Blood and Urine

1. Drugs screen
- Blood alcohol and salicylates, urine toxicology (screening for
benzodiazepines, narcotics, amphetamines)
- Necessary in any case of acute coma where the diagnosis is
not immediately clear

2. Biochemistry
- Urea, electrolytes, glucose, calcium, liver biochemistry

3. Metabolic and endocrine studies

- TSH, cortisol

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Blood and Urine
4. Arterial blood gases
- helpful in patients with lung disease and acid-base disorders
- for acidosis or high CO2 levels

5. Other
- Cerebral malaria (request thick blood film), porphyria

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Brain Imaging
 CT brain : most readily available and safest modality in
the unconscious patient
• MRI is useful where CT is normal but presents greater
monitoring challenges in the unconscious patient

 CT is quick and effective in demonstrating all types of

brain haemorrhage and most mass lesions;
• Infarcts may be missed in the early stages and where only
the brainstem is affected

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CSF Examination
 Lumbar puncture should be performed in coma only
after careful risk assessment.
 Contraindicated when an intracranial mass lesion is a
possibility: !! CT is essential to exclude this
 CSF examination is likely to alter therapy only if
undiagnosed meningoencephalitis or other infection is
present or in subarachnoid haemorrhage where CT may
give a false negative result, particularly after 24 h

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EEG
 Diagnosis of:
1. Metabolic coma
2. Encephalitis
3. Non-convulsive status epilepticus

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 Once the patient is stable from a cardiorespiratory
perspective, examination should include accurate assessment
of conscious level and a thorough general medical
examination, looking for clues such as needle tracks indicating
drug abuse, rashes, fever and focal signs of infection, including
neck stiffness or evidence of head injury. Focal neurological
signs may suggest a structural explanation (stroke or tumour)
or may be falsely localising (for example, 6th nerve palsy can
occur as a consequence of raised intracerebral pressure). It is
vital to exclude non-neurological causes of coma. Sodium and
glucose should be measured urgently as part of the initial
assessment, as acute hyponatraemia (p. 358) and
hypoglycaemia (p. 738) are easily corrected and can cause
irreversible brain injury if missed.

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 hould be guided by the clinical presentation and examination findings; a
sudden onset suggests a vascular cause. An early CT scan of the brain may
demonstrate any gross pathology but if a brainstem stroke is suspected
(Fig. 10.11), a CT angiogram of the circle of Willis will provide more useful
information, as a non-contrast CT is frequently negative in this context. If
there are features suggestive of cerebral venous thrombosis, such as
thrombophilia or sinus infection, a CT venogram should be performed.
Meningitis or encephalitis may be suggested by the history, signs of
infection or subtle radiological findings. If these diagnoses are considered,
it is best to commence treatment with broad-spectrum antibiotics and
antivirals while awaiting more definitive diagnostic information.
 Other drug, metabolic and hepatic causes of reduced conscious level are
dealt with in the relevant chapters. An ammonia level (sent on ice) can
narrow the differential diagnosis to a metabolic or hepatic cause if there is
diagnostic doubt; levels > 100 μmol/L (140 μg/dL) are significantly
abnormal. Psychiatric conditions such as catatonic depression or
neurological conditions such as the autoimmune encephalitides can cause
a reduced level of consciousness, but they are diagnoses of exclusion and
will require specialist input.