Post on 05-Mar-2016
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Jofizal Jannis
Neurologist
National Brain Centre
DIAGNOSA BANDINGPENURUNAN KESADARAN
MANAJEMEN
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Kesadaran adalah : is the body’s state ofarousal or awareness of self and environment
Koma : keadaan tidak sadar total terhadap diri
dan lingkungan meski di stimulasi dengankuat.
Diantara sadar dan koma terdapat variasi
status gangguan kesadaran.Klinis dapat ditentukan dengan bedside.
Defnisi
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BJEKTIF
• Dokter mampu melakukan
stabilisasi, diagnosis, mengatasi
dan evaluasi pasien koma.
• Dokter dapat mengatur prioritas
pendekatan secara berurutan
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bjektif
Primer• Airway
• Breathing
• Circulation• erapi progresif cepat !koma hipoglikemik"
• #valuasi $% atau lesi massa
• erapi $%, kemungkinan intervensi bedah
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bjektif
Sekunder
• Dokter mengenal perbedaan koma
struktural dan metabolik toksik
•Dokter mengerti dan mengenal• %oma
• $%
• &indrom 'erniasi• anda lesi massa supratentorial
•anda lesi massa infra tentorial
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Dua (2) komponen kesadaran : formasio retikularis dan hemisfer serebral
Formasio retikularis : a diffuse collection of
neurons that extends throughout the brainstem(terpusat pons. Dari mes, pons dan m.o).
Reticular Activating System : a diffuse collection
of neuron in the reticular formation, plays an
essential role in keeping the concious brain.
ARA : locking !aras asending antara formatioreti"ular dan korteks serebri men#ebabkan tidak
sadar
Anatomi Kesadaran
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Supra orbital
Sternum
Metode menimul!anRes"ons "asien tida! sada
Kuku jari
Sendi
temporo mandibular
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WHAT YOUR FIND
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$%&'A'A& $%&R&A& K%ADARA&
PENURUNAN
KESADARAN
KUA#I$A$I% KUAN$I$A$I%
APA$IS
SOMNO#EN
SOPOR
KOMA
G#ASGO& COMASCA#E
E'ES
OPEN
() S"ontan*) Bi+ara,) N-eri
.) None
MO$ORIK
/) I!utPerinta01)N-eri lo!al()Menola!
*)%le!si,)E!stensi
2ERBA#
1) Orientasi ai! () Bingung*) Kata !ata,) Suara.) None
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D'A*&+' $%&R&A&K%ADARA&
K+A -RK-RA K+A %-A+'K
TANDA
#A$ERA#ISASI345
#A$ERA#ISASI365
Kelainan di7us
Ingat SA8
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E$IO#OGI KOMA
GANGGUANS$RUK$URA#
GANGGUANME$ABO#IK
Kerusa!an RAS Metaolism
e energi
Multi7a!t
or
#angsung $ida!#angsung
Perdara0anIn7ar! $raumatumorIn7e!si
8erniasi
Is!emi9
ano!sia9
0i"o!sia8i"ogli! emi8i"er:
0i"otermia
Imalansele!trolitGangguanasam asa8i"er:0i"oosmolarKe;ang
umum
Kegagalan organ
8e"ati!
RenalPulmonerPan!reati!
Kera+unan
A!ti<itas
neuronalmemran
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Koma Struktural
eninggal elamat
Komplikasi ati +tak
enolak
dibantu
-idakadar
adar
$emulihan
Disabilitas$/
0
Disabiltas erat
Disabilitasringan
Keluaran KomaKarena esi truktural
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2as!ular
In7e! si
$rauma
Al!o0ol
Metaoli!
Neo"lasti!
Imunitas
PENYEB
AB
PENURU
NAN
KESADA
RAN
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• Asending RAS, dari sisi bawah pons ke
pons ke talamus ventromedial• Sel yang berasal dari sistem ini menduduki
area paramedian di brainstem
Kesadaran (arousal)
Korte!ssereral
RAS
$A#AMUS
8JPO$A#AMUS
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0ons"iousness
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Kesadaran normal
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1akefulness
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Aareness
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RA'& D%A-3
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inimall# 0on"iousness
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DIAGNOSIS DI%ERENSIA#
KOMA#OCK IN
S'NDROME
2EGE$A$I2ES$A$E PSIKIA$RI
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Koma
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/%*%-A-'/% -A-%
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/egetative
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• Pasien tertolong dari !oma9ta"i er!emang !eadaan
"ersistent unres"onsi79 ta"islee"=>a!e +-+les !emali)
• Setela0 +edera !e"ala erat97ungsi rainstem !enalimengalami slee"=>a!e
+-+les9 memu!a mata
!egetative state "coma vigil, apallic syndrome#
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o"k4in #ndrome
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o"ked4in
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$ocked in syndrome
• Pasien a>a!e and alert9ta"i tida! sanggu"
ergera! atau i+ara• #esi Pontine
mem"engaru0i"ergera!an mata !elateral dan !ontrol gera!)
•
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$sikogenik unresponsif
• Pasien9 >alau tam"a! tida!sadar9 iasa menun;u!!an
eera"a res"ons stimulie!sternal
• Re?e!s !ornea
men-ea!an !ontra!siotot ori!ularis o!uli
• Ditandai ole0 resistensi
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PENI#AIAN K#INIS PENURUNAN KESADARAN
PERNAPASAN
Soma3iso!or5Aniso!orMidriasisMiosis
$EN$UKAN SECARAKUA#I$A$I% DAN
KUAN$I$A$I%
N) O!ulerN) %a+ial
#ateralisasi
PUPI# N) KRANIA# MO$ORIK
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D'A*&+' $%&R&A&K%ADARA&
A&A&%'$%%R'KAA&
F''K$%%R'KAA&
&%R++*'
3istor#Ria#at
makanobat-rauma'nfeksi
-ekanandarahuhu$ernapasanklera
ateralisasi
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Gamaran Koma D2S BrainDeat0
#OS A!ineti!Mutisme
Sel7a>areness
6 6 6 4 4
Slee" >a<e+-+le
6 4 6 4 4
%ungsimotori!
6 6 6 $eratas 444
%ungsi
"erna7asan
4 6 4 4
EEG
Polimorti!
$etaDelta
Slo>
6 @ Nons"esif+ slo>>a<e
Cereral 1 1 6
Keadaan $erubahan evelKesadaran
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BI#A MENGA#AMI
DE#IRIUMSEGERA
ASES
PEN'EBAB
N'ERI RE$ENSIO URINE
8IPOKSIA
8IPO$ENSI
DE8IDRASI
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Abnormalitas pernafasan dapat
membantu lokalisasi tetapi tidak selalu
dalam konteks tanda lain sepertihiperpnea refleks sentral (midbrain4
hipotalamus)
Apneustik, kluster, ataksik,(pons baah)
3ilangn#a pernafasan otomatis (medula)
$%R&AFAA&
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AnormalitasPena7asan
Des!ri"si #o!alisasi
C0e-ne = Sto!es Pola "erna7asan !resendode!resendo diiluti ole0a"nue atau 0i"onea9meneta" selama tidur
Bi0emis7er3unilateral : ilateral59atau rainstem
Cluster Ireguler "erna7asan dii!uti"eriode a"nue -anglaman-a er<ariasi
Bi0emis7er :"ons
Atai+ orirregular
Ke+e"atan "erna7asan-ang tida! teratur iramadan am"litudo di"utus ole0a"nue
$ida! terlo!alisasiatau meduladorsomedial
A"neusti+ Ins"irasi "an;ang dengan,6* deti! er0enti!emudian e!s"irasi)
$e!mentum lateraldari "ons a>a0
Centralneurogeneti+0i"er<entilation
8i"er<entilasi terusterusan !e+e"atan"erna7asana tida! melei0i
( !ali:menit
Bi0emis7er "ons danmidrain
A&+RA'-A $%R&AFAA&
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Pernafasan cheyne stok
Hiperventilasi neurogeniksentral
apnestik
Pernafasan cluster pernafasanata!ic
Apnoe
0 P il d
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erua0an Pu"il "ada
si di ota! a!iat Koma
pektrum abnormalitas pupil dan
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$upil normal
Anisokor di pupil karena herniasi
+val pupil (gambaran aal mati otak)
idriasis (ansietas, delirium, ke!ang,obat4obat seperti atrofin, &%, dopamin)
idposisi (mati otak, lesi mesenfalon)
indrom 3ordner
iosis (opioid, lesi pons akut,hiperkapni, hiperglikemi non ketotik
pektrum abnormalitas pupil danpen#ebab
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WHAT TO DO
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Pendek!t!n DD
(lucosa, AB(, )ytes, *g, Ca,o+, ammonia
nresponsif
ABCs
$- D/, narcan,
C$
Brainstem at tanda
0okal
Disfungsi otak difus*etabolik 1 infeksi
Un+ons+ious
)esi fokal
umor $C'1&A'1 infark
2seudo3Coma
2sikogenik,
)ooked3in,
4* paralysis
#PC$
5 &
5
&
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Koma
'ntubasi 6ventilasi7stabilisasi tekanan darah
indrom&eurologi
$en"itraanotak
3asil
$ilihanpengobatan
Jaringan Otak dan
pergeseran batang otak
CT otak
Abnormal
ntrinsik batang otak
"valuasi Pasien Koma
!edah "vakuasi
Kraniektomi
R# C$
Stroke T! %assa
Tumor n&eksi
CT otak
'ormal
Trombolisis
$engambilan
bekuan
!asilar
embolus
arteri
C( T!
Abnormal
%assa
Perawatan
medik
Perawatan
medik
!iopsi
$en#ebab
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& 6 &e"kA 6 Aira# 6 reathing0 6 0ir"ulationD 6 Diabetes
Drug
% 6 %pilepsiF 6 Fever * 6 *0
3 6 3erniation' 6 'nvestigate
Resusitasi9 mema!ai ABCNeurologi
ana!emen $asien tidak sadar
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!n!jemen "!n##u!n Ke$!d!r!n
Ke$!d!r!n menurun
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&europrotektan
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Neur%&r%tek$i
u5uan untuk melindungi 5aringan otak
yang hampir rusak.
Beberapa obat yang pernah dipakai Citicholin 2iracetam 2iritinol
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J!rin#!n S!r!f
)ipid 6 7389
%omponen lipid terdiri:
2hospholipid 6 :;9
!lecithins, cephalins < sphingomyelin" %olesterol 6 7/9
Cerebroside !galactolipids" 6 =9
)ipid mengandung sulfur, aminolipid 6 >9
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'e(e) )e$it*in &!d! tr!um! k!&iti$
- &ecara eksperimental- 2ada sisi cedera 6
? hari pertama cedera ter5adi
penurunan lecithin
3 2ada sisi lain tidak ter5adi perubahan
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FARAK+D'&A'K '-'K3+'&
eker!a langsung pada $ engaktifkan for. retikularis di atang +tak sehingga menurunkan ambang rangsang reaksi
arousal untuk membantu membangkitkan kesadaran engaktifkan fungsi p#ramidal dan ekspiramidal #ang tersisa
enurunkan ambang rangsang evoke mus"ulardis"harge shg merangsang aktivitas s#stem
piramidal #ang berkaitan dg fungsi motorik
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Efek $itik*%)in &!d! +DP K*%)in $int*et!$e end%#en
d!n &en##un!!n FFA
0D$ Kholin (sitikholin)
istidin kholin
istidin kholin
0-$ F+F+R' K3+'&
'-'K3+'&
FFA
D5A05 *50%R+ 8
F+FA-'D' K3+'&
%RA& %
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ek!ni$me kerj! ,itik*%)in
&ebagai derivate asam nukleat melakukan
biosintesis lecithin dan stabilisasi membran sel *emperbaiki aktivitas membrane A2 ase
*engaktifkan kembali metabolisme serebral *emperbaiki sirkulasi serebral secara selektif 2embentukan neurotransmitter
*encegah akumulasi asam lemak toksik shg mencegah luas infark dan kerusakan 5aringan
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Ter!&eutik Wind%- ,itik*%)in ./ 0 /1 j!m
Citikholin mempunyai efek neuroproteksi *engurangi lesi pada membran saraf
dengan cara meningkatkan sintesis
fosfolipid dan mengurangi kadar asam lemak bebas Beberapa studi membuktikan bahwa
citikholin mempunyai.terapeutik window :8 @ 8; 5am
-reatment of a"ute "erebral
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-reatment of a"ute "erebralinfar"tion ith a "holine pre"ursor in
a multi"enter
A multi"enter double4blind pla"ebo4"ontrolled stud# of "#tidine 94diphospho"holine (0D$4"holine) as "ondu"ted to evaluate possible"lini"al benefits of the drug in patients ith a"ute, moderate to
severe "erebral infar"tion. -he patients in"luded also suffered frommoderate to mild disturban"es of "ons"iousness, and all ere admittedithin ;< da#s of the i"tus. $atients ere allo"ated randoml# to treatmentith either 0D$4"holine (;,=== mg7da# i.v. on"e dail# for ;< da#s) or ithpla"ebo (ph#siologi"al saline). +ne hundred thirt#4three patients re"eived0D$4"holine treatment, and ;>? re"eived pla"ebo. -he group treated ith0D$4"holine shoed signifi"ant improvements in level of "ons"iousness"ompared ith the pla"ebo4treated group, and 0D$4"holine as anentirel# safe treatment. "Stroke ;?@@ ;?:2;;42;B)
+ral 0iti"oline in A"ute 's"hemi" troke
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+ral 0iti"oline in A"ute 's"hemi" trokeAn 'ndividual $atient Data $ooling
Anal#sis of 0lini"al -rials
Treatment with oral )iti)oline within the
&irst *+ hours a&ter onset in patients with
moderate to severe stroke in)reases theprobability o& )omplete re)overy at
months- (Stroke. 2==2>>:2@9=42@9C.)
0iti"oline $re"lini"al and
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0iti"oline $re"lini"al and0lini"al pdate 2==?62=;=
Abstract .Citi)oline is a neuroprote)tant
and neurorestorative drug that is used in the
treatment o& a)ute is)hemi) stroke in some
)ountries- The resear)h with this )ompound)ontinues- n this review, we &o)us on the
latest publi)ations or )ommuni)ations or
both and on the ma/or ongoing e#perimentaland )lini)al pro/e)ts involving )iti)oline in
stroke re)overy- (Stroke. 2=;;<2suppl;E:>B4>?.)
0iti"oline in the treatment of a"ute is"haemi"
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0iti"oline in the treatment of a"ute is"haemi"stroke:
an international, randomised, multi"entre,
pla"ebo4"ontrolled stud# ('0- trial)Results 22?@ patients ere enrolled into the stud# from &ov 2B,2==B, to +"t 2C, 2=;;. >C "entres in pain, ;; in $ortugal, and ;; in*erman# re"ruited patients. +f the 22?@ patients ho gave
informed "onsent and underent randomisation, ;;<@ ereassigned to "iti"oline and ;;9= to pla"ebo. -he trial as stoppedfor futilit# at the third interim anal#sis on the basis of "ompletedata from 2=C@ patients. -he fi nal randomised anal#sis as basedon data for 22?@ patients: ;;<@ in "iti"oline group and ;;9= in
pla"ebo group. *lobal re"over# as similar in both groups(odds ratio ;%=>, ?9G 0' =%@B6;%29 pH=%>B<). &osignifi"ant diff eren"es ere reported in the safet# variables nor in
the rate of adverse events.
-he Role of 0iti"oline in &europrote"tion
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-he Role of 0iti"oline in &europrote"tionand &eurorepair in
's"hemi" troke
Advan)es in a)ute stroke therapy resulting &rom thrombolyti) treatment,
endovas)ular pro)edures, and stroke units have improved signi&i)antly
stroke survival and prognosis0 however, &or the large ma/ority o&
patients la)king a))ess to advan)ed therapies stroke mortality andresidual morbidity remain high and many patients be)ome
in)apa)itated by motor and )ognitive de&i)its, with loss o&
independen)e in a)tivities o& daily living- Citi)oline has therapeuti)
e&&e)ts at several stages o& the is)hemi) )as)ade in a)ute is)hemi)
stroke and has demonstrated e&&i)ien)y in a multipli)ity o& animal
models o& a)ute stroke- 1ong2term treatment with )iti)oline is sa&e and
e&&e)tive, improving post2stroke )ognitive de)line and enhan)ing
patients3 &un)tional re)overy- $rolonged )iti)oline administration at
optimal doses has been demonstrated to be remarkably well tolerated
and to enhan)e endogenous me)hanisms o& neurogenesis and
neurorepair )ontributing to physi)al therapy and rehabilitation-
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