Chapter 16. The unconscious patient
The unconscious patient is unable to ensure their own safety and in deeper levels of coma may be unable to protect their own airway.
Assessment of the unconscious patient
The first priority is to ensure safety before approaching the patient. Use the SAFE approach and evaluate the ABCs.
If there is any suspicion that the patient may have been a victim of trauma, the neck is immobilised in a rigid cervical collar while the airway is being assessed.
Give high-concentration oxygen, open the airway, check breathing and circulation status.
If there is no cardiac output, then immediately start CPR.
The next stage is to perform the rapid neurological checks – AVPU and assessment of pupillary responses.
DEFG: Don’t Ever Forget Glucose – a capillary glucose level (BM stix) MUST be checked in all unconscious patients.
Take a baseline set of observations and transfer the patient to hospital with monitoring on.
The assessment must be repeated regularly. A change in conscious level is the most important single sign in the assessment of the unconscious patient with a head injury.
AVPU
A – is the patient Alert?
V – is the patient responding to Verbal stimuli?
P – is the patient responding to Painful stimuli?
U – is the patient Unresponsive?
A response by speech or movement scores ‘V’. If there is no response, a painful stimulus is applied. The best stimulus to use is pressure over the supraorbital ridge, above one of the eyes: a response to this stimulus scores ‘P’, no response scores ‘U’.
Signs to look for in the unconscious patient
• Any sign of head injury (protect the C-spine)
• ‘Raccoon eyes’ (base of skull fracture)
• A bitten tongue and urinary incontinence (epileptic fit)
• Pyrexia and rash (meningococcal septicaemia)
• Pinpoint pupils, needle marks and slow, shallow respiration (signs of an opiate overdose. Give naloxone (Narcan) and assess response)
• Empty medication packaging (possible overdose)
• Medi-alert bracelet
• Insulin, needles, glucose monitor (diabetic patient).
Bilateral pinpoint pupils virtually always indicate opiate overdosage (although a brainstem stroke can produce the same appearance). Bilateral dilated pupils are less helpful because there are many potential causes.
A dilated pupil on one side may indicate an expanding intracranial haematoma on the same side.
Further neurological examination
Two other useful neurological checks can be performed: a more detailed assessment of the conscious level of the patient using the Glasgow Coma Scale, and a brief neurological examination to determine if the patient has any areas of localized weakness or paralysis (focal neurological deficit).
Glasgow Coma Scale
The Glasgow Coma Scale uses three areas of patient response to determine a score that indicates coma level: these are eye opening, speech and best motor response.
The highest score (the alert patient) is 15 and the lowest (in deep coma or dead) is 3.
‘Coma’ is defined as a GCS score of 8 or less.
 |
| Figure 16.1. |
| Management of the unconscious patient. |
| Component | Response | Score |
|---|---|---|
| Best motor response | Obeys commands | 6 |
| Localises to paina | 5 | |
| Withdraws from painb | 4 | |
| Flexor response to painc | 3 | |
| Extensor response to paind | 2 | |
| No motor response to pain | 1 | |
| Best verbal response (speech) | Oriented | 5 |
| Confused conversatione | 4 | |
| Inappropriate speechf | 3 | |
| Incomprehensible speechg | 2 | |
| No speech | 1 | |
| Eye opening | Spontaneous | 4 |
| In response to speech | 3 | |
| In response to pain | 2 | |
| No eye opening | 1 | |
| aMoves hand towards pain. | ||
| bMoves away from pain. | ||
| cBends arm at elbow and wrist in response to a painful stimulus. | ||
| dStraightens at elbow and knee in response to a painful stimulus. | ||
| eDisorientated in time, person and place. | ||
| fInappropriate response to question. | ||
| gMoans and groans. | ||
Focal neurological deficit
On close examination of the face, note should be made of a drooping of the smile on one side, indicating a facial paralysis, common in patients who have had a cerebrovascular accident (stroke).
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