What is the initial management of an unconscious patient?

Initial Management of an Unconscious Patient

The initial management of an unconscious patient should follow the ABC approach (Airway, Breathing, Circulation), with securing the airway as the highest priority to prevent hypoxia and subsequent brain damage. 1

Initial Assessment

• Check for responsiveness by gently shaking the patient and asking loudly if they are okay 2
• Immediately activate the emergency response system if the patient is unresponsive 2, 3
• Assess breathing and pulse for no more than 10 seconds 2, 3

Airway Management

• Position the patient on their back if not already in this position 2
• Open the airway using head tilt-chin lift maneuver 2
• Remove any visible obstructions from the mouth, including dislodged dentures, but leave well-fitting dentures in place 2
• The head tilt-chin lift technique is superior for continuous monitoring of breathing compared to the recovery position 4

Breathing Assessment and Management

• Look for chest movements, feel for air with your cheek, and listen at the mouth for breath sounds 2

• If the patient is breathing normally but remains unconscious:

  • Place in the recovery position to prevent the tongue from obstructing the airway and reduce risk of aspiration 2
  • Continue to monitor breathing 2

• If the patient is not breathing normally but has a pulse:

  • Provide rescue breathing or bag-mask ventilation until spontaneous breathing returns 2, 3
  • Give 10 breaths of expired air ventilation 2
  • Apply oxygen to achieve oxygen saturation >90% if available 2

• If the patient is not breathing and has no pulse:

  • Begin high-quality CPR immediately 2
  • Follow the 15:2 compression-to-ventilation ratio 2
  • Compress the chest 4-5 cm at a rate of about 100 compressions per minute 2

Circulation Assessment and Management

• Check for signs of circulation including movement, swallowing, or normal breathing 2
• Check the carotid pulse for no more than 10 seconds 2
• If circulation is present but patient remains unconscious, continue monitoring 2
• If no circulation is detected, begin chest compressions immediately 2

Potential Reversible Causes to Consider

• Hypoxia 2
• Hypovolemia 2
• Hypo/hyperkalemia and metabolic disorders 2
• Hypothermia 2
• Tension pneumothorax 2
• Cardiac tamponade 2
• Toxic/therapeutic disorders (including drug overdose) 2, 3
• Thrombo-embolic and mechanical obstruction 2

Special Considerations for Suspected Drug Overdose

• For suspected opioid overdose with respiratory depression and a definite pulse, administer naloxone while continuing standard care 2, 3
• For benzodiazepine overdose, flumazenil may be considered, but should be administered as a series of small injections rather than a single bolus 5
• Standard resuscitative measures should take priority over antidote administration in cardiac arrest 2, 3

Pitfalls and Caveats

• Do not delay activating emergency response systems while awaiting response to interventions 2, 3
• Avoid spending more than 10 seconds checking for pulse or breathing 2
• Not all unconscious non-trauma patients require immediate tracheal intubation; clinical judgment is essential 6
• When using the recovery position, re-evaluate breathing at least every minute to avoid missing cardiac arrest 4
• Hypoxia from obstructed airways can become life-threatening within 5-6 minutes, causing cerebral ischemia and cardiac arrest 7