Reduced level of consciousness and coma
First-minute treatment of the unresponsive patient, localising the problem with GCS, pupils, brainstem reflexes and breathing, toxidromes, and the structural causes you can't afford to miss.
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Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- Consciousness needs arousal (the ascending reticular activating system in the upper brainstem and thalamus) and awareness (both cerebral hemispheres). Coma results from a brainstem lesion or diffuse bilateral hemispheric dysfunction. A unilateral hemispheric lesion doesn't cause coma unless it compresses the brainstem.
- Toxic and metabolic causes are commonest. Structural lesions are rarer and more urgent.
- Treat first, diagnose second: airway, breathing, circulation, glucose, naloxone, thiamine, temperature.
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Sources
- Therapeutic Guidelines: Neurology and Toxicology and Toxinology (eTG complete, current online versions)AU/NZTherapeutic Guidelines Limited
- Emergency Neurological Life Support (ENLS) Version 6.0: Approach to the Patient With ComaNeurocritical Care Society, 2024
- Posner JB, Saper CB, Schiff ND, Claassen J. Plum and Posner's Diagnosis and Treatment of Stupor and Coma, 5th edition. Oxford University Press, 2019Oxford University Press, 2019
- Freund Y, Viglino D, Cachanado M et al. Effect of noninvasive airway management of comatose patients with acute poisoning: a randomized clinical trial (NICO). JAMA 2023;330(23):2267-2274JAMA, 2023
- The ANZICS Statement on Death and Organ DonationAU/NZAustralian and New Zealand Intensive Care Society, Edition 4.1, 2021
- Guidelines for the Treatment of Alcohol Problems: preventing and treating Wernicke's encephalopathyAU/NZAustralian Government Department of Health (Haber et al.), 2021
- Poisons Information Centre (13 11 26)AU/NZAustralian state poisons information centres
- Tao C, Nogueira RG, Zhu Y et al. Trial of endovascular treatment of acute basilar-artery occlusion (ATTENTION). N Engl J Med 2022;387:1361-1372New England Journal of Medicine, 2022
- Last updated
- 14 November 2026
What changed
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