# Male 30s CC: Unconscious/Unresponsive



## Mavrande (Dec 14, 2011)

I was considering just posting one part of this in BLS discussion (criteria for initiation of CPR/BVM on a borderline patient) but figured I'd give you a whole story. Based on a recent call I had, but obviously details have been changed to protect the guilty and I added a few details from other calls.

BLS toned out to a male unconscious, PD on scene reports that the patient may be drunk, and has some blood on his face. You arrive to find the patient sitting normally at a bus stop except that his head is down. You lift the head to check pupils, which are sluggish and dilated. No medic alert anything, no ID. There is some blood on the face and hands but no active bleeding and only a minimal amount of blood on the ground. You are unable to palp a radial pulse, the carotid pulse is weak. You are advised that ALS is a while out, and start packaging for transport. C-collar, back board, head bed, and on to the strecher. The clothing is removed. You can visualize only shallow chest rise at about 10 per minute and are unable to auscultate heart or lung sounds in the back of the rig. Carotid pulse is still present but weak at a rate of 80. The patient was decorticate for a while as you were removing the clothing, he is now GCS 3. Cap refill is 3-4 seconds, BP is UTO both auscultated and palped. Your poor service is unable to afford a pulse oximeter or glucometer. The jaw is clenched and you are unable to obtain oral airway access. ALS is still 10 minutes out, you are 1 minute from the local hospital and 10 minutes in the opposite direction from ALS from a level 1 trauma center.

Wait for ALS or transport? 
Does this patient need a trauma center?
Does this patient need an NPA? Try for an OPA
Does this patient need help breathing? CPR?
Guesses on condition?


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## usafmedic45 (Dec 14, 2011)

> Wait for ALS or transport?


Transport.  Honestly, there's not a lot that ALS could do but delay getting the patient to the hospital.



> Does this patient need a trauma center?


It's probably your best bet just to be safe.



> Does this patient need an NPA? Try for an OPA


I'd stay away from an NPA on the off hand chance there's a skull fracture.  



> Does this patient need help breathing? CPR?


Maybe.....I'd probably have to actually see the patient to judge it.  



> Guesses on condition?


Could be a number of things: Intoxication with minor trauma, EDH, SDH, etc, etc


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## mycrofft (Dec 14, 2011)

*Ditto USAF except following:*

Does he need CPR? What are your protocols....no palpable pulse right? Or what?

Assist breathing? Yeah! But you will not get in an oral airway. Buccal suction and try to assist with 100% O2 via BVM. (watch suction yield, anything like CSF?).

Since everything is bilateral, this is more of a global issue. Trauma center, step on it, don't wait for ALS. The "L" is for life, not lungs liver and other donated organs.

PS: anyone check the back, posterior neck and skull for signs? Mushiness? Knives?


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## Mavrande (Dec 14, 2011)

usafmedic45 said:


> I'd stay away from an NPA on the off hand chance there's a skull fracture.


Fair enough. We declined to NPA for the same reason, although there was no indication of a skull fracture. No CSF or blood from the ears, no battle's sign. 



usafmedic45 said:


> Maybe.....I'd probably have to actually see the patient to judge it.


How would you judge - based on resps? Skin color?



mycrofft said:


> Does he need CPR? What are your protocols....no palpable pulse right? Or what?


Guidelines for CPR class say no palpable carotid after 10 seconds. I have not taken EMT-B class yet and do now know any guidelines they might give, and we are a volunteer BLS agency in NJ with no formal protocols document that I've ever seen. If a patient was breathing but inadequately we can breathe for them, I wasn't sure if it was the same for inadequate circulation. The EMT riding in the back considered starting CPR but decided against it, I assume based on the weak carotid and the fact that with a BVM on 100% O2 his pulse got stronger almost right away. 



mycrofft said:


> PS: anyone check the back, posterior neck and skull for signs? Mushiness? Knives?


Yes we did and we found none. Skull intact, no skin discoloring or active bleeding, no CSF. No weapons either in the patient or in the area.

We canceled the ALS due to proximity, proceeded to the trauma center. Shortly into transport we tried and failed to find breath sounds or chest rise and switched him from an NRB to a BVM. The C-collar made it difficult to get a good seal, especially in the absence of an airway, but we did what we could. After another minute or so my partner told me that his radials returned and were fairly strong. The trauma center intubated him (etomidate and succs), ordered a chest x-ray and CT. After the x-ray and before the CT the patient started to seize (at least he isn't paralyzed?) which they gave him something for. His O2 sats were 100% upon arrival, cap refill was good, rate was in the 100s and regular.


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## usafmedic45 (Dec 14, 2011)

> no battle's sign



You do know that Battle's sign is a late sign of basilar skull fracture, right?  It's not reliably present until an hour or more after the injury.  Generally if you see "it" before then you're looking at an actual bruise rather than true extravasated blood from a basilar fracture.


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## AlphaButch (Dec 14, 2011)

Trauma center. By the time ALS arrives, you would be entering the Trauma center, reducing time to definitive care by 10 minutes.

As stated, 100% on BVM - avoid NPA, C-Spine as a precaution, rapid transport.

My suspicions would move towards toxicity or intracerebral hemorrhage c epistaxis given the lack of any assessment showing injury. 

He doesn't meet our CPR qualifications, but I'd be ready for it. Call ahead.

The local hospital would most likely not be ready for this patient who will need at the least - urgent airway and fluid management, head / chest CT.


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## Handsome Robb (Dec 14, 2011)

He has a pulse...why would you start CPR on him? Unless he's a pedi but even then a pulse of 80 still excludes it. His heart is pissed because of the lack of available oxygenated blood, hence why his pulses got stronger with mechanical ventilation. 

For destination I agree about the trauma center. With that said, if he's actively vomiting or excessively drooling with the trismus I'd be hauling the mail to the local ER for an emergent airway, unless you're in the business of delivering corpses to the hospital...

Other than that everyone pretty much covered it.


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## CritterNurse (Dec 14, 2011)

Mavrande said:


> The patient was decorticate for a while



I tried looking up decorticate, and it said to remove the cortex of. That doesn't make sense to me in context. Could someone tell me what it means here?


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## Handsome Robb (Dec 14, 2011)

Decorticate posturing. The flexing of limbs towards the core usually. Usually presents in patients with a severe head injury and ICP issues.


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## CritterNurse (Dec 14, 2011)

Thanks. Now that makes sense.


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## mycrofft (Dec 15, 2011)

*Two points*

1. De CORE ticate: hands point to the CORE (in an ideal world).
2. "Carotid pulse after ten second"...we teach basic CPR to check _respirations_ for _*no longer than ten seconds*_. Article in Circulation, section 4, says no pulse within ten seconds, and that is only for health care provider CPR. Bergeron MFR text says no less than five/no more than, and not for lay CPR.


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## Melclin (Dec 16, 2011)

*Wait for ALS or transport? *

Transport. Its probably ganna take a little under ten mins to get the pt ready for more advanced management anyway. It may as well be the level 1 hospital that does than rather than the ALS crew or the local hospital.   

*Does this patient need a trauma center?*

Maybe. Even if its not trauma specifically, I think he could certainly benefit from the efficiency and extra resources of a level 1. 

*Does this patient need an NPA? Try for an OPA*

If his airway is patent then its patent. All an OPA/NPA does is make the airway patent. If you can vent well without an adjunct, esp in the setting of possible head trauma (worried more about gagging and ICP spiking than anything), probably best to keep on plugging without one.

*Does this patient need help breathing? CPR?*

Sounds like he could do with some help breathing. How would I tell? I'd use pulse ox and capnography in combination with the following, but I guess you don't have the first two so... I'd look at the chest rise and fall, resp effort, the apparent tidal volume being inhaled through the circuit and lung sounds. 

I'm interested to hear why you'd think he needs CPR. Am I missing something? Its late and I've sunk a few. 

*Guesses on condition?*

Some kind of bleed or trauma I'd think. In the interests of casting the net wide, a hypo that went too far or an insulin OD are options. Heroin OD or seizure + aspiration leading to hypoxic nastiness.


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## Thriceknight (Dec 18, 2011)

Mavrande said:


> I was considering just posting one part of this in BLS discussion (criteria for initiation of CPR/BVM on a borderline patient) but figured I'd give you a whole story. Based on a recent call I had, but obviously details have been changed to protect the guilty and I added a few details from other calls.
> 
> BLS toned out to a male unconscious, PD on scene reports that the patient may be drunk, and has some blood on his face. You arrive to find the patient sitting normally at a bus stop except that his head is down. You lift the head to check pupils, which are sluggish and dilated. No medic alert anything, no ID. There is some blood on the face and hands but no active bleeding and only a minimal amount of blood on the ground. You are unable to palp a radial pulse, the carotid pulse is weak. You are advised that ALS is a while out, and start packaging for transport. C-collar, back board, head bed, and on to the strecher. The clothing is removed. You can visualize only shallow chest rise at about 10 per minute and are unable to auscultate heart or lung sounds in the back of the rig. Carotid pulse is still present but weak at a rate of 80. The patient was decorticate for a while as you were removing the clothing, he is now GCS 3. Cap refill is 3-4 seconds, BP is UTO both auscultated and palped. Your poor service is unable to afford a pulse oximeter or glucometer. The jaw is clenched and you are unable to obtain oral airway access. ALS is still 10 minutes out, you are 1 minute from the local hospital and 10 minutes in the opposite direction from ALS from a level 1 trauma center.
> 
> ...



I work in a rural area of the northern California coast where we are 1hr+ in any direction. So when ALS is out on a transport and BLS is backup,which i'm on, and I get a call anywhere near this type of situation,if i can't get air i'm headin in whatever direction is the closest to hand off to a higher level of care be it ALS intercept,local clinic,etc. 

So in your situation I would have gone to the local hospital to hand off to a higher level of care,protocols permitting.

As for condition..I don't know. I'd guess some sort of cerebral hemorrhage.


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## usafmedic45 (Dec 18, 2011)

> I'd guess some sort of cerebral hemorrhage.



I think you mean intracranial hemorrhage.


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## Thriceknight (Dec 18, 2011)

usafmedic45 said:


> I think you mean intracranial hemorrhage.



FAIL! LOL Yes that is correct! :wacko:


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## usafmedic45 (Dec 18, 2011)

Not fail....just you are still learning.  We do a piss poor job of teaching about intracranial processes and so we see the terms "cerebral hemorrhage" and "intracranial hemorrhage" used interchangeably and therefore incorrectly by a lot of folks.


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## exodus (Dec 18, 2011)

Let the medics go the local hospital where you bring the PT. There the hospital can RSI the patient.  Does the PT really need the level 1? Or will that hospital be able to handle him, or stabilize him?  After that, the pt can be transferred out to another facility if needed.


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## usafmedic45 (Dec 18, 2011)

exodus said:


> Let the medics go the local hospital where you bring the PT. There the hospital can RSI the patient.  Does the PT really need the level 1? Or will that hospital be able to handle him, or stabilize him?  After that, the pt can be transferred out to another facility if needed.



If the patient has a reversible intracranial process, why waste the couple of hours at the non-Level 1 when there's neurosurgical capability at a close hospital?


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## Medic Tim (Dec 18, 2011)

With transport time to the trauma center being ten or less that is the place to go. If you were more than 15 or 20 I would intercept on the way or go to closest facility. This would be the protocol where I work


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## AlphaButch (Dec 18, 2011)

exodus said:


> Let the medics go the local hospital where you bring the PT. There the hospital can RSI the patient.  Does the PT really need the level 1? Or will that hospital be able to handle him, or stabilize him?  After that, the pt can be transferred out to another facility if needed.



The local hospital in many systems will most likely not be able to stabilize this patient. The local hospital may be able to do RSI and secure the airway, but this patient seems to require a higher level of care and on a faster time scale than most local hospitals can provide. If he does have an intracranial hemorrhage, time may be one of the biggest factors working against the patient. 

If we were unable to ventilate the patient at all, then I would consider the local hospital. If I can use a BVM effectively on this patient, we'd go to the trauma center to;

a. shorten time until definitive care. Especially if we roll into a local hospital and they just decide to push it to the Trauma center anyway for a neurologist (most likely scenario and at least a delay of 30-45 minutes before definitive care.)

b. lessen cost for the patient (why add a second ER, second transport, maybe another CT/MRI) for unnecessary services.

Of course, if you change some of the variables (time to Trauma center, capability of the local hospital, etc), my decision may change. It's not about going to the nearest facility, it's about going to the nearest _appropriate_ facility.

~ A/P Tip ~

Intra(cranial) - within (the skull / cranial vault). 
Four sub-categories (from the outside - in) and their most common (although not definitive) cause/symptoms/etc;
Epidural - Typically due to trauma. Early recognition for evacuation. Faster onset.
Subdural - Slower onset, confusion and/or weakness.
Subarachnoid - Occipital or unilateral headache. Family Hx = higher risk.
Intracerebral - Sudden or Fast onset, blood vessel rupture in/amid brain tissue.


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