By: Charles D. Ponte, BS, PharmD, FAADE, FAPhA, FASHP, FCCP, FNAP
Many surgeons today prefer a mini-open anterior approach to heart attack blood pressure cheap diovan 40mg with visa the lumbar spine using a retraction frame (Case Introduction) heart attack effects generic diovan 160mg without a prescription, which allows a one or two level anterior fusion to blood pressure 300 150 160mg diovan with amex be performed through a short incision [2 hypertension questionnaire discount diovan 80mg mastercard, 186]. However, the anterior minimally invasive procedures are demonstrated superior often associated with a significantly greater incidence of complications and tech outcomes nical difficulty than their associated open approaches . Similarly to a primary intervention, the single most important factor in Functional and clinical achieving a successful clinical outcome is patient selection . It is well antici results of lumbar fusion pated that functional and clinical results of lumbar fusion are often not in corre are often not in correlation lation and the rate of non-union has no significant association with clinical results in the first place [81, 277], which challenges the clinical success of revision surgery for non-union. Interbody fusion is advocated to repair non-union because revision surgery the best lumbar fusion rates by posterolateral fusion has not been overly successful [55, 75]. Although solid fusion after non-union can be achieved in 94–100% of Despite successful fusion patients with appropriate techniques [36, 42, 99], there is only a poor correlation repair, clinical outcome of the radiographic and clinical results . These authors reported a fusion rate of 100% even in the face of factors often placing patients at high risk for developing a pseudarthrosis, i. Adjacent Segment Degeneration Adjacent segment degeneration following lumbar spine fusion remains a well known problem, but there is insufficient knowledge regarding the risk factors that contribute to its occurrence . Biomechanical and radiological investi gations have demonstrated increased forces, mobility, and intradiscal pressure in adjacent segments after fusion . Although it is hypothesized that these changes lead to an acceleration of degeneration, the natural history of the adja cent segment remains unaddressed . Radiographic segmental degeneration frequent problem weakly correlates with clinical symptoms  and the age of the individual [46, 104, 213]. It remains to be seen whether disc arthroplasty will alter the rate of adjacent seg ment degeneration . Motion Preserving Surgery Motion preservation With the advent of motion preserving surgical techniques, there is a great excite surgery is still emerging ment among surgeons and patients that the drawbacks of spinal fusion can be overcome. So far, the initial results are equivalent to those obtained with spinal fusion and it is hoped that there is a decrease in the rate of adjacent segment degen eration. Total Disc Arthroplasty Attempts to artificially replace the intervertebral discs were already made in the 1950s by Fernstrom . Both osteotomy and total joint replacement succeed because they alter the load transmission across the joint . The the dynamic stabilization rationale for dynamic or “soft” stabilization of a painful motion segment is to system may alter abnormal alter mechanical loading by unloading the disc but preserving lumbar motion in loading and thus contrast to spinal fusion . Best indications the Dynesys system is based on pedicle screws connected with a polyethylene for dynamic stabilization cord and a polyurethane tube reducing movement both in flexion and extension are not well established [238, 249]. However, often it also unloads the disc to a degree that is unpredict able . The clinical effectiveness of Recently, interspinous implants have been introduced as minimally invasive interspinous stabilization dynamic spine stabilization systems. This effect will reduce posterior anulus pressures and theoretically enlarge the neural foramen . Comparison of Treatment Modalities During the last decade, several high quality prospective randomized trials have elucidated the effect of conservative versus operative treatment on clinical out come for lumbar degenerative disorders. However, no significant differences between fusion techniques were found Surgical fusion techniques among the groups in terms of subjective or objective clinical outcome . Longer term follow-up, however, revealed that the benefits of surgery diminished over time (P. Although this study was highly acclaimed for being the first of its kind, criticism arose with regard to the patient inclusion criteria. No significant differ are key elements ences were found in terms of subjective outcome or disability. Patients with of non-operative care chronic low-back pain who followed cognitive intervention and exercise pro grammes improved significantly in muscle strength compared with patients who underwent lumbar fusion . No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation. However, sensitivity analyses show that this could change – for exam ple, if the proportion of rehabilitation patients requiring subsequent surgery continues to increase. Psychological, fected by the instability and not so much the range sociological and work-related factors have been of motion. Objective criteria for the definition of shown to affect treatment outcome more than clin segmental instability are lacking and the diagnosis ical and morphological findings. A facet joint syndrome ration (physical exercises), and cognitive-behaviou causes stiffness as well as pain on backward bend ral therapy (psychological intervention). The pain sometimes radiates into the buttocks effective for degenerative lumbar spondylosis. Spinal duration of persistent symptoms (<6 months), one instrumentation increases the fusion rate but not or two-level disease, absence of risk factor flags, equally the clinical outcome. Non-union and adjacent segment Blood supply to the spinal fusion area and the prop degenerations are frequent fusion related problems. Total used to support the anterior column and have some disc arthroplasty does not provide superior results biologic advantages compared to cages but carry compared to spinal fusion. Fritzell P, Hagg O, Wessberg P, Nordwall A (2001) 2001 Volvo Award Winner in Clinical Studies:Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multi center randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 26:2521–32 Fritzell P, Hagg O, Wessberg P, Nordwall A (2002) Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish Lumbar Spine Study Group. At the 2-year follow-up, back pain was significantly more reduced in the surgical group by 33% compared with 7% in the non-surgical group. The surgical patients had a significantly higher rate (63%) of a subjec tive favorable outcome (“much better” or “better”) compared to the non-surgical group (29%). A detailed analysis of the 222 surgical patients after 2 years revealed that fusion rate was dependent on the fusion technique, i. All surgical techniques substantially decreased pain and disability, but no significant differences were found among the groups in terms of subjec tive or objective clinical outcome. Fear-avoidance beliefs and fingertip floor distance were reduced more after non-operative treatment, and lower limb pain was reduced more after surgery. The success rate was not significantly different between the two groups based on an independent observer assessment. No significant differences between the treat mentgroups were observedin any ofthe other outcome measures. No clearevidence emergedthatprimaryspinal fusion surgerywasany moreben eficial than intensive rehabilitation. There was a clear tendency toward better overall functional outcome for patients with the circumferential procedure, and this patient group also showed signifi cantly less leg pain at the 1-year follow-up evaluation and less peak back pain at 2 years. Patients in the Charit e group had lower levels of disability at every time interval from 6 weeks to 24 months, compared with the control group, with statistically lower pain and disability scores at all but the 24-month follow-up. At the 24-month follow-up, a significantly greater percentage of patients in the Charit e group expressed satisfaction with their treatment and would have had the same treatment again, compared with the fusion group. Spine 32:1155–62 Two hundred and eighty-six patients were included in the trial and followed for 24 months. Visual analog scale patient satisfaction at 24 months showed a statistically significant difference favoring investigational patients over the control group. From this trial it was concluded that ProDisc-L implantation is safe, efficacious and in properly cho sen patients superior to circumferential fusion. Albrektsson T, Johansson C (2001) Osteoinduction, osteoconduction and osseointegration. Bertagnoli R, Kumar S (2002) Indications for full prosthetic disc arthroplasty: a correlation of clinical outcome against a variety of indications. Bohner M (2001) Physical and chemical aspects of calcium phosphates used in spinal sur gery. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Cinotti G, David T, Postacchini F (1996) Results of disc prosthesis after a minimum follow up period of 2 years. Cotrel Y, Dubousset J (1984) Nouvelle technique d’ost eosynth`ese rachidienne segmentaire par voie post erieure.
It is clear that patients in stage 1 may be resectable if they have no impairment of liver synthetic function blood pressure going up diovan 40mg online, and those with grade 3 will not survive even with treatment blood pressure levels up and down buy diovan 160mg lowest price. Therefore most effort in terms of treatment should be concentrated on patients with stage 1 and stage 2 disease blood pressure chart software free order diovan 80mg without prescription. Radionuclide or other treatment should be offered if the patient is unresectable or if there is residual and/or recurrent disease after resection blood pressure chart 13 year old cheap diovan 80mg mastercard. Tamoxifen was once held to reduce the rate of recurrence after surgery but once it was tested in a placebo controlled trial there was little evidence to support this view. The cannulation does not need to be precise since the origin of the right hepatic artery will feed the right lobe and likewise the left will feed the left lobe. Never theless, there are significant side effects to the treatment that can last for about 10 days after treatment, namely pain, often requiring infusion of opioids, severe nausea and jaundice. Despite these problems, this remains the only form of treatment that can be offered to a wide range of patients. This approach has not reached clinical practice but may be a possibility in patients with disease outside the liver. The other treatments including 131I-Lipiodol require local delivery of the radiopharmaceutical into the cancer via an angiographic catheter. Clinical trials are under way; 200 patients have received treatment, which is under review. It is also essential to decide who (the first key team member) will deal with the patient after treatment and tackle any potential problems that may arise. These occur most commonly because of the condition of the liver around the tumour; in a patient with poor liver function a significant degree of liver failure, requiring expert supportive therapy, may occur during the treatment. The second key team member is a competent radiologist with experience in identifying and cannulating the right and left hepatic arteries. This should be performed with a catheter of a reasonably wide bore such as a 5 French catheter. The type of catheter used will depend on local requirements but should have a Luer lock to enable connection of the syringes carrying the Lipiodol. The present manual merely serves as a guide, and any physician performing these studies should receive specific training in this technique. The fourth key team member is the physicist responsible for the safe handling of the product, monitoring the patient on the ward and calculating the dosimetry. Iodine-131 Lipiodol 131 Development of I-Lipiodol started in the 1980s and was pioneered by members of a liver cancer team from Rennes, France. Although they were able to demonstrate the efficacy of the method both in open label trials and in a 131 small trial comparing I-Lipiodol and Cisplatin-Lipiodol, the mechanism for its utility was not clearly understood. When the cells were bathed in Lipiodol there was a normal cell survival after 24 hours; when bathed in 131I there was again normal survival. However, when 131 131 bathed in I-Lipiodol at three different activities of I-Lipiodol, all the cancer cell lines died while the normal hepatocytes had a 90% 24 hour survival. The reason that 131I-Lipiodol does not work in colorectal cancer liver metastases is probably related to the poor blood supply of these metastases in vivo. When comparing 131I-Lipiodol with chemolipiodol, the Rennes group 131 noted that when 1. It was, however, clear that patients in Okuda grade 2 had a very poor prognosis despite treatment. This was confirmed by results from London in which 131I-Lipiodol was compared with Epirubicin-Lipiodol in a total of 70 patients. In the Okuda stage 2 patients, the survival of the London patients was worse in both treatment groups. There was, however, a significant difference in major side effects, these occurring in 15% of the 131I-Lipiodol group, with discharge after three days related to radiation protection issues. In the chemolipiodol group, 70% had major side effects and discharge was after seven days, related to the need for supportive therapy for the patient. The theory for this treatment is that, as the liver starts to regenerate after surgery, microscopic 131 daughter tumours can be stimulated. If these were pre-ablated by I-Lipiodol, there would be a lower chance of recurrence. A Hong Kong group working on this question has shown that after 24 months there is a significant increase in both the disease-free interval and the overall survival in those receiving 131I-Lipiodol compared with age matched controls. Unfortunately the numbers studied were small, and confirmation in a larger group of patients is required. Patient preparation 131 Patients being considered for I-Lipiodol must have a full understanding of the risks and possible benefits of the procedure, including the angiographic as well as the Lipiodol therapy. If a biopsy is required, a laparoscopic rather than a transdermal approach is generally recommended. The patient should not have a blocked portal vein and should have a tumour that is deemed non-resectable by a specialist liver surgeon. The patient should be clinically staged using the Okuda staging (or the Child–Pugh staging). In patients with a large right lobe tumour that is greater than 50% of the right lobe, evidence should be sought of a shunt, which would allow tracer to pass into the right lung. The patient should have normal clotting and a platelet count of more than –3 100 000 mm. Platelet infusions can be given but should be discontinued two hours before the angiogram. Since the Lipiodol very rarely leaves the liver, and given the very high ratio of non-radioactive to radioactive Lipiodol, no blockage of the thyroid is required for this treatment. Pharmaceutical preparation Although it is possible to produce radioiodinated Lipiodol by passing 131I gas through Lipiodol, it is not without danger as the gas is not only radioactive but highly corrosive. This volume is too small for most liver tumours and it is advisable that the 131I-Lipiodol be diluted in non-radioactive Lipiodol, to give a total volume of 6–12 mL depending on tumour size. If stored in a syringe, a polypropylene variety is recommended since it is important that the syringe does not dissolve in Lipiodol. If in doubt, non radioactive Lipiodol should be placed in a syringe and the time taken for the plastic to melt measured. Administration the patient should be prepared for angiography in the radiology department. The syringe 131 containing the I-Lipiodol is taken to the angiography room in a lead container. The Lipiodol can then be given over a period of three to five minutes via a non dissolvable three way tap, attached between the syringe containing the 131 I-Lipiodol and the Luer lock of the indwelling catheter. The rate should be sufficient to ensure delivery of the dose in five minutes, but not fast enough to cause reflux 131 of the I-Lipiodol into the gastroduodenal artery. As it is radiolucent, the distri bution of the 131I-Lipiodol can be seen in fluoroscopic examinations. This infusion is performed with a plastic sheet between the syringe and the patient so that any spills will not result in contamination of the patient. The infusion should be completed within five minutes or there is a danger of the catheter dissolving in the Lipiodol. If this starts to happen at any point during the infusion, the catheter should be removed and the infusion of Lipiodol stopped. When the last Lipiodol has been given, the catheter should be flushed with 10 mL saline and gently removed. As is the case with all angiograms, haemostasis is achieved, although the radiologist should not stand close to the liver to do this. Once the patient is removed from the fluoroscopy room, the drapes used on the patient are collected and put in a sealed plastic bag. This is monitored for contamination; if clear the drapes can be laundered, if not they should be stored until the activity is low enough for them to be cleaned. Monitoring of the room for contamination is also performed and any spills cleaned up. Post-procedure care Patients should remain in a supine position for eight hours after an angiogram. Vital signs should be monitored hourly; automatic monitoring devices are ideal for this purpose. After this time, patients may move around, eat and drink normally, and do as they wish within the confines of local radiation protection legislation. There may be some pain and fever 48–72 hours after a procedure, which can be treated with pain relievers and anti-pyrogens such as paracetamol. Discharge will depend on the radiation levels allowed for discharge of 131 patients who have received I.
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Tumor size and anatomy is still required important information blood pressure medication vasodilators buy diovan 80 mg visa, but evaluation of tissue viability is increasingly needed heart attack what to do buy diovan with a mastercard. Another specificity of abdominal malignancies is the increasing number of patients who are candidates for an integrated approach including systemic therapies blood pressure just before heart attack buy generic diovan on-line, local therapies heart attack lyrics one direction purchase diovan online now, radiation therapy and surgery. This underlines the necessity of a team approach and the major role of the radiologist within this group. In secondary liver tumors, targeted therapies are usually administered in association with cytotoxic drugs. As up to 30% of patients with liver metastases from colon cancer might become resectable, the evaluation is not limited to volumetric response. The report should mention in addition relevant information on tumor viability and aggressiveness and also comment on useful elements for guidance of potential surgery or intervention. In other abdominal advanced malignancies, targeted therapies are not yet standard. However, due to the poor prognosis of these diseases, very active research develops in this field and interestingly favors a better selection of patients. Imaging may play a role with this issue, like classifying locally advanced vs metastatic patients as well as highly vs less agressive tumors. In summary, the Radiologist should have knowledge of the main clinical challenges, of ongoing and potential treatments in order to provide relevant information to the Multi Disciplinary Team. However, following initiation of chemotherapy, tumor progression can occur in up to 33% of patients. Early determination of this therapeutic failure can be important in management and can assist clinical decisions concerning discontinuation of ineffective treatment and institution of alternative therapy. Additionally, an essential component of evaluating the results of cancer treatment in patients on clinical trials is the reporting of the response rate. Because small differences in the response rate can affect the outcome clinical trials, it is important that the criteria used to make this determination are meaningful and consistent. Furthermore, the assessment of objective response has also been complicated by the development of treatment protocols that target tumor biology including tumor cell proliferation and invasion, angiogenesis and metastasis. Anti-tumor effect in many of these regimens is cytostatic and, unlike anticancer cytotoxic agents, may not cause regression in tumor size. Radiologists can contribute to the diagnosis and management in patients who are not responding to conservative management. Spine injection procedures can frequently be performed on an outpatient basis with a brief recovery phase. An understanding of patient selection, indications and contraindications, are paramount to the safety and success of these procedures. The diagnostic and therapeutic potential of these procedures is also facilitated by a thorough evaluation of the spine, with respect to both anatomy and potential pathology, with cross sectional imaging techniques as well as other radiologic tests. Communication of these results between the Radiologist and the spine proceduralist will contribute to optimal patient outcomes. This session will explain the motivations for the creation of the RadLex imaging lexicon and describe RadLex-based applications in structured reporting, radiology information retrieval, image annotation, image navigation and decision support. RadLex technical experts will describe the formats in which RadLex is distributed, and will demonstrate some of the tools available to incorporate RadLex into the development of useful software applications. The RadLex Playbook system for standardized radiology procedure names and codes will also be reviewed. Over the last 10 years there has been increasing interest in the percutaneous treatment of varicosities. The patient population with varicosities, the presentation of varicosities, and the treatment of varicosities will be presented. Other venous anomalies can worse the symptoms of varicosities and may need to be treated. These include May-Thurner syndrome, pelvic congestion, and the male variant of pelvic congestion syndrome (varicoceles). The patient population, symptoms and presentations, and the treatment of these other venous abnormalities will also be discussed. Liver biopsy has been considered the reference standard for fibrosis assessment and stage classification. However, biopsy is invasive, with potential complications that can be severe in up to 1% of cases. In addition, a liver biopsy represents roughly 1/50, 000 of the liver volume and there is interobserver variability at microscopic evaluation. Elastography is a non-invasive method for liver fibrosis assessment and has been an area of intense research. With ultrasound elastography systems now widely available worldwide this technique is beginning to replace liver biopsy as method for diagnosis and follow-up of liver fibrosis. A discussion of the clinical applications of this technique and future potential applications will be discussed. It may be especially helpful for a group of indeterminate nodules with follicular lesions finding on fine needle aspirationB. This accounts for the efficacy of palpation for detecting abnormalities and provides motivation for developing practical methods to assess tissue elasticity. Chronic liver disease is serious worldwide problem, and hepatic fibrosis is the most important consequence, which if not detected and treated, eventually leads to cirrhosis which is irreversible and associated with high mortality. The data are automatically processed generate quantitative images showing the elasticity of the liver and other tissues in the upper abdomen. Despite this fact, even in those countries where some level of radiological services and residency program for radiology exist, pediatric imaging gets least priority. Thus supporting pediatric imaging in such countries within the context of an international education outreach is understandably justified. Collaborating with a local teaching hospital that has a radiology residency program and supporting the pediatric imaging is an easy first step to take. However, a long-term and sustainable way to improve pediatric imaging is to train the teachers in pediatric imaging i. This can be integrated in the institutional framework and provide a lasting and continuous support to pediatric imaging in the country. In many ways, this challenge can be described as a "Big Data" problem, requiring the application of newer "Big Data" approaches and tools. These approaches will require the ability to consume and utilize all available enterprise data, including unstructured reports, multimedia objects, etc. Both of these require extensive manual engineering making them very slow to build, limited in their flexibility, and less accurate than we would like. As radiology requires complex associative pattern recognition, deep learning is the ideal companion tool. Enlitic is developing a deep neural network of the entire human body that will offer a new way forward in which the radiologist has immediate access to the most relevant clinical information. In this talk, we will present a technical overview of machine learning and deep learning, illustrate its applications in radiology, and detail some of the challenges improving radiological workflow using deep learning poses. Functional imaging and serum-based biomarkers can enable a more detailed understanding of the tumor, its characteristics, and early indications of its response to therapy. In addition, they can also be utilized to assess an individual patients risk for toxicity, enabling a personalize approach to radiotherapy. These advanced imaging techniques can be combined with anatomical information to generate high precision treatment plans which can be adapted over the course of treatment to account for identified uncertainties, changes, and deviations which may compromise the delivery of the intended treatment or identify the ability to re-optimize treatment to improve the therapeutic ration. In this session, technical and clinical concepts will be described to design and deliver personalized radiotherapy in the abdomen. Technical concepts will include incorporation of multi modality imaging for treatment planning, image guidance at treatment, and functional and anatomical adaption. Clinical concepts will include functional targeting, clinical goals, and toxicity risks. Most research to date has focused on identifying specific biomarkers used to personalize systemic or targeted therapies. Radiation-specific biomarkers are emerging and may eventually be used to determine whether radiation is indicated or identify specific radiation sensitizers for use in abdominal tumors. Fundamental physical issues of limited spatial resolution relative to the biological process, partial volume effects, image misregistration, motion management, and edge delineation must be carefully considered and can differ by agent or the method applied. Further, interpretation of tumor response should be standardized, and scans should be obtained at consistent time intervals. Finally, we will evaluate common dose and fractionation regimens as well as established dose constraints used in treating abdominal tumors with conventional and stereotactic body radiation therapy.
Neurons from the dorsolateral pontine tegmentum: a biochem containing hypocretin (orexin) project tomultiple neu ical and electron microscopic study blood pressure cuff cvs order discount diovan online. Catecholami tribution of melanin-concentrating hormone in the nergic-cholinergic interaction in the basal forebrain blood pressure medication withdrawal discount 160mg diovan with amex. The melanin basal forebrain neurons burst with theta during concentrating hormone system of the rat brain: an waking and paradoxical sleep blood pressure below 100 buy cheap diovan on line. J Neurosci 25 arrhythmia of the heart generic 80 mg diovan with amex, 4365– immuno and hybridization histochemical character 4369, 2005. Discharge of iden responses of primate nucleus basalis neuron in a go/ ti ed orexin/hypocretin neurons across the sleep no-go-go task. Con ict of in preoptic nucleus contains sleep-active, galaninergic tentionsduetocallosaldisconnection. Long organization of functionally segregated circuits linking lasting insomnia induced by preoptic neuron lesions basal ganglia and cortex. Annu Rev Neurosci 9, 357– and its transient reversal by muscimol injection into 381, 1986. Selective activation failure of forebrain with sparing of brain-stem func of the extended ventrolateral preoptic nucleus dur tion. Cortical lation of orexin neurons in mice results in narcolepsy, laminar abnormalities—occurrence and clinical sig hypophagia, and obesity. The neuropathol of neostigmine into the pontine reticular formation of ogy of the vegetative state after an acute brain insult. New 31 patients with Behcet’s disease and neurological York: Oxford University Press, pp 291–340, 1938. High-resolution 2 Mutism developing after bilateral thalamo-capsular deoxyglucose mapping of functional cortical columns lesions by neuro-Behcet disease. Columnar speci city of in pathological ndings in the brain of Karen Ann trinsic horizontal and corticocortical connections in Quinlan. The examina Coma, indeed any alteration of consciousness, tion begins by informally assessing the patient’s is a medical emergency. First, the physician ad tering such a patient must begin examination dresses the patient verbally. If the patient does 38 Examination of the Comatose Patient 39 not respond to the physician’s voice, the phy Table 2–1 Examination of the sician may speak more loudly or shake the pa Comatose Patient tient. When this fails to produce a response, the physician begins a more formal coma eval History (from Relatives, Friends, or Attendants) uation. Onset of coma (abrupt, gradual) the examiner must systematically assess the Recent complaints. To determine if there is a focal weakness, vertigo) structural lesion involving those pathways, it is Recent injury necessary also to examine the function of brain Previous medical illnesses. In particular, be Previous psychiatric history cause the oculomotor circuitry enfolds and Access to drugs (sedatives, psychotropic drugs) surrounds most of the arousal system, this part General Physical Examination of the examination is particularly informative. Vital signs Fortunately, the examination of the comatose Evidence of trauma patient can usually beaccomplishedvery quickly Evidence of acute or chronic systemic illness because the patient has such a limited range of Evidence of drug ingestion (needle marks, responses. However, theexaminermustbecome alcohol on breath) conversant with the meaning of the signs elic Nuchal rigidity (assuming that cervical trauma ited in that examination, so that decisions that has been excluded) may save the patient’s life can then be made Neurologic Examination quickly and accurately. Verbal responses the evaluation of the patient with a reduced Eye opening level of consciousness, like that of any patient, Optic fundi requires a history (to the extent possible), phys Pupillary reactions ical examination, and laboratory evaluation. Oculocephalic responses (assuming cervical However, as soon as it is determined that a trauma has been excluded) patient has a depressed level of consciousness, Oculovestibular responses the next step is to ensure that the patient’s Corneal responses brain is receiving adequate blood and oxygen. Respiratory pattern the emergency treatment of the comatose pa Motor responses Deep tendon re exes tient is detailed in Chapter 7. The physiology Skeletal muscle tone and pathophysiology of the cerebral circulation and of respiration are considered in the para graphs below. A history of headache of recent onset from relatives, friends, or the individuals, points to a compressive lesion, whereas the his usually the emergency medical personnel, who tory of depression or psychiatric disease may brought the patient to the hospital. In a diabetes, renal failure, heart disease, or other previously healthy, young patient, the sudden chronic medical illness are more likely to be onset of coma may be due to drug poisoning, suffering from metabolic disorders or perhaps subarachnoid hemorrhage, or head trauma; in brainstem infarction. A history of premonitory the elderly, sudden coma is more likely caused signs, including focal weakness such asdragging 40 Plum and Posner’s Diagnosis of Stupor and Coma of the leg or complaints of unilateral sensory conduct a formal coma evaluation. In assessing symptoms or diplopia, suggests a cerebral or the level of consciousness of the patient, it is brainstem mass lesion. Several methods the general physical examination is an im for providing a suf ciently painful stimulus to portant source of clues as to the cause of arouse the patient without causing tissue dam unconsciousness. It is best to (Chapter 7), one should search for signs of begin with a modest, lateralized stimulus, such head trauma. Bilateral symmetric black eyes as compression of the nail beds, the supraor suggest basal skull fracture, as does blood be bital ridge, or the temporomandibular joint. Resistance to neck the stimulus, a more vigorous midline stimulus exion in the presence of easy lateral move may be given by the sternal rub. By vigorously ment suggests meningeal in ammation such as pressing the examiner’s knuckles into the pa meningitis or subarachnoid hemorrhage. Flex tient’s sternum and rubbing up and down the ion of the legs upon exing the neck (Brud chest, it is possible to create a suf ciently pain zinski’s sign) con rms meningismus. Examina ful stimulus to arouse any subject who is not tion of the skin is also useful. Petechiae may suggest the response of the patient is noted and meningitis or intravascular coagulation. The types of motor responses seen are sure sores or bullae indicate that the patient considered in the section on motor responses has been unconscious and lying in a single (page 73). However, the level of response is position for an extended period of time, and important to the initial consideration of the are especially frequent in patients with barbitu depth of impairment of consciousness. A patient whose best After conducting the brief history and exami response to deep pain is to attempt to push the nation as outlined above and stabilizing the examiner’s arm away is considered to be stu patients’ vital functions, the examiner should porous, with localizing responses. Noxious stimuli can be delivered with minimal trauma to the supraorbital ridge (A), the nail beds or the ngers or toes (B), the sternum (C) or the temporo mandibular joints (D). Box 2–1 Coma Scales A number of different scales have been devised for scoring patients with coma. The value of these is in providing a simple estimate of the prognosis for different groups of patients. Obviously, this is related as much to the cause of the coma (when known) as to the current status of the examination. Unfortunately, when used by emergency room physicians, in 3 terrater agreement is only moderate. However, no scale is adequate for all patients; hence, the best policy in recording the results of the coma examination is simply to describe the ndings. More elaborate coma scales are a directed attempt to defend against the stim described in Box 2–1, but many of these de ulus are considered to have a nonlocalizing re pend upon the results of later stages in the sponse and are comatose. Patients who fail to examination, and it is never justi ed to de respond at all are in the deepest stage of coma. The rst goal must be to to maintain the blood pressure at a level nor correct any of these conditions if they are found mal for the individual patient. Inaddition, bloodpres patient with chronic hypertension autoregu sure, heart rate, and respiration may provide lates at a higher level than a normotensive pa valuable clues to the cause of coma. Lowering the blood pressure to a ‘‘normal level’’ may deprive the brain of an adequate blood supply (see Figure 2–2). Cerebral per develop excessive perfusion if the blood pres fusion pressure is the systemic blood pressure sure is raised. The physician the perfusion pressure of the brain may can measure blood pressure but in the ini be in uenced by the position of the head. In tial examination can only estimate intracranial a normal individual, as the head is raised, the pressure. Over a wide range of blood pres systemic arterial pressure is maintained by sures, cerebral perfusion remains stable be blood pressure re exes. At the same time, the cause the brain autoregulates its blood ow by arterial perfusion pressure to the head is re mechanisms described in the paragraphs be duced by the distance the head is raised above low and illustrated in Figure 2–2. In this situation, both too in a patient with stenosis of a carotid or ver low (ischemia) and too high (hypertensive en tebral artery, the perfusion pressure for that cephalopathy; see Chapter 5) a blood pres vessel may be much lower than systemic arte sure can damage the brain. Note that hyper tensive encephalopathy (increased blood ow with pressures exceeding the autoregulatory range) may occur with a mean arterial pressure below 200 mm Hg in the normotensive individual, but may require a much higher mean arterial pressure in patients who have sustained hypertension. Such patients may show ple, pain is a major ascending sympathoexcit improvement in neurologic function when the atory stimulus, which acts via direct collaterals head of the bed is at.