Evaluation must be rapid since morbidity is often related to how quickly therapy is begun. Many of the diffuse metabolic or toxic causes of coma resolve without long-term central nervous system damage, whereas acute structural disease may rapidly be fatal, particularly if causing herniation.
A key tenet of the care of the comatose patient is that initial treatment must proceed simultaneously with diagnosis ( Bio£k...§nd BJ.§£k...220.127.116.11.). Acute coma (seconds to minutes) suggests cerebrovascular disease, either hemorrhagic or ischemic, or cardiac arrest. A recent history of head injury may indicate a subdural or epidural hematoma. A subacute course (many minutes to hours) may suggest intoxication or infection, while a more prolonged period of altered mental status might be caused by a central nervous system tumor or a systemic metabolic disturbance. Weakness or falling to one side suggests a focal lesion. A history of epilepsy may point to a postictal state. Witnesses should be carefully questioned about possible toxic ingestion.
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