Management of the Patient with Reduced Consciousness

Primary topic:

Initial management of the patient with reduced consciousness

Secondary topics:

Differential diagnosis
Management of DKA

Curriculum mapping

Foundation programme 7.1 (Core skills in relation to acute illness)


Common presenting symptoms and signs of acute illness
Manages patients with impaired consciousness including those with convulsions
Clinical interpretation of acutely abnormal physiology
Safe oxygen therapy


Promptly assesses the acutely ill or collapsed patient
Protects airway in an unconscious patient
Responds appropriately to abnormal physiology
Reassesses appropriately


Foundation programme 7.2 (Resuscitation)


Contents of advanced life support


Able to initiate resuscitation at advanced life support level


Foundation programme 7.3 (Management of the “take”)


Indications for urgent investigations and therapy
When to seek help and from whom


Able to prioritise
Interacts effectively with other health care professionals
Keeps patients and relatives informed
Receives and makes referrals appropriately
Delegates effectively and safely
Performs safe handover

Learning Objectives

At the end of this session the doctors should be able to:
In scenario role;
Confidently assess an acutely ill patient using the ABCDE approach
Protect the airway of the unconscious patient
Formulate a differential diagnosis
Initiate appropriate initial management
Reassess after intervention
Appropriately handover to a colleague

In observation role;
Critique colleague performance

In debrief;
Discuss different approaches to the clinical problem

Discussion topics

Airway management
Differential diagnosis for patient admitted unconscious
Triggers of DKA
Management of DKA


A male in his early twenties is brought to the ED resuscitation room by police. He was initially picked up by the police as he was thought to be ‘drunk and disorderly’ in the street, vomiting and they thought he smelt of alcohol. He collapsed in the police car and therefore they came to the ED.







Initial assessment



F1 arrives to see the patient.  A nurse is available and has applied monitoring.


Patient has reduced consciousness.

Obstructed sounding airway on back with no airway support.


Sats: 93% on air

Pulse: 130

BP: 90/50

RR: 30

Temp: 38




GCS = 10

Eyes open to pain (2)

Localises to pain (5)

Incomprehensible sounds (3)


Drowsy and confused

Normal pupils

Doesn’t tolerate oropharyngeal airway.


Introduces self

Takes focused but adequate history from the police/nursing staff.



Asks for high flow oxygen.

Notes ketotic smell.

Assesses airway as partially obstructed but improved with airway opening manoeuvres and suction. 


Asks for help with airway.




Assesses respiratory rate and SaO2

Palpates, percusses and auscultates.

Notes increased RR and low sats.

Notes focal creps.



Notes observations.

Asks for cap refill time (6).



Assesses GCS

Assesses pupils

Assesses for obvious signs of head injury

Asks for BM


Encourage to talk to police and nurse and treat as would usually, if doesn’t take much history or hesitant.











Initial management

Patient is unconscious.

Sats: 95% on high flow 02

Pulse: 130

BP: 90/50

RR: 30

Temp: 38.1



Eyes open to pain (2)

Localises to pain (5)

Incomprehensible sounds (3)


ABG on high flow 02

P02 – 15.5

PC02 – 2.8

HC03 – 13

BE - -10

Hb 14

Lactate 3.8

Optimises airway


Applies high flow oxygen


Gains IV access


Gives IV fluid (N/Saline) over 30 mins and states plans for further fluids


Recognises high BM and commences insulin


Takes ABG


Takes blood for other tests: glucose, renal function, electrolytes, LFTs, clotting, G+S


Orders ECG (sinus tachy)







If not done patient becomes more drowsy and hypotensive.










*if appropriate treatment not given during initial management patient will continue to become more hypotensive and will drop GCS accordingly

Patient more responsive and confused.








*patient less responsive

Airway noisier again

BP 100/60

P 120

Sa02 97% on high flow 02

RR 26

Temp 36.8




*BP 85/40

P 130

Sa02 94% on high flow 02

RR 30

Recognises improvement


Reassesses ABCDE


Looks for potential trigger for DKA (orders CXR, blood cultures, MSU, blood alcohol)


*Recognises deterioration

Recognises airway obstruction and continues airway opening manoeuvres which help.

If GCS has dropped below 7 may tolerate oropharyngeal.

Reassesses ABCDE











*Nurse can prompt – “He isn’t looking any better doctor, he looks worse”.

Management after reassessment


















*if patient deteriorating

Patient more responsive and confused.


















*patient unconscious

BP 100/60

P 120

Sa02 97% on high flow 02

RR 26

Temp 36.8














*BP 85/40

P 130

Sa02 92% on high flow 02

RR 30


Continues high flow oxygen.


Gives clear update of situation to seniors.


Makes plan for continued insulin, fluids, potassium.


Recognises chest infection as trigger and starts appropriate antibiotics for community acquired chest infection


Communicates with patient to help their orientation.


*Calls for help

Protects airway

Gives high flow oxygen

Gives IV n/saline

Commences insulin

Nurse can prompt “What is the plan Doctor, can he go to the ward?”

















*Nurse can prompt “Would you like me to give some fluids?”

“Would you like to give anything for this fit?”

“What shall we do about this high BM?”