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Glasgow Coma Scale
Classified as:
• Severe: GCS 3-8
• Moderate: GCS 9-12
• Mild: GCCS 13-15
Mild à can result in temporary / permanent neurological
symptoms & neuroimaging test bisa gak nunjukkin adanya
damage
Moderate & severe à biasanya hasil dari long-term impairment
in cognition (thinking skill), physical skill, and/or emotional /
behavioral func
Apnea test
o Mandatory examination à untuk determine brain death à dia provide essential sign of
definitive loss of brainstem func
o Cuma beberapa penulis concern dengan procedure safety nya à ada pontensi untuk
komplikasi: severe hypotension, pneumothorax, > hypercarbia, hypoxia, acidosis, cardiac
arrhythmia, asystole à tapi saat appropriate O2-diffusion procedure digunakan, teknik
ini aman
o Jika keadaan tidak bisa untuk apnea test à bisa pake alternative ancillary test
o Preparation:
• Body temp >=32°C à necessary to warm the body to 36°C jika body temp < à
koreksi hypothermia facilitates CO2 prod & < chances of hypotension (by stabilin BP
dan hemodynamic state)
• Recommended preoxygenation dengan 100% O2 selama 10min à avoid hypoxia
Some expert recommend jaga normal PO2 / preoxygenation sampai arterial PO2 >=
200 mmHg.
Preoxygenation à bantu untuk avoid kemungkinan hypocapnia
• Ensure arterial PCO2 / PaCO2 normal atau > 36/40 mmHg
• pH darah normal / low basic range
• Pretest systolic BP minimal 90 mmHg
• Fluid balance à euvolemia / (+) fluid balance selama 6 jam sebelumnya
• Medication à AT gaboleh dilakukan ketika pasien dibawah pengaruh obat yang bisa
paralyze resp muscle
o Procedure:
• Adjust vasopressors to a systolic blood pressure _100 mm Hg.
• Preoxygenate for at least 10 minutes with 100% oxygen to a PaO2 _200 mm Hg.
• If pulse oximetry oxygen saturation remains_95%, obtain a baseline blood gas (PaO2,
PaCO2, pH, bicarbonate, base excess).
• Look closely for respiratory movements for 8–10 minutes. Respiration is defined as
abdominal or chest excursions and may include a brief gasp.
• Abort if oxygen saturation measured by pulse oximetry is _85% for _30 seconds. Retry
procedure with T-piece, CPAP 10 cm H2O, and 100% O2 12 L/min.
• If no respiratory drive is observed, repeat blood gas (PaO2, PaCO2, pH, bicarbonate,
base excess) after approximately 8 minutes.
Techniques of evaluation:
1. Determine level of consciousness
2. Evaluation of the patient à search the cause of confusion / coma
- History dari pasien atau orang yang nemenin pasien atau dari medical record
- Vital sign à infection / HT / shock / > ICP dengan bradycardia
- Evidence of head trauma / elsewhere?
- Periorbital / retroauricular ecchymosis?
- Blood behind tympanic membrane to suggest basilar skull fracture?
- Papilledema / intraocular hemorrhage?
- Conjunctiva icteric, liver enlarged, asterixis?
- Lips/nailbeds discolored atau pale? à suggest anemia / pulmo dysfunc?
- Leher kaku? à warning of meningitis / subarachnoid hemorrhage
- Anything to sugges intoxication with drugs / poisons? à ex: unusual odor brearth / body
/ pinpoint pupil?
3. Presence / absence of focality of the disorder à level of dysfunc di rostrocaudal neuraxis
& specific involvement of cortical / brainstem structures
- Localize the problem that resulting in alteration of consciousness:
• Try localize the dysfunc to a level within rostrocaudal neuraxis
• Searching focal clues à specific cranial nerve deficits, abnormal reflexes, motor
asymmetry
- LOC bisa determines to a certain extent level of func disturbance within neuraxis:
• Grade I / II à cortical / diencephalic dysfunc
• Grade III à physiologic dysfunc above midbrain
• Grade IV à dysfunc above levels of cerebral peduncles / pons
• Grade V à yang sisa kerja mungkin hanya medulla
- Observe pattern respi à rate, pattern, depth
- Size and reactivity of the pupils
• Large pupil yang dilate à contract automatically (hippus), gak react to direct light
stimulus à tectal lesion
• Midposition fixed pupil à midbrain
• Bilateral pinpoint pupil à pontine trouble
- Brainstem Reflexes