refill timeCapillary refill time

Are peripheries warm or cold?Are peripheries warm or cold?

Types of shockTypes of shock

HypovolaemicHypovolaemicHaemorrhagic Haemorrhagic

DKADKA

GI upsetGI upset

ObstructiveObstructivePTEPTE

PTxPTx

Cardiac Cardiac TamponadeTamponade

Types of shockTypes of shock

CardiogenicCardiogenicACS ACS

Cardiac ContusionCardiac Contusion

DistributiveDistributiveNeurogenicNeurogenic

SepticSeptic

Anaphylactic Anaphylactic

DISABILITYDISABILITY

GCSGCS

PupilsPupils

BMBM

AA

BB

CC

DonDon’’tt

EverEver

ForgetForget

Glucose!Glucose!

ExposureExposure

TemperatureTemperature

External signs of traumaExternal signs of trauma

RashRash

Neck stiffnessNeck stiffness

FY1 FY1 -- 30 yr old male, found fitting on ward30 yr old male, found fitting on ward

A A -- gurglinggurgling

B B -- RR 40RR 40

SaOSaO22 96% on 15l O96% on 15l O22

chest clearchest clear

C C -- HR140 HR140 regreg

BP 150/90BP 150/90

CRT 3sCRT 3s

D D -- GCS E1 M3 V1GCS E1 M3 V1

PERL size 5PERL size 5

E E -- no rash / no neck stiffness / no external signs trauma / no no rash / no neck stiffness / no external signs trauma / no obvious seizure activityobvious seizure activity

Initial managementInitial management

A A -- Suction / NPA /OPASuction / NPA /OPA

B B -- Give OGive O22

C C -- Fluid challengeFluid challenge

D D -- DiazemulsDiazemuls 10 mg10 mg

Further GTCSFurther GTCS

What do you do?What do you do?DiazemulsDiazemuls??

LorazepamLorazepam??

PhenytoinPhenytoin??

No improvement on 10mgs No improvement on 10mgs diazemulsdiazemuls

What do you want to do now? He is still fitting!What do you want to do now? He is still fitting!

Further GTCS in EDFurther GTCS in ED

Who do you contact?Who do you contact?

What does this patient need?What does this patient need?

AnaethetiseAnaethetise and ventilate?and ventilate?

AA

BB

CC

DonDon’’tt

EverEver

ForgetForget

Glucose!Glucose!

BM BM –– 1.11.1

ManagementManagement

DextroseDextrose

25 year old male. Found collapsed in toilets of 25 year old male. Found collapsed in toilets of wardward

A A -- GruntingGrunting

B B -- RR 3 / minuteRR 3 / minute

C C -- HR 110 HR 110 regreg

BP 120/70BP 120/70

CRT <2sCRT <2s


Pupils pinpoint size 1, Pupils pinpoint size 1, unreactiveunreactive

E E -- multiple track marksmultiple track marksinsulin syringe found in toiletinsulin syringe found in toilet

Immediate stepsImmediate steps

A A -- head tilt /chin lift / jaw thrusthead tilt /chin lift / jaw thrustOPAOPA

B B -- bag valve mask ventilation with 15l 0bag valve mask ventilation with 15l 022

C C -- IV accessIV accessD D –– BMBM

Drug RxDrug Rx naloxonenaloxone

FY1 FY1 -- 30 yr old male 30 yr old male -- collapsed in wardcollapsed in ward

A A -- PatentPatentB B -- RR 45 / minuteRR 45 / minute

Sa0Sa022 100% on 15l100% on 15lchest clearchest clear

C C -- HR 170 HR 170 regregBP 70/30BP 70/30CRT 6sCRT 6s



BM HiBM Hi

E E -- no external signs trauma / rash / neck no external signs trauma / rash / neck stiffnessstiffness

ABGABG

HH++ 155155

pOpO22 4040

PCOPCO22 1.51.5

HCOHCO33-- incalcincalc

BEBE incalcincalc

DKADKA

A A -- SupportiveSupportive

B B -- SupportiveSupportiveC C -- Fluid Fluid NaClNaCl 0.9% as per protocol0.9% as per protocol

D D -- SupportiveSupportive

Drug RxDrug Rx insulin infusion 6 units / hourinsulin infusion 6 units / hour

FY1 FY1 -- 40 yr old female. Brought to ED feeling 40 yr old female. Brought to ED feeling sick moved to Msick moved to Meedicaldical wardward

A A -- SnoringSnoring

B B -- RR 30RR 30

Sp0Sp022 82% air82% air

Chest clearChest clear

C C -- HR 160 bounding , BCT on monitorHR 160 bounding , BCT on monitor

BP 70/30BP 70/30

CRT 4sCRT 4s



BM 6BM 6

E E -- Warm and Warm and vasodilatedvasodilated

Blue tablets found on floorBlue tablets found on floor

Jerking limb movementsJerking limb movements

ManagementManagement

A A -- Head tilt / chin lift / jaw thrustHead tilt / chin lift / jaw thrust

NPA or OPA?NPA or OPA?

B B -- 15l O15l O22

C C -- ECG ECG

Fluid challengeFluid challenge

ECGECG

ABGsABGs on 15l O2on 15l O2

H+H+ 5050

pCOpCO22 3.53.5

pOpO22 6060

HCOHCO33 1717

BEBE --88

KK++ 4.24.2

NaNa++ 140140

Treatment?Treatment?

NaNa++HCOHCO33-- 8.4 % titrated to normalisation of QRS8.4 % titrated to normalisation of QRS

63 year old male teacher. Found collapsed and 63 year old male teacher. Found collapsed and unresponsive in bathroom by nurse. Last seen unresponsive in bathroom by nurse. Last seen

well 45 minutes previouslywell 45 minutes previously

A A -- MaintainedMaintained

B B -- RR14 / min (irregular)RR14 / min (irregular)

SaOSaO22 99% on 10l O99% on 10l O22 via facemaskvia facemask

Normal breath sounds throughout chestNormal breath sounds throughout chest

C C -- Good capillary refillGood capillary refill

BP 180/98 mmHgBP 180/98 mmHg

HR 110 HR 110 bpmbpm with with ectopicsectopics

D and ED and E

ApyrexialApyrexial

GCS (7/15)GCS (7/15)

Eyes Eyes –– nil (1)nil (1)

Motor response Motor response –– localises pain (5)localises pain (5)

Verbal response Verbal response –– Incomprehensible sounds (1)Incomprehensible sounds (1)

Exposure Exposure –– no signs traumano signs trauma

Initial investigationsInitial investigations

BMBM 5.65.6

ABG ABG –– HH++ 43 43

pCOpCO2 2 5.75.7

pOpO2 2 18.218.2

HCOHCO33-- 23 23

ECG ECG –– Rate 110 with prolonged QTRate 110 with prolonged QT

CXR CXR -- normalnormal

What now?What now?

Further history?Further history?

Further examination?Further examination?

Further investigations?Further investigations?

Further management?Further management?

Further historyFurther history

2 days ago 2 days ago –– occipital headache lasted about 40 minutes occipital headache lasted about 40 minutes and gradually resolved over 1 hourand gradually resolved over 1 hour

Further examinationFurther examination

Neck stiffnessNeck stiffness

FundoscopyFundoscopy –– ??? ??? papilloedemapapilloedema

Pupils Pupils –– 2mm left 6mm right and reactive to light2mm left 6mm right and reactive to light

DollDoll’’s eye reflex intacts eye reflex intact

Corneal reflex intactCorneal reflex intact

Tone in limbs normalTone in limbs normal

Reflexes symmetricalReflexes symmetrical

Bilateral extensor Bilateral extensor plantarsplantars

Further investigationsFurther investigations

CT brain and CT angiogramCT brain and CT angiogram

ImagingImaging

Diagnosis Diagnosis –– SAHSAH

SAH Grade Signs, Symptoms &SAH Grade Signs, Symptoms & SurvivalSurvival

I.I. Asymptomatic or minimal headache and slight Asymptomatic or minimal headache and slight neck stiffnessneck stiffness 70%70%

II.II. Moderate to severe headache; neck stiffness; no Moderate to severe headache; neck stiffness; no neurologic deficit except cranial nerve palsyneurologic deficit except cranial nerve palsy60%60%

III.III. Drowsy; minimal neurologic deficitDrowsy; minimal neurologic deficit 50%50%

IV.IV. StuporousStuporous; moderate to severe ; moderate to severe hemiparesishemiparesis; ; possibly early possibly early decerebratedecerebrate rigidity and rigidity and vegetative disturbancesvegetative disturbances 20%20%

V.V. Deep coma; Deep coma; decerebratedecerebrate rigidity; moribundrigidity; moribund

10%10%

CTCT--angiogramangiogram

AnatomyAnatomy

Infarction Intervention: AngiographyInfarction Intervention: Angiography

Basilar Artery Occlusion: Basilar Artery Occlusion: INS Current ManagementINS Current Management

IV IV rtPArtPA ((alteplasealteplase) 66% of standard dose) 66% of standard dose

IaIa rtPArtPA maximum 20mg maximum 20mg ±± mechanical clot disruptionmechanical clot disruption

IVI IVI eptifibatideeptifibatide 72h minimum72h minimum

ReRe--establish oral aspirin + establish oral aspirin + clopdigrelclopdigrel + + statinstatin ((egegsimvastatinsimvastatin 4040--80mg) as soon as possible80mg) as soon as possible

Clinical progressClinical progress

PostPost--procedure:procedure:

Deficit unchangedDeficit unchanged

Week 4:Week 4:

Speaking intelligiblySpeaking intelligibly

Swallow returned fullySwallow returned fully

Walking with Walking with PhysioPhysio help (AFO on L leg)help (AFO on L leg)

Improved eye movementsImproved eye movements

35 yr old 35 stone male35 yr old 35 stone male

Found collapsed on bathroom floorFound collapsed on bathroom floor

No history availableNo history available

Arrived with 4 paramedics and 2 firemenArrived with 4 paramedics and 2 firemen

On ArrivalOn Arrival

A A -- patent with OPApatent with OPA

B B -- RR 16, decreased AE throughout, Sa0RR 16, decreased AE throughout, Sa022 87% 87% on on high flow O2high flow O2

CC-- HR 120 HR 120 regreg, pulses bounding, , pulses bounding, peripherally peripherally vasodilatedvasodilated, BP 180/100, , BP 180/100, CRT<2sCRT<2s

DD-- GCS E2 M4 V2GCS E2 M4 V2

BM 7, PERL size 5BM 7, PERL size 5

ECG ECG –– normalnormal

CXR CXR –– small lungs ++small lungs ++

ABGsABGs on 15l Oon 15l O22

H+H+ 9595

pCOpCO22 1919

pO2pO2 99

HCO3HCO3-- 4545

BEBE +12+12

Treatment?Treatment?

Sit up!Sit up!

Non invasive ventilation?Non invasive ventilation?

Intubation and ventilation?Intubation and ventilation?

Should we reduce oxygen concentration?Should we reduce oxygen concentration?

Clinical courseClinical course

Patient made full recovery after 4 hours of NIVPatient made full recovery after 4 hours of NIV

Did not collapse, simple fall with ensuing Did not collapse, simple fall with ensuing ventilatoryventilatoryfailure as could not get up from lying flatfailure as could not get up from lying flat

18yr old female found collapsed at home18yr old female found collapsed at home

1 day 1 day h/oh/o headacheheadache

Conversational but irritable that morningConversational but irritable that morning

40 minutes later found collapsed40 minutes later found collapsed

Standby call Standby call ““respiratory rate 6 and GCS 3respiratory rate 6 and GCS 3””

AssessmentAssessment

A A -- patent with OPApatent with OPA

B B -- apnoeic apnoeic –– BVM 15l OBVM 15l O22

C C -- HR 150 HR 150 regreg, BP 60/0, CRT 4s, , BP 60/0, CRT 4s,

6mm ST depression on monitor6mm ST depression on monitor

D D -- GCS E1 M1 V1, pupils fixed and dilated, BM 6GCS E1 M1 V1, pupils fixed and dilated, BM 6

E E -- temp 36.7 C, no neck stiffnesstemp 36.7 C, no neck stiffness

ABG 15l OABG 15l O22 via BVMvia BVM

HH++ 52.752.7

pCOpCO22 4.64.6

pOpO22 77.577.5

HCO3HCO3-- 1616

LactateLactate 4.94.9

Differential diagnosis?Differential diagnosis?

SAHSAH

Bacterial meningitisBacterial meningitis

EncephalitisEncephalitis

TreatmentTreatment

A A -- suppportsuppport airwayairwayB B -- BVM BVM respsresps

prepare to anaesthetise and prepare to anaesthetise and intubateintubateC C -- fluid challenges of fluid challenges of NaClNaCl 0.9% 250ml over 2 0.9% 250ml over 2

minutes and assess responseminutes and assess response

Drug treatment: Drug treatment: ceftriaxoneceftriaxone 2g IV2g IVdexamethasonedexamethasone 10mg IV10mg IVacicloviraciclovir 10mg/ kg IV 10mg/ kg IV

Questions?Questions?

unconscious patient in the scenariosscenarios · 2019. 7. 17. · unconscious patient in the...

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