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before the patient comes to the attention of the physician Again, the problem may be highly complex, for the disturbance may be attributable not to a single cause but to several factors acting in unison, no one of which could account for the total clinical picture Moreover, in certain circumstances two processes frequently contribute to depressing consciousness, particularly head injury combined with drug or alcohol intoxication In lieu of speci c therapy, supportive measures must be used; indeed, the patient s chances of surviving the original disease often depend on the effectiveness of these general medical measures The successful management of the insensate patient requires the services of a well-coordinated team of nurses under the close guidance of a physician Necessary treatment must be instituted immediately, even before all the diagnostic steps have been completed; diagnosis and treatment may have to proceed concurrently The following is a brief outline of the principles involved in the treatment of such patients The details of management of shock, uid and electrolyte imbalance, and other complications that threaten the comatose patient (pneumonia, urinary tract infections, deep venous thrombosis, etc) are found in Harrison s Principles of Internal Medicine 1 Shallow and irregular respirations, stertorous breathing (indicating obstruction to inspiration), and cyanosis require the establishment of a clear airway and delivery of oxygen The patient should initially be placed in a lateral position so that secretions and vomitus do not enter the tracheobronchial tree Secretions should be removed by suctioning as soon as they accumulate; otherwise they will lead to atelectasis and bronchopneumonia Arterial blood gases should be measured and further observed by monitoring of oxygen saturation A patient s inability to protect against aspiration and the presence of either hypoxia or hypoventilation dictates the use of endotracheal intubation and a positive-pressure respirator The management of shock, if present, takes precedence over all other diagnostic and therapeutic measures Concurrently, an intravenous line is established and blood samples are drawn for determination of glucose, intoxicating drugs, and electrolytes and for tests of liver and kidney function Naloxone, 05 mg, should be given intravenously if a narcotic overdose is a possibility Hypoglycemia that has produced stupor or coma demands the infusion of glucose, usually 25 to 50 mL of a 50% solution followed by a 5% infusion; this must be supplemented with thiamine A urine sample is obtained for drug and glucose testing If the diagnosis is uncertain, both naloxone and the glucosethiamine combination should be administered With the development of elevated intracranial pressure from a mass lesion, mannitol, 25 to 50 g in a 20% solution, should be given intravenously over 10 to 20 min and hyperventilation instituted if deterioration occurs, as judged by pupillary enlargement or deepening coma Repeated CT scanning allows the physician to follow the size of the lesion and degree of localized edema and to detect displacements of cerebral tissue With massive cerebral lesions, it may be appropriate to place a pressure-measuring device in the cranium of selected patients (see Chap 35 for details of intracranial pressure monitoring and treatment) A lumbar puncture should be performed if meningitis or subarachnoid hemorrhage is suspected on the basis of head-.

2 3

Once that is complete, we have our finished results Again, the texture background and the colors used are changeable and will need to be approved by the corporate marketing department We have now finished several chart types and used only about 6 8 steps each but the results are a very good and well-defined set of charts

Seriously impaired states of consciousness, regardless of their cause, are often fatal not only because they represent an advanced stage of many diseases but also because they add their own particular burdens to the primary disease The physician s main objective, of course, is to nd the cause of the coma and to treat it appropriately It often happens, however, that the disease process is one for which there is no speci c therapy; or, as in hypoxia or hypoglycemia, the acute, irreversible effects have already occurred

Coma with focal or lateralizing signs Cerebral hemorrhage Hemiplegia, hypertension, cyclic breathing, speci c ocular signs (See Chaps 14 and 33) CT scan

Basilar artery occlusion (thrombotic or embolic)

Normal early CT; MRI shows cerebellar and brainstem or thalamic infarction, normal CSF CT and MRI show massive edema of hemisphere CT scan; CSF xanthochromic with relatively low protein

Now, for the final result, we take the three charts we have developed and combine them into a table in the BI WAD to see what some minor changes have done for this information The results are shown in the following illustration Compare what we had before and what we have now This is definitely of the level to be published and distributed at a meeting and can be used for presentations and corporate management The others were okay but not quite robust enough to catch the eye of the user and deliver the message about the corporate revenue Now, with a little effort, we have a very good basis for a corporate dashboard

Sudden onset, often with headache, vomiting; history of chronic hypertension; late pupillary enlargement Onset subacute (thrombosis), or sudden (rostral basilar embolism)

318 Massive infarction and edema in carotid territory Subdural hematoma Trauma Brain abscess Hypertensive encephalopathy; eclampsia Thrombotic thrombocytopenic purpura (TTP) Meningitis and encephalitis Neurologic signs depending on location Blood pressure 210/110 (lower in eclampsia and in children), headache, seizures, hypertensive retinal changes Petechiae, seizures shifting focal signs Stiff neck, Kernig sign, fever, headache Stertorous breathing, hypertension, stiff neck, Kernig sign Subarachnoid hemorrhage

Extensor posturing and bilateral Babinski signs; early loss of oculocephalic responses; ocular bobbing Hemiplegia, unilateral unresponsive or enlarged pupil Slow or cyclic respiration, rising blood pressure, hemiparesis, unilateral enlarged pupil Signs of cranial and facial injury

ingspreads are an advanced adaptation of some of the spreads we discussed in s 6 and 7 These spreads are called wingspreads because, when you lay out the spread, you are creating two options close together that make up the body of the spread and two options on the outside that become the wings to the spread Wingspreads are part of the neutral delta or nondirectional family of spreads and are designed to take advantage of ranges of market trading, volatility, and time value decay