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Emergency Stroke Management.pdf neurolog
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- 2. ● ● ● 2008 ProfesiNers,FIKUI 2022 M.Kep,FIKUI 2023Sp.Kep.MB ● ● ● ● 2010-2012 IGDRSCM –Sta 2012-2017 IGDRS PON-HeadNurse 2017-2020 IBS RS PON-HeadNurse 2020-recent RS PON-SeniorNurseSupe isor ● ● ● ● 2013 DPK RS PON–Ketua 2014 HIPGABIDKI-Diklat 2014 HIPENIPusat-Sekretaris Anggota 2019 HIPENIPusat-Sekretaris R.IsnawanRisqiR,Ners,M.Kep.,Sp.Kep.MB 081280304884 @risqirakhman risqi.rakhman@gmail.com
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- 11. risqi.rakhman@gmail.com Patophysiology:AcuteIschemicStroke • • • • Atherosclerosis Cardiacembolism Smalla e lipohyanolisis Cptogenicembolism A erialOcclusion O2danGlucosedelive toBraintissue • • • • • • • • LacticAcidproduction Bloodbrainbarrierbreakdown In ammation Na-Kpumpdysfunction Glutamaterelease IntracellularCa-in ux Freeradicalgeneration Membrane&nucleicacid breakdown CELLDEATH Greer,D.M.(Ed.).(2007).AcuteIschemicStrokeAnEvidence-BasedApproach.John Wiley&Sons,Incorporated.
- 12. risqi.rakhman@gmail.com Aktivasipathwayyangdistimulasioleh adanyaperdarahanintraparenkim Efekmasa perdarahan Initialdamagefromhemorrhage Ekspansi hematoma hidrosefalus Reaksi inamasi Iron&blood related toxicity Stress oksidatif Midline shift-herniasi PeningkatanTIK PERBURUKANNEUROLOGIS In amasiselependimaldi plexuschoroideus HipersekresiLCS 0-6hours >6hours Patophysiology:AcuteIschemicStroke Greenberg,S.M.,et.al(2022).2022GuidelinefortheManagementof PatientsWithSpontaneousIntracerebralHemorrhage:AGuideline FromtheAmericanHea Association/AmericanStrokeAssociation. InStroke(Vol.53,Issue7).https:
- 13. RUPTUREDANEURYSM TIK↑ CBF↓ CPP↓ Responhemostatik Responsitotoksik In amasi Edemaotak Darahdi Subarachnoidspace (SAS) GangguanCSF EarlyBrainInju Hipope usi Hydrocephalus DelayedCerebralIschemia(DCI) Vasospasm Rebleeding Seizure Patophysiology:SubarachnoidHemorrhage(SAH) vanLieshout, J. H., Dibué-Adjei, M., Cornelius, J. F., Slotty, P. J., Schneider, T., Restin, T., Boogaa s, H. D., Steiger, H. J., Petridis, A. K., &Kamp, M. A. (2018). Anintroductionto thepathophysiologyofaneu smal subarachnoid hemorrhage. NeurosurgicalReview, 41(4), 917–930. https:
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- 16. DETECTION DISPATCH DELIVERY DOOR DISPOSITIONDRUG DECISION DATA DETEKSITANDAGEJALASTROKE!
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- 23. DETECTION DELIVERY DISPATCH DOOR DISPOSITION DRUG DECISIONDATA StrokeUnit StrokeWard Stroke corner
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- 25. risqi.rakhman@gmail.com STRATIFIKASIKEMAMPUANLAYANAN MADYA UTAMA PARIPURNA Trombolisis InteensiVaskulerNonBedah Inte ensiVaskulerBedah PenangananKomprehensif
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- 28. risqi.rakhman@gmail.com HYPERACUTE -ACUTE POSTACUTE TRANSITIONTOHOME-COMMUNITY • • • Rekognisi Initial Assessment AcuteCare • • • Establish therapeutic parameters Preventionand Complication Management Transitiontohome readiness • • • Rehabilitation Longterm-preventionstrategy Familyandcommunitiesreadiness Duncan,P.W.,Bushnell,C.,Sissine,M.,Coleman,S.,Lutz,B.J.,Johnson,A.M.,Radman,M.,PvruBettger,J.,Zorowitz,R.D.,&Stein,J. (2021).ComprehensiveStroke Care and Outcomes: Time fora ParadigmShift.Stroke,52(1),385–393.https: //doi.org/10.1161/STROKEAHA.120.029678
- 29. risqi.rakhman@gmail.com GENERALNURSINGCARE Camicia,M.,Lutz,B.,Summers,D.,Klassman,L.,&Vaughn,S.(2021).Nursing’srole insuccessfulstroke caretransitionsacrossthe continuum: Fromacute care intothe community.Stroke,52(12),E794–E805.https://doi.org/10.1161/STROKEAHA.121.033938 VITALSIGNS NEUROLOGICAL OBSERVATIONS BLOODSUGAR LEVEL FLUID MANAGEMENT DVT PROPHYLAXIS SWALLOWING FEVER CONTINENCE CARE PREVENTION AND MANAGEMENT OF COMPLICATION
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- 32. 1981:EarlyStudyAboutCBFrelatedstroke Jones,T.H.,Morawetz,R.B.,Crowell,R.M.,Marcoux,F.W.,FitzGibbon,S.J., DeGirolami,U.,Ojemann,R.G.(1981). resholdsoffocalcerebral ischemiainawakemonkeys.JournalofNeurosurge ,54(6),773–782. …clinicaldogma:strokedamage nalizedwithinminutesofsymptomonset—strokeconveyedahopeless prognosis,immediately(Leyden,2019). resholdfor function r e s h o l d f o r i n f a r c t i o n involved2di erentparameters: blood owandtime TIMEISBRAIN!! penumbra
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- 34. risqi.rakhman@gmail.com EARLYAISCAREMANAGEMENTFLOWCHART PRA-RS IGDRS REKOGNISI REKOGNISI Kajitanda gejala(FAST) Kajitanda gejala(FAST) KontakRS KontakRS positi f positi f NIHSS NIHSS Diagnosis Segera Diagnosis Segera KandidatIV alteplase? KandidatIV alteplase? simultan simultan Kandidat Mechanical rombectomy? Kandidat Mechanical rombectomy? ya yaIValteplase IValteplase Mechanical rombectomy Mechanical rombectomy ya ya 24 jam 24 jam
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- 39. Neurologist Radiologist Attending Physician TrainedNurses Patient Lab FarmasiRadiograf er admin sekuriti
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- 43. risqi.rakhman@gmail.com FactorIn uencingDelayedinDoortoNeedle Time HOSPITALFACTORS • • • Delaydiagnosis In-hospitaldelay Equipment-relateddelay PATIENTFACTORS • • • • • Hype ension Hyperglycemia Seizure Emergencystabilization Eligibility:Informedconsentrefusal Kamal,N.,Sheng,S.,Xian,Y.,Matsouaka,R.,Hill,M.D.,Bhatt,D.L.,Saver,J.L.,Reeves,M.J.,Fonarow,G.C.,Schwamm,L.H.,Smith,E.E. (2017).DelaysinDoor-to-NeedleTimesand eirImpactonTreatmentTime and OutcomesinGetWith e Guidelines-Stroke.Stroke,48(4), 946–954.https://doi.org/10.1161/STROKEAHA.116.015712 ebene tofIVAlteplaseis TIMEDEPENDENT QUALITYIMPROVEMENT!!
- 44. risqi.rakhman@gmail.com KriteriaInklusiALTEPLASEIV a. b. c. d. e. f. g. h. usia≥18tahun Diagnosisklinisstrokedengande sitneurologisyangjelas. Onset≤4,5jamatau≤6jam TidakadagambaranperdarahanintracranialpadaCTscan Pasienataukeluargamenge idanmenerimakeuntungandanrisikoyangmungkintimbul. Harusadapersetujuanteulisdaripasienataukeluargauntukdilakukanterapi PA (Alteplase) Bolehdiberikanpadapasienyangmengonsumsiaspirinataukombinasiaspirindan klopidogrelsebelumnya. BolehdiberikanpadapasiengagalginjalkronikdenganaPTTnormal(risikoperdarahan meningkatpadapasiendenganpeningkatanaPTT). Bolehdiberikanpadapasiendengansicklecelldisease. PNPKSTROKE,2019
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- 55. risqi.rakhman@gmail.com DosisTotal: BBPasienx0,9=….mg Dosisbolus=10%daritotaldosis= mgselama1menit Dosisinfuskontinyu=90%daritotaldosis= mg selama60menit HIPERAKUT: PemberianObat 50kg 45cc 0,9mg 4,5cc 40,5cc
- 56. risqi.rakhman@gmail.com 1. 2. 3. Hentikantrombolisissegera,jika adanyerikepalahebat, penurunankesadaran, perdarahan,kesulitanbernafas hubungineurologist CTScan kepalacito NilaiskorNIHSSsetelah trombolisisselesai Rawatdiruangstrokehiperakut, minimal1x24jam monitoring paskatrombolisis @15’pada2jampe ama @30’ pada6jamberikutnya @60’ s.d24jamsetelah trombolisisdiberikan HIPERAKUT: NurseMonitoring
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- 60. Monitoringpaskatrombolisis(24jam) Tirah baring O2nasalkanul2-4lpm, agarSpO2≥95% Hindaripungsivena sebisa mungkin. Apabila terpaksa dipasang vena sentral(a erifemoral brachial) Hindaripemasangan kateter atau NGT(bila memungkinkan) Tunda antiplatelet, heparin iv dalam24jam pe ama Obse asiangioedema (wajah,lidah,faringeal) 30menit,45menit, 60menit,75menit,24 jam Terapisimptomatik paracetamol, metoclopramide Nilaiskor NIHSS24jam paska pa CTScan Kepala kontrol 24jampaska pa
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- 62. risqi.rakhman@gmail.com SymtomaticICH(sICH) • • • • • • • • IndependentRiskFactorofsICHinNINDSTrialII: rTPAtreatment Severityof eNeurologicalDe sit Evidenceofbrainedemaormasseectonpre-treatmentCT ECASS-IandECASS-III HaemorrhagicInfarction: smallpetechiaewithoutmasse ect Parenchymalhematoma: bloodclot(sometimesaccompaniedbymasse ect) RatesofsICHinthe7majorpublishedrandomizedtrialsofpatientswithacutemyo- cardialinfarctiontreatedwithalteplaseandlow-doseheparinrangedfrom0.64%to 0.94%
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