From the Guidelines
When encountering an unconscious patient, EMS providers should immediately assess the patient's airway, breathing, and circulation, and begin CPR if necessary, while also gathering information from bystanders or family members using the SAMPLE history approach. The assessment of the patient's level of consciousness can be done using the AVPU scale (Alert, Verbal, Pain, Unresponsive) 1. Key questions to ask include: What happened before the patient became unconscious? When did the patient last appear normal? Does the patient have any known medical conditions like diabetes, epilepsy, heart disease, or stroke history? Is the patient taking any medications, particularly insulin, anticoagulants, or cardiac medications? Does the patient have any allergies? When did they last eat or drink? Has the patient complained of any symptoms before losing consciousness such as chest pain, headache, or difficulty breathing? Has the patient experienced any recent trauma or falls? Does the patient have a history of substance use? These questions help determine potential causes of unconsciousness such as hypoglycemia, overdose, stroke, cardiac event, or trauma, guiding appropriate interventions 1.
Some important considerations when assessing an unconscious patient include:
- Determining if the patient is in cardiac arrest, and if so, starting CPR immediately 1
- Providing chest compression-only CPR instructions to callers for adults with suspected out-of-hospital cardiac arrest (OHCA) 1
- Using a standardized algorithm or criteria to determine if a patient is in cardiac arrest at the time of emergency call 1
- Considering the use of naloxone in suspected opioid-related respiratory or circulatory arrest 1
- Performing a primary assessment focusing on airway, breathing, circulation, and disability, as unconscious patients require immediate life-saving interventions regardless of the cause 1
It is also important to note that dispatchers should be educated to identify unconsciousness with abnormal and agonal gasps across a range of clinical presentations and descriptions, and provide chest compression-only CPR instructions to callers for adults with suspected OHCA 1. Additionally, the use of audiovisual feedback devices during CPR for real-time optimization of CPR performance may be considered 1.
In terms of specific interventions, EMS providers should provide chest compressions and ventilation for all adult patients in cardiac arrest, from either a cardiac or a noncardiac cause, and consider the use of naloxone in suspected opioid-related respiratory or circulatory arrest 1. The patient's airway, breathing, and circulation should be continuously monitored and managed, and any changes in the patient's condition should be promptly addressed.
From the FDA Drug Label
Midazolam Injection should only be administered intramuscular or intravenous (see WARNINGS) The initial intravenous dose for sedation in adult patients may be as little as 1 mg, but should not exceed 2. 5 mg in a normal healthy adult. Lower doses are necessary for older (over 60 years) or debilitated patients and in patients receiving concomitant narcotics or other central nervous system (CNS) depressants. For deeply sedated pediatric patients, a dedicated individual, other than the practitioner performing the procedure, should monitor the patient throughout the procedure. Doses of sedative medications in pediatric patients must be calculated on a mg/kg basis, and initial doses and all subsequent doses should always be titrated slowly
Key Considerations for Unconscious Patients:
- Dosing: The initial dose for sedation in adult patients may be as little as 1 mg, but should not exceed 2.5 mg in a normal healthy adult 2.
- Monitoring: Continuous monitoring of respiratory and cardiac function is required, and a dedicated individual should monitor the patient throughout the procedure 2.
- Concomitant Medications: Lower doses are necessary for patients receiving concomitant narcotics or other CNS depressants 3.
- Pediatric Patients: Doses must be calculated on a mg/kg basis, and initial doses and all subsequent doses should always be titrated slowly 2.
From the Research
Assessment of Unconscious Patient
When assessing an unconscious patient, EMS personnel should follow the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach 4. This approach is widely accepted in emergency medicine and helps healthcare professionals focus on the most life-threatening clinical problems.
Key Questions to Ask
Some key questions to ask when assessing an unconscious patient include:
- What is the patient's level of consciousness?
- Is the patient breathing normally?
- Is the patient's airway secure?
- Are there any signs of trauma or injury?
- Is there any evidence of opioid overdose, such as pinpoint pupils or slow breathing? 5, 6
Opioid Overdose Considerations
If opioid overdose is suspected, EMS personnel should administer naloxone, an opioid antagonist 5, 7. Naloxone can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Effective ventilation is also crucial in the management of opioid overdose 5.
Airway Management
Airway management is critical in the assessment and treatment of unconscious patients 8. EMS personnel should be trained in airway management techniques, including the use of reversal agents and the assessment and treatment of coingestions and associated complications 6.