Coma with meningealirritation but without physical signs

Patients in this group will usually be suffering from subarachnoid haemorrhage, acute bacterial meningitis, or viral meningoencephalitis. The distinction between infective and non-infective causes can usually be made on the basis of fever and a lumbar puncture which would be expected to reveal the cause. It is a counsel of perfection that because of the theoretical potential of a collection of pus or of identifying the site of a subarachnoid haemorrhage, CT should be undertaken before lumbar puncture. In practice in many hospitals throughout the United Kingdom, CT of the head is not easily available, especially in the emergency situation, and the presence of meningism, particularly if associated with fever, raises the possibility of meningitis and indicates the need for an assessment of CSF. When CSF examination is undertaken by lumbar puncture it is important to remember that an inadequate lumbar puncture does not preclude the possibility of a pressure cone but may prevent proper assessment of the CSF. Although some authorities still recommend that only a few millilitres of fluid needs to be obtained for bacterial culture and cell count,13 in practice once the dura and arachnoid are breached by a lumbar puncture needle the possibility of herniation does not depend solely upon the fluid which is collected but rather upon that which leaks out during subsequent hours; it is therefore important that when a decision to undertake a lumbar puncture is made, sufficient CSF is obtained to enable an adequate assessment of the cell count and a gram stain and to provide fluid for culture and antibody analyses, measurement of the total protein and sugar, and possibly polymerised chain reaction (PCR) testing.

In those centres where a CT is available the detection of blood in the subarachnoid space at CT avoids the need for a lumbar puncture. Whether or not lumbar puncture has been carried out to identify the presence of subarachnoid haemorrhage, the patient should then be transferred to a neurosurgical unit, probably be given intravenous nimodipine, and be subjected to angiography and surgery if indicated. In general those patients who are in coma from subarachnoid haemorrhage are less of a surgical emergency than those who have higher states of consciousness.

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