What is the initial management for an unconscious patient?

Initial Management of an Unconscious Patient

Immediately check for responsiveness by shouting and tapping the patient, then simultaneously assess breathing and pulse for no more than 10 seconds—if no definite pulse is felt or breathing is absent/abnormal (gasping only), begin CPR without delay. 1, 2, 3

Immediate Assessment (First 10 Seconds)

• Check responsiveness by shaking the patient's shoulders and shouting loudly 1, 4
• Assess breathing by looking for chest rise, listening for breath sounds at the mouth, and feeling for air movement with your cheek 1, 2
• Check carotid pulse simultaneously—take no more than 10 seconds total for this assessment 1, 3
• Activate emergency services immediately if the patient is unresponsive, even before completing your full assessment 1, 4

Critical Decision Point: Breathing and Pulse Status

If pulse present but not breathing normally:

• Open the airway using head tilt-chin lift maneuver: place one hand on the forehead tilting the head back while lifting the chin with fingers of the other hand 1, 4, 2
• Remove visible obstructions from the mouth, including dislodged dentures (leave well-fitting dentures in place) 1
• Provide rescue breathing at 10 breaths per minute (one breath every 6 seconds), with each breath delivered over 1-2 seconds and achieving visible chest rise 1, 4, 2
• Reassess pulse every 2 minutes while continuing ventilation 2

If no pulse or gasping only (agonal breathing):

• Begin high-quality CPR immediately with chest compressions at 100-120 per minute, pushing at least 5 cm deep, allowing complete chest recoil 1, 2, 3
• Position hands correctly on the lower half of the sternum: locate where ribs join the sternum, place middle finger at this point with index finger on sternum, then slide heel of other hand down to meet the index finger 1, 2
• Deliver compressions and breaths in a 30:2 ratio if alone, or 15:2 if two rescuers present 1, 2
• Apply AED as soon as available and follow prompts for rhythm analysis 2

Critical Pitfall: Gasping Respirations

Gasping or agonal breathing occurs in 40-60% of cardiac arrest victims and should NOT be considered normal breathing—treat as cardiac arrest and begin CPR immediately 3. This is one of the most commonly missed signs leading to delayed resuscitation.

Airway Management for Breathing Unconscious Patients

If the patient is breathing spontaneously but remains unconscious:

• Place in lateral (recovery) position to prevent airway obstruction from the tongue and reduce aspiration risk 1, 2
• The recovery position should be true lateral with head dependent, stable, avoiding chest compression, and allowing easy observation of the airway 1
• Unconscious patients must be positioned laterally because the tongue slides back and blocks the airway when supine 1, 5
• Maintain continuous airway monitoring—be prepared to reposition supine and restart rescue breathing if respiratory status deteriorates 2

For patients requiring assisted ventilation:

• Administer oxygen to achieve saturation ≥90% (ideally ≥94%) 1, 3
• If pulse oximetry unavailable, administer oxygen empirically to all unconscious patients 1
• Place in semi-recumbent position (head of bed 30-45°) once hemodynamically stable to reduce aspiration risk 1

Specific Considerations Based on Suspected Etiology

Suspected Opioid Overdose

• Administer naloxone while continuing standard resuscitative measures—naloxone is secondary to basic life support, not a replacement 4
• Naloxone can be given IV, IM, or subcutaneously, repeated at 2-3 minute intervals if respiratory function does not improve 4
• Monitor for at least 2 hours after naloxone administration; longer observation needed for long-acting opioids due to resedation risk 4

Suspected Benzodiazepine Overdose

• Secure airway and establish IV access first before considering flumazenil 6
• Initial dose: 0.2 mg IV over 30 seconds, followed by 0.3 mg if needed, then 0.5 mg doses at 1-minute intervals up to cumulative 3 mg 6
• Do not rush administration—awaken gradually to avoid complications 6

Severe Respiratory Acidosis with Gasping

• Immediate tracheal intubation is required for airway protection and ventilatory support 3
• Provide bag-valve-mask ventilation with 100% oxygen (10 breaths/minute) while preparing for intubation 3
• Consider differential diagnosis including recurrent stroke, aspiration pneumonia, medication-related respiratory depression, and post-ictal state 3

Key Pitfalls to Avoid

• Never delay CPR to obtain history or assess for injuries—resuscitation takes absolute priority 2
• Never assume adequate breathing based on chest movement alone; gasping is not effective breathing 3
• Never leave an unconscious breathing patient supine without continuous airway management—lateral positioning is mandatory 1
• Do not exceed 10 seconds for initial pulse/breathing assessment—prolonged assessment delays critical interventions 1, 3
• Avoid excessive ventilation which increases intrathoracic pressure and impairs venous return 2

Advanced Airway Considerations

• Video laryngoscopy is preferred over direct laryngoscopy when resources allow, showing higher first-attempt success and lower complication rates 7
• Limit intubation attempts to three or fewer before declaring failure and considering exit strategies 7
• If intubation fails and patient remains oxygenated, options include temporizing with supraglottic airway, single further attempt with different technique, or front-of-neck airway access 7
• Emergency front-of-neck access using scalpel-bougie-tube technique should occur without delay in "cannot ventilate, cannot oxygenate" scenarios 7