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ache and meningismus (and fever in the case of infectious meningitis), keeping in mind the risks of this procedure and the means of dealing with them A CT scan may have disclosed a primary subarachnoid hemorrhage, in which case lumbar puncture is not necessary In the case of meningitis, broad spectrum antibiotics that penetrate the meninges may be instituted, especially if the lumbar puncture is delayed The choice of drug is then determined by the principles set forth in Chap 32 Convulsions should be controlled by measures outlined in Chap 16 As indicated above, gastric aspiration and lavage with normal saline may be diagnostically and therapeutically useful in some instances of coma due to drug ingestion Salicylates, opiates, and anticholinergic drugs (tricyclic antidepressants, phenothiazines, scopolamine), all of which induce gastric atony, may be recovered many hours after ingestion Caustic materials should not be lavaged because of the danger of gastrointestinal perforation The administration of activated charcoal is indicated in certain drug poisonings Measures to prevent gastric hemorrhage and excessive gastric acid secretion are usually advisable The temperature-regulating mechanisms may be disturbed, and extreme hypothermia or hyperthermia should be corrected In severe hyperthermia, evaporative-cooling measures are indicated in addition to antipyretics The bladder should not be permitted to become distended; if the patient does not void, decompression should be carried out with an indwelling catheter Needless to say, the patient should not be permitted to lie in a wet or soiled bed Diseases of the CNS may disrupt the control of water, glucose, and sodium The unconscious patient can no longer adjust the intake of food and uids by hunger and thirst Both salt-losing and salt-retaining syndromes have been described with brain disease (see Chap 27) Water intoxication and severe hyponatremia may of themselves prove damaging If coma is prolonged, the insertion of a nasogastric tube will ease the problems of feeding the patient and maintaining uid and electrolyte balance It is quite acceptable to leave the tube in place for long periods Otherwise, approximately 35 mL/kg of isotonic uid should be administered per 24 h (5% dextrose in 045% saline with potassium supplementation unless there is brain edema, in which case the use of isotonic normal saline is indicated).

type, and then in each of the series we choose a different chart type This can be seen in the following illustration

Aspiration pneumonia is avoided by prevention of vomiting (gastric tube and endotracheal intubation), proper positioning of the patient, and restriction of oral uids Should aspiration pneumonia occur, it requires treatment with appropriate antibiotics and aggressive pulmonary physical therapy Leg vein thrombosis a common occurrence in comatose and hemiplegic patients often does not manifest itself by obvious clinical signs An attempt may be made to prevent it by the subcutaneous administration of heparin, 5000 U q 12 h, or of low-molecular-weight heparin, and by the use of intermittent pneumatic compression boots If the patient is capable of moving, suitable restraints should be used to prevent him from falling out of bed and to avert self-injury from convulsions Regular conjunctival lubrication and oral cleansing should be instituted

Prognosis of Coma (See also page 963)

As a general rule, recovery from coma of metabolic and toxic causes is far better than from anoxic coma, with head injury occupying an intermediate prognostic position Most patients who are comatose as a result of a stroke will die; subarachnoid hemorrhage in which coma is due to hydrocephalus is an exception In regard to all forms of coma, but particularly after cardiac arrest, if there are no pupillary, corneal, or oculovestibular responses within several hours of the onset of coma, the chances of regaining independent function are practically nil (see Levy et al) Other signs that predict a poor outcome are absence of corneal re exes and eyeopening responses and atonia of the limbs at 1 and 3 days after the onset of coma and absence of the cortical component of the somatosensory evoked responses on both sides It is the unfortunate survivor from this latter group who may remain in a vegetative state for months or years, breathing without aid and with preserved hypothalamopituitary functions The frequency of this persistent vegetative state after head injury and the negligible chances of improvement if the condition persists for several weeks have already been discussed, and a discussion of the outcome of anoxic-ischemic coma can be found in Chap 40 In all other cases, the nature of the underlying disease determines outcome; the reader should refer to the appropriate section of this book for further details

ADAMS JH, GRAHAM DI, JENNET B: The neuropathology of the vegetative state after an acute brain insult Brain 125:1327, 2000 ANDREWS BT, CHILES BW, OLSEN WL, et al: The effects of intracerebral hematoma location on the risk of brainstem compression and outcome J Neurosurg 69:518, 1988 ANDREWS K: Recovery of patients after four months or more in the persistent vegetative state BMJ 306:1597, 1993 BEECHER HK, ADAMS RD, SWEET WH: A de nition of irreversible coma: Report of the Committee of Harvard Medical School to examine the de nition of brain death JAMA 205:85, 1968 BRAAKMAN R, JENNETT WB, MINDERHOUND JM: Prognosis of the posttraumatic vegetative state Acta Neurochir 95:49, 1988 BREMER F: L activite cerebrale au cours du sommeil et de la narcose Bull Acad R Soc Belg 2:68, 1937 CAIRNS H, OLDFIELD RC, PENNYBACKER JB, et al: Akinetic mutism with an epidermoid cyst of the third ventricle Brain 64:273, 1941 CRICK FA, KOCH C Framework for consciousness Nat Neurosci 6(2)119 126, 2003 FELDMAN MH: The decerebrate state in the primate: I Studies in monkeys Arch Neurol 25:501, 1971 FELDMAN MH, SAHRMANN S: The decerebrate state in the primate: II Studies in man Arch Neurol 25:517, 1971 FISHER CM: The neurological examination of the comatose patient Acta Neurol Scand Suppl 36: 1969

Then we went into each of the series and used what we learned before about the primary and secondary colors and the gradient approach to liven up the report In this case we also use the Line Type in the second series to show the line chart type incorporated into the column chart, as shown in the next illustration

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