During your career, you will likely encounter an unconscious athlete and not know the etiology of her condition. Although unconsciousness may result from traumatic injury, it may also result from a variety of general medical conditions or drug interactions (see chapters 21-23).
Systematically examine patients who are unconscious for no known reason, proceeding from searching for life-threatening conditions to identifying potential signs and symptoms that may reveal the cause for unconsciousness. Most of the examination techniques you will use in general examination of the unconscious patient are described in other chapters. Therefore, in this section you will read about the general framework of the examination and be referred to the appropriate chapters for details.
Your first goal is to look for unconsciousness and life-threatening conditions by examining vital signs and checking for severe bleeding. Attempt to arouse the patient by calling her name. Check airway, breathing, and circulation for respirations and pulse. Because you do not know the cause for unconsciousness, you must use spinal precautions until you have ruled out cervical spine injury (chapter 11). If pulse or breathing is absent, call EMS and begin cardiopulmonary resuscitation. There is no need to continue the examination. If respirations and pulse are present, check for signs of severe bleeding and if these are present, control the bleeding before proceeding.
In your secondary survey, continue to look for life-threatening conditions and signs of the cause of unconsciousness. However, considering the number of conditions that may cause abnormal findings, your primary goal is not so much to determine the nature of the injury or illness as to identify positive signs that will help you make decisions about referral and emergency care or first aid. Your main examination tools include history taken from bystanders, observation, and palpation.
Obviously, an unconscious patient will not be able to give you any information. However, you may gain valuable information from the environment, bystanders, or both. As you look at the surroundings, check for evidence that indicates a traumatic event. Ask bystanders if they have any idea what caused the unconsciousness. Did they witness an accident or event, or was there no apparent trauma or injury mechanism? Did they note whether the loss of consciousness was gradual or rapid? Sudden onset is common with such conditions as syncopal episodes, concussion, and epilepsy, whereas gradual onset is common with increasing intracranial hemorrhage, shock, heat illness, and diabetic coma. Ask how long the athlete has been unconscious. If bystanders observed her losing consciousness, try to determine her level of consciousness or behavior before losing consciousness and the activity in which she was engaged. Was she confused or disoriented, or did she seem fine just before losing consciousness? Did she complain of any pain, illness, or other symptoms? Abdominal pain may be a clue to internal hemorrhage, and chest pain may indicate cardiorespiratory pathology.
Finally, ask bystanders if they know of any aspects of the patient’s medical history that may have contributed to her unconsciousness. For instance, does she have diabetes or epilepsy? Has she lost consciousness before, and if so, what was the cause of the previous episode? Friends may also know whether she is taking medications or abusing drugs or alcohol. The more information you can obtain from bystanders, the more precisely you can define the patient’s condition and the more information you will be able to provide to emergency medical personnel when they arrive.
Observation and Inspection
Inspect the patient for any signs indicating a life-threatening condition as well as clues to the type of trauma or illness. As you approach the unconscious athlete, for example, observe the head, neck, and extremities for deformities or unusual positioning. Note any unusual body posturing (decorticate or decerebrate rigidity; see chapter 19) that indicates head trauma or brain injury. An athlete who appears relaxed and is positioned normally usually has a less serious condition. Note any evidence of seizure activity and take the appropriate actions to protect the patient from further injury.
Although you have already checked for breathing, recheck respirations for presence, rate, depth, and rhythm (chapter 9). Aside from the fact that he may have been performing physical activity before the injury, observe if his respirations are rapid and shallow (shock, syncope) or slow, shallow, or irregular (head injury). Normal respiration immediately following activity may be rapid, but the breaths will be deep, not shallow. Note any signs of respiratory distress such as wheezing or difficulty exchanging air. Chapters 19 through 21 cover conditions that could alter respiration.
Inspect the skin for temperature, coloration, and moisture. Is the skin hot and dry, indicating a heat-related illness? Or is it cool, pale, and clammy, which might indicate shock and internal hemorrhage? Is the athlete cyanotic around the lips and face? This could indicate inadequate oxygenation.
Next, check pupils for size, equality, and reaction to light (chapter 19). Someone who has simply fainted will have equal and reactive pupils. Pupils that are equal and dilated may indicate a grand mal seizure or shock. Pinpoint pupils indicate drug overdose. Dilation, inequality, or lack of reactivity in one pupil indicates a space-occupying brain lesion.
Inspect the mouth for bleeding and evidence of an unusual odor. The hyperglycemic patient has a sweet, fruity breath odor (see the discussion of diabetes in chapter 22). A patient who has suffered a seizure may have bitten the tongue, and bleeding may be observable.
Inspect the patient head to toe for evidence of trauma. First inspect around the head, scalp, and neck for any swelling, deformity, or discoloration that would indicate a skull fracture or head injury. Check the nose for rhinorrhea, or fluid coming from the nose, and check the ears for otorrhea, or fluid coming from the ear (chapter 19). Inspect for swelling, deformity, or discoloration of the chest wall, trunk, and abdomen that may indicate a rib fracture or underlying internal pathology (chapter 20).
Finally, inspect the extremities for swelling, deformity, or discoloration. Although injuries to the extremities usually do not cause loss of consciousness, these signs may indicate the severity of trauma and other conditions (i.e., shock and internal injuries). If this inspection reveals any positive signs, call EMS at once.
Use palpation to confirm the presence and strength of vital signs and to screen the patient head to toe for evidence of trauma. First palpate the pulse for presence, rate, and strength (chapter 9). Take and record blood pressure. Hypertension and bradycardia may indicate intracranial hemorrhage (chapter 19), whereas a rapid, weak pulse and low blood pressure indicate shock and internal hemorrhage (chapters 9 and 20). The pulse is also fast and weak secondary to a variety of medical conditions (chapters 21-23).
After examining vital signs, palpate the body head to toe. Palpate the head, neck, and scalp for deformity, crepitus, depressions, or swelling for possible bleeding, fracture, or dislocation. Palpate the chest, trunk, and extremities for deformity (fracture and dislocation), crepitus (fracture), unusual contours, and swelling that would indicate trauma. Palpate the abdomen for distension and rigidity to discern internal injury.
Level of Consciousness
Finally, examine the level of consciousness if you have not already done so. You should also constantly reexamine vital signs throughout the examination to monitor for worsening or improving conditions. Use the Glasgow Coma Scale described in chapter 19 to determine whether the athlete is drowsy, stuporous, or comatose. An athlete is drowsy if she can be aroused with verbal stimuli and stuporous if she can be aroused with painful stimuli such as a pinch to the trapezius or the inner arm or thigh. If there is no response to either stimulus, she is comatose.
Use the “Checklist for the Examination of an Unconscious Athlete” on page 174 to guide your examination. You may use this checklist to help you develop your own routine.
When to Refer
Do not use any special or functional tests to examine an unconscious athlete unless she regains consciousness and you get a better sense of the cause. The history, observation, and palpation should give you sufficient information for determining the need to summon EMS and provide emergency first aid. In almost all cases of unconsciousness, the patient should be referred to a physician for medical examination and diagnosis. Immediate emergency referral is warranted in any of the following situations:
- The athlete fails to regain consciousness within a few minutes.
- You cannot determine the cause of unconsciousness, even if consciousness is regained.
- You observe any abnormal vital signs.
- You note any signs of serious or limb-threatening or life-threatening injury or illness.