Penurunan Kesadaran 2013

KEDARURATAN
NEUROLOGI
(Level Of Conciousness)
Anwar Wardy W
Juni 2013
anwar wardy w Dept.Neyrosain FKK.UMJ.2010
The General Principle For Managing
Neurologic Emergencies
Principle I: (Kaidah I)
Kerusakan sistem saraf tidak menyebabkan
kematian organ yang disarafi. Jaringan dan
fungsi diharapkan dapat diperbaiki.
Anwar Wardy W.FKK.UMJ

Emergency Symptoms
 Confusion
 Drowsiness
 Difficulty speaking clearly
 Numbness in any part of the body
 One pupil that is larger than the other

Focal brain dysfunction
•Brain tumour
•Vascular events (CVA)
•Demyelination
•Infection, such as cerebral abcess
•Focal head injury
Diffuse brain dysfunction
•Infection, such as meningitis or encephalitis
•Epilepsy
•Hypoxia and hypercarbia
•Drugs, poisoning and overdoses ( including alcohol)
•Metabolic/endocrine causes, such as diabetic coma,
•Hepatic or renal failure,
•Hypothyroidism, severe electrolyte disturbances
•Hypotension, or hypertensive crisis
•Diffuse head injury
•Subarachnoid haemorrhage
•Hypothermia,
anwar wardy w hyperthermiaDept.Neyrosain FKK.UMJ.2010

Primary Events:
 Cell, Axonal atau Myelin (Transmisi terganggu)
Penyebabnya:
1. Anoxia 7. Toxin/Infeksi
2. Intracranial Hemorrhage. 8. Metabolic
3. Ischemia
4. TRAUMA
5. Hypoglicemia
6. Tumors

TRAUMA
 Concussion
 Cerebral contusion
 Epidural hematoma
 Subdural hematoma/effusion
 Intracerebral hematoma
 Diffuse axonal injury
anwar wardy FKK UMJ

EPIDURAL HEMATOMA
anwar wardy FKK UMJ

SUBDURAL HEMATOMA
anwar wardy FKK UMJ

Secondary Events
• Edema Cerebri
• TIK
• Obstruksi dari Liquor CS. Anoxia
• Vasospasme ICH
Ischemia
• Kegagalan Autoregulasi Tumors
Trauma
• Kegagalan Collateral supply
• Gagal Jantung
• Gagal Nafas.

Principle II (Kaidah 2)
Selalu memerlukan intubasi
Agar pernapasan terjamin dan
oksigenasi ke otak terjamin baik.
Cegah terjadinya:
1. Coma hypoventilasi.
2. Hypoxia otak dan acidosis /
hypercarbia.

Glasgow Coma Score
 Eye Opening (E)
4=Spontaneous
3=To voice
2=To pain
1=None
 Verbal Response (V)
5=Normal conversation
4=Disoriented conversation
3=Words, but not coherent Total = E+V+M
2=No words......only sounds
1=None
 Motor Response (M)
6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Decorticate posture
2=Decerebrate
1=None

Principle III (Kaidah 3)
 Stop perdarahan (Stop the Bleeding)
PRINCIPLE iv ( Kaidah 4)
 Sirkulasi peredaran daraf keotak dipertahankan.

Principle V (kaidah 5)
 Penyakit tersebut Struktural atau Non-
Structural.
Biasanya dilakukan dengan pemeriksaan

Rontgen / CT.Scan atau
Suspect N-Struktural dengan LP.

INFRATENTORIAL LESIONS
 Brainstem symptoms are often seen
initially
 Sudden onset of coma
 Cranial nerve abnormalities
 Alteration of the respiratory pattern
anwar wardy FKK UMJ

PROGRESSION OF MASS LESIONS
anwar wardy FKK UMJ

TYPES OF BRAIN HERNIATIONS
1= subfalcine
2 = uncus
3 = caudal
displacement
4 = cerebellar
tonsils
anwar wardy FKK UMJ

HERNIATION SYNDROMES
• Tonsillar or Foramen Magnum Herniation
– Displacement of brainstem and cerebellar tonsils into
the foramen magnum
• Progressive ALOC, hypertension, bradycardia and irregular
respirations (Cushing Triad)
• Transtentorial herniation
– Displacement of medial aspect of temporal lobe into
tentorial hiatus
• ALOC, ipsilaterial pupillary dilatation, contralateral
hemiparesis
• Upward tentoral herniation
– Cerebellar vermis moves into incisura
– Produces brain stem compression
anwar wardy FKK UMJ

Principle VI (Kaidah 6)
 Diagnosis cepat dan sederhana

(Simple & Spot Diagnosis) : yaitu
dengan menggunakan pengetahuan
Anatomi saraf (Topis Diagnostic) untuk
mengetahui letak lesi di Otak.

Herniation: The Brain Under Pressure
 Bleeding or swelling in the brain can
cause pressure that forces the brain
downward in the skull.

THE STATE OF CONSCIOUSNESS
(AROUSAL)
 The ascending RAS, from the lower border
of the pons to the ventromedial thalamus
 The cells of origin of this system occupy a
paramedian area in the brainstem

r t
p o
p
S u Part I. Neurological Examination
stic
agn
o and Neurodiagnostic Testing
Di
n
ai
M
1. Neurological examination;
2. Neuroradiology;
3. Electroencephalography;
4. Lumbar puncture;
5. Electromyography;
6. Electronystagmography;
7. Evoked potentials;

Part II. Common Neurological
Presentations
8. Altered level of consciousness;

9. Headache;
10. Weakness;
11. Dizziness;
12. Seizures;
13. Gait disturbance;

Part III. Specific Neurological
Conditions:
14. CNS infections in adults; 22. Dementia;
15. Viral encephalitis; 23. Neurooncology;
16. Vascular disease; 24. Neuropsychiatric
17. Movement disorders;
25.Neuroanesthesiology;
18. Neuromuscular disorders; 26. TIK
19. Musculoskeletal and neurogenic pain;
20. Neuroophthalmological disorders;
21. Multiple sclerosis; 28. Sleep disorders;
27. Normal pressure hydrocephalus;

Part IV. Neurological Trauma and
Environmental Emergencies
29. Traumatic brain injury;

30. Spinal cord injury;
31. Peripheral nerve injury;
32. Neurological complications of
environmental emergencies

Part V. Pediatric Neurology
33. Hydrocephalus and shunts in

children;
34. Pediatric CNS infections;
35. Pediatric stroke;
36. Pediatric seizures;
37. The hypotonic infant;

Part VI. Neurological Emergencies
of Pregnancy:
38. Neurological emergencies of

pregnancy;

Part VII. Brain Resuscitation and
Neurotoxicology:
39. General neurotoxicology;
40. Neurotoxicology of alcohol and
substances of abuse;
41. Brain resuscitation.










Evaluation
ICP monitoring is most often used in head trauma in
the following situations:
 1) GCS less than 8
 2) Drowsy with CT findings (operative or non
operative)
 3) Post op hematoma evacuation
 4) High risk patients (a) Above 40 yrs. (b) Low BP
(c) Those who require ventilation.
 There is nothing to achieve in monitoring ICP in
the patients with GCS of less than 3.



Bahan Bacaan:
•Gilroy John, Textbook Medical Neurology, MacMillan Publ. co.Inc. 5th Edition
London, 2009.
•Surgery, and Internal Medicine, Neuroscience Intensive Care Unit, 2006.
•Epstein, Owen, Clinical Examination on Neurology Emergency, Mosby 2005
TERIMA KASIH,
….Wassalam..//
a2w@telkom.net FKK.UMJ.Juni 2008

Penurunan Kesadaran 2013

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KEDARURATAN

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy FKK UMJ

anwar wardy FKK UMJ

anwar wardy FKK UMJ

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

 Sirkulasi peredaran daraf keotak dipertahankan.

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

Biasanya dilakukan dengan pemeriksaan

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy FKK UMJ

anwar wardy FKK UMJ

anwar wardy FKK UMJ

anwar wardy FKK UMJ

 Diagnosis cepat dan sederhana

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

8. Altered level of consciousness;

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

29. Traumatic brain injury;

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

33. Hydrocephalus and shunts in

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

38. Neurological emergencies of

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

Anwar Wardy W.FKK.UMJ

a2w@telkom.net FKK.UMJ.Juni 2008

Anwar Wardy W.FKK.UMJ

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