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Bedside emergency: Unconscious patients


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CE credit is no longer available for this article. (Expired September 2009)


Originally Posted September 2007

By SALLY BEATTIE, RN, MS, GNP, CS

SALLY BEATTIE is a member of the RN editorial board and is a clinic manager at University of Missouri Hospital and Clinics in Columbia, MO. The author has no financial relationships to disclose. STAFF EDITOR: TERRI METULES, RN, BSN

When a patient loses consciousness, his survival depends on your rapid assessment and quick action. Are you prepared?

Imagine walking down the hall on your way home, and as you stop by to say good night to one of your patients, you find him face down on the floor, or slumped over in bed or in his chair. You know that he was fine 45 minutes ago. Imagine, too, that when you call his name, he doesn't respond. When you shake his shoulder, he doesn't rouse.

You know intuitively that your quick assessment and intervention spells the difference between a swift recovery, disability, or death for your patient. But being able to act on what you know depends on how much you practice and review—and how long it's been since you've had to use these skills.

Without regular practice, emergency skills deteriorate, and that can lead to panic. In the final installment of our bedside emergency series, we'll cover the steps you need to take to potentially save your patient's life when he's "found down."

Your initial response should be automatic

A person's level of consciousness (LOC) is the most sensitive indicator of brain function.1-3 Normal consciousness is a state of being fully aware of oneself and the environment, and the ability to react and respond appropriately.1,2 Any change in LOC is often the first clue to a deteriorating condition.4,5 Unconsciousness is a medical emergency.

When you find an unconscious patient, your first response should be to call a code, immediately. Don't worry about what caused the problem. You can help solve that mystery once the patient's condition is stabilized.

Quickly begin assessing the patient's airway, breathing, and circulation, according to the American Heart Association (AHA) guidelines for basic life support.6 To do this, you'll have to first place the patient supine on a hard surface.6 If he's in bed, place him on a backboard; if he's slumped in a chair, you'll have to ease him to the floor; if he's on the floor, carefully log-roll him onto his back.

Open the airway using the head tilt–chin lift (or jaw thrust maneuver if you suspect head trauma from a fall). If you can see an obstruction, try using a finger sweep to remove it.6,7 If you see nothing, look, listen, and feel for breathing.

When the unconscious patient is breathing spontaneously, you'll be able to see his chest rise and fall, and feel air moving out of his mouth and nose. Count his respirations, and assess his carotid pulse. If both are adequate, place your patient in the recovery, or side-lying, position to prevent aspiration and airway obstruction.1,6 Stay with the patient, and monitor his vital signs until help arrives.

Stabilize the patient, determine the cause

To help stabilize an unconscious patient who's breathing on his own, administer supplemental oxygen, as ordered.8 Apply cardiac monitoring, pulse oximetry, and cerebral oximetry if available. Take a set of vitals. You'll want to monitor your patient's blood pressure, pulse, and respirations at least every 15 minutes. As you assess the individual, inspect the tongue for signs of biting, which may indicate a seizure.

As soon as help arrives, make sure that you have adequate IV access.3 It's best to have two that are large bore—one IV for fluids and another for medications. You'll also want to insert an oral airway to ensure potency and facilitate suctioning.9 Unconscious patients may benefit from a nasogastric tube to prevent aspiration, and an indwelling urinary catheter to manage incontinence and monitor intake and output.8

Because most acute cases of unconsciousness are potentially reversible,1 you'll need to quickly anticipate and facilitate diagnostic testing. The task may seem daunting, given the sheer number of causes. (For a list of possibilities, see the list at the bottom of this page.)

The top three include stroke, traumatic brain injury, and drug intoxication. But other common causes such as hypoglycemia, myxedema, hypoxia, renal or hepatic failure, infection, and seizures all have to be ruled out. 2,3

Anticipate diagnostic tests

The quicker the cause is determined, the faster effective treatment can begin. Knowing your patient's history can help sort through factors leading up to the event. But diagnostic testing and your rapid clinical evaluation are key to appropriate treatment.

Delegate one colleague to draw blood and collect urine samples. You'll need a red top for electrolytes, glucose, bicarbonate, blood urea nitrogen, creatinine, and liver function tests; a lavender top for a complete blood count; and a blue top for a coagulation panel. Send the urine sample off for a tox screen and ketones if the patient's history and physical warrants.

Then, go ahead and arrange for a CT (computed tomography) scan of the head in anticipation of an order. It's the test of choice for the initial evaluation of brain function.1,4 The CT scan can quickly pinpoint damage or disease to intracranial structures. Other tests that may be ordered include an emergent EEG for suspected seizures or a lumbar puncture to rule out meningitis.8

Your job is to assess your patient's LOC as accurately as you can, using a simple tool such as the Glasgow Coma Scale (GCS). His progress or decline will be measured against your initial assessment.

Tips for interpreting the GCS accurately

The GCS is an objective measure made up of three tests.10 You have to score your patient's ability to open his eyes on a scale of 1 – 4; his best verbal response on a scale of 1 – 5; and his best motor response on a scale of 1 – 6, and then add them up. The lowest total score he can get is 3; the highest is 15. (For a review of the GCS, see the list at the bottom of this page.)

Many unconscious patients will score 1 on the best eye opening and verbal response,8 and then up to 6 on motor function, giving them an overall GCS score of 8. These patients generally require mechanical ventilation.

Likewise, there are a couple of other caveats to consider when interpreting this test. For instance, applying pressure to nail beds, although noxious, can elicit a reflexive response that's often misinterpreted as a higher level of function.3-5 A better way to assess a response to pain is to apply firm pressure to the supraorbital area or to squeeze the trapezius or pectoralis major at the back of the neck. Rubbing the sternum, although considered an acceptable alternative, causes soft tissue bruising and should be avoided.

Also, a patient with a complete C5 or C6 spinal cord injury, and no head trauma, should score a 15. That's because he can follow commands. And while it's true that he likely can't wiggle his toes or lift his fingers, this patient can certainly stick out his tongue and raise his eyebrows. The point is that you need to use sound clinical judgment, and remember that the GSC should only be used to assess level of consciousness, not motor function of the extremities.3,11

Signs that can help pinpoint the cause

The patient's breathing pattern may provide clues to the cause of coma.12 For instance, Cheyne-Stokes breathing, which is the rhythmic increase and decrease in depth that's punctuated by regular episodes of apnea, may indicate a brain tumor or trauma, stroke, or carbon monoxide poisoning.12

Biot's respirations are quick, shallow breaths followed by periods of apnea about every four or five cycles. The pattern suggests stroke or trauma with damage to the medulla. It can also be a sign of uncal or tentorial herniation.11,12

Kussmaul's respiration is a rapid, deep labored breathing that indicates metabolic acidosis.11 Hypopnea, an abnormal decrease in rate and depth, suggests hypoxia and points to a buildup of carbon dioxide that often occurs with sleep apnea or drug or alcohol intoxication.12

If the patient's pupils are symmetrical in size and reactive to light, the cause of a coma is almost always metabolic.12 This sign also tells you that herniation is unlikely and neurosurgery may not be necessary.12

Pinpoint pupils (miosis) that are reactive to light indicate narcotic overdose, unless you need a magnifying glass to see the light reaction. In that case the problem may be pontine hemorrhage or infarct.12

When one pupil is dilated and unreactive, it may be a sign of uncal herniation, requiring emergency neurosurgery to fix.12 Oculocephalic reflex, or "dolls eyes" tells you that the brain stem is intact. Turning the head to the right, for instance, should cause the eyes to appear to turn to the left. Prognosis is poor when this reflex is absent.12

What to do if the worst should happen

If your patient stops breathing, but has a pulse, you need to breathe for him, using a bag-valve mask device until help arrives. Give rescue breaths every five or six seconds (10 – 12 breaths per minute).6 This patient should be intubated as soon as possible.

If he becomes pulseless (or had no pulse when you found him), you'll need to start basic life support, according to the latest guidelines.7 Confirm a lack of breathing and pulse in 10 seconds or less.6,7 Deliver two rescue breaths, each over one second with just enough force to see the chest rise so that you prevent gastric distention. Then, quickly begin compressions by placing the heel of your dominant hand over the middle of the sternum on the nipple-line. Place your other hand on top, and compress the chest to a depth of one and a half to two inches for adults.

Aim for a rate of 100 compressions per minute in cycles of 30 compressions: two breaths.7 Do not interrupt CPR to deliver rescue breaths unless you're alone, and when you must check pulses, be quick: Interrupting compressions for longer than 10 seconds is linked to poorer outcomes.

Some patients remain in a coma for weeks

Many patients respond to emergency interventions, but some remain in a coma for days to weeks. If your patient doesn't immediately regain consciousness, you'll need to begin formulating a plan of care aimed at preventing complications from his total inability to care for himself. You'll also have to field questions and concerns from family and friends, provide them with appropriate explanations and emotional support, and help this patient transfer to your hospital's intensive care or a neuro special care unit.

Being the first one to find a patient with an acute alteration in LOC can be a frightening experience. Your immediate actions and skilled nursing assessments and care may literally save his life.


REFERENCES

1. Geraghty, M. (2005). Nursing the unconscious patient. Nursing Standard, 20(1), 54.

2. "Coma and related disorders of consciousness: Introduction." 2007. www.accessmedicine.com/content.aspx?aID=969675. (7 May 2007).

3. Hickey, J. V. (2003). Neurological assessment. In J. V. Hickey (Ed.), The clinical practice of neurological and neurosurgical nursing (5th ed.), (p. 15). Philadelphia: Lippincott Williams & Wilkins.

4. Young, G. B. "Stupor and coma in adults." 2006. patients.uptodate.com/topic.asp?file=genneuro/7735 (14 May 2007).

5. Noah, P. "Neurological assessment: A refresher." 2004. Travel Nursing Today. www.rnweb.com/rnweb/article/articleDetail.jsp?id=120796 (7 May 2007).

6. "2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: Adult basic life support." Circulation. 2005. www.circ.ahajournals.org/cgi/content/short/112/24_suppl/IV-19 (14 May 2007).

7. "Adult Basic Life Support: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations." 2005. www.guideline.gov/summary/summary.aspx?doc_id=8480&nbr=004731. (21 May 2007).

8. Erickson, T. B., Thompson, T, M., & Lu, J. J. (2007). The approach to the patient with an unknown overdose. Emerg Clin North Am, 25(2), 19.

9. Beattie, S. "Placing an oropharyngeal airway." 2005. www.rnweb.com/rnweb/article/articleDetail.jsp?id=144515 (7 May 2007).

10. Denison, D. (2007). Assessment of neurological function. In R. Daniels, L. Hosek, and L. Nicoll (Eds.), Contemporary medical-surgical nursing (p. 1136). Victoria, Australia: Thomson Delmar Learning.

11. Barker, E. (2002). Neuroscience nursing: A spectrum of care (2nd ed.). St. Louis: Mosby.

12. Malik, K., & Hess, D. C. "Evaluating the comatose patient." 2002. www.postgradmed.com/issues/2002/02_02/malik.htm (10 July 2007).


Unconsciousness has many causes

Differential diagnosis of the unconscious patient can be broken down into the following categories. The top three causes are stroke, trauma, and drug intoxication.

Cardiovascular—Sudden cardiac arrest, MI, subarachnoid hemorrhage, intracerebral bleed, pulmonary artery thrombosis
Infectious—Encephalitis, meningitis, sepsis, malaria, aspergillosis
Metabolic —Hyponatremia, hypernatremia, uremia, hepatic encephalopathy, hypomagnesmic pseudocoma
Endocrine —Hypoglycemia, diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic coma, myxedema, hyperthyroidism
Seizures -Post trauma, epilepsy, idiopathic, febrile, electrolyte imbalance, neurodegenerative disorders, toxins
Drugs, side effects—Illicit or prescribed drugs: phencyclidine, heroin, ecstasy, MDMA, alcohol, barbiturates, narcotics, sedatives, general anesthetics, etc. Side effects: serotonin syndrome, Reye's syndrome, neuroleptic malignant syndrome, central anticholinergic syndrome, isoniazid intoxication
Poisons —Carbon dioxide, carbon monoxide, ethylene glycol, acetaminophen
Other —Neoplasm, trauma, Wernicke's encephalopathy, pellagra, hypothermia, psychogenic causes

Sources: 1. Erickson, T. B., Thompson, T. M., & Lu, J. J. (2007). The approach to the patient with an unknown overdose. Emerg Clin North Am, 25(2), 19. 2. Gerahty, M. (2005). Nursing the unconscious patient. Nursing Standard, 20(1), 54. 3. Malik, K., & Hess, D. C. (2002). "Evaluating the comatose patient." www.postgradmed.com/issues/2002/02_02/malik.htm (10 Jul 2007). 4. Young, G. B. "Stupor and coma in adults." 2006. patients.uptodate.com/topic.asp?file=genneuro/7735 (14 May 2007).


Using the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) was developed to standardize observations of a patient's level of consciousness (LOC). It's a quick, objective, and easy way to assess central nervous system function. There are three tests that you must score separately. They are the best eye opening, the best verbal response, and the best motor response. Once you've scored each response, add them together. The best possible score is 15, the lowest is 3.

Best eye opening

4 Spontaneous
3 To speech
2 To pain
1 None

Best verbal

5 Oriented to person, place, and time
4 Confused, but speaking
3 Inappropriate or garbled words
2 Groans and grunts
1 None

Best motor

6 Follows commands
5 Localizes to pain
4 Nonpurposeful movement
3 Abnormal flexion
2 Abnormal extension
1 None

Sources: 1. Denison, D. (2007). Assessment of neurological function. In R. Daniels, L. Nosek, & L. Nicoll (Eds.), Contemporary medical-surgical nursing (p. 1136). Victoria, Australia: Thomson Delmar Learning. 2. Geraghty, M. (2005). Nursing the unconscious patient. Nursing Standard, 20(1), 54. 3. Hickey, J. V. (2003). Neurological assessment. In J. V. Hickey (Ed.), The clinical practice of neurological and neurosurgical nursing (5th ed.), (p. 159). Philadelphia: Lippincott Williams & Wilkins.

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