04-Care of Unconscious Patients and Foreign-Body Airway Obstruction

Definition and Nature of Consciousness

• Definition of Consciousness: Consciousness is defined as our awareness of ourselves and our environment. It involves the following characteristics:

  • Subjective awareness of one’s self (internal sensations).

  • Subjective awareness of one’s environment (external events).

  • Functions at an intellectual and cognitive level.

• Criteria for Conscious Functioning: Undisturbed consciousness requires the perception of both the outside world and internal stimuli, resulting in adequate thinking, action, and behavior.

• Impaired Consciousness: This state occurs when a patient’s awareness of self or their environment is missing or compromised.

Assessment of the Depth of Unconsciousness

• AVPU Scale: A simplified method for assessing levels of responsiveness:

  • Alert: The patient is alert and awake.

  • Verbal: The patient responds to verbal instructions.

  • Pain: The patient responds only to a painful stimulus.

  • Unresponsive: The patient does not respond to any stimuli.

• Glasgow Coma Scale (GCS): A neurological scale used to assess the conscious state of a person based on three reaction categories:

  • Eye Opening (Score 1-4):

    • 4: Spontaneous.

    • 3: To instruction.

    • 2: To a stimulus of pain.

    • 1: None.

  • Verbal Response (Score 1-5):

    • 5: Oriented.

    • 4: Disoriented / Confused.

    • 3: Wrong word / Inappropriate words.

    • 2: Unrecognizable vocal sounds.

    • 1: None.

  • Motoric Response (Score 1-6):

    • 6: Follows instructions / Obeys commands.

    • 5: Localization of pain.

    • 4: Flexion / Pulling away from pain.

    • 3: Abnormal flexion to pain (decortication).

    • 2: Extension to pain (decerebration).

    • 1: None.

• Interpretation of Total GCS Scores:

  • 13-15: Mild brain injury or altered consciousness (e.g., concussion).

  • 9-12: Moderate brain injury; signifies a significant state of confusion or drowsiness.

  • 3-8: Severe brain injury; often defined as being in a Coma.

  • 3: The lowest possible score, representing the deepest state of unconsciousness.

Pathophysiology and Classification of Impaired Consciousness

• Requirements for Healthy Central Nervous System (CNS) Functioning:

  • Intactness of anatomical structures.

  • Proper cerebral blood flow.

  • Adequate supply of oxygen ($O_2$) and nutrition, primarily glucose.

• Categorization Based on Time Frame:

  • Short-term impaired consciousness: Lasting typically $5$ to $10$ minutes.

  • Long-term (lasting) impaired consciousness: Prolonged duration.

  • Impaired consciousness accompanied by convulsive attacks: Involves muscle tightening or jerking.

Short-Term Impaired Consciousness: Simple Faint

• Pre-fainting Symptoms (Prodromal signs):

  • Paleness and increased sweating.

  • Concentration disturbance and dizziness.

  • Impaired eye-sight and tinnitus (ringing in the ears).

  • Nausea and vomiting.

• Primary Risks: Injury from falling and choking.

• Potential Causes:

  • Suddenly occurring emotional shock.

  • Standing or waiting for extended periods.

  • High fever or heat exposure.

  • Menstruation or the first stage of pregnancy.

  • Insufficient fluid intake resulting from vomiting, diarrhea, or excessive sweating.

• Common Characteristics: Weakness, sweating, black-outs, and paleness.

• Care and Management:

  • Check basic vital signs.

  • Move the patient to a shady, airy place.

  • Lay the person down.

  • If the background cause (potential serious disease) cannot be determined, call an ambulance immediately.

Long-Term Impaired Consciousness

• Etiology (Main Reasons):

  • Central Nervous System Processes: Serious skull injuries, infections of the nervous system, or circulatory disorders.

  • Metabolic Disorders: Changes in blood sugar levels or disorders of the salt and water equilibrium (electrolyte balance).

  • Poisoning: Illicit drugs (LSD, cocaine), medicinal overdoses.

  • Accidents: Drowning, electric shock, or heat damage.

  • Circulatory and Respiratory Deficiency: Heart rhythm disorders or pulmonary embolism.

• Care Protocol:

  • Examine basic vital signs.

  • Lay the patient in a stable sideway position (recovery position).

  • Call an ambulance as soon as possible.

  • Maintain continuous observation of the patient's condition, specifically watching their breathing.

Loss of Consciousness with Convulsive Attacks

• Etiological Factors:

  • Circulatory disorders (e.g., heart rhythm disorders).

  • Nervous system diseases including epilepsy, tumors, or injury.

  • Poisoning from alcohol, cyanide, or lead.

  • Metabolic disorders including liver deficiency, kidney deficiency, and diabetes.

  • High fever.

  • Pregnancy toxemia.

• Physical Appearance: Characterized by involuntary tightening (tonic) or jerking (clonic) of body muscles.

• General Action Plan:

  • Protect the patient from injury at the onset of the attack.

  • Assess the patient's status once the attack concludes.

  • Ensure free airways.

  • Place the patient into the recovery position.

  • Address wound care if injuries occurred.

  • Call for an ambulance.

Epilepsy: Phases and First Aid

• Etiology: Nervous system infections, serious skull injuries, or genetic factors (powerful electrical discharges of nerve cells).

• Seizure Characteristics (Generalised Tonic-Clonic):

  • Aura: The state immediately before the convulsive attack.

  • Tonic Phase: Generalized stiffening of body and limbs; back may be arched (opisthotonus); patient loses consciousness and falls; may feature an "epileptic cry" (sudden unarticulated loud cry); cyanosis (bluish skin) or apnea may occur.

  • Clonic Phase: Involuntary jerking of limbs, body, and head; tongue biting (tip or sides); salivary frothing or foaming at the mouth; incontinence (urinary or fecal).

  • Postictal Stupor: Following the seizure, limbs and body go limp; patient remains unresponsive and drowsy for a period before regaining clear consciousness.

• First Aid Procedures:

  • Protect the person from injury; do not restrain movements.

  • Do not put anything in the person’s mouth.

  • Ensure free airways and aid breathing by placing the patient in the recovery position once the seizure finishes.

  • Call for an ambulance.

  • Monitor the condition continuously, particularly during the "twilight state" of recovery.

Recovery Position and Airway Management

• Protocol for Unresponsive and Non-Breathing Patients:

  1. Call Emergency Services.

  2. Give $30$ chest compressions.

  3. Give $2$ rescue breaths.

  4. Continue CPR at a ratio of $30:2$.

  5. Use an AED (Automated External Defibrillator) as soon as it arrives, following voice instructions.

• Recovery Position Details:

  • Aim: To ensure nothing blocks the airway and to allow secretions to flow out of the mouth.

  • Benefits: The patient lies without external support, and breathing can be easily monitored.

  • Contraindications: Suspected spinal injury, major chest or abdominal injury, or suspected femur fracture.

• Non-Appliance Airway Techniques:

  • Cleaning and drying the mouth and pharyngeal cavity.

  • Pulling the tongue forward.

  • Head tilt and chin lift.

  • Esmarch-Heiberg maneuver (jaw thrust).

Foreign-Body Airway Obstruction (Choking)

• Types of Foreign Bodies:

  • External objects: Games, toys, food.

  • Internal body processes: Swelling of the throat, tongue drop back, or phlegm.

• Clinical Presentation:

  • History of eating or playing.

  • Sudden change in breathing: intermittent, abrupt, or coughing.

  • Inability to speak.

  • Presence of cyanosis (bluish skin tint).

  • Decay of consciousness.

• Care for Adult Airway Obstruction:

  • Mild Obstruction (Efficient Cough): Encourage the patient to cough and monitor for status changes.

  • Severe Obstruction (Inefficient Cough, conscious):

    • Give $5$ back blows (slaps) between the shoulder blades.

    • Give $5$ abdominal thrusts (Heimlich maneuver).

  • Severe Obstruction (Unconscious): Call an ambulance and start CPR.

• Care for Children and Infants:

  • Infant Modification: Use chest compressions instead of abdominal thrusts.

  • Unconscious Pediatric Care: Perform $5$ initial ventilations followed by starting CPR.