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One day Laura, 19 year old, was cycling with you in Lippo Karawaci. You are cycling from
Medical Faculty of UPH to Benton Junction. Unfortunately she was hit by rude driver of the
public bus. She immediately unconscious and was brought to Siloam Hospitals. In the
emergency room she slowly regained consciousness, never be fully alert, but at the same time
become restless, yelling inappropriate words. She got right ear bleeds which is gradually stop.
She also vomits couple times in the emergency.

 The physician in the emergency asks you, why do you thick Laura become unconscious?

CASE :

State nya moderate to severe brain injury, dd nya contusion

1. What are Laura’s problem?

- She slowly regained consciousness

- dibawa ke ER terus dia regain consciousness Never be fully alert, but at the same time become
restless

- Yelling inappropriate words 

- Right ear bleeds which is gradually stop

- Vomits couple of time in emergency

2. What causes unconsciousness/consciousness? 

- Hit by rude drivers, causing brain trauma

- due to moderate to severe head injury  causing brain trauma

 The reticular activating system (RAS) is a network of neurons located in the brain
stem that project anteriorly to the hypothalamus to mediate behavior, as well as both
posteriorly to the thalamus and directly to the cortex for activation of awake,
desynchronized cortical EEG patterns.

- Jadi sebenernya part of brain yang control conscious sama unconsciousness itu bagian
brainstem spesifically di cerebral hempisphere yang later akan di regulate oleh reticular
activating system (RAS)  jadi munculnya unconsciousness itu bisa saja akibat
temporary/permanent impairment pada RAS tadi akibat terjadinya head injury yang
menyebabkan brain trauma, makanya system regulasi RAS untuk membuat orang
tersebut sadar itu ngga berfungsi jadinya pasien unconscious (jadi intinya karena head
injury  temporary impairment pada system RAS  unconscious)

 Vasovagal syncope
3. Why has she slowly regain her consciousness level, never be fully alert, but at the same
time she become restless? 

-> karena sedang mengalami moderate to severe head injury, beberapa symptom nya itu

Because of ear bleeding which can be a sign of brain trauma

Risk of ear bleeding:

 Dizziness.
 Bleeding from the ear/nose.
 Behavior changes
 Vomiting.
 Problems with vision.
 Confusion or loss of consciousness.
 Hearing loss.

-> never be fully alert karena kalo head injury, kan brain kita terdampak akibat kerusakan tapi
system otak bakal terus mempertahanka supaya tetap hidup/berfungsi makanya dia regain
conscious tapi ga fully alert dan jadi restless = badan nya ga bisa melakukan aktivitas maksimal
tp kalo diajak ngomong dia masih bisa respon dengan yelling/keluarin kata2 tp kurang jelas ,
jadi dia termasuk ke concussion grade 2/moderate state karena dia akhirnya bisa regain
conscious level tapi not fully alert

Unconscious = koma, vegetative, minimally conscious state

Vegetative state = (dimana dia conscious, jantung msh mompa, dia msh ekspirasi & inspiration
dll tapi brain stem nya terganggu/dead makanya dia conscious dalam arti bisa buka mata, tp ga
berfungsi secara cognitive untuk kontak sm orang disekitar tidak bisa )

4. List the learning issues you need to deal with this case

- The cause of ear bleeding might be disruption of blood brain-barrier due to brain trauma

- types of head injury

- anatomy of the brain kira2 kena nya dimana

- bagian otak mengontrol apa aja yg berhubungan conscious sm unconsciousness

- general symptoms mild head injury sm moderate to severe head injury

- ethiology unconsciousness

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During the work up she deteriorated with a “blown pupil” on the left side, and with pain
stimulation showed right side weakness.

The Emergency physician asks you to explain what has happened.

He asks you if there is any additional information you would like to have.

1. What has changed and what are your hypotheses?

no hypotheses has been changed, blown pupil or mydriasis is caused due to injury,
in this case brain injury due to accident.

 Blown pupil/mydriasis included as Moderate to severe head injury symptoms =

dia ga berkonstruksi ketika mata nya exposed ke cahaya
  Terus juga dia blown pupil on the left side = itu bisa mendukung hipotesis head
injury nya itu sebelah kanan
 Blown pupil on the left side = juga bisa akibat brain trauma (otak swelling),
intracranial pressure jadi increase makanya dia suppress oculomotor nerve
jadinya dia dilated

Kenapa partial weakness nya ke sebelah kanan which means head injury kemungkinan pada
sebelah kiri tapi blown pupil nya di left side dimana itu bisa support hypothesis head injury
sebelah kanan????

 Ride sided weakness = haemiparesis is mild or partious weakness, masih bisa

attempt to do activity contohnya kayak angkat tangan tapi ngga sekuat orang
normal. Jadi half loss of strength ((haemiplegia total lose of strength, bener2
gabisa ngapa2in ))
 Probably Head injury more into ke kiri = kebagian kiri bukan kanan karena dia
menunjukkan right side weakness
 Pain stimulator showed right side weakness. This might shows that the left
hemisphere is injured.

 partial weakness  bisa juga diakibatkan oleh blood clotting, subdural

hematoma
 Dia severe head injury jd harus langsung dikasih tindakan
 Ear bleeding di sebelah kanan = mendukung hipotesis dia head injury sebelah kiri

 Damage to the brain can cause increased intracranial pressure within the brain,
which can affect eye health and damage nerves. Pressure can come from
physical trauma or internal brain damage, such as a stroke.

2. What questions would you like to ask?

- setelah masuk ke ER kita gatau dikaish apa, apakah di cek doang ga dikash first aid
- asses GCS
- tanya secara spesifik jatohnya kayak gimana? Details jatohnya?

- CT scan or MRI

- Possible previous accident = kalo pasien nya unconscious/not fully alert mungkin bisa
call ke family membernya dirumah, tanya dia ada previous accident gak sebelumnya, yg udh
bisa memicu brain injury ditambah dengan kejadian accident waktu cycling jadinya semakin
severe
State nya moderate to severe brain injury, dd nya contusion

- Coupe and counter cope

- WO no.1-4
- Type of haemorrage