Acute care: Brain failure
In the final part of our series, Nicola Cooper focuses on the D for disability in the ABCDE system of managing acutely ill patients
The most common reason for a reduced conscious level is critical illness--not necessarily a primary brain problem. Patients who have a serious problem with A (airways), B (breathing), or C (circulation) can be drowsy or unresponsive--for example, obstruction of the airway, any severe lung problem, or shock from any cause.
Coma, by definition, is when the Glasgow coma score is less than 9 (box 1). This is associated with potentially life-threatening complications which require urgent intervention. Such patients have reduced airway reflexes and are considered unable to protect their own airway from aspiration of obstruction. Intubation with a cuffed endotracheal tube is the definitive method of protecting the airway.
Head injury is a common cause of coma. In non-trauma patients who have been unconscious for six hours, 40% will have taken some form of sedative and of the remaining 60%, about a third have hypoxic brain injury (for example, after