Immediate management

Assess the airway and breathing

• clear airway ^a and stabilise the cervical spine if there is a history of head or neck trauma  ^a
• ventilate with a bag-valve-mask and 100% oxygen ^a
• consider intubation  ^d

Assess the circulation ^d

• Correct any hypovolaemia or arrhythmias ^d
• Obtain large bore IV access and consider central venous pressure monitoring ^d

Look for evidence of hypoglycaemia ^c  

• Measure glucose rapidly using reagent strips ^{a  b} or a capillary blood glucose in triage ^a  
• Measure blood glucose ^a.   
  Remember patients with diabetes may experience hypoglycaemia at 'normoglycaemic levels'.
  
  
• If you believe hypoglycaemia is present, try a test dose of 50% glucose intravenously ^c  

Give thiamine 100 mg ^d iv ^c to alcoholics or malnourished patients ^d

Assess the level of consciousness using the Glasgow Coma Scale.

Look for status epilepticus ^c  

• Signs can be subtle. Look for twitching of extremities, mouth and eyes, but these may be absent.
• If suspected, give lorazepam  ^a  0.1 mg/kg iv at 2 mg/min

If an overdose is possible

• Give flumazenil iv  ^a 400 microgram ^d 
• Give naloxone  ^b intramuscularly 400 microgram followed by 400 microgram intravenously ^d

Correct hypothermia or hyperthermia ^d

Treat any underlying cause. ^a

• Acute hypoglycaemia
• Diabetic ketoacidosis
• Meningitis
• Hypercalcaemia
• Hypertensive crisis
• Stroke

Traumatic brain injury

There is no clear benefit from

• hyperventilation  ^d  
• CSF drainage  ^d  
• steroids  ^d  
• barbiturates  ^d  
• mannitol  ^d  
• hypertonic saline ^d