CONSCIOUSNESS

o Psychologist à state of continuous awareness of one’s self & environment; knowledge

of self includes all feeling, attitudes and emotions, impulses, volitions, and the active or
striving aspects of conduct;

Near continuous self-awareness of a person’s mental func (particularly cognitive
processes) and relation to memories and experience.
o Physician à lebih practical dan objective à melihat patient’s behavior and reaction to
overt stimuli than to what the patient says:
The state of awareness of self and environment, and responsiveness to external
stimulation and inner need.

STATES OF NORMAL AND IMPAIRED CONSCIOUSNESS
Normal Consciousness
o Kondisi normal saat orang sadar
o Fully responsive ke thought / perception à indicates by: behavior, speech
o Ada perhatian dan interaksi dengan sekitar

Confusion
o Inability to think with customary speed, clarity, coherence
o Majority marked by: inattentiveness & disorientation
o Difficulty to define thinking (problem solving / coherence of ideas)
o Most often hasil dari proses yang mempengaruhi otak secara global
o Linked to alertness and the level of consciousness
o Yang terjadi selama pasien confused tidak membekas di ingatan à ada (-) di working
memory (butuh temporary storage solusi dari sebuah task untuk dipakai berikutnya) à
test: serial subtraction, spelling words (atau sebutin nomor hp forward backward),

Drowsiness and Stupor
o Drowsiness à gak bisa sustain wakeful state tanpa external stimuli
Alertness à tersustain spontaneously untuk beberapa saat, tanpa perlu stimuli
o Stupor à state dimana patient bisa bangun hanya dengan stimuli yang kuat dan
berulang à stimuli hilang, patient quickly drift back into a deep sleep-like state
- Respon ke perintah à absent / terbatas / slow dan tidak cukup
- Restless
- (-) natural shifting of body position

Coma
o Pasien yang tidak bisa disadarkan lewat external stimuli / inner need
o Deepest stages à tes untuk cek respon nya sia2
 Lighter stages (semicoma/obtundation) à majority dari reflex di atas (corneal, pupillary,
pharyngeal reflex) bisa terlihat
o Hubungan dengan Sleep
- Sleep à little evidence of being aware terhadap diri mereka / lingk (include:
yawning, tutup mata, (-) berkedip, (-) swallowing,

NEURAL BASIS EXAM:
LEVEL OF CONSCIOUSNESS

o Clouding of consciousness à very mild form of altered mental status; inattention & (-)
wakefulness
o Confusional state à more profound deficit; disorientation, bewilderment, susah ikuti
commands
o Lethargy à severe drowsiness, can be aroused by moderate stimuli
o Obtundation à mirip dengan lethargy; < interest in environment, slowed responses on
stimulation, sleep more than normal
o Stupor à
o Coma

Grady Coma Scale

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. 


• Reduce ventilation frequency to 10 breaths per minute to eucapnia. 


• Reduce positive end-expiratory pressure (PEEP) to 5 cm H2O (oxygen desaturation

with decreasing PEEP may suggest difficulty with apnea testing). 


• If pulse oximetry oxygen saturation remains_95%, obtain a baseline blood gas (PaO2,
PaCO2, pH, bicarbonate, base excess). 


• Disconnect the patient from the ventilator. 


• Preserve oxygenation (e.g., place an insufflations catheter through the endotracheal

tube and close to the level of the carina and deliver 100% O2 at 6 L/min). 


• 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 systolic blood pressure decreases to _90 mm Hg. 


• 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. 


• If respiratory movements are absent and arterial PCO2 is _60 mm Hg (or 20 mm Hg

increase in arterial PCO2 over a baseline normal arterial PCO2), the apnea test result
is positive (i.e., sports the clinical diagnosis of brain death). 


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

Motor Function Test

5 = normal strength à able to maintain the muscle contraction against examiner resistance
4 = mild weakness à weakly / briefly able to overcome examiner resistance
3 = able to support limb against resistance but unable to overcome examiner resistance
2 = can move the limb, unable to lift against gravity
1 = flicker but no movement
0 = no movement
Ascending Reticular Activating System (ARAS)
o ARAS: diffuse group of neuronal connection dari reticular formation à projecting up ke
midbrain à ke thalamic à ke cortex
o Reticular formation à di periventricular area of midbrain, pons, medulla
o Menerima input dari semua sensory system
o It is thought that this system is responsible for modulating alertness and sleep à
gangguan di sistem ini mempengaruhi level of consciousness / abnormal di sleep cycle