Penurunan Kesadaran

KEDARURATAN
NEUROLOGI
(Level Of Conciousness)
Anwar Wardy W
Juni 2015
Dept.Neurosains FK.UMJ.2015
NEURAL BASIS OF
CONSCIOUSNESS
Consciousness
cannot be readily
defined in terms of anything else
A state
of awareness of self and

surrounding
Anwar Wardy W. FK.UMJ
Mental
Status =
Arousal + Content
ANATOMY OF MENTAL STATUS

Ascending
Activating
reticular activating system (ARAS)
systems of upper brainstem, hypothalamus,
thalamus
Determines
the level of arousal
Cerebral
hemispheres and interaction

between functional areas in cerebral
hemispheres
Determines
the intellectual and emotional functioning
Interaction
between cerebral hemispheres and

activating systems
THE CONTENT OF CONSCIOUSNESS

Sum
of patients intellectual (cognitive)

functions and emotions (affect)
Sensations, emotions, memories, images,

ideas (SEMII)
Depends upon the activities of the cerebral
cortex, the thalamus & their interrelationship
Lesions of these structures will diminish the
content of consciousness (without changing the
state of consciousness)
THE STATE OF CONSCIOUSNESS (AROUSAL)

The
ascending RAS, from the lower border

of the pons to the ventromedial thalamus
The cells of origin of this system occupy a
paramedian area in the brainstem
LESION OBJECTIVES
Describe
the common causes of a deteriorating

conscious level.
Describe how to assess a patient with a altered
conscious level using the Glasgow coma scale.
Describe the emergency management of a
patient with a decreasing conscious level.
RAPID ASSESSMENT
A
Alert
responds to Voice
responds to Pain
Unresponsive
GLASGOW COMA SCALE

Assesses
Value
3
patients neurological condition
range 3 to 15
totally comatose patient
15
fully alert patient

CLASSIFICATION OF BRAIN INJURY

ACCORDING TO GLASGOW COMA SCALE
(GCS)
(HICKEY 2003)
SEVERE
GCS 3-8
MODERATE
GCS 9-12
MILD
GCS 13-15
NEUROLOGICAL GUIDE
GCS
top section
Temperature/BP/pulse/respiratory
Pupil
size / reaction to light
Limb
movement arms and legs
rate
EYE OPENING
Spontaneous
To speech
To pain
None
=4
=3
=2
=1
VERBAL RESPONSE
Orientated
=5
Disorientated
=4
Monosyllabic
=3
Incomprehensive
None
=2
=1
MOTOR RESPONSE
Obeys
commands = 6
Localises
pain = 5
Withdrawal
Flexion
to pain = 3
Extension
None
to pain = 4
=1
to pain = 2
Posturing
The General Principle For Managing

Neurologic Emergencies
Principle I: (Kaidah I)
Kerusakan sistem saraf tidak menyebabkan
kematian organ yang disarafi. Jaringan dan
fungsi diharapkan dapat diperbaiki.
Emergency Symptoms
Confusion
Drowsiness
Difficulty
speaking clearly
Numbness in any part of the body
One pupil that is larger than the other
Focal brain dysfunction

Brain tumour
Vascular events (CVA)
Demyelination
Infection, such as cerebral abcess
Focal head injury
Diffuse brain dysfunction
Infection, such as meningitis or encephalitis
Epilepsy
Hypoxia and hypercarbia
Drugs, poisoning and overdoses ( including alcohol)
Metabolic/endocrine causes, such as diabetic coma,
Hepatic or renal failure,
Hypothyroidism, severe electrolyte disturbances
Hypotension, or hypertensive crisis
Diffuse head injury
Subarachnoid haemorrhage
Hypothermia, hyperthermia
Primary Events:
Cell, Axonal
atau Myelin (Transmisi terganggu)

Penyebabnya:
1. Anoxia
7. Toxin/Infeksi
2. Intracranial Hemorrhage.
8. Metabolic
3. Ischemia
4. Trauma
5. Hypoglicemia
6. Tumors
Tumors
Brain Abscess
Symptoms of Brain Tumors?

nausea
- impaired sense of smell
Vomiting
- memory loss
headaches
- seizures
behavioral and emotional changes - muscle weakness
impaired judgment
-paralysis on one side of the body
loss of hearing
-reduced mental capacity
vision loss
Secondary Events
Edema Cerebri
TIK
Obstruksi dari Liquor CS.
Vasospasme
Kegagalan Autoregulasi
Kegagalan Collateral supply
Gagal Jantung
Gagal Nafas.
Anoxia
ICH
Ischemia
Tumors
Trauma
Principle II (Kaidah 2)
Selalu memerlukan intubasi
Agar pernapasan terjamin dan
oksigenasi ke otak terjamin baik.
Cegah terjadinya:
1. Coma hypoventilasi.
2. Hypoxia otak dan acidosis /
hypercarbia.
Glasgow Coma Score
Eye Opening (E)

4=Spontaneous
3=To voice
2=To pain
1=None
Verbal Response (V)

5=Normal conversation
4=Disoriented conversation
3=Words, but not coherent
2=No words......only sounds
1=None
Total = E+V+M
Motor Response (M)

6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Decorticate posture
2=Decerebrate
1=None
Principle III (Kaidah 3)

Stop
perdarahan (Stop the Bleeding)
PRINCIPLE iv ( Kaidah 4)
Sirkulasi
peredaran daraf keotak

dipertahankan.
Principle V (kaidah 5)
Penyakit tersebut Struktural atau NonStructural.

Biasanya dilakukan dengan pemeriksaan
Rontgen / CT.Scan atau
Suspect N-Struktural dengan LP.
Principle VI (Kaidah 6)
Diagnosis
cepat dan sederhana

(Simple & Spot Diagnosis) : yaitu
dengan menggunakan pengetahuan
Anatomi saraf (Topis Diagnostic) untuk
mengetahui letak lesi di Otak.
Bleeding
or swelling in the brain can

cause pressure that forces the brain
downward in the skull.
Herniation: The Brain Under Pressure
WHEN SPECIFIC AREAS OF THE

BRAIN ARE DAMAGED
Emboli (Perifer)
n
ai
M
gn
a
Di
tic
s
o
p
u
S
r
o
p
Part I. Neurological Examination

and Neurodiagnostic Testing
1. Neurological examination;
2. Neuroradiology;
3. Electroencephalography;
4. Lumbar puncture;
5. Electromyography;
6. Electronystagmography;
7. Evoked potentials;
Part II. Common Neurological

Presentations
8. Altered level of consciousness;
9. Headache;
10. Weakness;
11. Dizziness;
12. Seizures;
13. Gait disturbance;
Part III. Specific Neurological

Conditions:
14. CNS infections in adults;
15. Viral encephalitis;
16. Vascular disease;
17. Movement disorders;
18. Neuromuscular disorders;
19. Musculoskeletal and neurogenic pain;
20. Neuroophthalmological disorders;
21. Multiple sclerosis;
Specific Neurological
Conditions:
22. Dementia;
23. Neurooncology;
24. Neuropsychiatric
25. Neuroanesthesiology;
26. TIK (Tekanan Intra Kranial)
27. Normal pressure hydrocephalus;
28. Sleep disorders;
Part IV. Neurological Trauma and

Environmental Emergencies
29. Traumatic brain injury;
30. Spinal cord injury;
31. Peripheral nerve injury;
32. Neurological complications of
environmental emergencies
Part V. Pediatric Neurology

33. Hydrocephalus and shunts in
children;
34. Pediatric CNS infections;
35. Pediatric stroke;
36. Pediatric seizures;
37. The hypotonic infant;
Part VI. Neurological Emergencies

of Pregnancy:
38. Neurological emergencies of
pregnancy;
Part VII. Brain Resuscitation and

Neurotoxicology:
39. General neurotoxicology;
40. Neurotoxicology of alcohol and
substances of abuse;
41. Brain resuscitation.
PERUBAHAN KESADARAN
Dizziness
(pening / pusing?)
Fainting (menjadi pinsan)
Dissociation (pemisahan diri)
Confusion or delirium (ingauan / kacau)
Dementia
Seizures
Coma
Stupor
CONSCIOUSNESS is defined by levels

of behavior in response to stimuli
as:
1) alertness (kesiagaan)
2) drowsiness or lethargy (kelesuan)
3) stupor (keadaan pinsan / dengkur)
4) coma.
CONSCIOUSNESS IS A MANIFESTATION OF
HOLISTIC INFORMATION PROCESSING ,
THE MAJOR POINTS OF WHICH ARE:
1. Consciousness involves simultaneous activity of
large areas of the cerebral cortex.
2. Consciousness is superimposed on other types
of neural activity, so that they are not only
involved with their specific activity.
3. Consciousness is totally interconnected.
Thought occurs in many areas of the cerebrum
simultaneously.
Fainting, or syncopse, is a temporary

loss of consciousness that is usually due
to inadequate blood flow to the brain.
It may also be due to head injury, edema,
hemorrhaging, or sudden emotional
stress.
Coma is loss of consciousness in which
the victim is unresponsive to stimuli.
Evaluation
ICP monitoring is most often used in head trauma in
the following situations:
1) GCS less than 8
2) Drowsy with CT findings (operative or non
operative)
3) Post op hematoma evacuation
4) High risk patients (a) Above 40 yrs. (b) Low BP
(c) Those who require ventilation.
There is nothing to achieve in monitoring ICP in
the patients with GCS of less than 3.
Daftar Bacaan;
J. A. Fodor, "The big idea: can there be science of the mind," Times
Literary Supplement, pp. 5-7, July 2012.
J. Norden, Understanding the brain, Video lecture series.
M. Velmans, "Where experiences are: Dualist, physicalist, enactive and
reflexive accounts of phenomenal consciousness," Phenomenology and
the Cognitive Sciences, vol. 6, pp. 547-563, 2014
A. Sloman, "Developing concept of consciousness," Behavioral and
Brain Sciences, vol. 14 (4), pp. 694-695, Dec 2014.
W. H. Calvin and G. A. Ojemann, Conversation with Neil's brain: the
neural nature of thought and language: Addison-Wesley, 2014.
J. Hawkins and S. Blakeslee, On intelligence. New York: Henry Holt &
Company, LLC., 2014.
S. Greenfield, The private life of the brain. New York: John Wiley &
Sons, Inc., 2003
D. C. Dennett, Consciousness Explained, Penguin Press 2013.
D. M. Rosenthal, The nature of Mind, Oxford University Press, 2011.
B. J. Baars A cognitive theory of consciousness, Cambridge University
Press, 2014.
Jakarta, 17 Juni 2015

FKK-UMJ
WassalamuAlaikum Wr, Wbr.
Anwar Wardy W

Penurunan Kesadaran

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KEDARURATAN

of awareness of self and

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

ANATOMY OF MENTAL STATUS

reticular activating system (ARAS)

systems of upper brainstem, hypothalamus,

the level of arousal

hemispheres and interaction

the intellectual and emotional functioning

between cerebral hemispheres and

Anwar Wardy W. FK.UMJ

THE CONTENT OF CONSCIOUSNESS

of patients intellectual (cognitive)

Sensations, emotions, memories, images,

Anwar Wardy W. FK.UMJ

THE STATE OF CONSCIOUSNESS (AROUSAL)

ascending RAS, from the lower border

Anwar Wardy W. FK.UMJ

the common causes of a deteriorating

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

GLASGOW COMA SCALE

patients neurological condition

totally comatose patient

fully alert patient

Anwar Wardy W. FK.UMJ

CLASSIFICATION OF BRAIN INJURY

Anwar Wardy W. FK.UMJ

size / reaction to light

movement arms and legs

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

The General Principle For Managing

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Focal brain dysfunction

atau Myelin (Transmisi terganggu)

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Symptoms of Brain Tumors?

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Glasgow Coma Score

Eye Opening (E)

Verbal Response (V)

Motor Response (M)

Anwar Wardy W. FK.UMJ

Principle III (Kaidah 3)

perdarahan (Stop the Bleeding)

peredaran daraf keotak

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

Penyakit tersebut Struktural atau NonStructural.

Anwar Wardy W. FK.UMJ

Anwar Wardy W. FK.UMJ

cepat dan sederhana