Kegawatan Neurologi_Jofizal J

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Text of Kegawatan Neurologi_Jofizal J

  • KEGAWATAN NEUROLOGI

    JOFIZAL JANNISBAGIAN NEUROLOGI FKUI/RSCM

  • ObjectiveDefinition and component of consciousness describe in a repeatable way the level of consciousness, qualitative and quantitativeTo examine meningeal sign.Elaboration of neurological cases

  • KEGAWATAN NEUROLOGI

    Suatu sindroma / penyakit yang dapat menyebabkan kecacatan/kematian seperti STROKE, MENINGO ENCEFALITIS, Trauma kapit,dan keadaan spt. Koma, kejang, tinggi tekanan intrakranial

  • Salah satu kegawatan neurologi

    Keadaan Unresponsive-unarousableMenunjukkan keadaan gagalnya fungsi integritas otakMenunjukkan tingkat penurunan kesadaran paling berat

  • ASPEK FUNGSIONAL KESADARAN

    Aspek on-off quality atau Arousibility Rostral batang otak (ARAS )2. Aspek Content ( isi kesadaran ) Korteks Serebri PERBEDAAN kerusakan pada ARAS dan KORTEKS SEREBRI Kerusakan pada Rostral Batang Otak/ formatio reticularis : kesadaran turun dengan cepat/langsung koma Kerusakan pada korteks serebri(> 2/3 luas, korteks rusak) koma didahului dengan delirium.

  • ETIOLOGI KOMA

    KOMA NEUROLOGIK Kerusakan primer pada struktur susunan saraf pusat KOMA NON NEUROLOGIK - kerusakan pada Millieu interieur sel neuron - struktur neuron tidak rusak

  • ETIOLOGI KOMA

    Koma neurologik terjadi pada :Stroke, perdarahan, traumatik, radang, tumor.Koma non neurologik :Metabolik : Diabetik ketoasidosis, uremia, ensefalopati, hepatik, hyponatremia, hypoglikemia.Toksik : Narkotik, CO2

  • KOMA SUPRA TENTORIAL :- Dimulai dengan tanda-tanda fokal - Gejala makin berat, tergantung pada ekspansi /progresivitas penyakit- Penurunan kesadaran, umumnya didahului oleh Tekanan Tinggi Intra Kranial herniasi unkus- Perubahan reaktivitas pupil unilateral terjadi berangsu- angsur. KOMA INFRA TENTORIAL :- Penyebab : adanya kerusakan struktur dibawah tentorium serebelum yang berisi batang otak dan serebelum- Fokal bilateral dalam waktu singkat- Kesadaran turun waktu relatif singkat.

  • TUJUAN PEMERIKSAAN NEUROLOGI :Menentukan riwayat gagal otakPenentuan jenis komaKemajuan / kemunduran pengobatan

    PEMERIKSAAN NEUROLOGI KOMA :Tingkat kesadaran Pemeriksaan reflek batang otakPemeriksaan motorik / funduskopi

  • ConsciousnessIs the state of full awareness of the self and one s relationship to the environmentClinically, the level of consciousness of a patient is defined operationally at the bedside by the response of the patient to the examiner

  • Qualitative level of conciousnessNormal waking state ( compos mentis): sensorium fully intact.The person sleeps at appropriate time, arouses fully, and appropriately maintains the waking state.Somnolence : the patient arouses spontaneously at times after normal stimuli but drift off inapprpriately.The sensorium functions adequately when aroused

  • Sopor (Stupor): Appears asleep but arouses to vigorous verbal stimuli. May awaken spontaneously for brief period, but sensorium clouded. Shows some spontaneous movement and follow some brief command Slight coma (semi-coma): No response to verbal stimuli. Moves mainly in response to painful stimuli. Reflexes (corneal, pupillary intact). Breathes adequatelyDeep or complete coma: No spontaneous movements or arousal. Reflexes absent. Breathing impaired or absent

  • ARAS

  • Conc. has two mayor componentsContent : is represent of sum the all functions mediated of cerebral cortical level, including both a cognitive and affective responseArousal: if a reduced of conc. Is not due to focal impairment to cognitive function, but the rather to a global reduction in the level of behavioral responsiveness of conc.

  • Quantitative level of conc.Glasgow Coma ScaleEstimate : Eye response ( E ) Motor response ( M ) Verbal response ( V ) A GCS score 13 15 mild 9 12 moderate 3 - 9 severe

  • Eye responseEyes open spontaneously = 4Eye opening to verbal command = 3Eye opening to pain = 2No eye open = 1

  • Motor responseObeys command = 6Localizing pain = 5Withdrawal from pain = 4Flexien response to pain = 3Extension response to pain = 2No motor response = 1

  • Verbal responseOriented = 5Confuse = 4Inappropriate word = 3 Incomprehensible sound = 2No verbal response = 1

  • Approach to the diagnosis of the unconscious patientDetermine rapidly the cause of the impairment the structural or metabolic and what treatment The key component of the examine include ,the level of conc, the pattern of breathing, the size and the reactivity of the pupils, the eye movement and oculovestibular response

  • PEMERIKSAAN REFLEKS BATANG OTAK 1. Refleks pupil 2. Reflek cornea3. Reflek okulo encepfalik (Dolls eye manuver) Integritas nukl vestibular Nukl okulomotor. Jika negatif : koma Juga untuk melihat : Gaze Abnormality Paresis saraf penggerak bola mata (N.III,N.IV,N.VI)

  • 4. Observasi pernafasan

  • OBSERVASI PERNAFASAN ABNORMALMEMBERI INFORMASI tentang FUNGSI BATANG OTAK/PUSAT PERNAFASANBEBERAPA CORAK PERNAFASAN mempunyai KORELASI dengan LOKASI LESI di BATANG OTAK

  • PERNAFASAN ABNORMAL tsb. A.L.:- Cheyne stokes : kerusakan bilateral hemisfer atau diencephalon atau lesi sepanjang jaras forebrain-pons bagian rostral- Central neurogenic respiration : pernafasan cepat 40-7-x/menit, karena lesi di bagian sentral tegmentumpons, ventral dari aquaductus Sylvii atau ventrikel IV - Biot : pernafasan ireguler, akibat lesi di medula oblongata

  • KESIMPULANKoma adalah gejala-gejala neurologik indikator gagal otak.Tindakan resusitasi diikuti pemeriksaan neurologik untuk menetapkan sebab komaSegi emergensi, manajemen koma neurologi dibagi : Manajemen koma bedah Manajemen koma non bedah Penting untuk Triage, agar tindakan Life Saving segera di antisipasi

  • Meningeal signNeck stiffness Not to be performed if the could be cervical instability e.g following trauma What to do : The patient should be lying down Place your hands behind the patient head Gently rotate the head moving the head as the patient was indicating no. Fell the stiffness.

  • Gently lift the head off the bed, feel the tone in the neckWatch the legs for hip and knee flexion

    What you find and what it meansNeck moves easily in both planes, with the chin easily reaching the chest, or neck flexion : normal

  • Neck rigid on movement - neck stiffnessIndicates meningeal irritation common causes bacterial, viral, subarachnoid hemorrhage, rare causes meningeal carcinomatosis

  • Brudzinski neck sign (1)What to do Moving until the chin easily reaching the chestWhat you find (+) when response both flexed on lower extremities

  • Kernig signWhat to do The patient is lying flat on the bed -flex the leg at the hip with the knee flexed -then try to extend the knee -repeat on the other side. What you find -knee straigten without difficulty normal -resistance to knee straightening indicates meningeal irritation, if unilateral , may occur root irritation on HNP

  • Brudzinski contralateral leg sign(2)What to do -the patient lying flat on the bed, flex the leg at the hip,with the knee flexed what you find -flex the knee at contralateral

  • Lasegue signWhat to doLifting the right sign lower extremityWhat you find More than 70 positive lasegue sign

  • MENINGEAL SIGN

    1. NECK STIFFNESS 2. BRUDZINSKI I 3. KERNIG SIGN ( N > 1350 )

  • MENINGEAL SIGN4. BRUDZINSKI II 5. LASEQUE SIGN (N > 60 - 700)

  • Kasus IPenderita laki-laki, usia 62 tahun datang ke IGD karena tiba-tiba mengalami penurunan kesadaran disertai muntah.Sebelumnya penderita sering mengeluh sakit kepala.Ada riwayat hipertensi, DM disangkal

    Pemeriksaan neurologi : TD 190/100, kesadaran sopor RR 22x/m, N 90x/menit, suhu 375 C

    Meningeal sign (+) Rf +/+nRp +/+

  • Pertanyaan :

    Apa yang harus saudara kerjakan pertama kali ?Pemeriksaan laboratorium segera apa yang harus dilakukan ?Tindak lanjut pemeriksaan radiologi ?

  • Setelah dilakukan pemeriksaan laboratorium ternyata gula darah rendah 40 mg/dl, elektrolit : Na 117; K 2,4; Cl 100Penderita gelisah, muntah masih ada, NGT terpasang, ternyata berdarah

  • Pertanyaan :Apa yang saudara lakukan untuk tata laksana sebelum perawatan di ruangan ?

  • Kasus IISeorang wanita 77 tahun mengeluh gangguan menelansetiap kali makan/minum, cairan/makanan keluar darihidung. Selain itu berbicara pelo, dan sebelumnya seringmengeluh gangguan keseimbangan bila berjalan.Riwayat Hipertensi dan DM disangkal.Tiba-tiba 3 hari kemudian penderita terjatuh, masih sadar, muntah (+)

  • Pertanyaan :1. Apa yang harus saudara lakukan ?2. Pemeriksaan klinis apa yang menjadi perhatian penting saat ini ?3. Pemeriksaan penunjang untuk diagnostik

  • Bila selanjutnya penderita ngantuk (tidak sadar ?), tanda vital masih normal. Pupil anisokor, refleks +/+ lambat, Motorik slight hemiparesis kiri

  • Pertanyaan 1. Perkiraan diagnosis saudara ?2. Apa yang harus dilakukan, bila ternyata hasil CT Sken normal, tapi penderita kejang berulang. PO2 < 5