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Level 2 of 6Must-remember

The collapsed and undifferentiated patient

Assess, manage and stay safe — enough on its own

The card — assess, manage, caution

Assessment— look, ask, measure

  • Decide which of two patients you have: the one still unresponsive (coma) or the one who went down and got up again (transient loss of consciousness) — "collapse" is a lay description of an event, not a diagnosis, and the two are managed differently after the first minutes.
  • Capillary glucose is the single highest-yield test in this chapter: obtain it within minutes on every collapsed, confused, fitting, weak or apparently "stroke" patient, because hypoglycaemia below 4.0 mmol/L (72 mg/dL) imitates stroke including focal signs, seizure, psychosis, aggression and intoxication, is reversible in minutes and lethal within the hour.
  • Score the Glasgow Coma Scale by component (E, V, M), not as a total: coma is a GCS of 8 or less, minimum 3 and maximum 15, and a falling serial GCS is a diagnosis — it is what identifies an expanding haematoma or worsening oedema.
  • Measure the temperature accurately with a low-reading rectal thermometer where hypothermia is possible, since a standard device simply reports its own floor; a temperature below 36°C in suspected infection is a poor prognostic sign that should raise, not lower, concern about sepsis.
  • Smell the breath for ketones, alcohol, hepatic fetor and organophosphate, and inspect the whole skin front and back for trauma and occult head injury, a non-blanching petechial or purpuric rash, jaundice and stigmata of chronic liver disease, injection marks and transdermal patches, an arteriovenous fistula, and skin blisters over pressure areas that mark the duration of collapse.
  • Read the respiratory pattern: Cheyne–Stokes (alternating hyperpnoea and apnoea) means bilateral hemisphere or upper brainstem dysfunction; Kussmaul deep sighing hyperventilation means metabolic acidosis; a slow shallow rate with pinpoint pupils means opioid toxicity; a falling rate in an exhausted patient is pre-arrest, not improvement.
  • The pupils are the most informative part of the neurological examination: a unilateral dilated pupil becoming fixed to light means third nerve compression from uncal herniation and is a neurosurgical emergency; bilateral mid-point reactive pupils are characteristic of metabolic and sedative coma (opiates excepted); bilateral pinpoint light-fixed pupils mean opiates or a pontine lesion; bilateral fixed and dilated pupils occur in deep coma of any cause — but ask about mydriatic drops and previous iris or cataract surgery.
  • Look for lateralisation — asymmetry of response to visual threat, of facial droop or cheek blowing, of tone, of posturing, of response to pain and of tendon reflexes — remembering that both plantar responses are often extensor in deep coma of any cause and that finding alone means nothing.
  • Danger signs in the unconscious patient: an unprotected airway (snoring, gurgling, silence with visible effort); a respiratory rate under 8 or falling; hypoxaemia not correctable with high-flow oxygen; systolic pressure below 90 mmHg or central capillary refill over 3 seconds; a unilaterally dilating pupil; a falling GCS; new lateralising signs; fever with neck stiffness or a non-blanching rash; seizure beyond 5 minutes.
  • In transient loss of consciousness the witness carries the diagnosis — ask about posture and circumstance at onset, the prodrome, and the speed of recovery, because the physical examination is frequently normal since the arrhythmia has stopped.
  • Syncope almost never occurs in the recumbent posture: loss of consciousness while lying flat, while seated, or during exertion is a seizure or an arrhythmia until proved otherwise.
  • A vasovagal prodrome is long and characteristic — dizziness, nausea, sweating, tinnitus, yawning, blurring or greying of vision and a sinking feeling — whereas cardiac syncope is usually sudden and without warning, though brief light-headedness, palpitation or chest discomfort may precede it, so a short prodrome does not reassure.
  • Record a 12-lead ECG in every case of transient loss of consciousness — it is part of the circulation assessment, not an optional extra — looking for complete or Mobitz II AV block, a pause over 3 seconds, bifascicular or trifascicular block, QTc over 500 ms, pre-excitation, Brugada pattern, ventricular tachycardia, Q waves or acute ischaemia, S1Q3T3, tall tented T waves with a broadening QRS (hyperkalaemia), a broad QRS with a terminal R wave in aVR (tricyclic toxicity), and low voltage with electrical alternans (tamponade).
  • High-risk features after TLoC, any one of which mandates cardiac monitoring: onset during exertion or while supine or seated; absent prodrome or one of palpitation or chest pain; structural heart disease, heart failure, previous infarction or low ejection fraction; sudden cardiac death in a first-degree relative under 50; an aortic stenosis murmur, heart failure or systolic BP below 90 mmHg; haematocrit below 30%; breathlessness; respiratory rate over 24/min; age over 75 with an abnormal ECG; injury sustained without protective reflexes.
  • Test for the coma look-alikes in ten seconds: ask for blinking and vertical eye movement to command in every unresponsive patient, because locked-in syndrome, severe neuromuscular paralysis and psychogenic unresponsiveness all produce an apparently unresponsive patient who is neither comatose nor unaware.
  • In children collapse is different: hypoglycaemia is far commoner because glycogen stores are small, hypotension is pre-terminal, bradycardia is a pre-arrest rhythm caused by hypoxia until proved otherwise, a previously distressed child who becomes quiet and slow is deteriorating rather than settling, and exertional collapse, collapse while swimming or collapse triggered by fright or a loud noise raises the inherited arrhythmia syndromes.

Management— do this, in order

  • Physiology first and diagnosis second — four interventions precede the diagnostic effort because they are both fast and specific: correct hypoxaemia, correct hypoglycaemia, stop a seizure, and treat presumed meningitis or anaphylaxis where suspected.
  • Assume an unconscious patient cannot protect the airway until proved otherwise: position, suction what is visible, insert a correctly sized oropharyngeal airway (incisors to angle of jaw) or a nasopharyngeal airway where the gag is intact (avoided if base-of-skull fracture is possible), and place any unconscious breathing patient not about to be intubated in the left lateral recovery position.
  • Oxygen at high flow, titrated to 94–98%, or 88–92% where chronic type 2 respiratory failure is known or suspected — hypoxaemia is never left uncorrected out of concern for carbon dioxide; definitive airway protection is indicated for GCS 8 or less not immediately reversible, a soiled airway outstripping suction, stridor or airway burn.
  • Circulation: two large-bore cannulae, bloods on insertion, and a fluid challenge of 500 mL of balanced crystalloid or 0.9% sodium chloride over 15 minutes (250 mL if elderly, small or in known heart failure), reassessing pulse, pressure, respiratory rate, chest auscultation and mental state after every bolus; in septic shock the target is approximately 30 mL/kg within the first hour, and paediatric boluses are 10 mL/kg over 10–20 minutes reassessed for hepatomegaly, new crackles and rising respiratory rate before repeating.Doctor / Nurse
  • Hypoglycaemia (glucose below 4.0 mmol/L): 20% glucose 100 mL IV over 10–15 minutes into a large vein, or 10% glucose 150–200 mL IV; in a child 10% glucose 2 mL/kg IV/IO (neonate 2.5 mL/kg), and never 25% or 50% glucose peripherally in a child.Doctor / Nurse
  • Hypoglycaemia with no IV access: glucagon 1 mg IM — ineffective in starvation, alcohol dependence or hepatic depletion; in a child 0.5 mg IM if under 25 kg and 1 mg if 25 kg or more.
  • Thiamine 100 mg IV slowly, or high-potency parenteral B-complex, before or with glucose in thiamine deficiency, alcohol dependence or malnutrition; the paediatric dose is 10–25 mg IV.Doctor / Nurse
  • Opioid toxicity (rate under 8, pinpoint pupils): naloxone 400 micrograms IV, repeated every 2–3 minutes to 2 mg, titrated to respiratory rate and not to wakefulness, starting at 100 micrograms if opioid-dependent; in a child 10 micrograms/kg IV/IO to a maximum of 400 micrograms per dose, repeated.Doctor / Nurse
  • Seizure beyond 5 minutes: lorazepam 4 mg IV, repeated once at 10 minutes; alternatives are buccal midazolam 10 mg or diazepam 10 mg IV or per rectum; in a child lorazepam 0.1 mg/kg IV (maximum 4 mg) or buccal midazolam 0.5 mg/kg (maximum 10 mg), repeated once.Doctor / Nurse
  • Suspected bacterial meningitis: ceftriaxone 2 g IV plus dexamethasone 10 mg IV with or just before the first dose, adding amoxicillin 2 g IV if over 55 years, pregnant or immunosuppressed (for *Listeria*); in a child ceftriaxone 80 mg/kg IV daily, and in neonates under 28 days cefotaxime plus amoxicillin (avoid ceftriaxone in jaundice and with calcium-containing fluids).Doctor / Nurse
  • Suspected encephalitis: aciclovir 10 mg/kg IV 8-hourly in an adult, 20 mg/kg IV 8-hourly in a child.Doctor / Nurse
  • Anaphylaxis: adrenaline 500 micrograms IM (0.5 mL of 1:1000) into the anterolateral thigh, repeated at 5 minutes; 300 micrograms at 6–12 years and 150 micrograms under 6 years.
  • Antimicrobials in suspected sepsis or meningitis are given within one hour of recognition, before imaging and before lumbar puncture; cultures are taken first only if that does not delay treatment.Doctor / NurseNot available at your setup — Blood culture. If cultures would delay treatment, give the antimicrobial immediately without them.
  • Persisting hypotension despite adequate volume: noradrenaline as first-line vasopressor, titrated to a mean arterial pressure of approximately 65 mmHg.Doctor / NurseNot available at your setup — Infusion pump.
  • Bradycardia with hypotension or reduced consciousness: atropine 500 micrograms IV, repeated every 3–5 minutes to a maximum of 3 mg (paediatric 20 micrograms/kg, minimum 100, maximum 600 micrograms), with chronotropic infusion or pacing if refractory; unstable tachyarrhythmia with shock, syncope, ischaemia or heart failure requires prompt synchronised cardioversion.Doctor / NurseNot available at your setup — Defibrillator.
  • Hypothermia: remove wet clothing, warm blankets, warmed intravenous fluid and warmed humidified oxygen, and handle the patient with extreme gentleness — rough movement can precipitate fatal ventricular arrhythmia, termed rescue collapse; resuscitation continues through profound hypothermia, because nobody is dead until they are warm and dead.
  • Reassess after every intervention, and if the patient does not improve as the working diagnosis predicts, the working diagnosis is wrong — restart deliberately from airway, breathing, circulation, glucose, temperature, pupils, ECG and drug history.

Caution— what harms

  • The commonest preventable death in this group is aspiration or airway obstruction while the diagnosis is debated — protect the airway before you argue about the cause.
  • Never accept alcohol on the breath or a psychiatric label as the diagnosis: premature diagnostic closure ends the search before a subdural haematoma or a hypoglycaemic episode is found.
  • A single focal hemisphere or cerebellar lesion does not produce coma unless it compresses the brainstem — a comatose patient with a small isolated cortical infarct on imaging has a second, unmade diagnosis.
  • A normal CT excludes neither stroke nor encephalitis: early infarcts are frequently missed and brainstem lesions may be invisible, and lumbar puncture is contraindicated where an intracranial mass lesion is possible until CT has been done.Not available at your setup — CT scan.
  • Bilateral fixed dilated pupils are never a reason to stop resuscitating a cold or poisoned patient, and mydriatic drops or previous iris or cataract surgery reproduce the finding in an entirely normal brainstem.
  • Both plantar responses are often extensor in deep coma of any cause, and that finding alone means nothing.
  • Flumazenil is the deliberate exception, not a routine reversal agent: in an unknown or mixed overdose, with a seizure history, or where tricyclic co-ingestion is possible, it can precipitate uncontrollable seizures and arrhythmia — in undifferentiated coma the safer position is to support ventilation and let the benzodiazepine wear off.
  • Not every collapsed patient needs fluid: in uncomplicated poisoning a cannula is routine but fluid is unnecessary unless the patient has been unconscious for more than 12 hours, is dehydrated or is hypotensive, and in pulmonary oedema and cardiogenic shock fluid is harmful.
  • Glucagon is ineffective in starvation, alcohol dependence or hepatic glycogen depletion — give intravenous glucose in those patients, and never give 25% or 50% glucose peripherally in a child because extravasation causes necrosis.
  • Wernicke's encephalopathy may be precipitated by a glucose load in a thiamine-deplete patient — give thiamine before or with the glucose in alcohol dependence and malnutrition, but never delay the glucose to find it.
  • Handle the hypothermic patient with extreme gentleness: rough movement can precipitate fatal ventricular arrhythmia (rescue collapse), and hypothermia below 30–32°C makes arrhythmias refractory to drugs until rewarming is achieved.
  • Rapid phenytoin infusion causes hypotension and asystole — give no faster than 50 mg/min with continuous ECG and blood pressure monitoring — and excessive naloxone precipitates acute withdrawal.
  • An unwitnessed fall in an older person should be treated as possible syncope rather than assumed mechanical, because amnesia for the event is common and multiple causes coexist — a postural drop, a urinary infection, a sedative and an occult subdural haematoma in one patient.
  • Brief jerking does not make an event epileptic: reflex anoxic jerks are common in ordinary syncope, and prolonged cerebral hypoxia in a Stokes–Adams attack may provoke a convulsion and a mistaken diagnosis of epilepsy.

Refer / escalate

Escalate or transfer urgently for a unilaterally dilating pupil, a falling serial GCS or new lateralising signs (suspected herniation needing neurosurgery), GCS 8 or less not immediately reversible, hypoxaemia not correctable with high-flow oxygen, seizure continuing beyond two doses of benzodiazepine, any high-risk feature after transient loss of consciousness, and any patient who does not wake after apparent correction of the physiology.

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