By Mike McEvoy, Ph.D., RN, CCRN, REMT-P
Watching another health care provider awaken a patient you believed was unresponsive is an embarrassing moment in patient care. The many scoring systems used to grade levels of wakefulness often blur the lines between patients we can arouse and those who truly are not responsive. Add to the mix patients who pretend to be unconscious, and it becomes extremely difficult at times to identify patients who really are unconscious.
The term “unconscious” is vague in a medical sense but commonly refers to someone who simply is not awake. In medical textbooks, unconsciousness is typically divided into four subcategories: obtundation, hypersomnia, stupor, and coma. Obtundation is simply a reduced level of alertness/consciousness, similar to the confused state with which you awaken from a sound sleep. Hypersomnia is a very deep sleep from which you can only be awakened by vigorous stimulation. Stupor is deep unconsciousness from which you can only be aroused briefly using noxious or painful stimuli. Coma is deep unconsciousness from which you cannot be awakened at all–truly “unresponsive.”
Emergency medical dispatch protocols usually recognize only two mental states: conscious and unconscious. People who are awake are considered conscious; anyone not awake is unconscious. Those rated as conscious are further considered to be either alert or not alert depending on whether they are “fully awake” or “with the program.” The EMS provider must sort those supposedly unconscious patients into various levels of unconsciousness.
The mnemonic “AVPU”–Alert, Verbal, Pain, and Unresponsive–is a rating tool for levels of consciousness. Alert patients have their eyes open and appear awake. Verbal patients typically have their eyes closed but will open them to loud commands, perhaps accompanied by light touch such as a tap on the shoulder. Patients who respond only to pain stimuli have truly crossed the line into unconsciousness. These patients can cause us some embarrassment if we fail to apply enough stimuli to arouse them from their stupor. The key here is twofold: Use medically accepted stimuli (such as a sternal rub or compression of a fingernail bed) with significant force to cause deep pain (accepted medical stimuli should not injure the patient). If you don’t get a response, assume that your patient is unresponsive and unable to protect his or her airway and insert an oral airway. A truly unresponsive patient will tolerate an oral airway without difficulty. Note: A gag reflex indicates that your patient is responsive. It also means you probably did not apply adequate stimuli when you tested for responsiveness.
Nasal airways are helpful for patients who are unconscious but not deeply so (ie: stuporous). These patients often have a gag reflex but exhibit signs of inability to protect their airway, like snoring.
To be certain that your patient is unresponsive, make sure that you have applied adequate noxious stimuli but the patient could not be awakened and that you have inserted an oral airway without signs of a gag reflex. Not only will this improve your patient care, it will save you the embarrassment of watching a colleague awaken your patient.
Mike McEvoy, Ph.D., RN, CCRN, REMT-P, is the EMS coordinator for Saratoga County, New York. A former forensic psychologist, he now works in the Cardiac Surgical ICU at Albany Medical Center and teaches at Albany Medical College in NY. He is a paramedic for Clifton Park-Halfmoon Ambulance Corps and medical advisor for West Crescent Fire Department. He presently serves as a member of the New York State EMS Council and the State Emergency Medical Advisory Council and chairs the EMS Section of the New York State Association of Fire Chiefs.
