The comatose patient: A case study

I he evaluation and treatment of patients with altered mental status is a responsibility that has principally been given to ED health care providers. Nowhere in the hospital do unexpected alterations of consciousness occur as frequently as in the emergency department. Physicians and nurses who work in this area must be able to make a rapid and definitive diagnosis as to the cause of altered mental status. The following case represents the ultimate in altered mental status: the unconscious and/or unresponsive patient. The patient, a 40-year-old white alcoholic man called Charlie, was a frequent visitor to the emergency department. The local emergency medical service received a call that an unconscious patient was lying on a sidewalk outside a downtown bar. The emergency medical technicians transported this familiar patient to the emergency department. There was no history from anyone at the scene as to what happened. As he was being wheeled through the doors of the emergency department, the comment could be heard, “Oh, no, it’s Charlie again-drunk as usual.” No other history was obtainable, and no pill bottles or traces of other chemicals were found. When virtually no history is available, experienced ED personnel should have an initial assessment and treatment program in mind that can be activated instantaneously. Whenever there is a question about what to do first in any emergency situation, the answer should always be “airway, breathing, and circulation” (ABC). It matters very little whether a patient is complaining of a sprained ankle or is totally unresponsive; the first duty of the emergency service is to ensure an adequate airway, ventilation, and circulation. It should be assumed that all unconscious and/or unresponsive patients, particularly alcoholic patients, will vomit, and it seems that all these patients have recently completed a meal that will find itself in their lungs if we do not act immediately.