Coma and impaired consciousness

Management— do this, in order

• The airway precedes the diagnosis: snoring means pharyngeal obstruction by the tongue and gurgling means fluid needing suction; open the airway by chin lift, or by jaw thrust alone if the cervical spine is at risk.
• Adjuncts: a nasopharyngeal airway where the patient retains a gag reflex and an oropharyngeal airway provokes vomiting — but avoid it when base-of-skull fracture is suspected; place the vomiting patient without spinal precautions in the left lateral position.
• Intubate for GCS 8 or lower, or loss of the gag or cough reflex. Support ventilation by bag-valve-mask if the respiratory rate falls below 8/min or breaths are ineffective, without waiting for a gas result.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• Oxygen at high flow, remembering that pulse oximetry reads falsely normal in carbon monoxide poisoning and methaemoglobinaemia.
• Circulation — isotonic fluid only: 0.9% sodium chloride 250–500 mL boluses in adults, 10 mL/kg in children, reassessed after each; hypotonic fluid (5% dextrose alone or 0.45% saline) must never be given because it worsens cerebral oedema.Doctor / Nurse
• DONT — the four bedside reversals given before a diagnosis exists: Dextrose, Oxygen, Naloxone, Thiamine.
• Dextrose, adult below 4 mmol/L: 50% dextrose 50 mL IV through a large free-running vein, equivalently 20% dextrose 100 mL or 10% dextrose 250 mL (each delivers 25 g); recheck at 10 and 30 minutes and repeat if still low; without access give glucagon 1 mg intramuscularly, then obtain access.Doctor / Nurse
• Dextrose, child: never 50% dextrose (hyperosmolar and sclerosant) — give 10% dextrose 2 mL/kg IV or intraosseously, repeated as needed, then a maintenance infusion; hypoglycaemia from a sulphonylurea or long-acting insulin relapses hours later and needs a 10% dextrose infusion with prolonged observation.Doctor / Nurse
• Thiamine 100 mg intravenously slowly before or with the glucose in alcohol dependence, malnutrition, hyperemesis or chronic illness; established Wernicke's needs thiamine 500 mg IV three times daily for 2–3 days, then 250 mg daily for five days, then oral maintenance — but glucose is never withheld while thiamine is located.Doctor / Nurse
• Naloxone 0.4–2 mg intravenously, repeated every 2–3 minutes, with 5–10 mg needed for potent synthetic opioids; alternatives 0.4–2 mg IM or 2–4 mg intranasally; child 10 micrograms/kg IV or IO, escalating to 100 micrograms/kg if no response. Titrate to respiratory rate, not consciousness, aiming for about 12.Doctor / Nurse
• Stop a seizure immediately — adult: lorazepam 2–4 mg IV, or diazepam 5–10 mg IV, or without access midazolam 10 mg buccally or intramuscularly, repeated once after five minutes; child: lorazepam 0.1 mg/kg IV or IO (maximum 4 mg), buccal midazolam 0.3 mg/kg (maximum 10 mg), or diazepam 0.5 mg/kg rectally.Doctor / Nurse
• Second-line seizure control: phenytoin 15–20 mg/kg IV no faster than 50 mg/min in adults (20 mg/kg over 20 minutes in children) with continuous cardiac monitoring, flushed with saline and never dextrose; levetiracetam 40–60 mg/kg (maximum 3–4.5 g) and sodium valproate 40 mg/kg are alternatives with fewer haemodynamic effects; phenobarbital 15–20 mg/kg by slow infusion over at least 30 minutes is preferred for drug-induced seizures.Doctor / Nurse
• Give the antibiotic before the scan and before the tap in any comatose patient with fever, meningism, a petechial or purpuric rash or unexplained encephalopathy: adult ceftriaxone 2 g IV 12-hourly (or cefotaxime 2 g 6-hourly) plus amoxicillin or ampicillin 2 g IV 4-hourly for Listeria in those over 50, pregnant or immunosuppressed; child ceftriaxone 50 mg/kg IV 12-hourly (maximum 4 g/day).Doctor / Nurse
• Add dexamethasone 0.15 mg/kg (10 mg in adults) 6-hourly for four days with or just before the first antibiotic dose, and aciclovir 10 mg/kg IV 8-hourly (20 mg/kg 8-hourly under 12 years and in neonates) whenever encephalitis is possible; where cerebral malaria is possible give intravenous artesunate, which is superior to quinine, and check glucose repeatedly.Doctor / Nurse
• Raised intracranial pressure — free measures first: head of the bed to 30° with the head midline, loosen anything constricting the neck, avoid all hypotonic fluid, treat pain, agitation, fever and seizures, and maintain oxygenation and blood pressure; targets are ICP below 20 mmHg and CPP at least 60 mmHg, which without monitoring means saturations above 94% and never permitting even brief hypotension.
• Osmotherapy: mannitol 20%, 0.5–1 g/kg IV over 15–20 minutes (2.5–5 mL/kg of the 20% solution; 0.25–0.5 g/kg in children), repeated as required, keeping serum osmolality below 320 mosmol/kg, with catheterisation and replacement of the diuresis; or hypertonic saline 3% 3–5 mL/kg over 15 minutes (3 mL/kg in children) or a 30 mL bolus of 23.4% sodium chloride.Doctor / Nurse
• Temperature: hypothermia below 31°C causes coma in its own right — rewarm gradually with dry clothing, warm blankets, warmed intravenous fluid and warmed humidified oxygen, and remember hypotension will not reverse until the temperature is corrected; hyperthermia above 40–41 °C needs evaporative cooling with tepid water and high-volume fanning or ice-water immersion, not surface ice packs.
• Care of the unconscious body from the first hour: head elevated to 30° and midline, nil by mouth until swallowing is demonstrably safe, two-hourly turns and pressure-area care (a pressure sore can form within six hours), eye care with lubricant and lid closure, urinary catheterisation with hourly output, thromboprophylaxis once haemorrhage is excluded, frequent charted neurological observations — and speak to the patient by name, because hearing is often preserved.