Approach to the unresponsive patient
Vital signs
- vital signs include consciousness, breathing and blood circulation
- if only one vital sign fails, failures of the others will ensue
Consciousness
- Consciousness is a mental state in which an individual is fully aware of him-/herself and his/her surroundings, can act according to his/her will and responds adequately to any internal and external stimuli.
source: Ševčík, P. (2014). Intenzivní medicína. Galén.
We divide the disorders of consciousness into:
- quantitative disorders - this is characterised by the reduced patient's ability to respond adequately to the external stimuli
- qualitative disorders - the patient is awake with an inappropriate content of consciousness, i.e. disrupted self-awarenesses, disorientation in time and place
The quantitative disorder of consciousness can endanger the patient's life, especially by airway obstruction
While suffering from the qualitative disorder of consciousness, the patient's airway is usually opened, but the patient's behaviour can be dangerous to him-/herself or others
Unconsciousness
- a mental state that occurs when the central nervous system is malfunctioning
- in general, unconsciousness includes all quantitative disorders of consciousness
- in the narrow sense, we understand unconsciousness as a synonym for coma
- the patient's ability to respond to external stimuli is impaired according to the degree and severity of the disorder of consciousness. In the first aid, we assess the patient's ability to respond to asking and shaking the shoulder
- in the most severe state, the patient does not respond to any external stimuli
- once consciousness is impaired, the muscle tone of the tongue and pharyngeal muscles is decreased
- the root of the tongue could obstruct the patient's airway and thus cause the arrest of the breathing and, subsequently, of the circulation
- there are some states of impaired consciousness in which the simple manoeuvre of opening the airway by head tilt and chin lift ensures the efficient breathing; in these cases, it is enough to tilt the patient's head back and thus keep the airway open until the ambulance arrives
What does the unconscious patient look like?
- his/her eyes are closed, he/she appears to be asleep
- he/she is not moving and is lifeless
- when the rescuer handles the patient, he/she does not either resist or help them
- he/she does not maintain the open airway without any help (we must hold the patient's head in a tilt position)
Among possible causes of unconsciousness with the preserved breathing, we include the following examples:
- alcohol poisoning
- hypo- or hyperglycemia
- head injury
- CO poisoning
- hypothermia etc.
In all listed causes, you can open the airway by tilting the head back and thus save the patient's life.
Breathing
- the process of gas exchange between the organism and the external environment
- the normal respiratory rate of an adult at rest is about 16 breaths per minute
- the unresponsive patient’s muscle tone is decreased, that means that he/she is threatened by the airway obstruction
- before the checking of the breathing, the airway has to be opened by tilting the patient's head back - the procedure helps to pull the soft tissues of the neck and head and thus enables us to open the airway
- we have to look, listen and feel that the patient is breathing
- we check the patient's breathing for no more than 10 seconds; a healthy man should breathe in at least twice in those 10 seconds
- our goal is to determine whether the patient is breathing normally or not
- if the patient is unable to breathe or is not breathing normally, the circulation will stop shortly thereafter (see below)
The procedures used for opening the airway or checking the breathing will be further discussed in the next chapters of this unit.
Circulation
![Circulation](../pics/obr01_02_01_en.png)
- the circulatory system consists of the blood vessels and the heart
- the failure of circulation can occur when:
- the blood volume is low, i.e. due to massive bleeding (there is not enough blood to be pumped by the heart)
- the heart fails to function as a pump, i.e. due to myocardial infarction (the heart is damaged so it can not pump blood properly)
- circulation is characterised by the following parameters: blood pressure (BP) and heart rate (HR)
- the normal rates of an adult are: HR 60 - 90 beats per minute, BP 120/80 mmHg
- we do not assess the patient's circulation in the SSS ABC approach because:
- if the patient is not breathing, his circulation will fail anyway
- if the patient is breathing normally, his circulation is functioning correctly as well