The Comatose Patient

• Check glucose at once. Record GCS, pupils, brainstem reflexes and motor response before sedation when you can — without delaying the airway or resuscitation.
• Focal signs or abnormal pupils point to CT; symmetric findings with preserved pupils point to a metabolic/tox workup.
• Examine before sedating where feasible, but never delay resuscitation. Titrate naloxone for suspected opioid hypoventilation. Flumazenil only for known iatrogenic benzodiazepine oversedation with no dependence or seizure risk — never in an unknown overdose.
• Meningismus/fever: antibiotics before LP when imaging must come first.

First tests: Blood glucose, Focused neurological assessment, Sodium, potassium, bicarbonate, urea and creatinine, Arterial blood gas.

Only if indicated: Noncontrast CT head, EEG, Lumbar puncture and CSF studies, Targeted toxicology testing.

Repeat monitoring: Focused neurological assessment.

• Prognosticating Coma After Anoxic Brain Injury