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THE UNCONSCIOUS PatientManage the unconscious patient urgentlyClear airway• Clear mouth and throat and insert oropharyngeal airway if available.Give 40% oxygen via face-mask. Intubate if:• Patient centrally cyanosed (blue tongue/lips) and/or• Respiratory rate < 10 breaths/minute and/or• Coma score < 9 (to assess coma score see chart to the right)If equipment or skills unavailable give mask-bag ventilation.Establish IV access• Use as large bore venous access as possible.• If patient bleeding, give Ringer’s lactate; if no bleeding, give sodium chloride 0.9% solution.Check BP• If systolic BP < 90, give 500ml IV fluids rapidly. Repeat until systolic BP > 90. Stop if patient becomes breathless.Check glucose• If glucose < 3.5 or unable to measure, give 50ml of dextrose 50% IV.• If glucose ≥ 15, give sodium chloride 0.9% 1V/l in first hour and then 1l over the next 2 hours and 10U short-acting insulin IM.Manage according to likely cause:Assess coma scoreEye opening• 4 Spontaneous• 3 To speech• 2 To pain• 1 NoneBest motor response• 6 Obeying commands• 5 Localises purposefully to pain• 4 Withdraws to pain• 3 Flexing• 2 Extending• 1 NoneBest verbal response• 5 Orientated• 4 Confused• 3 Inappropriate words• 2 Incomprehensible• 1 NoneAdd scores to give a single scoreTemperature ≥ 38ºCSoft tissue swelling of eyes/lips/wheezeSmall pupils and/or history ofdrug overdoseSigns of traumaRecent seizure/fitPneumonia ormeningitis likely• Give ceftriaxone 1 2gIV/IM.Anaphylaxis likely• Give adrenaline 2 1ml (1:1000) IM every5 minutes until better• Give hydrocortisone 100mg slow IV• Give promethazine 50 mg IM/slow IVOpiate poisoning likely• Give naloxone 0.4–1.2mg IV• Stop bleeding• Stabilise cervicalspine• Stabilise fractures2.Write a clear referral letter and refer urgently to hospitalRecord history from relatives and emergency staff:• Onset of coma and details of how found.• Known chronic disease/s and medication. Ask about diabetes, hypertension, asthma, HIV, cancer, epilepsy. Send medication with patient to hospital.• Known substance abuse or depression. Was a suicide note found?• Any recent trauma.• Recent travel to a malaria area and any prophylaxis taken.Document level of consciousness, blood pressure and pulse and any treatment given.1Do not mix Ringer's lactate and IV ceftriaxone. Flush IV line with sodium chloride 0.9% before and after IV ceftriaxone. If giving ceftriaxone IM, divide dose: 1g into 2 different injection sites. 2 Adrenaline is also known as epinephrine.1