The unconscious patient
- Make sure that an unconscious patient:1. Has a clear airway;2. Is placed in the recovery position;3. Is never left alone.
- Maintain a clear airway, keeping the patient in the unconscious position.
- Never leave an unconscious patient unattended: he/she may move, vomit, have a fit, or fall out of the bunk.
How to insert a guedel airway in an unconscious patient
- Insert an airway if the patient is breathing without assistance but is doing so with difficulty: the airway ensures a clear passage between the lips and the back of the throat.
- Remove any dentures and suck or swab out any blood or vomit that is in the mouth.
- With the patient’s head pushed fully backwards, wet the airway and slide it gently into the mouth with its outer curve towards the tongue.
- If the patient gags, retches, or vomits, stop and try again later.
- Continue to insert the airway until its flange reaches the lips.
- Rotate the airway through 180° so that its outer curve is turned upwards towards the roof of the mouth.
- Bring the jaw upwards and push the airway in until the flange at the end of the airway is in front of the teeth (or gums) and behind the lips.
- If necessary tape one or both lips so that the end of the airway is not covered.
- Check that the patient’s breath is coming through the airway.
- Continue to push the patient’s jaws upwards with the head bent fully back: the airway will be held in place by the teeth or gums.
- The patient will probably spit out the airway as consciousness returns: make sure the airway is retained until the patient is fully conscious.
What to do general principles in managing an unconscious patient
- Make sure that a semi-conscious patient cannot suffer further injury, such as by falling on the floor or hitting against a hard edge or surface:1. A cot with sides is probably the safest place for a semi-conscious patient but make sure there are no pillows or other padding where the patient might lie face down.
- To prevent bedsores, turn the patient from one side to the other at least once every two hours:1. In turning a patient, keep the head in a straight line with the neck and prevent the head from bending forwards with the chin sagging;2. Have an attendant hold the patient’s head in the correct alignment during turning, in order to keep a clear airway and prevent spinal injury if there is a fracture of a neck vertebra;3. If you suspect a neck or spine injury, do not turn the patient, especially if evacuation will occur within 24-48 hours;4. Check breathing and make sure that the airway is securely in place as soon as you have turned the patient.
- Make sure the patient’s joints are neither fully straight nor fully bent but, ideally, midway between the two extremes.
- Place pillows under and between the bent knees and between the feet and ankles.
- Use a bed cage (a large stiff cardboard box will do) to keep the bedclothes from pressing on the feet and ankles.
- Check that elbows, wrists, and fingers are in a relaxed mid-position after turning.
- Never pull, strain, or stretch any joint.
- Make sure that the eyelids are closed and remain closed at all times, to prevent damage to the eyeball: if necessary use light tape to keep the eyelids closed.
- Irrigate the eyes every two hours by opening the lids slightly and pouring some saline solution gently into the corner of each eye so that it runs across the eye and drains from the opposite corner:1. Use 0.9% sodium chloride solution (normal saline) for intravenous infusion or make a saline solution by dissolving one level teaspoonful of salt in half a litre of boiled water that has been allowed to cool.
- Over the first 12 hours of unconsciousness do not worry about fluid intake.
- After 12 hours of unconsciousness, seek medical advice and give fluid intravenously, particularly in hot climates and/or if the patient is obviously sweating.
- Set up an input—output fluid chart.
- To collect the urine of a male patient, use an incontinence container with a condom over the penis and for a female patient, a bladder catheter.
- Moisten the patient’s mouth, cheeks, tongue, and teeth every 20 minutes with a small swab moistened with water.
- Carry out mouth care every time the patient is turned.
- After 48 hours of unconsciousness, move the patient’s joints at least once day:1. Move all the joints in all the limbs very gently in such a way as to put each joint through a full range of movement, provided there is no fracture or other contraindication to this exercise;2. Ensure that exercising the arms does not interfere with breathing;3. Take your time, moving each joint fully before going on to the next.4. Begin on the side of the patient that is most accessible, working in this order: a. Fingers b. Wrist elbow c. Shoulder d. Toes e. Foot f. Ankle g. Knee h. Hip5. Turn the patient with the help of another person and move the joints on the other side.
- Remember that unconscious patients may be relaxed and floppy, so do not let go of a limb until you have placed it safely back on the bed.
- Hold the limbs firmly but not tightly and do everything slowly, with the utmost gentleness.
