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Student Education

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
  1. Nicola Cooper, specialist registrar in general internal medicine and care of the elderly1
  1. 1St James's University Hospital, Leeds

In the final part of our series, Nicola Cooper focuses on the D for disability in the ABCDE system of managing acutely ill patients

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

RETURN TO TEXT

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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