Materi emergency neurology

1. KEDARURATAN
NEUROLOGI
dr. I Nym. Bgs. Surya Antara, M.Biomed,
Sp.N

2. Neurologic Emergency Outline
• Change in Mental Status / Coma
• Stroke/TIA Syndromes
• Seizure & Status Epilepticus
• Infectious

3. PENURUNAN KESADARAN

4. Etiologi
Non traumatic
(hypoxic-ischemic
neural injury)
Traumatic brain
injury
Stroke
Cardiopulmonary arrest
Meningoencephalitis
Final stage of certain
neurodegenerative disease
(Parkinson, Alzheimer)
VS

5. Etiologi
Structural
Metabolic
Supratentorial mass lesions
Infratentorial mass/destructive
lesions
VS
Hiperglikemia, hipoglikemia, uremia, ensefalopati anoksik, gangguan
elektrolit, ensefalopati Wernicke, intoksikasi

6. Penegakkan Diagnosis
History
Taking
Physical
Examinatio
n
+
General
Neurologic
+ Diagnostic
Aids

7. Change in Mental Status / COMA
• Potential Causes – “AEIOU TIPS”
• A = Alcohol ( Drugs & Toxins)
• E = Endocrine, Exocrine, Electrolyte
• I = Insulin
• O = Opiates, OD
• U = Uremia
• T = Trauma, Temperature
• I = Infection
• P = Psychiatric disorder
• S = Seizure , Stroke, Shock, Space occupying lesion

8. Penegakkan Diagnosis
Neurologic
Examination
Level of
consciousness
Pattern of breathing
Pupillary responses
Oculomotor
responses
Motor responses

9. Yang Dinilai pada GCS Nilai
MEMBUKA MATA / EYE (E)
Spontan
1. Atas Perintah
2. Dirangsang Nyeri
3. Tidak Ada Respon
4
3
2
1
VERBAL (V)
1. Orientasi Baik (Waktu, Tempat, Orang)
2. Berbicara Namun Disorientasi
3. Kata-kata Yang Tidak Tepat
4. Suara Yang Tidak Berarti
5. Tidak Ada Respon
5
4
3
2
1

10. MOTORIK (M)
1. Gerakan Mengikuti Perintah
2. Melokalisir Nyeri
3. Menarik Lengan atau Tungkai
4. Fleksi Abnormal (Dekortikasi)
5. Ekstensi Abnormal (Deserebrasi)
6. Tidak Ada Respon)
6
5
4
3
2
1

11. REFLEK PUPIL

12. Cheyne-Stokes
Central Neurologic
Hyperventilation
Apneusis
Cluster & Ataxic
Apnea

13. GERAK DAN KEDUDUKAN BOLA MATA
Modul Penurunan Kesadaran, 2008
Deviasi Konjugat
1. Kedua bola mata melirik ke
samping
2. Ke arah hemisfer yang terganggu
3. Ukuran dan bentuk pupil normal
4. Refleks cahaya positif
5. Deviasi terjadi pada area 8 lobus
frontalis
Proses di Talamus
1. Kedua bola mata melirik ke hidung
2. Bola mata tidak dapat digerakkan
ke atas
3. Pupil kecil dan refleks cahaya (-)
Proses di Pons
1. Kedua bola mata berada di tengah
2. Doll’s eye (-)
3. Pupil sangat kecil, reaksi cahaya
(+)
4. Kadang tampak ocular bobbing
Proses di
Serebelum
1. Pasien tidak dapat melihat
kesamping
2. Bentuk pupil normal (bentuk dan
reaksi terhadap cahaya)
3. Refleks cahaya (+)

14. ALGORITMA PASIEN KOMA
Modul Penurunan Kesadaran, 2008
Pasien penurunan kesadaran
Pemeriksaan Neurologi Lengkap
Pemeriksaan Penunjang
Assesment Etiologi
Toksik Metabolik (Diffuse Brain Disease)
Pupil reaktif, neurologik fokal (-),
peningkatan TIK (-)
Lesi Struktural (Dekstruktif Intrakranial)
Terdapat defisit neurologi fokal, dilatasi
unreaktif pupil, TIK meningkat
Supratentorial Infratentorial Eksogen Endogen
Trauma, Perdarahan intrakranial, Stroke
Iskemik, Abnormalitas mikrovaskuler
difus, Tumor intrakranial, dll
Intoksikasi obat,
Napza,
insektisida, dll
Gangguan
endokrin,
Gangguan
metabolik,
Psikogenik, dll

15. PENANGANAN AWAL

16. STROKE

17. Terminologi Stroke
“Suatu sindroma klinis yang ditandai oleh
gangguan fungsi otak fokal maupun global
mendadak berlangsung lebih dari 24 jam,
mempunyai kecenderungan perburukan
bahkan kematian yang diakibatkan oleh satu-
satunya gangguan vaskuler”
Terminologi Baru memasukkan juga stroke
spinal
17
17

18. Jenis Stroke
18
18
Albers GW et al. Chest. 1998;114:683S-698S.
Rosamond WD et al. Stroke. 1999;30:736-743.
Stroke Iskemik
Stroke Hemoragik
Atherothrombotic
disease (20%)
Embolism (20%)
Lacunar small vessel
disease (25%)
Cryptogenic (30%)
Intracerebral
hemorrhage (59%)
SAH (41%)

19. Deteksi dini Stroke:
Cincinnati Prehospital Stroke Scale (CPSS).
1. Facial droop. Suruh pasien tersenyum
atau memperlihatkan gigi.
2. Arm drift. Suruh pasien mengangkat
tangan 90º dari tubuh dan tahan 10 detik.
3. Slurred speech. Suruh pasien mengulang
kalimat sederhana.
4. Time. Segera mencari RS terdekat.
FAST
19
19

20. Skor Stroke Siriraj
• (2.5 x S) + (2 x M) + (2 x N) + (0.1 D) – (3 x A) – 12
− S : kesadaran (0 = CM, 1 = somnolen, 2 = sopor/koma)
− M : muntah (0 = tidak ada, 1 = ada)
− N : nyeri kepala (0 = tidak ada, 1 = ada)
− D : tekanan darah diastolik
− A : ateroma (0 = tidak ada, 1 = salah satu/lebih : DM,
angina, penyakit pembuluh darah)
• Penilaian
− SSS > 1 = perdarahan supratentorial,
− SSS < -1 = infark serebri,
− SSS -1 s/d 1 = meragukan
20

21. Treatment of Stroke
• AS ALWAYS – ABC’s FIRST
• What’s the Serum Glucose??
– Consider Thiamine 100mg IV, D 50 bolus if hypoglycemic.
– Treat Hyperglycemia if Serum Glucose > 300mg/dl
• Protect the “Penumbra”
– Keep SBP >90mm Hg
– Goal keep CPP > 60mm Hg (CPP=MAP-ICP)
– Treat Fever ( Mild Hypothermia beneficial)
• Acetaminophen 650mg po or pr, cooling blanket
– Oxygenate (Keep Sao2 >95%)
– Elevate head of bed 30 deg. (Clear c-spine)
• Frequent repeat Neuro checks!! Reassess GCS!

22. Treatment of Stroke
• What type of stroke is Present??
– Hemorrhagic vs Ischemic
• Any signs of shift herniation?
• Neurosurgery evaluation or transfer necessary?
• Other management adjuncts:
• Ischemic strokes
– ASA 81-325mg
– Patients with Systolic BP >220 , Diastolic>120 need BP control with
Nitroprusside or Labetolol.
– DO NOT OVERTREAT BP or risk extending the infarct.
– Heparin not shown to be of benefit in recent studies, however, still
frequently used.
• Consult Neurologist before use
• If used, No bolus, just infusion.
• Risk of hemorrhagic transformation.

23. Treatment of Strokes
• Strokes with Edema, Mass Effect or Shift
– Load with Phosphenytoin 1000mg for seizure prophylaxis
– Acute seizure prophylaxis still of benefit.
– Mannitol, Decadron??
• Recently shown to be of NO benefit, some Neurosurgeons still advocate,
so consult first.
– Hyperventilation??
• NOT beneficial and perhaps harmful, don’t do it!
• Thrombolytics???
– Ischemic strokes ONLY with large deficit NOT improving.
– Time from symptom onset <3 hours
– No ABSOLUTE Contraindications!!
– Inclusion and Exclusion Criteria
– Benefit Questionable

24. Stroke Hemoragik
dibuktikan dengan
CT Scan kepala non kontras
Non Operatif
•Selain kondisi yang
menjadi
indikasi operatif.
•GCS ≤ 4
Operatif:
•Perdarahan lobar ≥ 50 CC.
•Perdarahan serebelar >3 cm.
•Hidrosefalus akut
•Lesi struktural vaskuler tertentu
•IVH masif dengan ancaman
hidrosefalus
•Syarat : GCS > 4.
Kriteria Operatif pada Stroke
Hemoragik
24

25. Emergency Treatment of
Aneurysmal SAH
• Notify neurosurgery and neurointerventional team
immediately
• Prevent rebleeding
− Risk = 5-15% in 1st 24h; mortality 70-80%
− Treat hypertension: Keep SBP 110-150 mmHg
• IV Antihypertensives
– Prns: labetalol, hydralazine
– Nicradipine gtt
• Judicious analgesia
– Tylenol  Ultram  very low-dose IV fentanyl or
hydromorphone
− Antifibrinolytics (tranexamic acid) if securing is expected
to be delayed > 6h after arrival

26. Emergency Treatment of
Aneurysmal SAH
• Secure aneurysm
− Goal: ASAP; within 18h of presentation
− Conventional angiogram from ED
• Operative planning
• Endovascular coils if possible
− Otherwise, surgical clipping

27. STATUS EPILEPTIKUS
• Status epilepticus
− Any single seizure lasting > 5min
− ≥ 2 seizures without clearing of mental status between
them

28. Bahaya Status Konvulsif
Kejang lama akan menyebabkan
kerusakan otak permanen
Cedera
Otak

29. Emergency Treatment of
Generalized Convulsive Status
Epilepticus
• Abort the seizure
− Lorazepam 4-6mg IV push
− diazepam 0,2 mg/kg (10-20 mg iv)
− Repeat 5 min later if seizure continues or
returns
• Prevent future seizures
− Phenytoin load: 20mg/kg IV infusion
− DO NOT just give 1g  only enough for a
small, 50kg person
− Alternatives:
• IV valproic acid 20-30mg/kg
• IV levetiracetam 25-30mg/kg

30. Algoritma
Resusitasi Kardiopulmoner
Monitoring
IV line
Ambil sampel darah
Periksa glukosa
Urea & elektrolit
DPL
CK
Glukosa
LFT
Ca2+, PO4-, Mg2+
Toksikologi
AGD
Diazepam
0,2 mg/kg dg kec < 2mg/min
Bangkitan dan
faktor penyebab
dikoreksi?
Ya
Tidak

31. Fenitoin
20 mg/kg dg kec <50 mg/kg
ATAU
Fosfenitoin
Equivalen fenitoin20 mg/kg dg kec <150 mg/kg
Tidak
Pertahankan keadaan
Penyembuhan tsb sambil
Pemulihan kesadaran
Ya
Bangkitan berhenti?
Fenitoin
Dosis tambahan 5-10mg/kg sampai total 30mg/kg
ATAU
Fosfenitoin
Equivalen fenitoin 5-10mg/kg sampai total 30mg/kg
Bangkitan berhenti?
Tidak
Ya
Tidak

32. ICU atau adakah
gangguan
sistemik mayor?
Anestesia umum
Propofol ATAU Thiopental
Tidak
Ya
Bangkitan berhenti?
60 menit
Tidak

34. Infectious Neurologic
Emergencies
• Meningitis: inflammation of the meninges
• History:
– Acute Bacterial Meningitis:
• Rapid onset of symptoms <24 hours
– Fever, Headache, Photophobia
– Stiff neck, Confusion
• Etiology By Age:
– 0-4 weeks: E. Coli, Group B Strep, Listeria
– 4-12 weeks: neotatal pathogens, S. pneumo, N.
meningitides, H. flu
– 3mos – 18 years: S.pneumo, N. menin.,H. flu
– >50/ alcholics: S. pneumo, Listeria, N. menin., Gram(-) bacilli

35. Meningitis
• Lymphocytic Meningitis (Aseptic/Viral)
– Gradual onset of symptoms as previously listed
over 1-7 days.
– Etiology:
• Viral
• Atypical Meningitis
– History (medical/social/environmental) crucial
– Insidious onset of symptoms over 1-2 weeks
– Etiology:
• TB(#1)
• Coccidiomycosis, crytococcus

36. Meningitis
• Physical Exam Pearls
– Infants and the elderly lack the usual signs and
symptoms, only clue may be AMS.
– Look for papilledema, focal neurologic signs,
ophthalmoplegia and rashes
– As always full exam
• Checking for above
• Brudzinski’s sign
• Kernigs sign
– KEY POINT: If you suspect meningococcemia do
NOT delay antibiotic therapy, MUST start within 20
minutes of arrival!!!!!

37. Meningitis
• Emergent CT Prior to LP
– Those with profoundly depressed MS
– Seizure
– Head Injury
– Focal Neurologic signs
– Immunocompromised with CD4 count <500
• DO NOT DELAY ANTIBIOTIC THERAPY!!

38. Meningitis
• Lumbar Puncture Results
TEST NORMAL BACTERIAL VIRAL
Pressure <170 >300 200
Protein <50 >200 <200
Glucose >40 <40 >40
WBC’s <5 >1000 <1000
Cell type Monos >50% PMN’s Monos
Gram Stain Neg Pos Neg

39. Meningitis Management
• Antibiotics By Age Group
– Neonates(<1month) = Ampicillin + Gent. or
Cefotaxime + Gent
- Infants (1-3mos) = Cefotaxime or Ceftriaxone
+ Ampicillin
- Children (3mos-18yrs) = Ceftriaxone
- Adults (18yr-up) = Ceftriaxone + Vancomycin
- Elderly/Immunocomp = Ceftriaxone +Ampicillin +
Vancomycin

40. Meningitis Management
• Steroids
– In children, dexamethasone has been shown to be
of benefit in reducing sensiorneural hearing loss,
when given before the first dose of antibiotic.
– Indications:
• Children> 6 weeks with meningitis due to H. flu or S.
pneumo.
• Adults with positive CSF gram stain
– Dose: 0.15mg/kg IV

41. Encephalitis
• Always think of in the young/elderly or
immunocompromised with FEVER + AMS
• Common Etiologies:
• Viral
– West Nile
– Herpes Simplex Virus (HSV)
– Varicella Zoster Virus (VZV)
– Arboviruses
• Eastern Equine viruses
• St. Louis Encephalitis

43. Encephalitis
• Always think of in the young/elderly or
immunocompromised with FEVER + AMS
• Common Etiologies:
• Viral
– West Nile
– Herpes Simplex Virus (HSV)
– Varicella Zoster Virus (VZV)
– Arboviruses
• Eastern Equine viruses
• St. Louis Encephalitis

44. Encephalitis
• Defined as: inflammation of the brain itself
• Most cases are self limited, and unless virulent
strain, or immunocompromised, will resolve.
• The ONLY treatable forms of encephalitis are:
– HSV
– Zoster

45. Encephalitis
• Management:
– Emergent CT : As indicated for meningitis
– ABC’s with supportive care.
– Lumbar puncture:
• Send for ELISA and PCR
– Acyclovir 10 mg/kg Q 8 hours IV for HSV and
Zoster
– Steroids not shown to be of benefit.