Drug misuse should always be considered in young people with impaired consciousness

EDITOR—We agree with Ikeda et al that the absence of systolic hypertension may provide some discriminatory power towards exclusion of brain lesions, be they ischaemic, haemorrhagic, or space occupying in nature.1 However, we disagree with them that neurological examination of patients with impaired consciousness is often a waste of time and resources and can delay diagnosis.

Although hypertension may be an important potential marker, a careful neurological examination of the papillary response, reflexes, and funduscopy is an important part of the assessment of any patient with impaired consciousness.2

Furthermore, we would like to raise concern over the idea that impaired consciousness in conjunction with systolic hypertension implies that a brain lesion is present. This may be true for older people (the mean age in the Ikeda study was 65 years), but in our experience, impaired consciousness with systolic hypertension in younger people (<30 years) implies ingestion of sympathomimetic drugs—for example, ecstasy, amphetamine, cocaine. 3 4

Hypertension secondary to ingestion of sympathomimetic drugs requires urgent correction (usually with intravenous nitrates) to prevent secondary complications such as intracerebral haemorrhage, renal failure, and myocardial ischaemia3^–5; if, as is said by Ikeda et al, the hypertension and impaired consciousness are assumed to be related to a brain lesion, the delays in obtaining imaging investigations could lead to delays in instituting potentially life saving treatment.

The possibility of illicit drug ingestion should be considered in any young, hypertensive patient presenting to an emergency department with reduced consciousness, so that appropriate management can be started without delay.