If one or more of the former are present, immediate resuscitative efforts are begun Point-of-care testing for glucose, sodium, blood gas analysis, and hemoglobin should be performed immediately History and Physical Examination Focused, goal-directed questioning pertaining to suspected diagnoses is required to treat coma quickly Caregivers should be specifically queried regarding current medications, medications and substances available to ingest, seizures, fever, headache, irritability, vomiting, changes in gait, and behavioral abnormalities The most important historical finding in a comatose patient is a history of recent head trauma If no history of head trauma is present, it should continue to be considered as a potential cause of ALOC, since many cases are unwitnessed and patients with nonaccidental trauma may have a misleading history A patient’s vital signs will reveal the presence of fever, hypotension, or hypertension The consciousness of a neurologically impaired patient may initially be evaluated using a simple AVPU scale, representing four major levels of alertness: Alert, responsive to Verbal stimuli, responsive to Painful stimuli, and Unresponsive Elements of a more detailed neurologic evaluation are discussed in the following section The patient should be carefully examined for physical findings consistent with head trauma, including retinal hemorrhage, hemotympanum, CSF otorrhea or rhinorrhea, postauricular hematoma (Battle sign), palpable or visual damage to scalp or skull, and periorbital hematoma (“raccoon eyes”) Child abuse should be suspected if unexplained bruising is present or the stated mechanism of injury is disproportionate to the degree of physical damage present or to the child’s developmental level (e.g., 1-month-old “rolled off bed”) Bruising on the face, neck, head, or ears in nonambulatory children is of great concern for abusive head trauma (“those who don’t cruise, rarely bruise”) Other significant physical findings include anisocoria, absent or reduced pupil reactivity, papilledema, and nuchal rigidity Purpuric or varicelliform rashes may signify the presence of systemic infections with CNS involvement Incontinence of urine or stool may indicate that an unwitnessed seizure has occurred