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Unresponsive Patient — Unknown Cause
The unresponsive or rapidly deteriorating patient is a common and high-stakes on-call emergency. The A-E framework provides a systematic approach regardless of the underlying cause. Always treat life-threatening problems as you find them.
A-E Assessment / ALS Algorithm
The pathway
1 · Shout for help
Do not leave the patient alone. Call the team/MET before starting A-E if you are alone.
2 · Airway
Look, listen, feel. Head-tilt chin-lift (if no trauma). Jaw thrust (if trauma suspected). Airway adjunct (NPA/OPA) if needed. Call anaesthetics if cannot maintain airway.
3 · Breathing
RR, SpO₂, chest expansion, auscultation. High-flow O₂ 15L NRB. Needle decompression if tension pneumothorax (absent breath sounds, tracheal deviation, hypotension).
4 · Circulation
HR, BP, cap refill, JVP. 2x IV access. 12-lead ECG. Fluid challenge 250–500ml if hypotensive. Bloods + cultures.
5 · Disability
GCS (E/V/M). BM immediately. Pupils (PEARL). BM <4 → 150ml 10% dextrose IV. Naloxone 400mcg IV/IM if opioid overdose suspected.
6 · Exposure
Full skin survey. Temperature. Any rashes (meningococcal?), signs of trauma, self-harm, medical alert bracelets. Drug chart review.
7 · Common reversible causes (4Hs & 4Ts)
- Hypoxia
- Hypovolaemia
- Hypo/Hyperkalaemia
- Hypothermia
- Tension pneumothorax
- Tamponade
- Toxins/drugs
- Thrombosis (PE/MI)
8 · If cardiac arrest
Start CPR immediately. 30:2. AED/defibrillator. ALS algorithm. Adrenaline 1mg IV every 3–5 minutes. Amiodarone 300mg IV after 3rd shock.
Drugs
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Dextrose 10% | 150ml (or 50ml 50% dextrose) | IV | For BM <4 mmol/L. Recheck BM 15 minutes later. |
| Naloxone | 400mcg | IV/IM/SC | Opioid reversal. Short half-life — may need repeat doses or infusion. |
| Flumazenil | 200mcg | IV | Benzodiazepine reversal. Seizure risk — use with caution. Senior guidance. |
| Adrenaline 1:10,000 | 1mg (10ml) | IV | Cardiac arrest — every 3–5 minutes. |
| Amiodarone | 300mg | IV | Shockable rhythm after 3rd shock. |
When to escalate
Cardiac arrest → immediate ALS,Airway not maintainable → anaesthetics urgently,GCS <8 → consider intubation,Hypotension not responding to 1L fluid → ITU,Signs of meningitis (rash, photophobia, neck stiffness) → immediate benzylpenicillin
Reference: Resuscitation Council UK ALS Guidelines 2021
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