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14 Unconsciousness

Unconsciousness

Unconsciousness is a state of unresponsiveness, where the patient is unaware of their surroundings and no purposeful response can be obtained.

Causes of unconsciousness

• The brain requires a constant supply of oxygenated blood and glucose to function. Interruption of this supply will cause loss of consciousness within a few seconds and permanent damage in minutes.
• The causes of unconsciousness can be classified into four broad groups:
• Blood oxygenation problems.Blood circulation problems.Metabolic problems (e.g. diabetes, overdose).Central nervous system problems (e.g. head injuries, stroke, tumour, epilepsy).
• Fainting is a common cause of unconsciousness and may occur when the patient's heart rate is too slow to maintain sufficient blood pressure for the brain. Combinations of different causes may be present in an unconscious patient e.g. head injury patient under the influence of alcohol.

Recognition of unconsciousness

• Assess the collapsed patient's response to verbal and tactile stimuli) talk & touch), ensuring that this does not cause or aggravate any injuries. Give simple commands such as "open your eyes, squeeze my hand, and let it go". Then grasp and squeeze the shoulders firmly to elicit a response. A person who fails to respond should be managed as if unconscious. A patient who shows only a minor response, such as groaning without eyes opening, should be managed as if unconscious.

Positioning an unconscious breathing patient.

• With an unconscious patient, care of the airway takes precedence over any injury, including the possibility of a spinal injury. All unconscious patients must be handled gently and every effort made to avoid any twisting or forward movement of the head and spine.

All unconscious breathing patients are turned onto the side to:

• Establish and maintain a clear airway.Facilitate drainage and reduce the risk of inhaling foreign material.

Principles to be followed when positioning the patient on the side.

Many versions of the side position (also known as recovery or lateral position) exist. When considering the specific position to be used, the following principles should be observed.

• The patient should be in as near lateral position as possible with the head dependant to allow free drainage of fluids.
• The position should be stable.
• Any pressure on the chest that impairs breathing should be avoided.
• It should be possible to turn the patient onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spinal injury.
• Good observation of and access to the airway should be possible.
• The position itself should not give rise to any injury to the patient.
• First aiders should continuously assess for, and manage deterioration.

The Airway

When a patient is unconscious, all muscles are relaxed. If the patient is left lying on their back, the tongue, which is attached to the back of the jaw, falls against the back of the throat and blocks air from entering the lungs. Other soft tissues of the airway may worsen this obstruction. The mouth open but this tends to block, rather than open, the airway.

The unconscious patient is further at risk because of being unable to swallow or cough out foreign material in the airway. This may cause airway obstruction, or laryngeal irritation and foreign material may enter the lungs. For this reason the first aider should not give an unconscious patient anything by mouth, and not attempt to induce vomiting.

If foreign material irritates the vocal cords, a protective reflex muscular spasm prevents the entry of material into the lungs. This may result in partial or complete airway blockage of the entrance to the windpipe with the patient often making an abnormal noise during attempts to breathe. Airway closure due to the spasms can be complete; in this case there is no noise because there is no airflow into or out of the patient. That can persist until the patient becomes blue or unconscious from lack of oxygen. When consciousness is lost, the spasm usually relaxes.

In an unconscious patient, care of airway takes precedence over an injury, including the possibility of spinal injury. All unconscious patients should be handled gently with no twisting or bending of the spinal column and especially the neck. If it is necessary, move the head gently to obtain a clear airway. Where possible, an assistant should support the head when an injured patient is being moved, but no time should be wasted in detailed positioning.

The patient should not be routinely rolled onto the side to assess airway and breathing. Assessing the airway of the patient without turning onto the side (i.e. leaving the patient on the back or in the position in which they have been found) has the advantages of simplified teaching, taking less time to perform and avoids movement.

The exceptions to this would be in submersion injuries or where the airway is obstructed with fluids (vomit or blood). In this instance the patient should be promptly rolled onto the side to clear the airway.

The mouth should be opened and turned slightly downwards to allow any obvious foreign material (e.g. food, vomit, blood and secretions) to drain using gravity. Loose dentures should be moved, but well – fitting ones be left in place. Visible material can be removed by finger sweeps. Case series reported the finger sweep as effective for relieving foreign body airway obstruction in unconscious adults and children aged less than 1 year.

If during CPR the airway becomes compromised, the patient should be promptly rolled onto the side to clear the airway. The patient should then be reassessed for responsiveness and normal breathing and then CPR commenced as appropriate.

Regurgitation is the passive flow of stomach contents into the mouth and nose. Although this can occur in any person, regurgitation and inhalation of stomach contents is a major threat to an unconscious person. It is often unrecognised because it is silent and there is no obvious muscle activity. Vomiting is an active process during which muscular action causes the stomach to eject its contents. In CPR, regurgitation and vomiting are managed in the same way by prompt positioning of the patient on the side and manual clearance of the airway prior to continuing CPR.

If breathing commences the patient can be left on the side with appropriate head tilt. If not breathing normally, the patient should be rolled onto the back and CPR commenced.

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