Level 1 of 6Core
The collapsed and undifferentiated patient
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Decide which of two patients you have: still unresponsive (coma — GCS 8 or less, scored by components E, V, M) or went down and got up again (transient loss of consciousness) — "collapse" is a lay description, not a diagnosis, and a falling serial GCS is itself a diagnosis.
- Capillary glucose is the single highest-yield test: obtain within minutes on every collapsed, confused, fitting, weak or apparently "stroke" patient — 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.
- The pupils are the most informative part of the examination: a unilateral dilated pupil becoming fixed means uncal herniation — a neurosurgical emergency; bilateral pinpoint light-fixed means opiates or a pontine lesion; bilateral mid-point reactive is characteristic of metabolic or sedative coma — but ask about mydriatic drops and previous eye surgery.
- Danger signs in the unconscious patient: unprotected airway (snoring, gurgling, silence with effort); RR under 8 or falling; hypoxaemia not correctable with high-flow oxygen; SBP below 90 mmHg or central capillary refill over 3 seconds; a unilaterally dilating pupil; a falling GCS; fever with neck stiffness or a non-blanching rash; seizure beyond 5 minutes.
- In transient loss of consciousness the witness carries the diagnosis, and syncope almost never occurs lying down: loss of consciousness while supine, seated or during exertion is a seizure or an arrhythmia until proved otherwise — record a 12-lead ECG in every case, and any high-risk feature (exertional or supine onset, no prodrome, structural heart disease, family sudden death under 50, SBP below 90 mmHg, abnormal ECG over 75) mandates cardiac monitoring.
- In children collapse is different: hypoglycaemia is far commoner, hypotension is pre-terminal, bradycardia is a pre-arrest rhythm caused by hypoxia until proved otherwise, and a previously distressed child who becomes quiet and slow is deteriorating, not settling.
Manage now— do this, in order
- Physiology first, diagnosis second — four interventions precede the diagnostic effort: correct hypoxaemia, correct hypoglycaemia, stop a seizure, and treat presumed meningitis or anaphylaxis where suspected.
- Assume the unconscious patient cannot protect the airway: position, suction what is visible, insert an oropharyngeal airway (incisors to angle of jaw) or nasopharyngeal airway if the gag is intact (not if base-of-skull fracture is possible), and place any unconscious breathing patient in the left lateral recovery position. Oxygen at high flow titrated to 94–98% (88–92% in chronic type 2 respiratory failure).
- Circulation: two large-bore cannulae, bloods on insertion, and a fluid challenge of 500 mL crystalloid over 15 minutes (250 mL if elderly, small or in known heart failure), reassessing after every bolus; septic shock target ~30 mL/kg within the first hour; paediatric boluses 10 mL/kg over 10–20 minutes.Doctor / Nurse
- Hypoglycaemia (below 4.0 mmol/L): 20% glucose 100 mL IV over 10–15 minutes into a large vein (or 10% 150–200 mL); child 10% glucose 2 mL/kg IV/IO — never 25% or 50% peripherally in a child. No IV access: glucagon 1 mg IM (ineffective in starvation, alcohol dependence or hepatic depletion). Give thiamine 100 mg IV slowly before or with glucose in alcohol dependence or malnutrition — but never delay the glucose to find it.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; child 10 micrograms/kg IV/IO (max 400 micrograms per dose).Doctor / Nurse
- Seizure beyond 5 minutes: lorazepam 4 mg IV, repeated once at 10 minutes (alternatives: buccal midazolam 10 mg, diazepam 10 mg IV/PR); child lorazepam 0.1 mg/kg IV (max 4 mg) or buccal midazolam 0.5 mg/kg (max 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, pregnant or immunosuppressed; child ceftriaxone 80 mg/kg IV daily. Suspected encephalitis: aciclovir 10 mg/kg IV 8-hourly (child 20 mg/kg). Give within one hour of recognition, before imaging and before lumbar puncture.Doctor / Nurse
- Hypothermia: remove wet clothing, warm blankets, warmed IV fluid and warmed humidified oxygen — and handle with extreme gentleness: rough movement can precipitate fatal ventricular arrhythmia (rescue collapse); nobody is dead until they are warm and dead.
- Reassess after every intervention — 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.
The pupils in coma
| Finding | Interpretation |
|---|---|
| Unilateral dilated, becoming fixed | Uncal herniation — neurosurgical emergency |
| Bilateral mid-point, reactive | Metabolic or sedative coma (opiates excepted) |
| Bilateral pinpoint, light-fixed | Opiates, or pontine lesion |
| Bilateral fixed and dilated | Deep coma of any cause — never a reason to stop resuscitating a cold or poisoned patient |
Refer / escalate
Escalate or transfer urgently for a unilaterally dilating pupil, falling serial GCS or new lateralising signs (suspected herniation), 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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