What is the approach to managing a patient with sudden onset unconsciousness?

Approach to Sudden Onset Unconsciousness

Immediate assessment and high-quality CPR should be initiated for any patient with sudden onset unconsciousness who is not breathing normally or only gasping, as this should be assumed to be cardiac arrest until proven otherwise. 1

Initial Assessment (First 10 Seconds)

1. Ensure scene safety before approaching the patient 2
2. Check responsiveness by shouting and gently shaking the patient 1
3. If unresponsive:
   • Shout for nearby help
   • Activate emergency response system
   • Get an AED and emergency equipment (or send someone to do so) 1
4. Look for breathing and check pulse simultaneously (within 10 seconds) 1

Management Algorithm Based on Initial Assessment

If No Pulse and Not Breathing/Only Gasping:

• Begin high-quality CPR immediately 1
  • Push hard (at least 2 inches/5 cm deep)
  • Push fast (100-120 compressions/minute)
  • Allow complete chest recoil
  • Minimize interruptions in compressions 1
• Perform cycles of 30 compressions and 2 breaths
• Use AED as soon as available 1
  • If shock advised: Deliver shock, then immediately resume CPR for 2 minutes
  • If no shock advised: Continue CPR and check rhythm every 2 minutes 1
• Establish IV/IO access when possible 2
• Administer epinephrine 1 mg IV/IO every 3-5 minutes 1
• For refractory VF/pVT, consider amiodarone or lidocaine 1

If Pulse Present but Abnormal Breathing:

• Open airway using head tilt-chin lift (if no trauma suspected) 2
• Provide rescue breathing: 1 breath every 6 seconds (10 breaths/minute) 1
• Check pulse every 2 minutes; if pulse lost, start CPR 1
• If suspected opioid overdose, administer naloxone if available 1
  • After return of spontaneous breathing, observe patient until risk of recurrent toxicity is low 1
  • If recurrent opioid toxicity develops, repeated small doses or an infusion of naloxone may be beneficial 1

If Pulse Present and Normal Breathing:

• Place in recovery position to prevent airway obstruction 2
• Monitor until emergency responders arrive 1
• Continuously reassess vital signs 2

Special Considerations

Suspected Spinal Injury

• Use manual spinal motion restriction (placing hands on either side of head) rather than immobilization devices 1
• When transferring to a rigid immobilization device, maintain cervical spine precautions 1
• Initial CPR and defibrillation should occur at the location of collapse to avoid unnecessary delays 1

Suspected Opioid Overdose

• For patients with suspected opioid overdose with a pulse but no normal breathing, administer naloxone while continuing standard care 1
• After successful response to naloxone, observe patient in a healthcare setting until risk of recurrent toxicity is low 1

Potential Causes to Consider

Common causes of sudden unconsciousness include:

• Cardiac (sudden cardiac arrest, arrhythmias) 1
• Neurological (stroke, seizure, traumatic brain injury) 3
• Metabolic (diabetic emergencies, hypoglycemia) 3
• Respiratory (hypoxia)
• Toxic (drug overdose) 1

Common Pitfalls to Avoid

1. Delaying CPR to check for pulse in lay rescuers - If a patient is unresponsive and not breathing normally, begin CPR immediately 1

2. Misinterpreting agonal breathing - Seizure-like activity and abnormal breathing or gasping must be treated as cardiac arrest until proven otherwise 1, 4

   • Descriptions of agonal breathing include: difficulty breathing, gasping, wheezing, impaired or occasional breathing 4

3. Delaying activation of emergency response system - For lone rescuers, activate emergency response first, then begin CPR 1

4. Moving patient unnecessarily during resuscitation - External chest compression during transport may be less effective than when stationary 1

5. Fear of causing harm by performing CPR - It is reasonable for laypersons to initiate CPR for presumed cardiac arrest, as the risk of harm is low if the patient is not in cardiac arrest 1, 5

6. Prioritizing medication administration over high-quality CPR - CPR is the single most important intervention for a patient in cardiac arrest 1

By following this systematic approach, healthcare providers can optimize outcomes for patients with sudden onset unconsciousness, focusing on the interventions most likely to reduce morbidity and mortality.