Unconscious: Examination
  1. Inspection
  2. Consciousness level
  3. Head, neck
  4. Eyes, ears, nose, mouth
  5. Limbs
  6. Body, temperature
  7. Urine, glucose
  8. Stomach contents

Quick cause checklist: COMA:
CO narcosis
Overdose
Metabolic
Apoplexy

Inspection
  • ABC: Airway, Breathing, Circulation.
  • Breathing type is important clue:
    Cheyne-Stokes (diencephalic). (a cyclical pattern of breathing in which movement gradually decreases to a complete stop and then returns to normal. It occurs in various medical conditions, and at high altitudes.)
    Biot's [irregular, ataxic] (advanced brainstem).(Biot's respiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. It is named for Camille Biot, who characterized it in 1876.)
    Kussmaul (DM).ussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure
  • Circulation: shock, dehydration, cyanosis, BP, pulse rate.
    Cherry red (CO poisoning).
  • Posture: trauma, hyperextension, decerebrate, decorticate.
  • Involuntary movements:
    Recurrent convulsions (status epilepticus).
    Myoclonic jerks (hypoxia, metabolic encephalopathy).
Consciousness level
  • Press knuckles over sternum to cause pain and assess consciousness.
  • Note stage:
    Drowsiness: normal sleepiness, can we roused to wakefulness.
    Stupor: unconsciousness, can be aroused with effort, purposeful pain responses.
    Light coma: unconscious with reduced semi-purposeful response.
    Deep: no response, no reflex.
  • To assign a value, See Glasgow Coma Scale Reference.
Head, neck
  • If no evidence of neck trauma, assess neck stiffness, Kernig's sign (SAH, meningitis).
  • Inspect, palpate for head injures, including Battle's sign.
  • Facial asymmetry (affected side sucked in/ out with respiration).
  • Jaundice (hepatic coma).
  • Myxoedema manifestations.
Eyes
  • Pupils:
    Constricted (narcotic OD).
    1 dilated (subdural, raised ICP, SAH).
    Dilated (atropines, cloning from raised ICP).
  • Dolls eye test:
    Open lids, turn head from side to side.
    Normal: eyes fixate like a moved doll, don't follow head. Brainstem lesion: follow head.
  • Eye deviations:
    1 eye deviated (CN III, IV, VI palsy).
    Both eyes deviated (cerebral hemisphere [look towards lesion]).
    Up/down deviation (brainstem).
    Also skull fracture could restrict an eye muscle, so deviate.
Ears, nose
  • Blood leaking from ears/ nose.
  • CSF leaking from ears/ nose (skull fracture).
    CSF test of watery discharge: test for glucose.
Mouth
  • Gum hyperplasia: epilepsy clue (taking phenytoin).
  • Trauma (previous seizure).
  • Smell breath (ketoacidosis, alcohol, hepatic coma, uremia).
  • Gag reflex: absent (brainstem dz, deep coma).
  • Mouth corrosion (could be poison).
Limbs
  • Injection marks (addict, DM).
  • Tone: pick up arm, let fall.
  • Deep tendon reflexes (coma: may be absent on paralyzed side).
  • Pain: press pen on distal toe/ finger and see if leg/ arm withdrawal (if grimace/twitch and not withdrawal, could be sensation but paralyzed).
    Grimacing important: segmental reflexes alone can cause withdrawal.
Body
  • Signs of trauma.
  • Examine heart, lungs, abdomen.
Temperature
  • Hypothermia (hypothyroidism), fever (meningitis).
Urine
  • Incontinence.
  • Test urine for glucose, ketones (diabetes), protein (uracemia), blood (trauma).
Glucose
  • Prick finger, drop of blood on test strip.
    If can't give an IV of glucose (saves hypoglycemia, won't harm ketoacidosis).
  • If Wernicke's possible, give thiamine.
Stomach contents
  • Perform if suspect drug OD, or no other obvious cause.
  • While protecting airway, examine stomach by nasogastric tube.