From the Guidelines
For an unresponsive but breathing patient who collapses in front of the ICU, the best course of action is to immediately call for help and position the patient in a safe position, considering a lateral side-lying recovery position if the airway is patent but at risk of obstruction, as recommended by the 2015 American Heart Association guidelines update for first aid 1. When approaching the patient, it is crucial to assess the situation quickly and ensure the area is safe for both the patient and the responder.
- The patient should not be moved unless the area is unsafe or the patient's airway is compromised, in which case, moving to a safe location or adjusting the patient's position to open the airway is necessary, as indicated by the guidelines 1.
- If the patient is unresponsive and breathing normally, placing them in a lateral side-lying recovery position may be reasonable, as it can help increase total airway volume and decrease stridor severity, according to the 2015 guidelines 1.
- However, if there is suspicion of a neck, back, hip, or pelvic injury, the patient should not be rolled onto their side and instead should be left in the position found, unless this position causes the airway to be blocked or the area is unsafe, as advised by the guidelines 1.
- The most recent guidelines from 2020 emphasize the importance of recognizing cardiac arrest and initiating CPR promptly, but in this scenario, since the patient is breathing, the focus should be on ensuring a patent airway, providing supplemental oxygen if available, and monitoring the patient's vital signs closely, as suggested by the principles outlined in the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.
- It is also essential to perform a focused neurological assessment, including checking pupillary response and Glasgow Coma Scale, and to rule out hypoglycemia as a cause of unresponsiveness, as part of a comprehensive approach to managing the patient's care.
From the Research
Assessment of the Situation
The patient is unresponsive but breathing, having been dropped in front of the Intensive Care Unit (ICU). The best course of action involves assessing the patient's condition accurately and promptly.
Initial Steps
- Check for pulse: According to 2, the accuracy of checking the carotid pulse can be unreliable, even among trained responders. However, it remains a crucial initial step to determine if the patient is in cardiac arrest.
- Give oxygen: If the patient is breathing but unresponsive, ensuring adequate oxygenation is vital. Studies like 3 highlight the importance of oxygenation during cardiopulmonary resuscitation (CPR), though the optimal concentration may vary.
Considerations for CPR and Oxygen Administration
- CPR should be commenced if the patient is found to be pulseless, as indicated by guidelines and supported by studies such as 4, which discusses the limitations of manual pulse checks in pediatric patients.
- Administration of oxygen is critical, as shown in 3, where initial ventilation with room air or higher oxygen levels during CPR resulted in a high rate of return of spontaneous circulation (ROSC) with good neurologic recovery.
Response Time and Team Activation
- The response time of the arrest team is crucial, as demonstrated in 5, where the time from the emergency call to the initiation of CPR and administration of oxygen was evaluated. Prompt action is necessary to improve outcomes.
Decision Making
- The decision to initiate CPR or other interventions should be based on accurate assessment and guidelines. Given the patient's condition (unresponsive but breathing), checking for a pulse and ensuring adequate oxygenation are immediate priorities.
- Moving the patient to the ICU (option D) might be necessary after initial assessment and stabilization but is not the first step.
- Calling for help (option E) is appropriate if not already done, to ensure a team response.
Best Course of Action
Given the information and the context provided:
- Check for pulse and give oxygen seems to be the most appropriate initial response among the options provided, aligning with the need for immediate assessment and intervention to ensure the patient's airway, breathing, and circulation (ABCs) are maintained. This approach is supported by the principles outlined in the studies referenced, particularly the importance of oxygenation and the challenges associated with pulse checks.