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hyperventilation Diseases that elevate intracranial pressure or damage the brain often cause slow, irregular, or cyclic CheyneStokes respiration (see further on) The various disordered patterns of breathing and their clinical signi cance are described further on and on page 474 Vomiting at the outset of sudden coma, particularly if combined with pronounced hypertension, is highly characteristic of cerebral hemorrhage within the hemispheres, brainstem, cerebellum, or subarachnoid space The pulse rate, if exceptionally slow, should suggest heart block from medications such as tricyclic antidepressants or anticonvulsants, or if combined with periodic breathing and hypertension an increase in intracranial pressure that re ects the presence of a mass lesion A myocardial infarction of the inferior wall may also be the cause of bradycardia Marked hypertension is observed in patients with cerebral hemorrhage and hypertensive encephalopathy and sometimes in those with greatly increased intracranial pressure Hypotension is the usual nding in states of depressed consciousness due to diabetes, alcohol or barbiturate intoxication, internal hemorrhage, myocardial infarction, dissecting aortic aneurysm, septicemia, Addison disease, or massive brain trauma Inspection of the skin may yield valuable information Cyanosis of the lips and nail beds signi es inadequate oxygenation Cherry-red coloration is typical of carbon monoxide poisoning Multiple bruises (particularly a bruise or boggy area in the scalp), bleeding, CSF leakage from an ear or the nose, or periorbital hemorrhage greatly raises the likelihood of cranial fracture and intracranial trauma Telangiectases and hyperemia of the face and conjunctivae are the common stigmata of alcoholism; myxedema imparts a characteristic puf ness of the face, and hypopituitarism an equally characteristic sallow complexion Marked pallor suggests internal hemorrhage A maculohemorrhagic rash indicates the possibility of meningococcal infection, staphylococcal endocarditis, typhus, or Rocky Mountain spotted fever Excessive sweating suggests hypoglycemia or shock, and excessively dry skin, diabetic acidosis or uremia Skin turgor is reduced in dehydration Large blisters, sometimes bloody, may form over pressure points such as the buttocks if the patient has been motionless for a time; they are particularly characteristic of acute barbiturate, alcohol, and opiate intoxication Thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and fat embolism may cause diffuse petechiae The odor of the breath may provide a clue to the etiology of coma Alcohol is easily recognized (except for vodka, which is odorless) The spoiled-fruit odor of diabetic coma, the uriniferous odor of uremia, the musty fetor of hepatic coma, and the burnt almond odor of cyanide poisoning are distinctive enough to be identi ed by physicians who possess a keen sense of smell.

Although limited in many ways, the neurologic examination of the comatose patient is of crucial importance Simply watching the patient for a few moments often yields considerable information The predominant postures of the limbs and body; the presence or absence of spontaneous movements on one side; the position of the head and eyes; and the rate, depth, and rhythm of respiration should be noted The state of responsiveness is then estimated by noting the patient s reaction to calling his name, to simple commands, or to noxious stimuli such as supraorbital or sternal pressure, pinching the side of the neck or inner parts of the arms or thighs, or applying

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pressure to the knuckles By gradually increasing the strength of these stimuli, one can roughly estimate both the degree of unresponsiveness and changes from hour to hour Vocalization may persist in stupor and is the rst response to be lost as coma appears Grimacing and deft avoidance movements of the stimulated parts are preserved in light coma; their presence substantiates the integrity of corticobulbar and corticospinal tracts Yawning and spontaneous shifting of body positions indicate a minimal degree of unresponsiveness These various signs have been elegantly summarized by Fisher based on his own observations The Glasgow Coma Scale, constructed originally as a quick and simple means of quantitating the responsiveness of patients with severe cerebral trauma, can be used in the grading of other acute coma-producing diseases but is of little use in diagnosis (see Chap 35) It is usually possible to determine whether coma is associated with meningeal irritation In all but the deepest stages of coma, meningeal irritation from either bacterial meningitis or subarachnoid hemorrhage will cause resistance to passive exion of the neck but not to extension, turning, or tilting of the head It should be noted that in some patients the signs of meningeal irritation do not develop for 12 to 24 h after the onset of subarachnoid hemorrhage Resistance to movement of the neck in all directions may be part of generalized muscular rigidity (as in phenothiazine intoxication) or indicate disease of the cervical spine In the infant, bulging of the anterior fontanel is at times a more reliable sign of meningitis than stiff neck A temporal lobe or cerebellar herniation or decerebrate rigidity may also limit passive exion of the neck and be confused with meningeal irritation A lesion in a cerebral hemisphere can usually be detected, even though the patient is comatose, by careful observation of the patient s spontaneous movements, responses to stimulation, prevailing postures, respiratory rate and rhythm, and by examination of the cranial nerves A hemiplegia is revealed by a lack of restless movements of the limbs and by inadequate protective movements in response to painful stimuli on only one side The paralyzed limbs are usually slack; they tend to remain in passive positions and, if lifted from the bed, they fall ail The hemiplegic leg lies in a position of external rotation (this may also be due to a fractured femur), and the affected thigh may appear wider and atter than the nonhemiplegic one In expiration, the cheek and lips puff out on the paralyzed side With hemispheric lesions, the eyes are often turned away from the paralyzed side (toward the lesion, as described below); the opposite may occur with brainstem lesions In most cases, a hemiplegia and an accompanying Babinski sign are indicative of a contralateral hemispheral lesion; but with lateral mass effect and compression of the opposite cerebral peduncle against the tentorium, extensor rigidity, a Babinski sign, and weakness of arm and leg may also occur ipsilateral to the lesion (the above described Kernohan-Woltman sign) A moan or grimace may be provoked by painful stimuli on one side but not on the other, re ecting the presence of a hemianesthesia; also during grimacing, facial weakness may be noted Of the various indicators of brainstem function, the most useful are pupillary size and reactivity, ocular movements, oculovestibular re exes, and, to a lesser extent, the pattern of breathing These functions, like consciousness itself, are to a large extent dependent on the integrity of structures in the midbrain and rostral pons Pupillary Reactions These are of great diagnostic importance in the comatose patient A unilaterally enlarged pupil (55 mm diameter) is an early indicator of stretching or compression of the.

Finally, in Step 6, the properties of the exception are assigned The two settings in this screen are for the Exception Is Active option; therefore, the exception will be immediately applied before the display of the results and the description of the exception The following illustration shows an example of applying the exception generated by the Exception Wizard Here, we defined the exception against the Incoming Orders, set the Good setting for anything above 1,000,000, and set the Defective/Bad setting for anything less than 500,000; the values between those two benchmarks are displayed as the normal color (colorless) in the background

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