Option 1: Obtunded and unstable

Uh-oh, the patient is obtunded. She's slumped over with closed eyes, and her breathing is slow and shallow. Vital signs on the portable monitor show BP 89/56 mm Hg, heart rate 65 beats/minute, SpO2 84%, and respiratory rate of 8 breaths/minute. She doesn't respond when you say her name loudly or gently shake her shoulder.

In addition, you just learned the following information from the nurse:

• The patient's baseline cognition is normal.
• The patient has been intermittently somnolent throughout the day, but when she wakes she always reports severe pain.
• She has received 4 doses of hydromorphone in the last 2 hours.
• The recovery room nurse noted the patient was “sensitive” in her signout.
• The patient's code status is full code (verified and documented before surgery).

Ask for clarification of ambiguous terms like “sensitive” or “odd” to avoid missing or misinterpreting key clinical information.

Question: What are you going to do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Order stat labs.
• Pull out AMBOSS and develop a differential diagnosis.
• Call a rapid response immediately.

Many hospitals have a rapid response team that quickly provides additional help in emergencies. Learn if your hospital has one and how to activate it before your first night on call!

Question: Help is on the way! Now what?

While you’re waiting for the rapid response team to arrive, do the following steps (concurrently, not sequentially):

• Begin oxygen therapy.
• Perform a rapid ABCDE survey.
• Consider basic airway maneuvers if breathing appears labored.
• Prepare for bag-mask ventilation.
  • Call for the emergency airway cart.
  • Assemble the bag valve mask (typically available in all rooms).
• Place continuous monitors (pulse oximeter, end-tidal CO₂ monitor, ECG).
• Calculate a coma score.

The cavalry (i.e., the rapid response team) has arrived, and they take over administering oxygenation and ventilation, establishing additional IV access, and drawing labs. Now it's time to figure out the best next step for this patient's specific scenario.

More information...

• Your targeted physical examination of the patient revealed the following:
  • Heart rate: 65 beats/minute and regular
  • Breath sounds: clear bilaterally
  • Abdomen: soft and nondistended; palpation elicits no pain response
  • Neurological exam: The patient does not participate in the neurological exam, but the upper and lower reflexes are within normal limits.

Question: Now that you have more time to think, what's on your mental list?

Make your choices, then click on the explanation bubbles for more information.

• Comparing your observations to the clinical features of underlying AMS etiologies
• Rapidly reviewing critical causes of AMS or coma and their immediate management
• Considering potential postoperative complications

That's right—all of the above!

Always notify the surgical service as soon as possible when caring for a patient with an acute postoperative clinical deterioration. The surgeon will be able to provide more information and clinical context.

Question: Based on what you know about this patient's clinical picture, what do you do now?

Make your choice, then click on the explanation bubble to reveal the answer.

• Administer naloxone.
• Await the results from pending diagnostics for altered mental status.

Check out “Management of opioid overdose” for more details. For now, check out a few key points on dosage.

• If the patient remains hypoxic despite airway management, proceed with immediate high-dose IV naloxone
• If oxygenation is adequate (e.g., SpO2 ≥ 90%) consider administering low-dose IV naloxone (off-label) , repeating every 2 minutes until the patient is awake and ventilating adequately. ^[1][2][3]

Supportive cardiorespiratory care with frequent reevaluation of respiratory and neurologic status is the cornerstone of sedative-hypnotic drug overdose management. ^[4][5]

High-dose naloxone administration for iatrogenic opioid overdose in a postsurgical patient may cause severe pain that is difficult to control. Consider titration of low-dose naloxone if oxygenation and ventilation are adequate with basic airway maneuvers.

Naloxone delivered, oxygen flowing, and the patient’s eyes are opening! The patient is doing great because of your interventions, but there's still an hour to go before your shift ends and you can ride off into the sunrise. The initial lab studies just came back, so time to dust off those blood gas interpretation skills!

Here's a recap of the patient's clinical findings from the time the blood gas was drawn: respiratory rate 8 breaths/minute, SpO2 84%, GCS score 6.

Question: Which of the following blood gases do you expect in this patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• pH 7.16, PaCO₂70 mm Hg, PaO₂ 52 mm Hg, HCO₃ 27 mEq/L (on room air)
• pH 7.36, PaCO₂ 62 mm Hg, PaO₂ 52 mm Hg, HCO₃ 34 mEq/L (on room air)
• pH 7.51, PaCO₂ 32 mm Hg, PaO₂ 52 mm Hg, HCO₃ 25 mEq/L (on room air)
• pH 7.20, PaCO₂ 37 mm Hg, PaO₂ 52 mm Hg, HCO₃ 14 mEq/L (on room air)

Of course, in real life at 4 am, you may want a little refresher on arterial blood gas analysis and acid-base disorders (they can be challenging even without sleep deprivation!). In that case, you can easily check out these flowcharts for rapid reference.

Take a bow, intern extraordinaire—you just scored a critical win in the battle against hypoventilation.

Related resources

• Altered mental status and coma
• Sedative-hypnotic drug overdose
• Postoperative management

Want to explore the other scenario? Jump over to “Option 2: Disoriented with stable vital signs.” You can also return to the main module to wrap up “In a fog.”