Immediate Questions

A. Is patient breathing spontaneously? What are the other vital signs? As in all emergencies, rapid evaluation and support of airway, breathing, and circulation (ABCs) are initial management priorities. All patients should receive 100% oxygen via face mask. Comatose patients may not have effective spontaneous respirations or may have lost their protective airway reflexes and therefore may require assisted ventilation with a bag-valve-mask device or endotracheal intubation.

B. Is patient's condition the result of head injury? If head injury is suspected, immediately immobilize the cervical spine using inline manual stabilization or placement of a cervical spine collar. Maintain cervical spine immobilization during airway management, especially during endotracheal intubation. Obtain rapid IV access.

C. What is patient's Glasgow Coma Scale (GCS) score? Although it was originally proposed for patients with head injury, the GCS is helpful in assessing the depth of nontraumatic coma (see Appendix F, p. 765). Patients with a GCS score < 8 should be intubated.

D. Does patient have signs of herniation (dilated nonreactive pupil, papilledema, posturing) or intracranial hypertension (Cushing triad: hypertension, bradycardia, irregular respirations)? These patients should be intubated and given controlled mild hyperventilation. IV administration of mannitol or normal saline should be considered. They will require emergent CT scan of the head and neurosurgical consultation.

E. What is patient's dextrose level? Hypoglycemia is a common cause of coma and is readily detected by bedside determination. Timely glucose administration to hypoglycemic patients can be lifesaving.

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