History of Head Trauma The patient with deeply depressed consciousness (GCS score less than 9) after head trauma is presumed to have increased ICP until proven otherwise Rapid sequence intubation is indicated to protect the airway and to maintain effective ventilation Cervical spine injury should be assumed and cervical immobilization maintained at all times An emergent noncontrast brain CT scan should be obtained and neurosurgery consulted Elevation of the head of the bed to 30 degrees and maintenance of the midline position of the head are simple nonpharmacologic maneuvers to try to reduce ICP In cases when immediate but necessary neurosurgical intervention is not possible for intracranial hemorrhage (e.g., extended transport time) or in cases of diffuse cerebral edema, 3% saline or mannitol may be helpful to treat elevated ICP History of Seizures The patient with ALOC in the absence of trauma should be evaluated for recent seizure activity with current postictal state (see Chapters 72 Seizures and 97 Neurologic Emergencies ) A history of previous seizures, witnessed convulsive activity, and ALOC consistent with previous postictal periods are valuable clues to this etiology of coma Ongoing seizure activity may be revealed by the presence of muscular twitching, increased tonicity, nystagmus, or eyelid fluttering Patients with subtle or completely nonconvulsive forms of status epilepticus may exhibit tachycardia but may require an EEG to diagnose The mental status examination of the postictal patient should gradually improve over several hours Although temporary focal neurologic deficits (e.g., Todd paralysis) may follow seizures, they must be presumed to indicate the presence of focal CNS lesions until proven otherwise The evaluation of neurologically depressed patients with seizures varies based on the patient’s history, type of seizure, and presence or absence of fever Patients with a history of seizures should have serum antiepileptic concentrations measured and be observed until they approach their neurologic baseline Children who have had a simple febrile seizure (see Chapter 72 Seizures ) should return to their baseline state soon, usually within hour Those who remain lethargic or irritable past this point (especially after antipyretic administration) should be suspected of having meningitis and are candidates for lumbar puncture Patients with new-onset generalized seizures who are afebrile warrant additional evaluation Depending on recent history (e.g., vomiting or diarrhea), it may be advisable to check serum electrolytes or a toxicologic screen Depending on local resources and practice, patients with newly diagnosed afebrile seizures