Management of the Unresponsive Patient

1. Management of the Unresponsive Patient Tenagne Haile-Mariam MD Michael Levinson, MD GW Emergency Medicine

2. Initial Management Address the ABCDs Airway Breathing Circulation Dextrose

3. Initial Management Airway Open airway Remove obstruction C-spine precautions, if indicated (Modified jaw thrust)

4. Initial Management Breathing Absent respirations BVM Prepare for intubation Spontaneous respirations Is the rate too slow? Assist with BVM Consider naloxone to reverse opioid toxicity Prepare for intubation for definitive management Consider airway adjuncts Nasotracheal airway (semi-conscious/present gag) Orotracheal airway (unconscious/ absent gag)

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8. Initial Management Circulation Pulse Central: Carotid ~60mmHg systolic Peripheral: Radial ~80mmHg systolic Blood Pressure appropriately sized cuff for body habitus End organ perfusion Pulse Oximetry Minimum UOP 50cc/hr on reassessments

9. Initial Management Dextrose/Dexi-stick Easily correctable cause of unresponsiveness If glucometer unavailable: Empiric IV glucose bolus supported by ACEP Assess for response to treatment Naloxone if narcotic overdose suspected

10. Clues to HPI HPI from witnesses (EMS/Acquaintances) Who called EMS to scene? Scene reports from EMS Drug/toxin exposure? Empty pill bottles Suicide note Evaluate for toxidromes follow poisoning algorithm if suspected Rescued from fire? Carbon monoxide Cyanide from burning plastics and clothing Possible head trauma? Fall, MVC, assault

11. Clues to Past Medical History Medic Alert tags? Immunocompromised? HIV/Transplant recipient/ Chemotherapy/ Recent steroid/ Diabetic Seizure disorder? ROS aka �Review of Stuff� with caution for needle sticks! Check pockets, wallet, and belongings for: Pills/bottles Drug paraphernalia Identification Reverse search address for phone number Physician cards Specialty may suggest underlying illness May be able to give background information

12. Search for AEIOU TIPS Physical exam to uncover etiology AEIOU TIPS Alcohol Epilepsy Insulin Overdose Uremia Trauma Infection Psychiatric Stroke/Subarachnoid or Silent MI

13. Physical Clues Vital signs Address abnormals General Signs of trauma Assault or struggle Abnormal odors Toxins Underlying medical conditions Neuro GCS/Pain response Reflexes Increased/Diminished/Absent

14. Physical Clues Eye (the window to the CNS) Pupil Asymmetric: Head CT r/o bleed vs. mass occupying lesion Pinpoint Naloxone for opiate intoxication Consider Head CT for pontine infarct (protect airway) Scleral icterus w/u for hepatic encephalopathy Retina (if possible) Papilledema Head CT to r/o increased cerebral pressures Hemorrhages (subhyaloid) w/u for SAH with Head CT/LP

15. Physical Clues ENT Evaluate for occult head trauma Hemotympanum � basilar skull fracture: CT Head with temporal cuts CSF rhinorrhea � cribiform plate fracture: CT Head Neck Nuchal rigidity � if meningitis suspected CT/LP/ABx Abdomen Guarding/Groaning with palpation: Consider CT vs. surgical consult Ascites/Caput medusa w/u for hepatic encephalopathy +/- SBP Skin Needle tracks w/u for toxin versus infection with possible immunocompromised host Petechial rash w/u for meningococcemia and CT/LP to r/o meningitis

16. AEIOU TIPSSpecial Considerations Alcohol intoxication Classic odor Serum alcohol level and dexi-stick if patient unresponsive ETOH metabolism ~50gm/dL varies by sex, age, experience Serial assessments for improvements in mentation Head CT if patient not improving to rule out occult brain pathology/bleed If other alcohols suspected follow appropriate toxic ingestion algorithm

17. AEIOU TIPSSpecial Considerations Epilepsy Postictal period usually 30 � 60 minutes Search belongings for anti-epileptic pill bottles Check appropriate drug levels (per patient): dilantin, valproic acid, carbamazipine Newer anti-epileptics are �send-out� labs Examples: Keppra, Lamictal, Trileptal, Topamax Hypoglycemic patients will continue to seize despite benzos

18. AEIOU TIPSSpecial Considerations Insulin Always check a fingerstick. EKG to asses for hyperkalemia/hypokalemia Hypoglycemia definitions <60 in adults (<45 in kids) IV dextrose 25-50 gm D50 (D10 or D25 in kids) Follow serum potassium for repeated dextrose boluses Is hypoglycemia due to oral hypoglycemic? admission is recommended Follow serial glucose

19. AEIOU TIPSSpecial Considerations Overdose Suggestive history or classic toxidrome presentation. Follow poisoned patient algorithm ABCs and supportive care EKG, ASA, APAP Chem 7 (Serum Osm and ABG when appropriate) Gastric lavage rarely indicated unless presents under one hour Activated charcoal PO or via NG Antidotes when indicated Psychiatry consult for suicide attempt National Poison center hotline 800-222-1222 Great resource for information

20. AEIOU TIPSSpecial Considerations Uremia Elevated anion gap metabolic acidosis Assess for signs and sequelae on history and physical CVS: Pericarditis/ Effusion/ Friction rub Lung: Pulmonary edema GI: Vomiting Skin: Numerous eccymosis from platelet dysfunction, color yellowish tinge �Uremic frost� uremic fetor smells like stale urine Management: intensive/supportive care/ Renal consult Treat underlying problem

21. AEIOU TIPSSpecial Considerations Trauma Assess for historical and physical clues for occult head trauma Fall, MVC, assault Head CT to evaluate for traumatic hemorrhage. epidural subdural subarachnoid intraparenchymal

22. AEIOU TIPSSpecial Considerations Infection Fever, hHR, iBP, petechiae, hi WBC Greater vigilance in the immunocompromised host Consider early antibiotics Consider diagnoses of meningitis vs. encephalitis Elderly frequently manifest infections with alterations of mental status

23. AEIOU TIPSSpecial Considerations Psychiatric Search for organic cause especially in older populations Delirious patients may not be able to describe disease process in organized fashion Psych patients are at higher risk for overdose Pure catatonia is an extremely rare cause of coma, warranting the search for other causes.

24. AEIOU TIPSSpecial Considerations Stroke, Subarachnoid, Head CT if history or physical suggests intracranial pathology Silent MI Routine EKG and selective ordering of cardiac enzymes to evaluate for cardiac infarction Symptomatic bradycardia or hypotension Therapeutic interventions to consider: Pacing/ Meds/ Lytics/ Cardiac cath

25. Summary Unresponsive patients are notoriously poor historians Activate ABCDs and stabilize patient prior to gathering history from others Use EMS and acquaintances to assist in piecing together story. �Review of stuff� may crack the case Focused physical exam to evaluate for AEIOU TIPS Vitals signs, Dexi-stick, and pulse oximetry in all patients EKG, CBC, Chem 7, Drug levels, Head CT when appropriate