Acute care: Brain failure
BMJ 2004; 328 doi: https://doi.org/10.1136/sbmj.0406228 (Published 01 June 2004) Cite this as: BMJ 2004;328:0406228- Nicola Cooper, specialist registrar in general internal medicine and care of the elderly1
- 1St James's University Hospital, Leeds
How to manage the unconscious patient
The most common reason for a reduced conscious level is critical illness--not necessarily a primary brain problem. Patients who have a serious problem with A (airways), B (breathing), or C (circulation) can be drowsy or unresponsive--for example, obstruction of the airway, any severe lung problem, or shock from any cause.
Coma, by definition, is when the Glasgow coma score is less than 9 (box 1). This is associated with potentially life-threatening complications which require urgent intervention. Such patients have reduced airway reflexes and are considered unable to protect their own airway from aspiration of obstruction. Intubation with a cuffed endotracheal tube is the definitive method of protecting the airway.
Box 1: Glasgow coma score
Eye opening:
Spontaneous--4
To speech--3
To pain--2
Nil--1
Best motor response
Obeys commands--6
Localises pain--5
Withdraws to pain--4
Abnormal flexion to pain--3
Extensor response to pain--2
Nil--1
Best verbal response
Orientated--5
Confused conversation--4
Inappropriate words--3
Incomprehensible sounds--2
Nil--1
Head injury is a common cause of coma. In non-trauma patients who have been unconscious for six hours, 40% will have taken some form of sedative and of the remaining 60%, about a third have hypoxic brain injury (for example, after cardiac arrest), a third have a cerebrovascular cause (infarct or haemorrhage), and a third have a metabolic cause for coma (for example, in diabetes or liver disease). Coma has many causes, and no history is available from the patient. A systematic approach is therefore required:
A (airway)--Ensure patient airway (airway manoeuvres, suction, and adjuncts may be required)
B (breathing)--Ensure adequate breathing (treat any problems as you find them)
C (circulation)--Ensure adequate circulation (treat any problems as you find them)
D (disability)--Assess Glasgow coma score, pupils, and bedside glucose measurement
E (examination)--Do an examination (including notes, eye …
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