Unconscious person

Any person, 16 years and over, presenting as unconscious, excluding cardiorespiratory arrest.

Escalate immediately as per local CERS protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Place in recovery position Elevate head to 30°
Suspected cervical spine injury	Position supine Stabilise the C-spine with in-line immobilisation and/or foam collar (appendix)

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturations (SpO2)	Assist ventilation if required Apply oxygen If there is absence of effective breathing or no signs of life commence CPR, switch to cardiorespiratory arrest protocol If hypoxic or signs of hypoventilation consider opiate overdose
Suspected opiate overdose: hypoventilation and difficult to rouse	Select: IV access No IV access IV access Give naloxone 400 microg IV Repeat dose as required, every 2 minutes, until the patient is more awake and breathing adequately Maximum total dose 2 mg No IV access Give naloxone 400 microg IM Repeat dose as required, every 2 minutes, until the patient is more awake and breathing adequately Maximum total dose 2 mg If no response after initial dose, consider non-opiate cause or fentanyl analogue

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG Attach defibrillator, follow local guidelines
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
BGL	Measure BGL If BGL is less than 4 mmol/L: give 50 mL of 50% glucose by slow IV injection, once only. Use with caution as extravasation can cause potential serious necrosis if no IV access available, give glucagon 1 mg IM, once only Reassess BGL within 15 minutes Once stabilised continue to check BGL hourly, or as clinically indicated
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Inspect for signs of trauma

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
NBM	Remain NBM

Focused assessment

Complete secondary survey.

Complete a neurological focused assessment.

Precautions and notes

• Assess for opioid withdrawal after the administration of naloxone. The half-life of naloxone is much shorter than the opioid. Repeated doses of naloxone may be required.
• Have a high index of suspicion for illicit fentanyl and fentanyl analogues that require larger doses of naloxone. Patients who deny opioid use and report use of other illicit drugs such as cocaine and ketamine remain at risk.
• Consider carbon dioxide retention in unconscious hypoxic patients with a history of COPD, particularly if high-flow oxygen has been administered in transit to the emergency department.

Interventions and diagnostics

Specific treatment

Specific treatment will be determined by the underlying cause.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• FBC, UEC, VBG
• Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
• If clinically indicated: troponin, LFT, Ca/Mg/PO4
• Patient with suspected long lie: CK
• Warfarinised: INR
• If bleeding is suspected: group and hold
• Temp less than 35°C, or 38.5°C and over: take two sets of blood cultures from two separate sites
• Female of childbearing age: urine βHCG. Attend quantitative βHCG if urine positive or known pregnancy.

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au