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If one or more of the former are present, immediate resuscitative efforts are
begun. Point-of-care testing for glucose, sodium, blood gas analysis, and
hemoglobin should be performed immediately.

History and Physical Examination
Focused, goal-directed questioning pertaining to suspected diagnoses is required
to treat coma quickly. Caregivers should be specifically queried regarding current
medications, medications and substances available to ingest, seizures, fever,
headache, irritability, vomiting, changes in gait, and behavioral abnormalities.
The most important historical finding in a comatose patient is a history of recent
head trauma. If no history of head trauma is present, it should continue to be
considered as a potential cause of ALOC, since many cases are unwitnessed and
patients with nonaccidental trauma may have a misleading history.
A patient’s vital signs will reveal the presence of fever, hypotension, or
hypertension. The consciousness of a neurologically impaired patient may
initially be evaluated using a simple AVPU scale, representing four major levels
of alertness: Alert, responsive to Verbal stimuli, responsive to Painful stimuli, and
Unresponsive. Elements of a more detailed neurologic evaluation are discussed in
the following section.
The patient should be carefully examined for physical findings consistent with
head trauma, including retinal hemorrhage, hemotympanum, CSF otorrhea or
rhinorrhea, postauricular hematoma (Battle sign), palpable or visual damage to
scalp or skull, and periorbital hematoma (“raccoon eyes”). Child abuse should be
suspected if unexplained bruising is present or the stated mechanism of injury is
disproportionate to the degree of physical damage present or to the child’s
developmental level (e.g., 1-month-old “rolled off bed”). Bruising on the face,
neck, head, or ears in nonambulatory children is of great concern for abusive head
trauma (“those who don’t cruise, rarely bruise”). Other significant physical
findings include anisocoria, absent or reduced pupil reactivity, papilledema, and
nuchal rigidity. Purpuric or varicelliform rashes may signify the presence of
systemic infections with CNS involvement. Incontinence of urine or stool may

indicate that an unwitnessed seizure has occurred.