Resuscitation

Although resuscitation is commonly performed by the casualty officer or the anaesthetist in the intensive care unit rather than by the neurologist, it is appropriate that the neurologist remembers that in patients who are unconscious, protection of the airway, respiration, support of the circulation, and provision of an adequate supply of glucose are all important in stabilising the patient. It is frequently necessary to intubate the trachea in a patient in coma, not only to ensure an adequate airway but also to prevent the aspiration of vomit. It is also important to note the respiratory rate and pattern before intubation and certainly before instituting mechanical ventilation; because depressed respiration may be a clue to drug overdose or metabolic disturbance, increasing respiration to hypoxia, hypercapnia, or acidosis and fluctuating respiration to a brain stem lesion. The possibility that respiratory failure is the cause of a coma should always be considered in a patient with disordered respiration.

Once adequate oxygenation and circulation are ensured and monitored, blood should be withdrawn for the determination of blood glucose, biochemical estimations, and toxicology. It is reasonable to give a bolus of 25-50 g of dextrose despite the present controversy about the use of intravenous glucose in patients with ischaemic or anoxic brain damage. It could be argued that extra glucose in this situation might augment local lactic acid production by anaerobic glycolysis and eventually worsen ischaemic or anoxic damage. In practice, with ischaemic or anoxic brain damage and even in the presence of a diabetic ketoacidosis the administration of such a quantity of glucose will not be immediately harmful and in the hypoglycaemic patient it may well be life saving. A reasonable compromise would be to obtain an early assessment of the level of blood glucose by Dextrostix testing, but these are not sufficiently accurate to preclude the need for formal laboratory assessment. When glucose is given in this situation an argument can be made for giving a bolus of thiamine at the same time to prevent the precipitation of Wernicke's encephalopathy.13

An essential part of resuscitation includes the establishment of baseline blood pressure, pulse, temperature, the insertion of an intravenous line, and the stabilisation of the neck, together with an examination for meningitis. It may be difficult in those patients who sustain some degree of trauma in their collapse to assess the stability of the neck, but the establishment of an adequate airway certainly takes precedence and the identification of meningism in a febrile patient probably takes precedence over the stabilisation of neck movements. In a comatose, febrile patient with meningism seen outside the hospital environment, the intramuscular injection of penicillin before transfer is now recognised to carry a significant advantage.

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