Coma And Impaired Conscious Level

Examination of the unconscious patient (see pages 29, 30)

DIAGNOSTIC APPROACH

Questioning friends, relatives or the ambulance team, followed by general and neurological examination all provide important diagnostic information.

History

Head injury leading to admission

Previous head injury (e.g. 6 weeks) Sudden collapse-

Limb twitching, incontinence-

Gradual development of symptoms

Previous illness - diabetes -

- psychiatric illness

- alcoholism-

or drug abuse

- viral infection-

- malignancy-

POSSIBLE CAUSE OF COMA/IMPAIRED CONSCIOUS LEVEL

Diffuse shearing injury and)or intracranial haematoma

Chronic subdural haematoma

Intracerebral haemorrhage

Subarachnoid haemorrhage

Epilepsy I postictal state

Mass lesion, metabolic or infective cause

Hypo- or (less likely) hyperglycaemia

Postictal state

Drug overdose

Drug toxicity

Encephalitis Intracranial metastasis

General examination

Note the presence of:

Laceration, bruising, CSF leak -

Internal auditory meatus - bleeding pus -

Enlarged head "l

Tense anterior fontanelle J Neck stiffness, retraction —

Positive Kernig's sign -

Tongue biting

In infant

Emaciation, hepatomegaly, —

lymphadenopathy Infection source (ears, sinus, lungs, valvular disease) Pyrexia --

Head injury

Cerebral abscess ¡meningitis

Raised intracranial pressure

Tonsillar herniation ^fe Meningitis

Epilepsy ¡postictal state ■*■ Intracranial metastasis

Cerebral abscess, meningitis

Subarachnoid, intracerebral, pontine haemorrhage

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