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).
  • Biot's [irregular, ataxic] (advanced brainstem).
  • Kussmaul (DM).
• 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.