An approach to

uncouncious
patient
Cvs cause of unconsciousness

 Syncope
Cardiac causes:
Cardiac arrhythmias: Ventricular tachycardia, paroxysmal
supraventricular tachycardia, long QT syndrome, Brugada syndrome,
bradycardia (Mobitz type II or 3rd degree heart block)
Structural cardiac disease: Cardiac valvular disease (AS, MS, PS),
obstructive cardiomyopathy, atrial myxoma, acute aortic dissection,
pericardial disease/tamponade, acute myocardial infarction/ischemia
 Others_ cardiac arrest
Simple guide to investigation and diagnosis
of recurrent syncope and presyncope
Cardiac arrest
Cardiac arrest
 Cardiac arrest describes the sudden and complete loss of
cardiac output due to asystole, ventricular tachycardia or
ventricular fibrillation, or loss of mechanical cardiac
contraction (pulse less electrical activity). The clinical
diagnosis is based on the victim being unconscious and
pulseless; breathing may take some time to stop
completely after cardiac arrest. Death is virtually
inevitable unless effective treatment is given promptly.
Causes of cardiac arrest (6 H
and 4 T).
Hypoxia
Hypotension
Hypothermia
Hypoglycemia
Acidosis (H+)
Hyperkalemia (electrolyte disturbance)
Cardiac Tamponade
Tension pneumothorax
Thromboembolism (pulmonary, coronary)
Toxicity (e.g. digoxin, local anesthetics, insecticides)
 Management of cardiac
arrest.

Chain of Survival –
It refers to the sequence of events that is required to maximize
the chances of survival in a patient with cardiac arrest. Survival
is most likely if all links in the chain are strong.
The chain of survival consists of following links namely:
1 Immediate identification of cardiac arrest and activation of the emergency response system (ERS)
2 Immediate CPR with chest compressions.
3 Quick defibrillation.
4 Effective advanced life support (ALS).
5 Integrated post-cardiac arrest care.
Chain of survival
Immediate Identification and Activation of
Emergency Response System (ERS)
Immediate identification of cardiac arrest:
Assessment is of crucial importance. It includes:
(1)unresponsiveness
(2) no breathing or no normal breathing (i.e. only gasping)
(3) no pulse felt within 10seconds.
Activation of ERS: After activation of the ERS, all rescuers
should immediately begin CPR.
 Cardiopulmonary
Resuscitation (CPR)
 – It provides artificial ventilation
Phases of life
and perfusion to the vital organs,
particularly heart and brain
support and its
 until spontaneous cardiopulmonary steps.
function is restored. It consists of
both basic life supports Phase-1: Basic life C = Circulation, A
 (BLS) and advanced life support support (BLS) = Airway, B =
Breathing
(ALS). BLS provides adequate
oxygen and perfusion to vital Phase-2: Advance D = Drugs, E =
life support (ALS) ECG, F =
organs (brain and heart) until Fibrillation
advanced cardiac life support is
Phase-3: Prolonged Postresuscitation
available life support care
Basic life support (BLS)
Change from A-B-C to C-A-B:

Circulation:
Chest compressions
• Place the patient on a hard surface

• The palm of one hand is placed in the concavity of the

lower half of the sternum 2
Fingers above the xiphoid process.
The other hand is placed over the hand on the sternum.

• Shoulders should be positioned directly over the hands

with the elbows locked straight
and arms extended. Use your upper body weight to
compress
◊Sternum must be depressed at least 5 cm in adults a nd
2–4 cm in children, 1–2 cm infants.
◊ Push hard and push fast. Must be performed at a rate
of 100–120/min.
◊ During CPR the ratio of chest compressions to
ventilation should be: single rescuer =30:2 and in the
presence of 2 rescuers, chest compressions must not be
interrupted for ventilation.
◊ Chest compressions must be continued for 2 minutes
Airway: Loss of consciousness usually produces obstruction of
airway due to loss of the muscle tone in the airway and falling back
of the tongue. Hence, clear the airway. Basic techniques for airway
patency:

♦ Head tilt, chin lift: Place one hand on the forehead and the other on
the chin. The head is tilted upwards to displace the tongue anteriorly.

Jaw thrust method: In this angles of mandible are grasped with both
hands and the
mandible is lifted forward.
♦ Finger sweep: Sweep out foreign body in the mouth by index finger in unconscious patients
and not in a conscious or convulsing patient.

♦ Heimlich maneuver: Useful to remove the foreign body in a conscious patient. It is done
while the patient is standing up or lying down. In this subdiaphragmatic abdominal thrust
elevates the diaphragm and expels a blast of air from the lungs that displaces the foreign
body. In infants this is performed by a series of blows on the back and chest thrusts.
 Breathing: Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing
(if there is serious injury of the mouth or it cannot be opened). With the airway open pinch the nostrils
shut for mouth-to-mouth breathing and cover
the person’s mouth with rescuer making a seal.
♦ Mouth-to-mouth breathing:
♦ Mouth-to-nose breathing:
♦ Mouth-to-mouth and nose:
–

Assessment of restoration of breathing and circulation: Contraction of pupil, improved color

of the skin, free movement of the chest wall, swallowing attempts and struggling movements.
– Indications for termination of BLS: Pulse and respiration returns, emergency medical help
arrives, physician declared patient is deceased, in a non-health setting, another indication to stop BLS would be
that the rescuer was exhausted and physically unable to continue to
perform BLS.
Advanced life support (ALS): The
purpose is to restore normal cardiac rhythm by defibrillation
when the cause is tachyarrhythmia, or to restore cardiac output by correcting
other reversible causes of cardiac arrest. It includes:
– Circulation by cardiac massage.
– Airway management by equipment.
– Breathing by advanced techniques.
– Defibrillation by manual defibrillator.
– Drugs.
Rhythm in cardiac arrest

Shockable rhythms: Ventricular fibrillation or

pulseless ventricular tachycardia (VT).

Nonshockable rhythms: Pulseless electrical activity (PEA) and asystole.

Nonshockable rhythms: Pulseless electrical
activity (PEA) and asystole.

Start CPR. Begin with chest compressions, and continue for 2 minutes before the
rhythm check is
repeated.
Give 1 mg adrenaline IV immediately and re-check rhythm after 2 minutes of CPR.
If PEA or asystole persists, continue CPR and re-check rhythm every 2 minutes.
Administer adrenaline every 3–5 minutes. Do not give atropine.
Check rhythm. If it shows change, check for pulse. If pulse appears, start post-
resuscitation care. If
there is still no pulse, continue CPR with rhythm check every 2 minutes and adrenaline
every 3–5
minutes. If the rhythm develops into VF/VT, defibrillate the patient.
IV fluids: Infuse fluids rapidly if hypovolemia
is suspected. Use normal saline (0.9% NaCl) or
Ringer’s solution. Avoid dextrose which is
redistributed away from the intravascular
space rapidly and causes hyperglycemia which
may worsen neurological outcome after cardiac
arrest. Dextrose is indicated only if there is
documented hypoglycemia.
Postresuscitation care
.Maintain adequate airway and support breathing.
.Continue cardiac monitoring.
.Vasoactive medications (norepinephrine, dobutamine and
epinephrine) and IV fluids to support circulation.
.Avoid hyperthermia, hyperglycemia (maintain blood sugar
<200 mg/dL).
.Treating the precipitating cause of cardiac arrest.