24 Critical Care Emergencies

Unconscious Patient

The aim is to resuscitate the patient and treat urgent precipitating conditions

while a picture of the situation is built up. The definitive diagnosis may not be

made in the ED.

MANAGEMENT

1 Manage the patient in a monitored resuscitation area, and call the senior ED

doctor immediately.

(i) Clear obstructing material using a tongue depressor or

laryngoscope blade if the patient is unconscious with a noisy

airway, and remove broken dentures, vomit or blood with a

Yankauer sucker.

(ii) Improve airway opening using a head tilt, chin lift and or jaw

thrust

(a) open the airway with the jaw thrust alone in trauma cases,

avoiding any movement of the neck.

(iii) Insert an oropharyngeal airway and give high-dose oxygen via a

face mask. Attach a cardiac monitor and pulse oximeter to the

patient and aim for an oxygen saturation above 94%.

2 Commence cardiopulmonar y resuscitation if no pulse is felt (see p. 2).

3 A n a ir way-sk i l led doctor shou ld now inser t a n endot rachea l tube if t here is a

reduced or absent gag ref lex and an unprotected airway, using a rapid

sequence induction technique (see p. 467).

4 Otherwise:

(i) Apply a semi-rigid collar if there is any suggestion of face, head

or neck trauma, before moving the patient.

Tip: beware patients who are neutropenic from chemotherapy,

malnourished, elderly, diabetic, have HIV or are otherwise

immunosuppressed, as they have few signs of sepsis. Fever may be

minimal, focal features few, and only a non-specific inflammatory

response is found in the laboratory tests. Immediate blood cultures and

empirical antibiotics are essential.

✓

UNCONSCIOUS PATIENT

Warning: never attempt rapid sequence induction (RSI) unless you have

been trained. Use a bag-valve mask technique instead, while waiting for

help.

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