Loss of Consciousness on the CCFP exam

Approach

• Call for help. Make sure the scene is safe.
• Open the airway. Check for normal breathing and a pulse at the same time, and keep the check short.
• No pulse and no normal breathing: start cardiopulmonary resuscitation (CPR) and get a defibrillator.
• Breathing but not responding: protect the airway, give oxygen, and turn the patient on the side if the neck is not hurt.
• After a fall or a blow to the head, keep the neck still while you open the airway.
• Then check a bedside glucose and look for the quick fixes in key feature 6.

Approach

• Before: what was he doing? Standing, passing urine, coughing, in pain, exercising or lying down?
• Any warning: sweating, nausea, fading vision, palpitations or chest pain? No warning at all is a worry.
• During: how long was he out? Ask about colour, breathing, and jerks. Brief jerks after going limp are common in a faint.
• After: did he wake clear quickly, or stay confused for a long time? Was the side of the tongue bitten? Any injury?
• Ask about a head injury, a new headache or new weakness.
• Ask about medicines and recent changes, blood thinners, insulin, alcohol, street drugs and possible poisons.
• Ask about heart disease, and about sudden death or unexplained drowning in a young relative.

Approach

• Vital signs, temperature and oxygen level first. Fever with a stiff neck points to meningitis.
• Smell the breath: fruity in diabetic ketoacidosis (acid build-up from too little insulin), or alcohol.
• Yellow skin, a flapping tremor of the outstretched hands, or fluid in the belly point to liver failure.
• Pupils: pinpoint in opioid poisoning. One large pupil that does not react can mean rising pressure in the skull.
• One-sided weakness, a facial droop or eyes turned to one side point to a stroke or a bleed.
• Score the Glasgow Coma Scale: the eye, voice and movement response.
• Look for a bitten tongue, scalp wounds, needle marks and a medical alert bracelet.

Approach

• Minor head injury means a Glasgow Coma Scale of 13 to 15, with a witnessed blackout, clear memory loss or witnessed confusion.
• Adults: apply the Canadian CT Head Rule. Children: use the PECARN or CATCH rule. CATCH is less sensitive than PECARN.
• Check that the patient fits the rule before you use it.
• No head CT for minor head injury unless the rule is positive. The rule guides your judgment; it does not replace it.
• An adult with a simple faint needs no head CT unless there is a high-risk sign (table below).

Approach

• Treat a blood thinner as a high-risk sign. The no-CT rule for a simple faint does not apply, even with a normal exam.
• If she also hit her head, do not lean on the head CT rule alone. The rule guides your judgment; it does not replace it.
• Age over 65 is a high-risk sign on its own.
• Ask which blood thinner she takes, the dose and when she last took it.
• The scan does not replace the faint work-up. Still ask why she went down: a faint, a trip, or a heart rhythm problem.
• A bleed on the scan needs urgent transfer. Reversing the blood thinner is part of that plan.

Approach

• Check the oxygen level and give oxygen if it is low. Check a bedside glucose and treat a low one at once.
• Low blood pressure with cold, clammy skin is shock. Treat it at once and look for bleeding, infection or a heart cause.
• High glucose with ketones points to diabetic ketoacidosis. Treat it urgently.
• Suspected opioid overdose with slow breathing: give naloxone. Giving it to someone out cold for another reason is unlikely to harm them.
• Naloxone does not reverse benzodiazepines, alcohol, cocaine or other non-opioid drugs.
• Keep watching after it works. Most opioids outlast naloxone, so breathing can slow again. Repeat doses as needed.
• Fentanyl, buprenorphine or a very large overdose may need several doses close together. In opioid-dependent patients, naloxone can bring on withdrawal.

Approach

• Ask what he does at work and for fun: ladders, roofs, machinery, swimming, driving for a living.
• Until the cause is clear, advise against heights, swimming alone and driving.
• A clear warning and a known trigger lower the risk. A sudden faint with no warning raises it.
• Commercial drivers face stricter standards than private drivers.
• Write the advice and the reasons in the chart.

Approach

• In a child or teen with a heart red flag (next item), start with a resting 12-lead electrocardiogram (ECG). Look for a long QT interval, complete heart block and a thickened heart muscle.
• In children and young people, heart red flags: a blackout during exercise or swimming, or set off by a loud noise or a startle. Also no warning, known heart disease, an abnormal heart exam, or sudden death or drowning in a young relative.
• A typical faint with a normal exam needs little testing. Brain imaging and an EEG (a brain-wave test) will not help.
• Keep brain imaging and an EEG for a story that fits a seizure, or for focal brain signs.
• In a child with a suspected heart cause, refer urgently to a pediatric heart specialist (cardiologist). Longer rhythm monitoring is kept for palpitations or repeated unexplained faints.

Approach

• Remove the cause first. Review any new drug or dose change that drops standing blood pressure, such as an alpha-blocker, and stop it if there is no clear need.
• Review his other blood pressure pills and any recent dose changes too.
• Teach him to avoid triggers: getting up fast, standing a long time, too little fluid, and hot, crowded rooms.
• Teach him to spot the warning signs, such as warmth, nausea or fading vision, and to act on them at once.
• At the warning, squatting, crossing the legs or clenching the buttocks can stop a faint.

Approach

• Apply a head CT rule first (key feature 4). A low-risk concussion by that rule needs no head CT.
• Advise relative rest for up to 2 days. Then a gradual return to daily life, school and light exercise, as tolerated.
• Do not keep a student home for long. Students do not need to be symptom-free to go back to school.
• Teen with headaches, dizziness or neck pain past 10 days: refer for neck and balance therapy (cervicovestibular rehabilitation), not more rest.

Approach

• Tell the patient not to drive and why. Write it in the chart.
• Reporting rules differ by province. Some make reporting mandatory; others allow it.
• Report when the law requires it, or when the patient keeps driving against advice.
• Tell the patient you are reporting. Confidentiality does not override a legal duty to report.
• The wait before driving depends on the type of episode, and is longer for commercial drivers.