Coma: Immediate management

Immediate management

Assess airway, breathing, and circulation. Consider intubation if GCS <8. Support the circulation if required (ie IV fluids). Give O2 and treat any seizures. Protect the cervical spine.
Check blood glucose in all patients. Give 50mL 50% dextrose IV immediately if presumed hypoglycaemia.
IV thiamine if any suggestion of Wernicke's encephalopathy.
IV naloxone for opiate intoxication (may also be given IM or via ET tube); IV flumazenil for benzodiazepine intoxication if airway compromised (may precipitate seizures especially if tricyclic intoxication)




Examination
Vital signs are vital - obtain full set, including temperature.
Signs of trauma haematoma, laceration, bruising, CSF/blood in nose or ears, fracture deformity of skull, subcutaneous emphysema, "˜panda eyes"
Stigmata of other illnesses: liver disease, alcoholism, diabetes, myxoedema.
Skin for needle marks, cyanosis, pallor, rashes, poor turgor.
Smell the breath (alcohol, hepatic fetor, ketosis, uraemia).
Meningism but do not move neck unless cervical spine is cleared.
Pupils size, reactivity, gaze.
Heart/lung exam for murmurs, rubs, wheeze, consolidation, collapse.
Abdomen/rectal for organomegaly, ascites, bruising, peritonism, melaena.
Are there any foci of infection (abscesses, bites, middle ear infection?)
Any features of meningitis: neck stiffness, rash, focal neurology?
Note the absence of signs, eg no pin-point pupils in a known heroin addict.

Preliminary assessment (primary survey)

Airway
Protect cervical spine, if injury possible. Assessment: any signs of obstruction? Ascertain patency Management: establish a patent airway.

Breathing
Assessment: determine respiratory rate, check bilateral chest movement, percuss and auscultate. Management: if no respiratory effort, treat as arrest2 (see inside back cover), intubate and ventilate. If breathing compromised, give high concentration O2, manage according to findings, eg relieve tension pneumothorax.

Circulation
Assessment: check pulse and BP; is he peripherally shut-down?; check capillary refill; look for evidence of haemorrhage. Management:


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if no cardiac output, treat as arrest


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if shocked, treat as shock

Disability
Assess "˜level of consciousness" with AVPU score (alert? responds to voice? to pain? unresponsive?); check pupils: size, equality, reactions. Glasgow Coma scale, if time allows.

Exposure
Undress patient, but cover to avoid hypothermia.