Diagnosa Banding Penurunan Kesadaran

7/21/2019 Diagnosa Banding Penurunan Kesadaran

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Jofizal Jannis

Neurologist

National Brain Centre

DIAGNOSA BANDINGPENURUNAN KESADARAN

MANAJEMEN



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



BJEKTIF

• Dokter mampu melakukan

stabilisasi, diagnosis, mengatasi

dan evaluasi pasien koma.

• Dokter dapat mengatur prioritas

pendekatan secara berurutan



bjektif

Primer• Airway

• Breathing

• Circulation• erapi progresif cepat !koma hipoglikemik"

• #valuasi $% atau lesi massa

• erapi $%, kemungkinan intervensi bedah



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



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



Supra orbital

Sternum

Metode menimul!anRes"ons "asien tida! sada

Kuku jari

Sendi

temporo mandibular



WHAT YOUR FIND



$%&'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



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



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



Koma Struktural

eninggal elamat

Komplikasi ati +tak

enolak

dibantu

-idakadar

adar

$emulihan

Disabilitas$/

0

Disabiltas erat

Disabilitasringan

Keluaran KomaKarena esi truktural





2as!ular

In7e! si

$rauma

Al!o0ol

Metaoli!

Neo"lasti!

Imunitas

PENYEB

AB

PENURU

NAN

KESADA

RAN



• 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



0ons"iousness



Kesadaran normal



1akefulness



Aareness



RA'& D%A-3



inimall# 0on"iousness



DIAGNOSIS DI%ERENSIA#

KOMA#OCK IN

S'NDROME

2EGE$A$I2ES$A$E PSIKIA$RI



Koma



/%*%-A-'/% -A-%



/egetative



• 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#



o"k4in #ndrome



o"ked4in



$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!)

•



$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



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



D'A*&+' $%&R&A&K%ADARA&

A&A&%'$%%R'KAA&

F''K$%%R'KAA&

&%R++*'

3istor#Ria#at

makanobat-rauma'nfeksi

-ekanandarahuhu$ernapasanklera

ateralisasi



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



BI#A MENGA#AMI

DE#IRIUMSEGERA

ASES

PEN'EBAB

N'ERI RE$ENSIO URINE

8IPOKSIA

8IPO$ENSI

DE8IDRASI



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&



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&



Pernafasan cheyne stok

Hiperventilasi neurogeniksentral

apnestik

Pernafasan cluster pernafasanata!ic

Apnoe

0 P il d



erua0an Pu"il "ada

si di ota! a!iat Koma

pektrum abnormalitas pupil dan



$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



WHAT TO DO



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

&



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



& 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



!n!jemen "!n##u!n Ke$!d!r!n

Ke$!d!r!n menurun



&europrotektan



Neur%&r%tek$i

u5uan untuk melindungi 5aringan otak

yang hampir rusak.

Beberapa obat yang pernah dipakai Citicholin 2iracetam 2iritinol



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



'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



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



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& %



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



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



-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



+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



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"



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



-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-





Documents

Diagnosa Banding Penurunan Kesadaran