Overview of Coma and Impaired Consciousness
Coma is unresponsiveness from which the patient cannot be aroused. Impaired consciousness refers to similar, less severe disturbances of consciousness; these disturbances are not considered coma. The mechanism for coma or impaired consciousness involves dysfunction of both cerebral hemispheres or of the reticular activating system (also known as the ascending arousal system). Causes may be structural or nonstructural (eg, toxic or metabolic disturbances). Damage may be focal or diffuse. Diagnosis is clinical; identification of cause usually requires laboratory tests and neuroimaging. Treatment is immediate stabilization and specific management of the cause. For long-term coma, adjunctive treatment includes passive range-of-motion exercises, enteral feedings, and measures to prevent pressure ulcers.
Decreased or impaired consciousness or alertness refers to decreased responsiveness to external stimuli. Severe impairment includes
Coma: The patient usually cannot be aroused, and the eyes do not open in response to any stimulation.
Stupor: The patient can be awakened only by vigorous physical stimulation.
Less severely impaired levels of consciousness are often labeled as lethargy or, if more severe, obtundation. However, differentiation between less severely impaired levels is often imprecise; the label is less important than a precise clinical description (eg, “the best level of response is partial limb withdrawal to nail bed pressure”). Delirium differs because cognitive disturbances (in attention, cognition, and level of consciousness) fluctuate more; also, delirium is usually reversible (see Delirium and Dementia).
Maintaining alertness requires intact function of the cerebral hemispheres and preservation of arousal mechanisms in the reticular activating system (RAS—also known as the ascending arousal system)—an extensive network of nuclei and interconnecting fibers in the upper pons, midbrain, and posterior diencephalon. Therefore, the mechanism of impaired consciousness must involve both cerebral hemispheres or dysfunction of the RAS.
To impair consciousness, cerebral dysfunction must be bilateral; unilateral cerebral hemisphere disorders are not sufficient, although they may cause severe neurologic deficits. However, rarely, a unilateral massive hemispheric focal lesion (eg, left middle cerebral artery stroke) impairs consciousness if the contralateral hemisphere is already compromised or if it results in compression of the contralateral hemisphere (eg, by causing edema).
Usually, RAS dysfunction results from a condition that has diffuse effects, such as toxic or metabolic disturbances (eg, hypoglycemia, hypoxia, uremia, drug overdose). RAS dysfunction can also be caused by focal ischemia (eg, certain upper brain stem infarcts), hemorrhage, or direct, mechanical disruption.
Any condition that increases intracranial pressure (ICP) may decrease cerebral perfusion pressure, resulting in secondary brain ischemia. Secondary brain ischemia may affect the RAS or both cerebral hemispheres, impairing consciousness.
When brain damage is extensive, brain herniation (see Fig. 1: Coma and Impaired Consciousness: Brain herniation. and Table 1: Coma and Impaired Consciousness: Effects of Brain Herniation) contributes to neurologic deterioration because it directly compresses brain tissue, increases ICP, may lead to hydrocephalus, and results in neuronal and vascular cell dysfunction. In addition to the direct effects of increased ICP on neuronal and vascular cells, cellular pathways of apoptosis and autophagy, also detrimental to these cells, can become activated.
Because the skull is rigid after infancy, intracranial masses or swelling may increase intracranial pressure, sometimes causing protrusion (herniation) of brain tissue through one of the rigid intracranial barriers (tentorial notch, falx cerebri, foramen magnum). When intracranial pressure is increased sufficiently, regardless of the cause, Cushing reflex and other autonomic abnormalities can occur. Cushing reflex includes systolic hypertension with increased pulse pressure, irregular respirations, and bradycardia. Brain herniation is life threatening.
Transtentorial herniation: The medial temporal lobe is squeezed by a unilateral mass under the tentlike tentorium that supports the temporal lobe. The herniating lobe compresses the following structures:
Ipsilateral 3rd cranial nerve (often first) and posterior cerebral artery
As herniation progresses, the ipsilateral cerebral peduncle
In about 5% of patients, the contralateral 3rd cranial nerve and cerebral peduncle
Eventually, the upper brain stem and the area in or around the thalamus
Subfalcine herniation: The cingulate gyrus is pushed under the falx cerebri by an expanding mass high in a cerebral hemisphere. In this process, one or both anterior cerebral arteries become trapped, causing infarction of the paramedian cortex. As the infarcted area expands, patients are at risk of transtentorial herniation, central herniation, or both.
Central herniation: Both temporal lobes herniate because of bilateral mass effects or diffuse brain edema. Ultimately, brain death occurs.
Upward transtentorial herniation: This type can occur when an infratentorial mass (eg, tumor, cerebellar hemorrhage) compresses the brain stem, kinking it and causing patchy brain stem ischemia. The posterior 3rd ventricle becomes compressed. Upward herniation also distorts the mesencephalon vasculature, compresses the veins of Galen and Rosenthal, and causes superior cerebellar infarction due to occlusion of the superior cerebellar arteries.
Tonsillar herniation: Usually, the cause is an expanding infratentorial mass (eg, cerebellar hemorrhage). The cerebellar tonsils, forced through the foramen magnum, compress the brain stem and obstruct CSF flow.
Effects of Brain Herniation
Type of Herniation
Compression of ipsilateral 3rd cranial nerve
Unilateral dilated, fixed pupil
Compression of the posterior cerebral artery
Contralateral homonymous hemianopia
Absence of blinking in response to visual threat in obtunded patients
Compression of the contralateral 3rd cranial nerve and cerebral peduncle
Contralateral dilated pupil and oculomotor paresis
Compression of the ipsilateral cerebral peduncle
Eventually, compression of the upper brain stem and the area in and around the thalamus
Abnormal breathing patterns
Fixed, unequal pupils
Further compromise of the brain stem
Loss of oculocephalic reflex
Loss of oculovestibular reflex
Loss of corneal reflexes
Trapping of one or both anterior cerebral arteries, causing infarction of the paramedian cortex
Expansion of infarcted area
Increased intracranial pressure
Increased risk of transtentorial herniation, central herniation, or both
Bilateral, more or less symmetric damage to the midbrain
Pupils fixed in midposition
Many of the same symptoms as transtentorial herniation
Further compromise of the brain stem
Loss of all brain stem reflexes
Disappearance of decerebrate posturing
Cessation of respirations
Compression of the posterior 3rd ventricle
Hydrocephalus, which increases intracranial pressure
Distortion of the mesencephalon vasculature
Compression of the veins of Galen and Rosenthal
Superior cerebellar infarction due to occlusion of the superior cerebellar arteries
Early: Nausea, vomiting, occipital headache, ataxia
Later: Somnolence, breathing abnormalities, patchy and progressive loss of brain stem reflexes
Posterior fossa mass (eg, cerebellar hemorrhage)
Patchy but progressive loss of brain stem reflexes
Compression of the brain stem
Obstruction of CSF flow
Acute hydrocephalus (with impaired consciousness, headache, vomiting, and meningismus)
Dysconjugate eye movements
Later, abrupt respiratory and cardiac arrest
*Not all mechanisms occur in every patient.
Impaired consciousness may progress to coma and ultimately to brain death (see Coma and Impaired Consciousness: Brain Death).
Coma or impaired consciousness may result from structural disorders, which typically cause focal damage, or nonstructural disorders, which most often cause diffuse damage (see Table 2: Coma and Impaired Consciousness: Common Causes of Coma or Impaired Consciousness).
Common Causes of Coma or Impaired Consciousness
Head trauma (eg, concussion, cerebral lacerations or contusions, epidural or subdural hematoma)
Upper brain stem infarct or hemorrhage
Seizures (eg, nonconvulsive status epilepticus) or a postictal state caused by an epileptogenic focus
Diffuse axonal injury
Hyperthermia or hypothermia
Other CNS depressants
Psychiatric disorders (eg, psychogenic unresponsiveness) can mimic impaired consciousness but are usually distinguished from true impaired consciousness by neurologic examination.
Symptoms and Signs
Consciousness is decreased to varying degrees. Repeated stimuli arouse patients only briefly or not at all.
Depending on the cause, other symptoms develop (see Table 3: Coma and Impaired Consciousness: Findings by Location*):
Eye abnormalities: Pupils may be dilated, pinpoint, or unequal. One or both pupils may be fixed in midposition. Eye movement may be dysconjugate or absent (oculomotor paresis). Homonymous hemianopia may be present. Other abnormalities include absence of blinking in response to visual threat (almost touching the eye), as well as loss of the oculocephalic reflex (the eyes do not move in response to head rotation), the oculovestibular reflex (the eyes do not move in response to caloric stimulation), and corneal reflexes.
Autonomic dysfunction: Patients may have abnormal breathing patterns (Cheyne-Stokes or Biot respirations), sometimes with hypertension and bradycardia (Cushing reflex). Abrupt respiratory and cardiac arrest may occur.
Motor dysfunction: Abnormalities include flaccidity, hemiparesis, asterixis, multifocal myoclonus, decorticate posturing (elbow flexion and shoulder adduction with leg extension), and decerebrate posturing (limb extension and internal shoulder rotation).
Other symptoms: If the brain stem is compromised, nausea, vomiting, meningismus, occipital headache, ataxia, and increasing somnolence can occur.
Findings by Location*
Bilateral hemispheric damage or dysfunction*
Symmetric tone and response (flexor or extensor) to pain
Periodic cycling of breathing
Supratentorial mass compressing the brain stem
Ipsilateral 3rd cranial nerve palsy with unilateral dilated, fixed pupil and oculomotor paresis
Sometimes contralateral homonymous hemianopia and absent blinking response to visual threat
Brain stem lesion
Early abnormal pupillary and oculomotor signs
Abnormal oculocephalic reflex
Abnormal oculovestibular reflex
Asymmetrical motor responses
Decorticate rigidity (usually due to an upper brain stem lesion) or decerebrate rigidity (usually due to a bilateral midbrain or pontine lesion)
Hyperventilation (due to a midbrain or upper pontine lesion)
Spontaneous, conjugate roving eye movements in mild coma
Fixed eye position in deeper coma
Abnormal oculovestibular reflex
Asterixis (may be considered a type of negative myoclonus)
Decorticate and decerebrate rigidity or flaccidity
*Not all of the findings occur in all cases. Brain stem reflexes and pupillary light responses may be intact in patients with bilateral hemispheric damage or dysfunction or toxic-metabolic dysfunction; however, hypothermia, sedative overdose, or use of an anesthetic can cause partial loss of brain stem reflexes.
General physical examination
Neurologic examination, including eye examination
Laboratory tests (eg, pulse oximetry, bedside glucose measurement, blood and urine tests)
Sometimes measurement of ICP
If diagnosis is unclear, lumbar puncture or EEG
Impaired consciousness is diagnosed if repeated stimuli arouse patients only briefly or not at all. If stimulation triggers primitive reflex movements (eg, decerebrate or decorticate posturing), impaired consciousness may be deepening into coma.
Diagnosis and initial stabilization (airway, breathing, and circulation) should occur simultaneously. Glucose levels must be measured at bedside to identify low levels, which should be corrected immediately. If trauma is involved, the neck is immobilized until clinical history, physical examination, or imaging tests exclude an unstable injury and damage to the cervical spine.
History: Medical identification bracelets or the contents of a wallet or purse may provide clues (eg, hospital identification card, drugs). Relatives, paramedics, police officers, and any witnesses should be questioned about the circumstances and environment in which the patient was found; containers that may have held food, alcohol, drugs, or poisons should be examined and saved for identification (eg, drug identification aided by a poison center) and possible chemical analysis.
Relatives should be asked about the onset and time course of the problem (eg, whether seizure, headache, vomiting, head trauma, or drug ingestion was observed, how quickly symptoms appeared, whether the course has been progressive or waxing and waning), baseline mental status, recent infections and possible exposure to infections, recent travel, ingestions of unusual meals, psychiatric problems and symptoms, drug history, alcohol and other substance use, previous illnesses, the last time the patient was normal, and any hunches they may have about what might be the cause (eg, possible occult overdose, possible occult head trauma due to recent intoxication).
Medical records should be reviewed if available.
General physical examination: Physical examination should be focused and efficient and should include thorough examination of the head and face, skin, and extremities. Signs of head trauma include periorbital ecchymosis (raccoon eyes), ecchymosis behind the ear (Battle sign), hemotympanum, instability of the maxilla, and CSF rhinorrhea and otorrhea. Scalp contusions and small bullet holes can be missed unless the head is carefully inspected. If unstable injury and cervical spine damage have been excluded, passive neck flexion is done; stiffness suggests subarachnoid hemorrhage or meningitis.
Fever, petechial or purpuric rash, hypotension, or severe extremity infections (eg, gangrene of one or more toes) may suggest sepsis or CNS infection. Needle marks may suggest drug overdose (eg, of opioids or insulin
). A bitten tongue suggests seizure. Breath odor may
suggest alcohol, other drug intoxication, or diabetic ketoacidosis.
Neurologic examination: The neurologic examination determines whether the brain stem is intact and where the lesion is located within the CNS (see Approach to the Neurologic Patient: Neurologic Examination). The examination focuses on the following:
Level of consciousness
Deep tendon reflexes
Level of consciousness is evaluated by attempting to wake patients first with verbal commands, then with nonnoxious stimuli, and finally with noxious stimuli (eg, pressure to the supraorbital ridge, nail bed, or sternum). The Glasgow Coma Scale (see Table 4: Coma and Impaired Consciousness: Glasgow Coma Scale*) was developed to assess patients with head trauma. For head trauma, the score assigned by the scale is valuable prognostically. For coma or impaired consciousness of any cause, the scale is used because it is a relatively reliable, objective measure of the severity of unresponsiveness and can be used serially for monitoring. The scale assigns points based on responses to stimuli. Eye opening, facial grimacing, and purposeful withdrawal of limbs from a noxious stimulus indicate that consciousness is not greatly impaired. Asymmetric motor responses to pain or deep tendon reflexes may indicate a focal hemispheric lesion.
Glasgow Coma Scale*
Open spontaneously; open with blinking at baseline
Open to verbal command, speech, or shout
Open in response to pain applied to the limbs or sternum
Confused conversation but able to answer questions
Inappropriate responses; words discernible
Obeys commands for movement
Responds to pain with purposeful movement
Withdraws from pain stimuli
Responds to pain with abnormal flexion (decorticate posturing)
Responds to pain with abnormal extension (decerebrate posturing)
*Combined scores 40 breaths/min may indicate midbrain or upper pontine dysfunction.
An inspiratory gasp with respiratory pauses of about 3 sec after full inspiration (apneustic breathing) typically indicates pontine or medullary lesions; this type of breathing often progresses to respiratory arrest.
Testing: Initially, pulse oximetry, fingerstick plasma glucose measurements, and cardiac monitoring are done. Blood tests should include a comprehensive metabolic panel (including at least serum electrolytes, BUN, creatinine, and Ca levels), CBC with differential and platelets, liver function tests, and ammonia level. ABGs are measured, and if carbon monoxide toxicity is suspected, carboxyhemoglobin level is measured. Blood and urine should be obtained for culture and routine toxicology screening; serum ethanol level is also measured. Additional toxicology tests (eg, additional toxicology screening, serum drug levels) are done based on clinical suspicion. ECG (12-lead) should be done.
If the cause is not immediately apparent, noncontrast head CT should be done as soon as possible to check for masses, hemorrhage, edema, and hydrocephalus. Initially, noncontrast CT rather than contrast CT is preferred to rule out brain hemorrhage. MRI can be done instead if immediately available, but it is not as quick as newer-generation CT scanners. Contrast CT can then be done if noncontrast CT is not diagnostic. MRI or contrast CT may detect isodense subdural hematomas, multiple metastases, sagittal sinus thrombosis, herpes encephalitis, or other causes missed by noncontrast CT. A chest x-ray should also be taken.
If coma is unexplained after neuroimaging and other tests and if there is no obstruction in the CSF flow or ventricular system that would significantly increase ICP, lumbar puncture is done to check opening pressure and to exclude infection, subarachnoid hemorrhage, and other abnormalities. Lumbar puncture is not done until after imaging studies are done to exclude an intracranial mass and obstructive hydrocephalus because if either is present, suddenly lowering CSF pressure by lumbar puncture could trigger brain herniation. CSF analysis includes cell and differential counts, protein, glucose, Gram staining, cultures, and sometimes, based on clinical suspicion, specific tests (eg, cryptococcal antigen, Venereal Disease Research Laboratory [VDRL] tests, PCR for herpes simplex, visual or spectrophotometric determination of xanthochromia).
If increased ICP is suspected, pressure is measured. Hyperventilation, managed by an ICU specialist, should be considered. Hyperventilation causes hypocapnia, which in turn decreases cerebral blood flow globally through vasoconstriction. Reduction in Pco2 from 40 mm Hg to 30 mm Hg can reduce ICP by about 30%. Pco2 should be maintained at 25 mm Hg to 30 mm Hg, but aggressive hyperventilation to < 25 mm Hg should be avoided because this approach may reduce cerebral blood flow excessively and result in cerebral ischemia.
If pressure is increased, it is monitored continuously (see Approach to the Critically Ill Patient: Intracranial Pressure Monitoring).
If diagnosis remains uncertain, EEG may be done. In most comatose patients, EEG shows slowing and reductions in wave amplitude that are nonspecific but often occur in toxic-metabolic encephalopathy. However, EEG monitoring (eg, in the ICU) is increasingly identifying nonconvulsive status epilepticus. In such cases, the EEG may show spikes, sharp waves, or spike and slow complexes.
Prognosis depends on the cause, duration, and depth of the impairment of consciousness. For example, absent brain stem reflexes indicates a poor prognosis after cardiac arrest, but not always after a sedative overdose. In general, if unresponsiveness lasts 33 µg/L
If patients were treated with hypothermia, 72 h should be added to the times above because hypothermia slows recovery. If none of the above criteria is met, outcome is usually (but not always) poor; thus, whether to withdraw life support may be a difficult decision.
Immediate stabilization (airway, breathing, circulation, or ABCs)
Supportive measures, including, when necessary, control of ICP
Admission to an ICU
Treatment of underlying disorder
Airway, breathing, and circulation must be ensured immediately. Hypotension must be corrected (see Shock and Fluid Resuscitation: Cardiogenic shock). Patients are admitted to the ICU so that respiratory and neurologic status can be monitored.
Because some patients in coma are undernourished and susceptible to Wernicke encephalopathy, thiamin 100 mg IV or IM should be given routinely. If plasma glucose is low, patients should be given 50 mL of 50% dextrose IV. If opioid overdose is suspected, naloxone
2 mg IV is given. If trauma is involved, the neck is immobilized until damage to the
cervical spine is ruled out. If a recent (within about 1 h) drug overdose is possible, gastric lavage can be done through a large-bore orogastric tube (eg, ≥ 32 Fr) after endotracheal intubation. Activated charcoal can then be given via the orogastric tube.
Endotracheal intubation: Patients with any of the following require endotracheal intubation to prevent aspiration and ensure adequate ventilation:
Infrequent, shallow, or stertorous respirations
Low O2 saturation (determined by pulse oximetry or ABG measurements)
Impaired airway reflexes
Severe unresponsiveness (including most patients with a Glasgow Coma Scale score ≤ 8
If increased ICP is suspected, intubation should be done via rapid-sequence oral intubation (using a paralytic drug) rather than via nasotracheal intubation; nasotracheal intubation in a patient who is breathing spontaneously causes more coughing and gagging, thus increasing ICP, which is already increased because of intracranial abnormalities.
To minimize the increase in ICP that may occur when the airway is manipulated, some clinicians recommend giving lidocaine
1.5 mg/kg IV 1 to 2 min before giving the paralytic.
Patients are sedated before the paralytic is given. Etomidate
is a good choice in
hypotensive or trauma patients because it has minimal effects on BP; IV dose is 0.3 mg/kg for adults (or 20 mg for an average-sized adult) and 0.2 to 0.3 mg/kg for children. Alternatively, if hypotension is absent and unlikely and if propofol
is readily available, propofol
0.2 to 1.5
mg/kg may be used. Succinylcholine
1.5 mg/kg IV is typically used as a paralytic.
However, use of paralytics is minimized and, whenever possible, avoided because they can mask neurologic findings and changes.
Pulse oximetry and ABGs (if possible, end-tidal CO2) should be used to assess adequacy of oxygenation and ventilation.
ICP control: If ICP is increased, intracranial and cerebral perfusion pressure should be monitored (see Approach to the Critically Ill Patient: Intracranial Pressure Monitoring), and pressures should be controlled. The goal is to maintain ICP at ≤ 20 mm Hg and cerebral perfusion pressure at 50 to 70 mm Hg. Cerebral venous drainage can be enhanced (thus lowering ICP) by elevating the head of the bed to 30° and by keeping the patient’s head in a midline position.
Control of increased ICP involves several strategies:
Sedation: Sedatives may be necessary to control agitation, excessive muscular activity (eg, due to delirium), or pain, which can increase ICP. Propofol
is often used in adults (contraindicated
in children) because onset and duration of action are quick; dose is 0.3 mg/kg/h by continuous IV infusion, titrated gradually up to 3 mg/kg/h as needed. An initial bolus is not used. The most common adverse effect is hypotension. Prolonged use at high doses can cause pancreatitis. Benzodiazepines (eg, midazolam
) can also be used. Because sedatives can
mask neurologic findings and changes, their use should be minimized and, whenever possible, avoided. Antipsychotics should be avoided if possible because they can delay recovery. Sedatives are not used to treat agitation and delirium due to hypoxia; O2 is used instead.
Hyperventilation: Hyperventilation causes hypocapnia, which causes vasoconstriction, thus decreasing cerebral blood flow globally. Reduction in Pco2 from 40 to 30 mm Hg can reduce ICP about 30%. Hyperventilation that reduces Pco2 to 28 to 33 mm Hg decreases ICP for only about 30 min and is used by some clinicians as a temporary measure until other treatments take effect. Aggressive hyperventilation to 180/95 mm Hg). How much BP is reduced depends on the clinical context. Systemic BP needs to be high enough to maintain cerebral perfusion pressure even when ICP increases. Hypertension can be managed by titrating a nicardipine
drip (5 mg/h, increased by 2.5 mg q 5 min to a
maximum of 15 mg/h) or by boluses of labetalol
(10 mg IV over 1 to 2 min, repeated q 10 min
to a maximum of 150 mg).
Corticosteroids: These drugs are usually helpful for patients with a brain tumor or brain abscess, but they are ineffective for patients with head trauma, cerebral hemorrhage, ischemic stroke, or hypoxic brain damage after cardiac arrest. Corticosteroids increase plasma glucose; this increase may worsen the effects of cerebral ischemia and complicate management of diabetes mellitus. After an initial dose of dexamethasone
20 to 100 mg, 4 mg once/day
appears to be effective while minimizing adverse effects. Dexamethasone
can be given IV or
If ICP continues to increase despite other measures to control it, the following may be used:
Pentobarbital coma: Pentobarbital
can reduce cerebral blood flow and metabolic demands.
However, its use is controversial because the effect on clinical outcome is not consistently beneficial. Coma is induced by giving pentobarbital
10 mg/kg IV over 30 min, followed by 5 mg/
kg/h for 3 h, then 1 mg/kg/h. The dose may be adjusted to suppress bursts of EEG activity, which is continuously monitored. Hypotension is common and is managed by giving fluids and, if necessary, vasopressors. Other possible adverse effects include arrhythmias, myocardial depression, and impaired uptake or release of glutamate.
Decompressive craniotomy: Craniotomy with duraplasty can be done to provide room for brain swelling. This procedure can prevent deaths, but overall functional outcome may not improve much. It may be most useful for large cerebral infarcts with impending herniation, particularly in patients < 50 yr.
Long-term care: Patients require meticulous long-term care. Stimulants, sedatives, and opioids should be avoided.
Enteral feeding is started with precautions to prevent aspiration (eg, elevation of the head of the bed); a percutaneous endoscopic jejunostomy tube is placed if necessary.
Early, vigilant attention to skin care, including checking for breakdown especially at pressure points, is required to prevent pressure ulcers. Topical ointments to prevent desiccation of the eyes are beneficial.
Passive range-of-motion exercises done by physical therapists and taping or dynamic flexion splitting of the extremities may prevent contractures. Measures are also taken to prevent UTIs and deep venous thrombosis.
Coma and impaired consciousness require dysfunction of both cerebral hemispheres or dysfunction of the reticular activating system.
Manifestations include abnormalities of the eyes (eg, abnormal conjugate gaze, pupillary responses, and/or oculocephalic or oculovestibular reflexes), vital signs (eg, abnormal respirations), and motor function (eg, flaccidity, hemiparesis, asterixis, multifocal myoclonus, decorticate or decerebrate posturing).
Taking a complete history of prior events is critical; ask witnesses and relatives about the time course for the change in mental status and about possible causes (eg, recent travel, ingestion of unusual meals, exposure to possible infections, drug or alcohol use, possible trauma).
Do a general physical examination, including thorough examination of the head and face, skin, and extremities and a complete neurologic examination (focusing on level of consciousness, the eyes, motor function, and deep tendon reflexes), followed by appropriate blood and urine tests, toxicology screening, and fingerstick plasma glucose measurements.
Do noncontrast CT immediately as soon as the patient has been stabilized.
Ensure adequate airways, breathing, and circulation.
Give IV or IM thiamin and IV glucose if plasma glucose is low and IV naloxone
overdose is suspected.
Control ICP using various strategies, which may include sedatives (as needed) to control agitation, temporary hyperventilation, fluids and diuretics to maintain euvolemia, and antihypertensives to control BP.