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KEDARURATAN NEUROLOGI DR SURYA.pptx
- 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
- 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
- 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.