# Assessing an Unresponsive Pt



## benasack2000 (Dec 28, 2014)

When i'm assessing an unresponsive patient in the initial assessment, am I only checking for the presence/absence of breathing and a pulse. Do I take account of rate and quality if they are present? Is the purpose of this in this situation just to see if they are breathing and blood is moving?


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## DesertMedic66 (Dec 28, 2014)

In your initial assessment you are checking to make sure they are breathing. You also want the quality (shallow, deep, labored) and how fast (not an exact number just normal, fast, slow, or none). 

Same thing with the pulse. Is it there? Is it too fast? Too slow? Normal? Strong? Weak?


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## Jim37F (Dec 28, 2014)

When you first assess presence/absence of pulses and respirations in an unconscious/unresponsive patient, yes you're looking to see just that if they are there or not....however after you determine that your patient is in fact still alive, then you proceed through with your normal assessment, including assessing rate/rhythm/quality/etc of said pulses and respirations  (i.e. the patient is indeed breathing but do you need to assist that with a BVM or not?)


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## MedicDank (Dec 30, 2014)

If it were me I would first check to ensure they are breathing, then check quality. I've ran on people who are unconscious and breathing but could tell they were barely breathing. That will tell you where to go from there, ex: NRB,BVM, or possibly Intubate. From there you can tell if this is a " load and go, or stay and play".


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## Gurby (Dec 30, 2014)

Note that a patient can be in cardiac arrest but still breathing.  Always check for a pulse RIGHT AWAY in any unresponsive patient:


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## chaz90 (Dec 30, 2014)

@Gurby, that is a great video. Good find.


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## Underoath87 (Jan 3, 2015)

Gurby said:


> Note that a patient can be in cardiac arrest but still breathing.  Always check for a pulse RIGHT AWAY in any unresponsive patient:



The occasional gasp doesn't really count as breathing.


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## EMT11KDL (Jan 3, 2015)

Unresponsive patients are actually a lot easier to deal with.  They don't yell at you, lie to you, talk back to you.  Check Responsiveness, than pulse, Air Breathing, Rapid Trauma. 

Remember Unresponsive is a Trauma Patient until proven otherwise.


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## DesertMedic66 (Jan 3, 2015)

EMT11KDL said:


> Unresponsive patients are actually a lot easier to deal with.  They don't yell at you, lie to you, talk back to you.  Check Responsiveness, than pulse, Air Breathing, Rapid Trauma.
> 
> Remember Unresponsive is a Trauma Patient until proven otherwise.


For testing purposes yes. For real world no.


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## Gurby (Jan 5, 2015)

Underoath87 said:


> The occasional gasp doesn't really count as breathing.



Sure.  The point is that it'd be easy to get on scene to find the patient in the video and say, "oh, at least she's breathing so that's something..."  And it takes you an extra 1-2 minutes to even realize she doesn't have a pulse, and you're thinking "but she's breathing...?  Family says she does this all the time and it's just a seizure.  I must just not be finding the pulse."  So you have your partner check, and he can't find the pulse.  5 minutes later you've finally realized what's going on and started CPR.  You get pulses back, but the pt's brain is gone.

I know prior to seeing that video I would probably have been mislead if I had been dispatched to that patient for cc of a seizure.


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## MrLegsGuy (Jan 7, 2015)

Gurby said:


> Sure.  The point is that it'd be easy to get on scene to find the patient in the video and say, "oh, at least she's breathing so that's something..."  And it takes you an extra 1-2 minutes to even realize she doesn't have a pulse, and you're thinking "but she's breathing...?  Family says she does this all the time and it's just a seizure.  I must just not be finding the pulse."  So you have your partner check, and he can't find the pulse.  5 minutes later you've finally realized what's going on and started CPR.  You get pulses back, but the pt's brain is gone.
> 
> I know prior to seeing that video I would probably have been mislead if I had been dispatched to that patient for cc of a seizure.



Well personally if that were the situation, and a pulse could not be found in 7 minutes, I would have long made the decision to manage the airway, and get some oxygenated blood moving into the brain. That's a very long time just Looking for a pulse! I can't imagine having such a lack in faith of my own skill lasting that long lol. Maybe your times are exaggerated?


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## Tigger (Jan 7, 2015)

MrLegsGuy said:


> Well personally if that were the situation, and a pulse could not be found in 7 minutes, I would have long made the decision to manage the airway, and get some oxygenated blood moving into the brain. That's a very long time just Looking for a pulse! I can't imagine having such a lack in faith of my own skill lasting that long lol. Maybe your times are exaggerated?



If you can't find a pulse why are you then moving to airway management? What do we do when we don't find a pulse?

Edit: I kinda misread your post. Still, the focus should be on airway management in this stage.


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## Gurby (Jan 7, 2015)

MrLegsGuy said:


> Well personally if that were the situation, and a pulse could not be found in 7 minutes, I would have long made the decision to manage the airway, and get some oxygenated blood moving into the brain. That's a very long time just Looking for a pulse! I can't imagine having such a lack in faith of my own skill lasting that long lol. Maybe your times are exaggerated?



I don't mean I'd stand there looking for a pulse for 7 minutes, I mean it would be pretty easy to screw this call up and delay starting CPR by that long.

You get dispatched for the seizure, get on scene and family says "she has these all the time", fire has not taken vitals and just tells you "she's been seizing since we got here, probably going to need ALS".  Patient is unresponsive but breathing at ~30/minute... Cardiac arrest is probably not the first thing that comes to mind in this situation.

In school you learn CAB for unresponsive patients, so you should be checking a pulse right away... But in the real world it's easy to stray from these algorithms, especially when you're 2nd on scene and fire is giving you information, and you think you know what's going on.


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## Akulahawk (Jan 8, 2015)

If fire hasn't given me any vitals that they've taken, I'm going to get a set... and that's pretty much right away, or at least check the ABCs quickly. Downtime without a pulse would have been minimized and certainly less than the 7 minutes on scene...


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## Gurby (Jan 8, 2015)

Akulahawk said:


> If fire hasn't given me any vitals that they've taken, I'm going to get a set... and that's pretty much right away, or at least check the ABCs quickly. Downtime without a pulse would have been minimized and certainly less than the 7 minutes on scene...



Maybe this is just a sore spot for me because I made almost this exact mistake when I was first starting.  Get called for the seizure, find unconscious pt, fire and family say "he does this all the time, we caught him and lowered to the ground so no trauma, everything is cool".  Fortunately they were right and it turned out that it WAS just a seizure and he was postictal... But if it had been a cardiac arrest, it would have been a poorly handled one.

Also the fact that pt is breathing and everyone is saying it's a seizure would make me question myself when I didn't find a pulse.


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## Tigger (Jan 8, 2015)

Gurby said:


> I don't mean I'd stand there looking for a pulse for 7 minutes, I mean it would be pretty easy to screw this call up and delay starting CPR by that long.
> 
> You get dispatched for the seizure, get on scene and family says "she has these all the time", fire has not taken vitals and just tells you "she's been seizing since we got here, probably going to need ALS".  Patient is unresponsive but breathing at ~30/minute... Cardiac arrest is probably not the first thing that comes to mind in this situation.
> 
> In school you learn CAB for unresponsive patients, so you should be checking a pulse right away... But in the real world it's easy to stray from these algorithms, especially when you're 2nd on scene and fire is giving you information, and you think you know what's going on.



You should be feeling for a radial pulse pretty much immediately on every patient contact you make, regardless of what's going on. That's not a hard thing to remember to do.


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## Akulahawk (Jan 8, 2015)

Tigger said:


> You should be feeling for a radial pulse pretty much immediately on every patient contact you make, regardless of what's going on. That's not a hard thing to remember to do.


Exactly. And this must be done early on... Every time.


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## Carlos Danger (Jan 8, 2015)

I find it hard to believe you guys really check a pulse immediately on every patient encounter

edit: perhaps not _hard to believe_, but rather, I've never seen that practice before, and it seems really unnecessary to me with the many if not a majority of patient contacts


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## Tigger (Jan 8, 2015)

It's not very hard to to feel for a quick radial pulse when you introduce yourself. Just to ballpark a rate and regularity. Seems like that sort of information is indicated fairly regularly, no?


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## Carlos Danger (Jan 8, 2015)

Tigger said:


> It's not very hard to to feel for a quick radial pulse when you introduce yourself. Just to ballpark a rate and regularity. Seems like that sort of information is indicated fairly regularly, no?



Pulse rate and quality gives you good info, sure. I'm just not sure how standard a practice it actually is to assess it right away on every patient encounter. Most of the patients I transported when I did ground were standing by the curb waiting with their suitcase in hand when we pulled up.....I rarely had any concerns about their hemodynamic status.


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## Akulahawk (Jan 8, 2015)

Remi said:


> Pulse rate and quality gives you good info, sure. I'm just not sure how standard a practice it actually is to assess it right away on every patient encounter. Most of the patients I transported when I did ground were standing by the curb waiting with their suitcase in hand when we pulled up.....I rarely had any concerns about their hemodynamic status.


Someone standing at the curb is going to be perfusing reasonably well. That doesn't mean that you shouldn't take note of skin signs or do a quick pulse check early on. It's amazing what you can get out of a quick introduction with a handshake...


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## Tigger (Jan 8, 2015)

Remi said:


> Pulse rate and quality gives you good info, sure. I'm just not sure how standard a practice it actually is to assess it right away on every patient encounter. Most of the patients I transported when I did ground were standing by the curb waiting with their suitcase in hand when we pulled up.....I rarely had any concerns about their hemodynamic status.


I probably would change my approach when presented with that. I don't really deal with that where I am though, suppose that's part of working in a rural area. 

If someone is unresponsive I would hope that someone would be trying to find some sort of pulse right away, to get back to the OP...


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## Akulahawk (Jan 8, 2015)

The original question/issue was about an unconscious patient, not one standing on the curb with positive suitcase sign. My previous comments were generally along the lines of a patient that is unconscious... That still being said, at some point I'm usually able to do a pulse check early on in the encounter. I'd get a little worried about the positive suitcase patient that's got a pulse rate in the 160's and has been standing there for a few minutes and should have recovered from any exertion. I wouldn't necessarily know that the pulse rate is that high unless I did a quick check.


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## Brandon O (Jan 8, 2015)

Cast eyeballs, say hi, shake hands, feel a radial. That's my initial assessment.


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## Akulahawk (Jan 8, 2015)

Brandon O said:


> Cast eyeballs, say hi, shake hands, feel a radial. That's my initial assessment.


And in the process you learn a lot about the patient's immediate situation... in about 3 seconds.


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## Alpiner (Jan 22, 2015)

After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.

-Student


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## NomadicMedic (Jan 22, 2015)

Alpiner said:


> After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.
> 
> -Student




wait, what?

This is why people fail the NREMT. It's soooooo damn confusing.


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## teedubbyaw (Jan 22, 2015)

DEmedic said:


> wait, what?
> 
> This is why people fail the NREMT. It's soooooo damn confusing.



Did you know you could make light with two potatoes?


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## NomadicMedic (Jan 22, 2015)

teedubbyaw said:


> Did you know you could make light with two potatoes?



If you say "gullible" out loud, it sounds like "oranges".


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## Mantis Toboggan (Jan 23, 2015)

Gurby said:


> Note that a patient can be in cardiac arrest but still breathing.  Always check for a pulse RIGHT AWAY in any unresponsive patient:


 
Take a close look at her initial ECG morphology—awesome example of long QT syndrome triggering a Torsades event.


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## Joey DeMartino (Jan 23, 2015)

This video blew me away.  Because grabbing a "quick" and accurate pulse during an active seizure can be a fairly difficult endeavor, as is the opportunity to hook up leads without introducing placement errors. I have worked seizure pts. ranging from almost still and rigid to literally kicking items off the shelves in a grocery store. 

Now that I have actually seen time correlation with patient deterioration and the accompanying strip, I'm convinced that unless it is virtually impossible to obtain some sort of circulation through this patient-she is in full arrest and needs to be treated as such. This-obviously- may be extremely difficult depending on the magnitude and type of seizure.

I guess the most important questions for me are: Is this strip typical of most seizures? And If O2 admin is possible, is it as critical as circulating what is available?  Wouldn't mind a little guidance on this one.


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## BigBad (Jan 24, 2015)

Gurby said:


> Note that a patient can be in cardiac arrest but still breathing.  Always check for a pulse RIGHT AWAY in any unresponsive patient:




You do realize that is an EEG right?


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## Gurby (Jan 24, 2015)

BigBad said:


> You do realize that is an EEG right?



Ahhhh, good eye!  Too bad they didn't put a few more leads on to get an EKG and have it display at the bottom - that would have been interesting to see.  Still a pretty interesting video.


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## chaz90 (Jan 24, 2015)

BigBad said:


> You do realize that is an EEG right?





Gurby said:


> Ahhhh, good eye!  Too bad they didn't put a few more leads on to get an EKG and have it display at the bottom - that would have been interesting to see.  Still a pretty interesting video.



The bottom most line is an EKG. You can see it written on there. All other lines are from the EEG.


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## benasack2000 (Aug 22, 2015)

Alpiner said:


> After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.
> 
> -Student





DEmedic said:


> wait, what?
> 
> This is why people fail the NREMT. It's soooooo damn confusing.



This is correct in a real life situation right? I check responsiveness and check for a pulse. If I don't find a pulse, I go straight into CPR. If I do find a pulse, I manually open the airway (adjunct and suction maybe), check the approximate rate and quality of breathing, and then check the approximate rate and quality of the carotid pulse? Then move into the secondary? Seems to play out fine in my mind.


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## Gurby (Aug 22, 2015)

benasack2000 said:


> This is correct in a real life situation right? I check responsiveness and check for a pulse. If I don't find a pulse, I go straight into CPR. If I do find a pulse, I manually open the airway (adjunct and suction maybe), check the approximate rate and quality of breathing, and then check the approximate rate and quality of the carotid pulse? Then move into the secondary? Seems to play out fine in my mind.



Yep.


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## EBMEMT (Aug 25, 2015)

Alpiner said:


> After you get the general impression that your patient is unresponsive you should immediately switch from ABC to CAB and check a pulse, if a pulse is found then you go back to airway, breathing and circulation and if no pulse is found you correct the circulation before going back to airway.



Unresponsive patients get (A)BC during assessment, CAB during treatment.   People get confused about that one.    You don't switch to CAB until you have checked for responsiveness, checked for breathing, and checked for pulse and are actually treating the patient.

Adult BLS sequence from 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, Part 5: Adult Basic Life Support

Step 1A: Verify Unresponsive
(Lay rescuers Activate 911)
Step 1B:  check for absence of breathing or agonal breathing.    Do not "look, listen, and feel", anymore.   This can be done while verifying patient is unresponsive; indeed it is often lumped into the first step.  Do not open airway - this is done before rescue breathing.
Step 2: healthcare providers activate 911 unless drowning/choking,  get AED if nearby or send someone to fetch AED
Step 3: health care providers check for carotid pulse, 10 seconds max.   Lay people skip this step.  
If you found pulse, then you switch to rescue breathing and rechecking pulse every 2 minutes
Step 4A: 30 Chest compressions
Step 4B: open airway and give two breaths
Step 4C: repeat until AED arrives and is ready
Step 5: AED arrives.  Note that you can interrupt steps 4A and 4B if the AED arrives.
Step 6: check for shockable rhythm
Step 7: if shock advised , adminster shock followed by 2 minutes CPR
Step 8: otherwise (no shock advised), give 2 minutes CPR
If not already done, activate 911 (drowning/choking)
repeat step 6
Numbers are the steps numbers in the flowchart on figure 2.   A, B, C added when multiple sequencial steps from narrative are included in one box on flowchart.

National Registry of EMT's Implementation of 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care also says assess breathing before pulse.


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## patzyboi (Aug 26, 2015)

I didnt wanna make a new thread, but I just have a question that needs clarifying:

When assessing an unresponsive trauma patient, I was told that I have to use the radial pulses to assess circulation due to determining if systolic bp is at least 90. However, I was taught in every unresponsive pt, you assess carotid for circulation. Any insights?


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## DesertMedic66 (Aug 26, 2015)

patzyboi said:


> I didnt wanna make a new thread, but I just have a question that needs clarifying:
> 
> When assessing an unresponsive trauma patient, I was told that I have to use the radial pulses to assess circulation due to determining if systolic bp is at least 90. However, I was taught in every unresponsive pt, you assess carotid for circulation. Any insights?


At my college we teach to check both radial and carotid at the same time. 

The 90, 80, 70 that is taught widely is not true in the slightest. You can very easily have a patient with a SBP of 80 and still have radial pulses.


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## IrishMedicEMT (Aug 26, 2015)

I am an EMT from Ireland and I hope you don't mind me taking part in this thread as I find it interesting seeing how it's done outside Ireland. Over here we are thought to check radial and carotid on ALL unresponsive PT and adopt the CAB approach for BLS. ABC applies to all patients and this is what confuses our guys as to which to use and when. In general upon assessing a PT as an EMT we are trained to check for presence/absence of a pulse by palpating the carotid and the radial. We take not of the rythm and quality at this point. In the secondary survay I am looking for the rate also. 

There has been a bit of discussion on whether to check pulse on all patients. It's personally something I do for 99.9% of PT where appropriate as it can tell a lot about whats happening under the hood if you like.


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