Unresponsive patients present a challenge to EMS providers.
The potential causes of unresponsiveness range from head trauma to hypoglycemia, and very often the patient is so altered that he cannot provide answers to many of the common medical history questions.
In these cases, the responding EMS providers must play detective by taking in the scene, asking questions of bystanders, performing a thorough physical assessment and trusting their intuition.
Assessment
After ruling out trauma initially with a rapid assessment, the next step is to address the “must not miss” diagnoses. Though this patient is young and appears healthy, cardiac causes of unresponsiveness, particularly with hypotension, must be addressed.
A 12-lead ECG (if available and within scope) is a good place to start.
Next, other common causes of unresponsiveness like hypoglycemia and neurological events like a seizure must be considered. Medical alert bracelets or necklaces can provide clues to the presence of certain conditions and are common for diabetics and patients with seizure histories.
While findings like incontinence may point to a seizure, such a finding is no guarantee. Pupillary response is important to check during the physical exam. The appearance of the pupils can provide clues to conditions like hemorrhagic stroke or narcotic overdose.
Based on our patient’s somewhat recent history of a traumatic event (bruised ribs) and the finding of equal, but sluggish pupils and respiratory depression, a follow-up question for his friends about any prescription medications is a wise next step.
If asked, the friends would confirm that the patient has been prescribed Vicodin by the student health center, but that he has also been taking some additional Vicodin his girlfriend was prescribed when she had her wisdom teeth removed.
Possible overdose
An opioid overdose classically presents with depression of the central nervous system, which can manifest as decreased level of consciousness, respiratory depression, bradycardia and hypotension. These effects can be worsened if the opioid medication is mixed with a benzodiazepine or alcohol.
While treatments like oxygen and assisting ventilation can keep a patient from becoming or remaining hypoxic, ultimately the treatment for opioid overdose is to reverse the effects of the drug on the central nervous system. Naloxone (Narcan) is the commonly used EMS drug for opioid overdose.
Naloxone is classified as an opioid antagonist, meaning the drug disrupts the ability of the opioid molecules to bind to neuroreceptors in the central nervous system.
Naloxone does this by binding to the same receptor sites that an opioid drug would and keeping that drug from affecting the patient. Naloxone may be given through an IV, as an intramuscular injection or even through the intranasal route.
With a recent increase in heroin-related deaths, naloxone has received frequent media attention. Some states have begun to provide naloxone to friends and family of known drug users.
Other states are including naloxone in the medical first responder and EMT scopes of practice. Still other states are stocking law enforcement vehicles with naloxone so that police can treat drug overdoses early in the presentation.
These programs, while helpful for many patients, should be expanded carefully. Naloxone is a largely safe drug to administer, but side effects can include nausea and vomiting, changes in mood with aggressive behavior and pulmonary edema.
Additionally, long-acting opioids like methadone can stay in the patient’s system longer than naloxone, resulting in the patient becoming unresponsive again after a period of being awake. Like all medications, naloxone should be given only with an understanding of the indications, contraindications and side effects.
Treatment
After obtaining the remainder of the patient’s recent history, you elect to give intranasal naloxone for a suspected narcotic overdose.
After checking the dose, medication, route and expiration, you apply the mucosal atomizer device to the end of the syringe and administer the medication. Shortly after, the patient begins to gag on the OPA. You remove it and exchange the BVM for a nasal cannula.
Upon reassessing the patient, you find that he is gradually waking up and that his vital signs are improving. When he regains consciousness, the patient reports that he was experiencing increased pain in his ribs and took “a handful of Vicodin” in the bathroom.
You begin packaging the patient for transport and when your ALS intercept arrives you proceed to the local hospital for further assessment
