Ns Enny Mulyatsih,

Mulyatsih Mkep, SpKMB

Pendidikan: Lulus S2 Keperawatan Medikal Bedah FIK UI 2010

Pelatihan: Organisasi:
Manajemen Stroke (RPH, 1995) Ketua Umum PP HIPENI
Multiple Schlerosis (Singp, Perth) Anggota Collegium KMB
Anggota Australasian Neuroscience
Kegiatan Lain: Clinical Training ( Japan, 2015) Nursing Association (ANNA)
- Konsultan Surveyor KARS ( Jakarta, 2017) Anggota Asian Neuro Surgical
Keperawatan Surveyor SNARS (Jakarta, 2018) Nursing Forum
- Dosen tamu, Penulis
buku Pekerjaan:
- Surveyor KARS/ SNARS - RSCM: ICCU, ICU, IGD, Unit Stroke, Diklat, Manag Kep (1982-2012)
1 - Kepala Bidang Keperawatan RS Pusat Otak National (2012-
- Koordinator Home Care 2019)
- Kepala Bidang Penunjang (2019-skg)

Kedaruratan Stoke/ Enny/ 2019

/12/2019
 Enny Mulyatsih

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 STROKE is
A BRAIN ATTACK!!!

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 Stroke adalah suatu keadaan terputusnya atau
terhentinya aliran darah ke otak secara tiba-tiba,
yang mengakibatkan terjadinya kerusakan atau gg
fs pergerakan, perasaan,, memori, perabaan, dan
bicara yg bersifat sementara atau menetap
(Hickey, 2014 )

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 GLOBAL BURDEN OF STROKE
• 3rd leading cause of death in the USA and 2nd leading cause
of death worldwide.
• Major cause of long-
long-term disability.
• 795.000 new cases and 200.000 recurrent cases of stroke
occur each year in the USA (AHA 20162016)
• In the year 2000 total prevalence of stroke 4.7 million and
stroke cost appr
appr.. $51.2 billion every year for acute care
and long-
long-term consequences.

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 Data Terapi Trombolitok (Alteplase)
RS Pusat Otak Nasional Tahun 2018

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 Faktor risiko stroke

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 KLASIFIKASI
Patologi: perdarahan, penyumbatan/
penyumbatan iskemik

Perjalanan penyakit:: TIA, stroke involusi, stroke komplit

Lokasi: hemisfer, batang otak

Bamford:: TACS, PACS, LACS, POCS

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 Klasifikasi Stroke
Iskemik (Infak) Perdarahan
Karena penyumbatan karena pecahnya pembuluh darah

• Both cause clinically very similar symptoms but need opposing treatment from the
coagulation perspective

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 Stroke Iskemik & Perdarahan

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 Ahmed SH,et al. In: Fisher M,ed. Stroke Therapy. 2nd ed. Butterworth Heinmann;2001

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 MANIFESTASI KLINIS STROKE:
tergantung lokasi dan luas lesi

Penurunan tingkat kesadaran Ggn sensori

persepsiGangguan
Ggn penglihatan bicara dan bahasa
Ggn memori Ggn sensibilitas
Ggn lapang pandang Ggn fungsi kandung
Ggn menelan kemih
Ggn keseimbangan

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12/4/2019
 STROKE IS A BRAIN ATTACK
Kedaruratan medik
Intervensi dini dpt mengurangi “sequel”
Penanganan yg komprehensif dan terkoordinir
dari tim stroke.
Starting with pre hospital and emergency
department care

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 Stroke Care Management

 Hyperacute phase
 Acute Phase
 Subakut phase (recovery)
 Chronic phase/ adaptation/rehabilitation

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 In hyper acute stroke care….
Time is of the utmost importance
“therapeutic window”
Perlu keterlibatan pasien,
pasien klg & tim kes
Stroke management protocols: well known,
rehearsed ( trained ),easy to follow, should
be in place.

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 A stroke “Chain of survival”
Detection
Dispatch
Delivery
Door
Data
Decision
Drug

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 Detection:

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 Remember: Time is Brain

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 FLOWCHART RUJUKAN PASIEN STROKE
DI JAKARTA TIMUR

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 Dispatch & Delivery

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 En route…EMS personal should
Obtain time of onset
Time the pt was last seen to be a normal.
The presence of seizure/ trauma
The pt’s health history
the pt’s medication therapy

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 En route…EMS personal should
Elevate the head of bed 15-30
15
Begin with ABCs degree
A neurological Measuring Oxygen saturation
examination: Oxygen 2 L/ mnt
The Cincinnati Pre- Intravenous lines
hospital Stroke Scale Measuring serum glucose
Specific intervention Administaring glucose in
hypoglycemic
NPO/ NBM

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 DOOR – Emergency Room

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 Emergency Dept Evaluation
Time is of the essence of stroke Neurological examination
care Vital sign
receive the highest triage GCS
priority Kekuatan motorik
Rapid assessment & treatment Pupil
Stroke CP or protocol should be Other neurological
in place dysfunction
A collaborative team approach

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 ACUTE STROKE FAST TRACK
TRA

Onset > 24 jam Onset <4,5 jam Onset 4,5 – 24 jam Suspect Sirkulasi Posterior/ Arteri Vertebrobasiler

 Lapor dr Jaga Neuro Onsite  Lapor dr Jaga Neuro Onsite

 Pasang infus 2 lines
 Ambil sampling darah
 EKG
 Timbang BB
 Hubungi Tim Stroke
 Pasang infus 2 lines
 Ambil sampling darah
MRI/ MRA Kepala
 EKG
 Timbang BB
 Hubungi Tim Stroke

CT Scan Otak non kontras - CT Scan Otak non kontras + CTA Stenosis arteri basiler Oklusi arteri
- CTP atau MRI & MRA basiler

Perdarahan Iskemik

Ada stenosis arteri berat Tdak ada stenosis arteri atau

Berikan r-TPA oklusi arteri besar

CTA +
CTP Lihat PPK Stroke Lihat PPK Stroke
Ada stenosis arteri berat
Tidak ada stenosis
arteri/ oklusi arteri besar
Hubungi dr Neurointervensi & dr Pertimbangkan tindakan endovasculer/
Lihat PPK Stroke Anestesi Mechanical Thrombectomy
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 Stroke / Brain Attack Team
Nursing
Neurology
Neurosurgery
Radiology
Pharmacy
Clinical laboratory personel

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 DATA:
Laboratory Neuron imaging

Glucose & electrolytes CT Scan

Complete blood cell count MRI
PT/ aPTT MRA
Cardiac enzyme CT Angiography
ABG DSA

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 Phycical examination
Be strategic & directed toward: Level of consciousness
ABC’s Visual function
Vital signs: especially BP Motor function
Tanda SAH: kaku kuduk, nyeri Sensation & neglect
kepala Cerebellar function
Neurologic examination language

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 Decision

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 DRUG……
DRUG ……General Management
Goal: speed and efficiency
Supplement O2 if indicated
Monitor blood pressure
Continuous monitoring for cardiac ischemic or AF
Identify & treat hypoglycemia/ hyperglycemia
Avoiding hypotonic and excessive fluids
NBM in the first few hours
Avoid hyperthermia

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 Blood pressure management
Tekanan darah sebaiknya jangan diturunkan kecuali:
Bila sistolik >220 mmHg, Diastolik > 120mmHg (2x
pengukuran) atau MABP >130mmHg – 140mmHg.
Terdapat AMI, gagal jantung/
jantung ginjal akut

Stroke berdarah, tensi dapat diturunkan sedikit

(maks. 20%)
Hipotensi harus dilakukan koreksi.

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 Fase Hiperakut..Terapi
Terapi Trombolitik
Acute Ischemic Stroke.
The administration of recombinant tissue
plasminogen activator (t-PA)
(t improves the
outcome after stroke when given very early, and
within 4,5 hours of onset of stroke in
carefully selected persons.

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 Indikasi terapi tPA
• Diagnosis stroke Iskemik
• Onset kurang dari 4,5 jam
• Pasien dan keluarga setuju
• NIHSS > 2 atau ≤ 24
• Usia > 18 tahun

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 Kontra indikasi
ikasi terapi rTPA
Usia < 18 tahun
CT Scan: perdarahan otak
Kesadaran koma
Gejala sangat cepat membaik atau sangat ringan
Kejang saat onset
Operasi/ trauma berat dalam 14 hari terakhir

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 Kontra indikasi terapi rTPA
Cedera kepala berat atau stroke dalam 3 bulan terakhir
Hasil hemostase darah:
1) Platelet count < 100,000
2) Current use of oral anticoagulants
3) PT > 15 sec, INR > 1.7, 4) use of heparin in the
previous 48 hours and a prolonged PTT.

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 Peran Perawat
Identifikasi kontra indikasi r-TPA
r
Nilai NIHSS
Pastikan Inform Concent
Ambil Sampel darah
Timbang BB
Persiapan/ pemberian terapi r-TPA
Monitoring selama & setelah terapi r-TPA

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 Neurological Intervention
• DSA
• Mechanical Trombhectomy
• Coiling
• Ballooning
• Stenting

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 Contoh Kasus1: Laki-laki, 70 tahun
 Tgl 3/5/2019
jam 10.25: tiba di IGD. Triage: Emergent. Kel: mendadak lemas
kaki dan lengan kanan, pusing & bicara pelo. Suspect
Stroke, onset 45 menit, kandidat terapi altepelase
Jam 10.30: Esesmen kep & medik, termasuk form khusus rTPA
Jam 11.00: CT Scan, hasil Stroke Iskem
Jam 11.40: terapi Altepelase bolus 5 mg dilanjutkan drip 45
Jam 15.00: Alih rawat ke SCU
 tgl 5/5/2019 alih rawat lantai 7a
 Tgl 10/5/2019: Pulang dengan jalan kaki

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 NIHSS:
Pre terapi altepelase: 6
Post :3
24 jam post terap : nol
48 jam post terapi : nol
Discharge : nol

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