Coma and impaired consciousness

Manage now— do this, in order

• The airway precedes the diagnosis: chin lift, or jaw thrust alone if the cervical spine is at risk; nasopharyngeal airway if the gag is intact (avoid with suspected base-of-skull fracture); left lateral position if vomiting without spinal precautions. Intubate for GCS 8 or lower or loss of the gag or cough reflex; bag-valve-mask if the respiratory rate falls below 8/min.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
• High-flow oxygen — remembering pulse oximetry reads falsely normal in carbon monoxide poisoning and methaemoglobinaemia.
• 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 — it worsens cerebral oedema; this is the commonest fluid error. And never lower the blood pressure of the Cushing response.Doctor / Nurse
• DONT — Dextrose, Oxygen, Naloxone, Thiamine — the bedside reversals given before a diagnosis exists. Adult glucose below 4 mmol/L: 50% dextrose 50 mL IV (or 20% 100 mL, or 10% 250 mL, each 25 g), recheck at 10 and 30 minutes; glucagon 1 mg IM without access. Child: never 50% — 10% dextrose 2 mL/kg IV or IO. Thiamine 100 mg IV slowly before or with the glucose in alcohol dependence or malnutrition — but never delay the glucose to find the thiamine.Doctor / Nurse
• Naloxone 0.4-2 mg IV, repeated every 2-3 minutes (5-10 mg for potent synthetic opioids; child 10 micrograms/kg escalating to 100 micrograms/kg). Titrate to a respiratory rate of about 12, not to consciousness. Its duration (2-3 hours) is shorter than almost every opioid it reverses — observe continuously for at least 3-4 hours after the last dose.Doctor / Nurse
• Stop a seizure immediately: adult lorazepam 2-4 mg IV, or diazepam 5-10 mg IV, or midazolam 10 mg buccally/IM without access, repeated once after five minutes; child lorazepam 0.1 mg/kg IV/IO (max 4 mg) or buccal midazolam 0.3 mg/kg (max 10 mg). Second line: phenytoin 15-20 mg/kg IV at no more than 50 mg/min with cardiac monitoring, flushed with saline never dextrose; or levetiracetam 40-60 mg/kg (max 3-4.5 g).Doctor / Nurse
• Give the antibiotic before the scan and before the tap in any comatose patient with fever, meningism, purpura or unexplained encephalopathy: ceftriaxone 2 g IV 12-hourly plus amoxicillin/ampicillin 2 g IV 4-hourly for Listeria if over 50, pregnant or immunosuppressed (child ceftriaxone 50 mg/kg 12-hourly, max 4 g/day). Add dexamethasone 0.15 mg/kg (10 mg adult) 6-hourly with the first dose, aciclovir 10 mg/kg IV 8-hourly whenever encephalitis is possible, and IV artesunate where cerebral malaria is possible.Doctor / Nurse
• Raised intracranial pressure — free measures first: head up 30°, head midline, nothing constricting the neck, treat pain, fever and seizures, saturations above 94%, never even brief hypotension. Osmotherapy: mannitol 20% 0.5-1 g/kg IV over 15-20 minutes (child 0.25-0.5 g/kg), keeping osmolality below 320 mosmol/kg; or hypertonic saline 3% 3-5 mL/kg over 15 minutes.Doctor / Nurse
• Never perform a lumbar puncture before imaging in a comatose patient, and never before antibiotics — it causes tonsillar herniation and death. Avoid flumazenil — usually more dangerous than the coma it reverses. Never correct sodium faster than 8-10 mmol/L in 24 hours. Care of the unconscious body from the first hour: nil by mouth, two-hourly turns, eye care, catheter with hourly output, charted observations — and speak to the patient by name, because hearing is often preserved.