unconscious patient in the scenariosscenarios · patient made full recovery after 4 hours of...
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Unconscious patient in the Unconscious patient in the scenariosscenarios
Craig UrquhartCraig Urquhart
December 2011December 2011
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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
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Causes of Unconscious PatientCauses of Unconscious Patient
TraumaTraumaNonNon-- TraumaticTraumaticHaemorrhageHaemorrhageInfectionInfectionInfarctionInfarctionMetabolic / ToxicMetabolic / ToxicSeizureSeizureOtherOther
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What is the What is the commonest cause of commonest cause of Airway obstruction?Airway obstruction?
UNCONSCIOUSNESSUNCONSCIOUSNESS
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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
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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
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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
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AirwayAirway
How do you know if an airway is obstructed?How do you know if an airway is obstructed?
GurglingGurgling
SnoringSnoring
StridorStridor
ApnoeaApnoea
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Treatment of Airway obstructionTreatment of Airway obstruction
Airway manoeuvresAirway manoeuvres
Head tilt, chin lift, jaw thrustHead tilt, chin lift, jaw thrust
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Airway AdjunctsAirway Adjuncts
SIMPLE ADJUNCTSSIMPLE ADJUNCTSOPA OPA
NPA (unless NPA (unless hxhx ? Basal skull Fracture )? Basal skull Fracture )
ADVANCED ADJUNCTSADVANCED ADJUNCTSLMALMA
ETT ETT
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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?
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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?
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CirculationCirculation
Heart rateHeart rate
Blood PressureBlood Pressure
Capillary refill timeCapillary refill time
Are peripheries warm or cold?Are peripheries warm or cold?
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Types of shockTypes of shock
HypovolaemicHypovolaemicHaemorrhagic Haemorrhagic
DKADKA
GI upsetGI upset
ObstructiveObstructivePTEPTE
PTxPTx
Cardiac Cardiac TamponadeTamponade
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Types of shockTypes of shock
CardiogenicCardiogenicACS ACS
Cardiac ContusionCardiac Contusion
DistributiveDistributiveNeurogenicNeurogenic
SepticSeptic
Anaphylactic Anaphylactic
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DISABILITYDISABILITY
GCSGCS
PupilsPupils
BMBM
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AA
BB
CC
DonDon’’tt
EverEver
ForgetForget
Glucose!Glucose!
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ExposureExposure
TemperatureTemperature
External signs of traumaExternal signs of trauma
RashRash
Neck stiffnessNeck stiffness
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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
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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
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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!
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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?
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AA
BB
CC
DonDon’’tt
EverEver
ForgetForget
Glucose!Glucose!
BM BM –– 1.11.1
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ManagementManagement
DextroseDextrose
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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
D D -- GCS E1 M1 V1GCS E1 M1 V1
Pupils pinpoint size 1, Pupils pinpoint size 1, unreactiveunreactive
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E E -- multiple track marksmultiple track marksinsulin syringe found in toiletinsulin syringe found in toilet
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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
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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
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D D -- GCS E2 M3 V2GCS E2 M3 V2
PERL size 5PERL size 5
BM HiBM Hi
E E -- no external signs trauma / rash / neck no external signs trauma / rash / neck stiffnessstiffness
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ABGABG
HH++ 155155
pOpO22 4040
PCOPCO22 1.51.5
HCOHCO33-- incalcincalc
BEBE incalcincalc
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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
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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
D D -- GCS E1 M5 V3GCS E1 M5 V3
PERL size 7PERL size 7
BM 6BM 6
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E E -- Warm and Warm and vasodilatedvasodilated
Blue tablets found on floorBlue tablets found on floor
Jerking limb movementsJerking limb movements
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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
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ECGECG
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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
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Treatment?Treatment?
NaNa++HCOHCO33-- 8.4 % titrated to normalisation of QRS8.4 % titrated to normalisation of QRS
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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
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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
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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
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What now?What now?
Further history?Further history?
Further examination?Further examination?
Further investigations?Further investigations?
Further management?Further management?
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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
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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
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Further investigationsFurther investigations
CT brain and CT angiogramCT brain and CT angiogram
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ImagingImaging
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Diagnosis Diagnosis –– SAHSAH
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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%
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CTCT--angiogramangiogram
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AnatomyAnatomy
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Infarction Intervention: AngiographyInfarction Intervention: Angiography
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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
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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
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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
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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
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ECG ECG –– normalnormal
CXR CXR –– small lungs ++small lungs ++
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ABGsABGs on 15l Oon 15l O22
H+H+ 9595
pCOpCO22 1919
pO2pO2 99
HCO3HCO3-- 4545
BEBE +12+12
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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?
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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
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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””
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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
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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
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Differential diagnosis?Differential diagnosis?
SAHSAH
Bacterial meningitisBacterial meningitis
EncephalitisEncephalitis
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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
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Questions?Questions?