Primary Objective:  The physician should be able to stabilize, evaluate, and treat the comatose patient in the emergent setting.
The physician should understand this involves an organized, sequential, prioritized approach.

Primary Objectives
Treatment of rapidly progressive, dangerous metabolic causes of coma (hypoglycemia)
Evaluation as to whether there is significant increased ICP or mass lesions.
Treatment of ICP to temporize until surgical intervention is possible.

Secondary Objectives
The physician should understand and recognize:
 Herniation syndromes
 Signs of supratentorial mass lesions
 Signs of subtentorial mass lesions
The physician should be able to develop the differential diagnosis of metabolic coma.

Consciousness requires:
 An intact pontine reticular activating system
 An intact cerebral hemisphere, or at least part of a hemisphere
Coma requires dysfunction of either the:
 Pontine reticular activating system, or
 Bihemispheric cerebral dysfunction

Supratentorial lesions cause coma by either widespread bilateral disease, increased intracranial pressure, or herniation.
Infratentorial lesions involve the RAS, usually with associated brainstem signs
Metabolic coma causes diffuse hemispheric involvement and depression of RAS, usually  without focal findings

Herniation Syndromes
Central herniation
 Rostral caudal progression of respiratory, motor, and pupillary findings
 May not have other focal findings
Uncal herniation
 Rostral caudal progression
 CN III dysfunction and contralateral motor findings

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