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Instead cheap cialis extra dosage 60mg natural erectile dysfunction pills reviews, the velocity ratio or dimensionless index is used to estimate the severity of prosthetic stenosis generic 100 mg cialis extra dosage visa impotence quotes the sun also rises. The mean gradients obtained during catheterization should be equivalent to the mean gradients obtained by echocardiography buy 50 mg cialis extra dosage erectile dysfunction drug has least side effects. The peak gradient measured during catheterization is the peak-to-peak gradient, which is lower than the peak instantaneous gradient obtained with echocardiography (Fig. A less optimal method is measuring the peak-to-peak gradient by catheter pullback from the left ventricle to the ascending aorta. These cause less hypotension because of peripheral arterial vasodilation, less bradycardia, less transient myocardial dysfunction, and less osmotic diuresis after the procedure. The Gorlin formula measures the true anatomic area of the aortic valve, as it has a correction factor (the discharge coefficient) to account for the difference of flow across the true anatomic valve versus the flow at the level of the vena contracta. The continuity equation measures the physiologic area (vena contracta) and as such is smaller than that measured by Gorlin. Overly aggressive diuresis may cause hypotension if hypovolemia significant impairs cardiac output by diminishing preload. Nitrates may also cause hypotension and syncope by reducing preload and should be avoided or used with extreme caution. However, the procedures effects are short lived with an ~50% restenosis rate at 5 months and 80% at 15 months. Complication rates are diminishing with improvements in technology and techniques, but there are still considerable risks of vascular complications (6. However, it is always important to keep in mind that morbidity and mortality figures from clinical trials, although useful, should not replace knowledge of these risks for individual procedures at one’s own institution. The Medtronic CoreValve underwent a prospective, nonrandomized trial, which showed favorable outcomes at both 1- and 2-year follow- up and with outcomes being driven by the patients underlying comorbid conditions rather than valve performance. The relative advantages, disadvantages, and indications for use of different prostheses are outlined in Chapter 18. This procedure is best suited for pediatric and adolescent patients with growth potential because the autograft is capable of growth, does not require anticoagulants, and has an excellent hemodynamic profile. The procedure, however, is long and technically difficult and subsequently turns a single-valve problem into a double-valve problem. Problems with pulmonary homograft are common in adults who underwent this operation as are subsequent dilatation of the aorta in those with aortopathy such as with bicuspid valves. Aortic valve homografts have been used to treat younger patients, especially those who wish to avoid anticoagulation, in the hope that greater durability of this valve might result than with a bioprosthesis. Unfortunately, more recent data suggest that any durability advantage of a homograft over a bioprosthesis in a middle-aged patient is slight. Moreover, the homograft tends to calcify and is often difficult to remove at subsequent reoperations. These valves are most often used to treat patient older than 60 years because structural deterioration is much slower in this age group compared with younger patients. These valves have a low risk for thromboembolism and do not necessitate long-term anticoagulation. Because of the sewing ring and struts, all prostheses, both mechanical and biologic, have a pressure gradient across them, even with normal function. These all require anticoagulation to minimize the risk of valve thrombosis and thromboembolism. These valves are durable if anticoagulation is maintained and careful antibiotic prophylaxis is used over the years. Mechanical valves are used with caution in older patients (>65 years) given the substantial increase in anticoagulation-related hemorrhage and resultant mortality in this population. A minority of asymptomatic patients, however, may die suddenly or have rapid progression of disease. Patients with highly calcified valves and a rapid progression of disease (aortic velocity ≥ 0. These patients should be considered in two groups: high transvalvular gradients (mean gradient > 40 mm Hg) and low transvalvular gradients (mean gradient < 30 mm Hg). Despite a substantial operative mortality, survival appears improved in those treated surgically compared with medical management, especially if they demonstrate contractile reserve when challenged with dobutamine. Contractile reserve is defined as the ability to increase in stroke volume by >20% from baseline. Dobutamine infusion will generate an increase in cardiac output without a significant increase in the transvalvular pressure gradient. Low transvalvular gradients can also be seen in patients in which the peak aortic valve gradients are not accurately detected or there are errors in measurement. Careful evaluation of valve hemodynamics and valve anatomy is important to ensure that the valve is truly severely narrowed. Surgical removal of the membrane leading to subaortic obstruction is indicated for symptomatic patients or for asymptomatic patients with a peak pressure gradient >50 mm Hg. Surgery can also be considered in asymptomatic patients with peak gradient >30 mm Hg if they are planning to become pregnant or wishing to participate in competitive sports. The ventricle responds to added wall tension by compensatory eccentric hypertrophy of myocytes. The left ventricle produces a larger total stroke volume with each contraction, preserving normal effective forward stroke volume. The effective forward stroke volume and cardiac output fall acutely, potentially resulting in hypotension and cardiogenic shock. The tachycardia that accompanies cardiac deterioration helps shorten the diastolic-filling period during which the mitral valve is open. If left untreated, these patients quickly progress to total cardiovascular collapse. When severe chest pain is part of the initial clinical presentation, aortic dissection must be strongly suspected. A diastolic thrill may be palpable in the second left intercostal space, as may a systolic thrill caused by increased aortic flow. S may be soft, singly split (P obscured by the2 2 diastolic murmur) or paradoxically split. An S is3 4 often present and represents left atrial contraction into a poorly compliant left ventricle. The Austin Flint murmur is a middle-to-late diastolic rumble that is believed to be caused by vibration of the anterior mitral leaflet as it is struck by the regurgitant jet or by turbulence in the mitral inflow from partial closure of the mitral valve by the regurgitant jet. Unlike the murmur of true valvular mitral stenosis, the Austin Flint murmur is not associated with a loud S or with an opening snap. It reflects the increased ejection rate and large stroke volume traversing the aortic valve.

This allows for the second-stage elephant trunk operation to be done with stent-grafs buy cialis extra dosage online from canada impotence heart disease, using the wrap to The clamshell incision has been used since the early create a secure distal landing zone (Figure 9 buy discount cialis extra dosage 50 mg on line erectile dysfunction 31 years old. The patient had a history of atrial septal defect repair and right coronary artery occlusion order cheap cialis extra dosage hypogonadism erectile dysfunction and type 2 diabetes mellitus. We have not found complex repairs of the aortic arch, when there is involve- it necessary to elevate the lef arm in a sling or armrest ment of various extents of the descending aorta but not the for this operation, as the exposure is adequate. Any intercostal arteries in this segment need to be oversewn prior to performing the distal anastomosis. The descend- ing aorta is then carefully de-aired and blood flow re- established to the lower body. The clamshell procedure is particularly useful in patients with extensive disease of the proximal descend- ing aorta that cannot be addressed by an elephant trunk procedure. Examples are a very large aneurysm of the (b) (c) aortic arch or rupture of the aortic arch with acute dis- section or mycotic aneurysm where anastomosis must be performed further down the descending aorta than is usual. Similarly, the clamshell incision is a good approach for reoperations in patients in whom the ascending aorta and various extents of the aortic arch were previously replaced (e. In our experience, most of these patients have required longer ventilatory support than patients undergoing a median sternotomy approach. For that rea- son, this technique is not used unless proximal descend- ing pathologies need to be addressed at the same time Figure 9. Spreading the upper and lower rib cages apart then creates the clamshell exposure. Left-sided thoracotomy and The patient is cannulated with a right subclavian artery thoracoabdominal incisions graf and a two-stage venous cannula. If the patient is undergoing reoperation, the right femoral vein is exposed A lef thoracotomy or thoracoabdominal incision for aor- and a catheter fed into the right atrium using transesopha- tic arch surgery is not commonly used. Once the patient is on cardiopulmonary bypass, is not appropriate [9]; in these cases, a lef thoracotomy the lef lung is mobilized and wrapped in a laparotomy or thoracoabdominal incision must be used. Similarly, in sponge so that the lung can be moved up and down to patients with previous ascending aortic and/or proximal avoid obstruction of the operative field. In most patients, aortic arch procedures, the remaining arch pathology can once circulatory arrest is established, the ascending aorta ofen be addressed through the lef side during distal and aortic arch proximal to the recurrent nerve and the aortic repair, thus a mediastinal approach and elephant descending aorta beyond the recurrent nerve are opened. Through the lef tho- The greater vessels are anastomosed to the neoaortic graf racotomy or thoracoabdominal incision, the entire aortic through a side hole, and the graf is then clamped both arch, the ascending aorta and even the aortic valve can be proximal and distal to the greater vessels. Note bypass from the superior mesenteric artery to the common hepatic artery; this serves to prevent ischemic complications in case the celiac axis needs to be covered during stent-graft placement. Historically, cardiopulmonary bypass and hypothermic be significantly reduced by using the right subclavian circulatory arrest were activated via femoral cannula- artery with a side graf for arterial inflow rather than tion (Figure 9. The problem with this approach to conventional femoral artery cannulation (Figure 9. We found perfuse the brain during circulatory arrest by using an the incidence of stroke and neurocognitive deficit could occlusive balloon catheter in the innominate artery. With the gap between the patient and the table, the incision can be made from below the scapula and up across the costal Venous margin. Once the incision is made, the retractor inserted, Arterial the tissues mobilized as required, and the patient is fully heparinized. A side-grafis sewn onto the subclavian artery and connected to the arterial side of the heart-lung machine. The femoral vein is cannulated and the cannula is fed up into the right atrium during transesophageal monitoring. The patient is placed on cardiopulmonary bypass and HeatHeat cooled for circulatory arrest. If the patient has an aor- exchangerexchanger tic rupture, regardless of whether or not the patient has undergone a previous lef thoracotomy, the lung and hematoma are not entered prior to establishing profound hypothermia, due to the potential for exsanguination MembranceMembrane upon entering the hematoma. Afer establishing circu- oxygenatoroxygenator latory arrest, the repair is initiated by opening the aorta while atempting to preserve the recurrent laryngeal and phrenic nerves. If the patient has had prior ascending aor- tic and aortic arch surgery, the new graf is beveled and sewn to the old graf and around the origin of the great vessels (Figure 9. If an anastomosis needs to be done at the sinotubular ridge, an opening is made in the side of the graf and the great vessels atached to this opening first. The neoaortic graf is clamped, both proximal and distal to the great vessels, and perfusion to the right subclavian artery restarted. The anastomosis at the sinotubular ridge is performed, and the lef ventricle and ascending aorta Figure 9. Reperfusion of the heart is started atrial drainage and reperfusion via a ‘Y’ in the arterial line. The remainder of the descending or thoracoabdominal aortic aneurysm repair is then performed as needed. In some patients, aneurysmal disease at the origin of the reduces the risk of air filling the greater vessels and, thus, great vessels may be present (Figure 9. In these cases, the risk of air embolism is decreased once perfusion to the separate tube grafs may have to be placed to the origins of brain is restored. Furthermore, the period of circulatory the innominate, lef common carotid, and lef subclavian arrest is reduced because, once the greater vessels have arteries. If a bovine type of anatomy is present, one graf been atached to a graf, clamps can be placed and ante- can be placed to the common origin of the innominate and grade perfusion to the brain and upper body can be started lef common carotid arteries. Two towels are placed underneath the and repaired aferwards with 5-0 polypropylene sutures. This results in rotation of the patient to about porcelain aorta involving the entire arch in whom an aor- 30o to the table, with a gap underneath the chest to allow tic arch endarterectomy is not an option, an apico-lef access to the inferior margin of the lef scapula. The right ventricle to descending aorta valved conduit is an alter- subclavian artery area needs to be prepped into the field. The operation begins with exposure of the right sub- As discussed previously, the most serious problems clavian artery, which is encircled with a tape, and the with this operation are the risks of stroke and neurocog- right femoral vein [9]. An additional arterial line was placed in the distal femoral artery because of leg ischemia. With the use of the right subclavian artery perfusion and careful de- We have performed over 125 aortic operations using a vari- airing of the lef ventricle, this problem and its risks ety of minimally invasive incisions [11−15] (Figure 9. Cardiopulmonary bypass inflow is delivered through the right subclavian artery graft. In the first since, in patients with aortic aneurysms, the ascending minimally invasive approach, termed the ‘J-incision,’ aorta is ofen quite lengthened, and the heart is commonly the skin incision was made from the sternomanubrial displaced into the lef chest. The underlying sternum and J-incision particularly useful when the whole of the right manubrium were opened along the midline from the ventricle and lef side of the heart does not need to be sternal notch down to the third intercostal space, and the mobilized. Prior to minimally invasive reoperations, it J-incision extended into the right third intercostal space is important to advise the anesthesiologist that a pacing (Figure 9. In these patients, approach was used to replace the mitral valve prior to a side-graf is sewn onto the subclavian artery, and a can- inserting a composite valve graf in a patient with Marfan nula is placed through the femoral vein and positioned syndrome (Figure 9.

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The importance of gested that alcoholic skin preparations may decrease the this is demonstrated by the fact that even during warming discount cialis extra dosage 200 mg line over the counter erectile dysfunction pills uk, temperature of a 70 kg person by up to 0 purchase 60 mg cialis extra dosage with mastercard erectile dysfunction over 65. Thermal capacity This is defned as the amount of heat energy required to Conduction increase the temperature of a unit quantity of a substance This is defned as the transmission or conveying of energy by a specifc temperature interval and is signifcant in both through a medium without perceptible motion of the the loss of heat and its prevention generic cialis extra dosage 100mg online impotence marriage. In terms of heat, this is the transfer of temperature are the result of changes in the heat content thermal energy through a substance from a higher- to a of the tissues. In terms of perioperative thermal balance, of through conduction loss to the cooler peripheral tissues. Insulation Convection Within the body this affects the conductive component of This is defned as the transfer of heat through a fuid heat loss insofar as fat insulates almost three times as well medium (liquid or gas) caused by molecular motion. Passive devices Radiation Although ordinary blankets, bedding and clothes prevent This is defned as the transfer of heat from one surface to heat loss to some extent, they are not appropriate in the another via photons. It is not, therefore, dependent on the setting of the operating theatre where higher standards of temperature of the intervening air. The frst products specifcally the emissivity of two surfaces and the difference between designed for this setting were called ‘space’ blankets. The non-permeable element provides skin acts more like a black body having an emissivity of insulation from the operating theatre environment and 514 Warming devices Chapter | 30 | reduces the convective heat losses. Their effectiveness is partly based on the high emissivity of heat from the human body. They also have the advantage that they meet the safety standards of ‘Flammable Fabrics’ Acts. However, for the majority of procedures, insulation alone is insuffcient in preventing heat losses during anaesthesia, surgical pre- paration and subsequent surgery. Active devices Circulating water devices Initially, prior to the advent of forced-air warming, patients were placed on circulating hot water mattresses in an attempt to counteract heat loss and maintain normother- mia. In theory the high specifc heat capacity of water in the mattress should be very effective at providing heat. In practice, however, these devices only effectively deliver heat to those areas in direct contact with the mattress, A which constitutes a relatively small proportion of the body. Furthermore, those small areas in direct contact are under pressure and so have a compromised blood supply that reduces the amount of heat transfer even further. Additionally, in this situation the relatively high thermal capacity of the water is a disadvantage as it increases the likelihood of thermal damage, which has been described at settings of 39°C. Newer devices overcome these problems by circulating the water through special garments or pads. This conductive heating garment is divided into separate segments for arms and thighs, which allows clinicians to cover different body surfaces depending on the site of surgery. Perhaps unsurprisingly, given the different thermal characteristics of water and air, both the above have both been shown to be more effcient at warming volunteers than forced-air devices (see below). Carbon fbre and polymer devices Carbon fbre heating mattresses consist of electrically con- B ductive bundles of this material that criss-cross the device in much the same way as the wire element in electric Figure 30. However, the biggest problem with these is that Images courtesy of Kimberley-Clark Healthcare. This is because the area of heating surface may be inadequate and the hardness of the bundles means that 515 Ward’s Anaesthetic Equipment these require some form of pressure relief material on top The logistical advantages of carbon technologies which attenuates the warming performance. On the other hand, in circumstances where The heat generated in the polymer is caused by excita- there is reduced patient contact with the mattress (e. This is produced by a shaped (’specialist’) forced-air warming blankets has yet low-voltage source applied across the edges of the sheet. Recent advances incorporating carbon The polymer increases the electrical resistance by holding polymer into blankets may serve to overcome problems the pattern of the carbon particles. The properties of the polymer also allow a viscoelastic foam to be placed under the These have revolutionized patient warming. Broadly warming surface which provides pressure relief superior speaking a large volume of air is blown over a 450– to a standard operating table mattress or gel pad. It also prevents one of the 850 W for the lower powered devices and up to 1500 W problems with other warming mattresses in that there for the more powerful ones (i. There is a signifcant turn reduces the incidence of thermal damage and pres- variability in the performance of the different types of sure sores. A full-length mattress takes approximately 65W at full Various different blankets have been developed in order power (i. The power needed to maximize the surface area covered during different sur- to maintain temperature varies depending on patient gical procedures and exposures; including now forced characteristics and ambient conditions. A thermistor on warm air mattresses for positioning underneath the the rear face of the polymer sheet is connected to a micro- patient. With improving technology, the heating devices processor control unit that regulates the power to the themselves can be much smaller and so it has been mattress to maintain the selected temperature. This can possible to develop special jackets with portable heaters usually be set at between 37 and 40°C. The working components are encapsulated in a latex-free cover, with welded seams, which means that the mattress can be cleaned in the same way as an operat- ing table (Fig. What Radiant heaters are electric heaters that generate heat using is gained in terms of reduced consumables with the latter infrared radiation in the same way that the sun heats the may be partly lost by the environmental and fnancial Earth (Fig. Non-industrial heaters use the medium part Of the single-use types, there are two versions which of the spectrum (approx. Radiant heat transfer, unlike conduc- air out through small holes on the side of the blanket facing tion and convection, requires no intermediate conductor the patient. There is the unproven possibility that the latter or convector, as infrared energy, like light, passes directly may introduce pathogens into the surgical feld. Hypothermia during laparotomy can be prevented by locally applied warm water and pulsating negative pressure. Other devices A number of alternative surface warming devices have also been developed but which have not yet entered the main- stream of clinical practice. Locally applied warm water and pulsating negative pressure With appropriate methodology it is feasible to warm the whole patient with very localized heat application. It consists of a custom-built, tube-shaped, transparent Plexiglass chamber, which is sealed to the proximal part of the arm by a neoprene collar. Prior to commencing warming, the chamber is three- quarters flled, leaving an air pocket from which the air could be evacuated to give negative pressure, which is pulsated between 0 and 240 mmHg. They can either generate heat to a set Devices used to warm air temperature or, via a feedback mechanism, to a set skin intravenous fuids temperature. Extrapolating fected by air currents, such as those in laminar fow operat- from the thermal capacities of water and body tissues, the ing theatres. In addition, they do not generate air-currents, infusion of 1 L of fuid intravenously at room temperature which might facilitate the spread of pathogens. Thus, their use is largely restricted to variations in performance especially at higher fow rates paediatrics. Small warmer units are also available that can be placed close to the patient’s infusion site (Fig. The consist simply of a coil placed inside the hose of a forced latter is placed in direct contact with the heater element air warming mattress. Their poor performance can be and is responsible for the transfer of heat to fuid passing explained by the different thermal capacities of air and through the plastic channels in the cartridge.

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To start with buy cialis extra dosage 50 mg with mastercard erectile dysfunction and smoking, each organ in the body can be infected by an “itis” of the parenchyma best order for cialis extra dosage erectile dysfunction zurich, an “itis” of the capsule purchase genuine cialis extra dosage erectile dysfunction treatment philadelphia, or an abscess. Abscess: This should prompt the recall of cerebral abscess, epidural or subdural abscess, dental abscess, retropharyngeal abscess, lung abscess or empyema, liver abscess, subdiaphragmatic abscess, perinephric abscess, abscessed diverticulum, appendiceal abscess, tubo-ovarian abscess, pelvic abscess, prostatic abscess, and furuncles or carbuncles. Systemic infection: Some systemic infections are particularly likely to be associated with a chill. Malaria, relapsing fever, Weil 212 disease, rat-bite fever, yellow fever, smallpox, Rocky Mountain spotted fever, acute poliomyelitis, and pulmonary tuberculosis belong in this group. Venous thrombosis: Phlebitis in various portions of the body is often associated with chills. Cavernous sinus thrombosis, lateral sinus thrombosis, pylephlebitis, and, less frequently, thrombophlebitis of the extremities may be associated with a chill. Miscellaneous: Chills are often associated with intravenous injection of drugs or antibiotics, transfusion, hemolytic anemia, and introduction of contaminated equipment into the body. Approach to the Diagnosis The approach to the diagnosis of a patient with chills is similar to that of a patient with fever. However, when fever and chills are the only symptoms, a workup similar to that found below may be necessary. Careful charting of the temperature while the patient remains off aspirin or other antipyretics will be rewarding, especially in the diagnosis of malaria. V—Vascular suggests an infarction of the subthalamic nucleus, which produces hemiballism. I—Intoxication suggests Wilson disease, phenothiazine, lead or manganese toxicity, and carbon monoxide poisoning. T—Trauma suggests chorea from concussion, basilar skull fracture, or intracerebral hematoma. E—Endocrine and epilepsy suggest the possibility that the chorea is related to an epileptic focus. When presented with a case of clubbing, one might simply use anatomy and think of all the major internal organs (except the kidney); one would then be closer to an accurate and reliable differential diagnosis. To be more scientific, apply basic physiology to provide an extensive and organized differential diagnosis. The important basic science, then, is 1 physiology; according to Mauer, the principle common denominator is anoxia. Anoxic anoxia or poor intake of oxygen would suggest the first category of disease, pulmonary; most significant among these are chronic diseases of the lung, including chronic bronchitis and emphysema, empyema, pulmonary tuberculosis, carcinoma of the lung, pneumoconiosis, bronchiectasis, and pulmonary fibrosis. Acute pneumonia, pneumothorax, and bronchial asthma (where there may be many short episodes of anoxia) do not usually lead to clubbing. Table 16 Clubbing and Pulmonary Osteoarthropathy In the next group of disorders, the lungs may be normal but a significant amount of blood never reaches the alveoli; I call this shunt anoxia. Here are classified the tetralogy of Fallot and other congenital anomalies of the heart, recurrent pulmonary emboli, cirrhosis of the liver (associated with 216 small pulmonary arteriovenous shunts), and pulmonary hemangiomas. Thus, anemic anoxia may be a factor in portal cirrhosis, biliary cirrhosis, Banti disease, chronic malaria, and subacute bacterial endocarditis. It may also be a factor in disorders of the gastrointestinal tract, such as regional ileitis, ulcerative colitis, and carcinoma of the colon. Histotoxic anoxia is Mauer’s another explanation for clubbing in patients without low arterial oxygen saturation. This group includes subacute bacterial endocarditis, myxedema, ulcerative colitis, intestinal tuberculosis, and amebic dysentery. Of course, this is a regular occurrence in chronic methemoglobinemia or sulfhemoglobinemia. Approach to the Diagnosis The clinical approach to clubbing involves being certain that clubbing is present. A curved fingernail is not good evidence, and the “drumstick” appearance (which makes the finger look like a true club) does not occur until late. Early clubbing is determined by the angle between the nail- covered portion and the skin-covered portion of the dorsal surface of the terminal phalanx. When the angle becomes 180 degrees and disappears, that is, when the terminal phalanx becomes flat, clubbing exists. Careful examination for cyanosis and a thorough evaluation of the heart and lungs will determine the cause in most cases. Pulmonary function 218 studies, and arterial blood gases before and after exercise and before and after 100% oxygen, will help confirm the diagnosis in many cases. Blood cultures, stool culture and examination, and thorough radiologic studies of the gastrointestinal tract will be necessary in obscure cases. Because somnolence may be simply an early stage of coma, its etiologies are almost all identical to the etiologies of coma. While in medical school, I discovered a little text, Aids to Medical 2 Diagnosis by G. I have never forgotten the unique little mnemonic provided in the text for remembering the causes of coma, A-E- I-O-U, the vowels. The A also stands for arterial occlusions, arteriosclerosis, aneurysms, and autoimmune disorders. E—Endocrine disorders such as myxedema coma, hyperparathyroidism, diabetic coma, and insulin shock are included in this category. U—Uremia was used by Sutton, but because it is included above in organ failure, I prefer to use the U to designate the “undefined” disorders such as narcolepsy and conversion hysteria. Therefore, with the vowels A, E, I, O, and U, one has a useful system for recalling the causes of coma and somnolence. There are two other approaches to the differential diagnosis of coma that may be more instructive. The important conditions resulting from disease of each anatomic structure are reviewed here. Thinking of the skull reminds one of depressed skull fractures and epidural and subdural hematomas. In visualizing the meninges, meningitis and subarachnoid hemorrhages are recalled. Moving deeper into the brain itself will suggest encephalitis, encephalopathies (e. Considering the arteries at the base of the brain, one should recall arterial occlusions, hemorrhages, and emboli. The blood supply prompts the recall of anoxia and other metabolic disorders that may be responsible for coma. Finally, the pituitary should help recall not only the coma of hypopituitarism but all the other endocrinopathies. This, then, is the anatomic approach to the differential diagnosis of coma and somnolence. For the physiologic approach, simply ask the question, “What does the brain cell need to ‘keep awake’ or to continue functioning? In addition, the brain cell cannot afford to have any toxic substance in that medium that might block the use or action of these metabolic substances.

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