1. Inspection
2. Consciousness level
3. Headneck
4. Eyesearsnosemouth
5. Limbs
6. Bodytemperature
7. Urineglucose
8. Stomachcontents

Quick cause checklist: COMA:
• CO narcosis
• Overdose
• Metabolic
• Apoplexy

Inspection

• ABC: AirwayBreathingCirculation.
• Breathing type is important clue:
  • Cheyne-Stokes (diencephalic).
  • Biot's [irregularataxic] (advanced brainstem).
  • Kussmaul (DM).
• Circulation: shockdehydrationcyanosisBPpulse rate.
  • Cherry red (CO poisoning).
• Posture: traumahyperextensiondecerebratedecorticate.
• Involuntary movements:
  • Recurrent convulsions (status epilepticus).
  • Myoclonic jerks (hypoxiametabolic encephalopathy).

Consciousness level

• Press knuckles over sternum to cause pain and assess consciousness.
• Note stage:
  • Drowsiness: normal sleepinesscan we roused to wakefulness.
  • Stupor: unconsciousnesscan be aroused with effortpurposeful painresponses.
  • Light coma: unconscious with reduced semi-purposeful response.
  • Deep: no responseno reflex.
• To assign a valueSee Glasgow Coma ScaleReference.

Headneck

• If no evidence of neck traumaassess neck stiffnessKernig's sign(SAHmeningitis).
• Inspectpalpate for head injuresincluding Battle's sign.
• Facial asymmetry (affected side sucked in/ out with respiration).
• Jaundice (hepatic coma).
• Myxoedema manifestations.

Eyes

• Pupils:
  • Constricted (narcotic OD).
  • 1 dilated (subduralraised ICPSAH).
  • Dilated (atropinescloning from raised ICP).
• Dolls eye test:
  • Open lidsturn head from side to side.
  • Normal: eyes fixate like a moved dolldon't follow head. Brainstemlesion: follow head.
• Eye deviations:
  • 1 eye deviated (CN IIIIVVI palsy).
  • Both eyes deviated (cerebral hemisphere [look towards lesion]).
  • Up/down deviation (brainstem).
  • Also skull fracture could restrict an eye muscleso deviate.

Earsnose

• 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 (ketoacidosisalcoholhepatic comauremia).
• Gag reflex: absent (brainstem dzdeep coma).
• Mouth corrosion (could be poison).

Limbs

• Injection marks (addictDM).
• Tone: pick up armlet fall.
• Deep tendon reflexes (coma: may be absent on paralyzed side).
• Pain: press pen on distal toe/ finger and see if leg/ arm withdrawal (ifgrimace/twitch and not withdrawalcould be sensation but paralyzed).
  • Grimacing important: segmental reflexes alone can cause withdrawal.

Body

• Signs of trauma.
• Examine heartlungsabdomen.

Temperature

• Hypothermia (hypothyroidism)fever (meningitis).

Urine

• Incontinence.
• Test urine for glucoseketones (diabetes)protein (uracemia)blood(trauma).

Glucose

• Prick fingerdrop of blood on test strip.
  • If can't give an IV of glucose (saves hypoglycemiawon't harmketoacidosis).
• If Wernicke's possiblegive thiamine.

Stomach contents

• Perform if suspect drug ODor no other obvious cause.
• While protecting airwayexamine stomach by nasogastric tube.

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