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First, be grateful. A patient in psychogenic coma is better than one who is angry and combative. Approach the patient incorrectly, and you can awaken the patient to a hostile alert state. Do a careful neurologic examination. Open the eyelids. If the eyes deviate upward and only the sclera show (Bell’s phenomenon), you should suspect [...]

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Although CT scans have revolutionized the practice of neurology, they are not indicated in every comatose patient. A good history, physical examination, and a few simple laboratory tests are adequate in most cases seen in the Emergency room because drug and alcohol abuse are common. If a structural lesion is suspected, however, a CT scan [...]

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Obtain a rapid blood glucose (Dextrostix), and correct hypoglycemia if it is found. If alcohol intoxication is suspected, determine the alcohol level with either a Breathalyzer or serum blood alcohol. If the pupils are constricted or if narcotic ingestion is suspected, intravenous naloxone should be given. If hypoglycemia or alcohol intoxication is not found to [...]

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A cervical spine series must be obtained in any comatose patient with suspected trauma because physical examination is unreliable. A chest radiograph may be helpful if hypoxemia or pulmonary infection is suspected. Skull series are rarely indicated and have been supplanted by CT scan.

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If a confused patient is suspected of being postictal, look in the mouth. A tongue laceration supports the diagnosis of a seizure.
Put on gloves and inspect the scalp. Occult trauma is often overlooked, and you may find a laceration or dried blood. An old scar on the scalp may tip you off to a posttraumatic [...]

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The eyes should be examined for position, reactivity, and reflexes. When the eyelids are opened, note the position of the eyes. If the eyes flutter upward, exposing only the sclera, suspect psychogenic coma. If the eyes exhibit bilateral roving movements that cross the midline, you know that the brainstem is intact. Pupil reactivity is the [...]

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Check the cardiac monitor. Bradycardia or arrhythmias can alter cerebral perfusion and cause altered sensorium. Carefully count respirations. Tachypnea may indicate the presence of hypoxemia or a metabolic acidosis, and diminished respiratory efforts may require assisted ventilation. Check the blood pressure. Do not assume that hypotension has a CNS cause. Look for hypovolemia or sepsis [...]