mekanisme-gangguan-kesadaran

7/22/2019 mekanisme-gangguan-kesadaran

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Tanda Klinik Fase Diensefalik.


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Tanda Klinik Fase Diensefalik.


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Tanda Klinik Fase Midbrain Pons Atas.


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Tanda Klinik Herniasi Unkus Fase Dini N. III


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Tanda Klinik Herniasi Unkus Fase Lanjut N.III


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Tanda Klinik Fase Midbrain Pons Bawah


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Cardiac death:

Heartbeat and breathing stop

Brain death:

Irreversible cessation of all functions of the entirebrain, including the brain stem


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First introduced in a 1968 report authored by a specialcommittee of the Harvard Medical School

Adopted in 1980, with modifications, by the President'sCommission for the Study of Ethical Problems in

Medicine and Biomedical Research, as arecommendation for state legislatures and courts

The "brain death" standard was also employed in themodel legislation known as the Uniform Determination

of Death Act, which has been enacted by a largenumber of jurisdictions and the standard has beenendorsed by the influential American Bar Association.


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1. Clinical or radiographic evidence of an acutecatastrophic cerebral event consistent w/ dx ofbrain death

2. Exclusion of conditions that confound clinicalevidence (i.e.-metabolic)

3. Confirmation of absence of drug intoxication orpoisoning

Also barbiturates, NMBs

4. Core body temp >32oC (we use 34oC)


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Cerebral motor response to pain

Supra-orbital ridge, the nail beds, trapezius

Motor responses may occur spontaneously during

apnea testing (spinal reflexes) Spinal reflex responses occur more often in young

If pt had NMB, then test w/ train-of-four

Spinal arcs are intact!


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Round, oval, or irregularly shaped Midsize (4-6 mm), but may be totally dilated

Absent pupillary light reflex Although drugs can influence pupillary size, the light

reflex remains intact only in the absence of brain death IV atropine does not markedly affect response

Paralytics do not affect pupillary size

Topical administration of drugs and eye trauma may

influence pupillary size and reactivity Pre-existing ocular anatomic abnormalities may also

confound pupillary assessment in brain death


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Oculocephalic reflex = dolls eyes

Vestibulo-ocular = cold caloric test


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Oculocephalic reflex

Rapidly turn the head 90 on both sides

Normal response = deviation of the eyes to the

opposite side of head turning Brain death = oculocephalic reflexes are absent (no

Dolls eyes) = no eye movement in response to headmovement

Not Barbie, but old fashioned type dolls Painted vs. wooden eyes in porcelain heads


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http://images.google.com/imgres?imgurl=http://telemedicine.orbis.org/data/1/rec_imgs/57_9.jpg&imgrefurl=http://telemedicine.orbis.org/bins/volume_page.asp?cid=1-3-4-14&h=115&w=181&sz=8&tbnid=MQ3goRdz9I4J:&tbnh=60&tbnw=94&start=4&prev=/images?q=%22oculocephalic%22&hl=en&lr=&sa=G


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Elevate the HOB 30

Irrigate both tympanic membranes with icedwater

Observe pt for 1 minute after each ear irrigation,with a 5 minute wait between testing of each ear

Facial trauma involving the auditory canal andpetrous bone can also inhibit these reflexes


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Nystagmus both eyes slow toward cold, fast tomidline Not comatose

Both eyes tonically deviate toward cold water Coma with intact brainstem

Movement only of eye on side of stimulus Internuclear ophthalmoplegia

Suggests brainstem structural lesion No eye movement

Brainstem injury / death
http://www.fpnotebook.com/NEU90.htmhttp://www.fpnotebook.com/NEU160.htmhttp://www.fpnotebook.com/NEU160.htmhttp://www.fpnotebook.com/NEU90.htm


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Corneal reflexes are absent in brain death

Corneal reflexes - tested by using a cotton-tippedswab

Grimacing in response to pain can be tested byapplying deep pressure to the nail beds, supra-orbital ridge, TMJ, or swab in nose

Severe facial trauma can inhibit interpretation offacial brain stem reflexes


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Both gag and cough reflexes are absent inpatients with brain death

Gag reflex can be evaluated by stimulating theposterior pharynx with a tongue blade, but theresults can be difficult to evaluate in orally intubatedpatients

Cough reflex can be tested by using ETT suctioning,past end of ETT


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PaCO2 levels greater than 60 mmHg, 20mmHg over baseline

Technique: Pre-oxygenate with 100% oxygen several min

Allow baseline PaCO2 to be ~40 mmHg

Place pt on CPAP or bag-ETT

Observe for respiratory effort for ~6 minutes

Get ABG to determine PaCO

2 Apneic oxygenation


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EEG

30 minutes

4 vessel angiography

Cerebral blood flow = perfusion scan


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http://images.google.com/imgres?imgurl=http://pedsccm.wustl.edu/All-Net/media/gif/neurogif/trauma/cpscanbd.jpg&imgrefurl=http://pedsccm.wustl.edu/All-Net/english/neurpage/trauma/head-5.htm&h=249&w=538&sz=16&tbnid=oBGKQkhMfkYJ:&tbnh=60&tbnw=129&start=3&prev=/images?q=%22cerebral+perfusion+scan%22&hl=en&lr=&sa=N


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Necessary to repeat the clinical examination after anappropriate observation period has passed

Confirmatory EEG unless it is determined that there isno blood flow to the brain

Age 7 days to 2 monthsTwo examinations 48 hours apart and one EEG

Age 2 months-1 yearTwo examinations 24 hours apart and one EEG orperfusion scan

Repeat examination and EEG are not necessary if it isdetermined that there is no cerebral blood flow


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1. Clinical or radiographic evidence of an acutecatastrophic cerebral event consistent w/ dx ofbrain death

2. Exclusion of conditions that confound clinicalevidence (i.e.-metabolic)

3. Confirmation of absence of drug intoxicationor poisoning Also barbiturates, NMBs

4. Core body temp >32oC (we use 34oC)


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Cerebral motor response to pain

Supra-orbital ridge, the nail beds, trapezius

Motor responses may occur spontaneously duringapnea testing (spinal reflexes)

Spinal reflex responses occur more often in young

If pt had NMB, then test w/ train-of-four

Spinal arcs are intact!


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Round, oval, or irregularly shaped Midsize (4-6 mm), but may be totally dilated

Absent pupillary light reflex Although drugs can influence pupillary size, the light

reflex remains intact only in the absence of brain death IV atropine does not markedly affect response

Paralytics do not affect pupillary size

Topical administration of drugs and eye trauma may

influence pupillary size and reactivity Pre-existing ocular anatomic abnormalities may also

confound pupillary assessment in brain death


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Oculocephalic reflex = dolls eyes

Vestibulo-ocular = cold caloric test


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Oculocephalic reflex

Rapidly turn the head 90 on both sides

Normal response = deviation of the eyes to theopposite side of head turning

Brain death = oculocephalic reflexes are absent (noDolls eyes) = no eye movement in response to headmovement

Not Barbie, but old fashioned type dolls Painted vs. wooden eyes in porcelain heads


61/103
http://images.google.com/imgres?imgurl=http://telemedicine.orbis.org/data/1/rec_imgs/57_9.jpg&imgrefurl=http://telemedicine.orbis.org/bins/volume_page.asp?cid=1-3-4-14&h=115&w=181&sz=8&tbnid=MQ3goRdz9I4J:&tbnh=60&tbnw=94&start=4&prev=/images?q=%22oculocephalic%22&hl=en&lr=&sa=G


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Elevate the HOB 30

Irrigate both tympanic membranes with icedwater

Observe pt for 1 minute after each ear irrigation,with a 5 minute wait between testing of each ear

Facial trauma involving the auditory canal andpetrous bone can also inhibit these reflexes


63/103

Nystagmus both eyes slow toward cold, fast tomidline Not comatose

Both eyes tonically deviate toward cold water Coma with intact brainstem

Movement only of eye on side of stimulus Internuclear ophthalmoplegia

Suggests brainstem structural lesion No eye movement

Brainstem injury / death
http://www.fpnotebook.com/NEU90.htmhttp://www.fpnotebook.com/NEU160.htmhttp://www.fpnotebook.com/NEU160.htmhttp://www.fpnotebook.com/NEU90.htm


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Corneal reflexes are absent in brain death Corneal reflexes - tested by using a cotton-tipped

swab

Grimacing in response to pain can be tested byapplying deep pressure to the nail beds, supra-orbital ridge, TMJ, or swab in nose

Severe facial trauma can inhibit interpretation offacial brain stem reflexes


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Both gag and cough reflexes are absent inpatients with brain death

Gag reflex can be evaluated by stimulating theposterior pharynx with a tongue blade, but theresults can be difficult to evaluate in orally intubatedpatients

Cough reflex can be tested by using ETT suctioning,past end of ETT


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PaCO2 levels greater than 60 mmHg, 20mmHg over baseline

Technique: Pre-oxygenate with 100% oxygen several min

Allow baseline PaCO2 to be ~40 mmHg

Place pt on CPAP or bag-ETT

Observe for respiratory effort for ~6 minutes

Get ABG to determine PaCO2 Apneic oxygenation


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EEG 30 minutes

4 vessel angiography

Cerebral blood flow = perfusion scan


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Absent Cerebral Function

Absent Brainstem Function

Apnea


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Cerebral Cortex

Brain Stem

Reticular

Activating

System


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Cognition

Voluntary

Movement Sensation


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Midbrain

Cranial Nerve III

pupillary function

eye movement


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Pons

Cranial Nerves IV, V, VI

conjugate eye movement

corneal reflex


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Medulla

Cranial Nerves IX, X

Pharyngeal (Gag) Reflex

Tracheal (Cough) Reflex

Respiration


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Receives multiplesensory inputs

Mediates

wakefulness


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NormalCerebral Anoxia


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Normal Cerebral Hemorrhage


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Normal

Subarachnoid Hemorrhage


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Normal Trauma


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Normal Meningitis


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Neuronal Injury

Decreased Intracranial

Blood Flow

Neuronal Swelling

Increased Intracranial

Pressure

ICP>MAP is

incompatible

with life


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Persistent Vegetative State

Locked-in Syndrome

Minimally Responsive State


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Normal Sleep-Wake Cycles

No Response to Environmental Stimuli

Diffuse Brain Injury with Preservation of

Brain Stem Function


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Ventral Pontine Infarct

Complete Paralysis

Preserved Consciousness

Preserved Eye Movement


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Diffuse or Multi-Focal Brain Injury

Preserved Brain Stem Function

Variable Interaction with Environmental

Stimuli

Static Encephalopathy


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Clinical Prerequisites:

Known Irreversible Cause

Exclusion of Potentially Reversible Conditions Drug Intoxication or Poisoning

Electrolyte or Acid-Base Imbalance

Endocrine Disturbances

Core Body temperature > 32 C


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Coma

Absent Brain Stem Reflexes

Apnea


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No Response to Noxious Stimuli

Nail Bed Pressure

Sternal Rub

Supra-Orbital Ridge Pressure


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Pupillary Reflex

Eye Movements

Facial Sensation and Motor Response

Pharyngeal (Gag) Reflex

Tracheal (Cough) Reflex


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Pupils dilated with no constriction to bright light


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Occulo-Cephalic Response

Dolls Eyes Maneuver


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Oculo-Vestibular Response

Cold Caloric Testing


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Corneal Reflex

Jaw Reflex

Grimace to Supraorbital or

Temporo-Mandibular Pressure


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Prerequisites

Core Body Temperature > 32 C

Systolic Blood Pressure 90 mm Hg

Normal Electrolytes

Normal PCO2


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1. Pre-Oxygenation 100% Oxygen via Tracheal Cannula

PO2 = 200 mm Hg

2. Monitor PCO2 and PO2 with pulse oximetry

3. Disconnect Ventilator

4. Observe for Respiratory Movement until PCO2 =60 mm Hg

5. Discontinue Testing if BP < 90, PO2 saturationdecreases, or cardiac dysrhythmia observed


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Facial Trauma

Pupillary Abnormalities

CNS Sedatives or Neuromuscular Blockers

Hepatic Failure

Pulmonary Disease


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EE

G

Normal Electrocerebral Silence


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CerebralAngiography

Normal No Intracranial Flow


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Technetium-99 Isotope Brain Scan


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MR- Angiography


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Transcranial

Ultrasonography


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Somatosensory Evoked Potentials

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