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Disturbances of
Conciousness

Contributor:
M.Dalhar
Farhad Balatif
Achdiat Agoes
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Cerebrum

Diencephalon

Tentorium
Mesencephalon Cerebelli
Midbrain

Pons Cerebellum

Medulla
Oblongata
Medulla Spinalis
/ Spinal Cord
CORTICAL AWARENESS : Primary Secondary Tertier 3
Cortical Somato Sensory
123 5 7

Cortical
Visual

17 18 19

Cortical Auditory
41 42 22
CORTICAL AWARENESS : Primary Secondary Tertier 4
Somato Sensory Cortical
123 5 7

Visual
Cortical

17 18 19

Smell Cortical
28 35 25 34
Reticular System Brainstem 5

Diencephalon
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Central Nervous System
@ Energy of BRAIN : Glucose + Oxygen
@ Weight of Brain 2 % body weight :
- CBF 15 % of Cardia Output
- 20 % Consumption Oksigen
- 65 % Consumption Glucose
@ CBF Cortical : 80 100 ml/gr/mnt
CBF Sub cortical : 20 25 ml/gr/mnt
@ Endurance of CELL due to O2 (Anoxia) :
- Cell of Myocard 30 minute
- Cell of lung 2 hour
- Cell Liver 1 2 hour
- Cell Brain a minute
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Central Nervous System
CONCIOUSNESS 8

INPUT INTEGRATION OUT PUT


Stimulation The Brain Proses Reaction

The 5 Sense Open eyes


Visual Speech
Auditory Movement
Smell Spesific Autonom
Taste ARAS
Skin
AWARENESS
AROUSAL

Degree of Counciousness Quality of Counciousness


Intelectual Activity
Perception
Feeling Praxis
Gnosis
Wish Fluent
Input of Conciousness Non Specific 9

Specific
5 Sense Pathways Center Projection Cortical
Area 123
Skin SpinoThalamic Thalamus Thal.Cortic
Area 5 7
Area 17
Visual Tract. Opticus C.Genic.Lat. Rad.Optic
Area 18 19
Area 41
Auditory Lemnic.Lat. C.Genic.Med Rad.Acustic
Area 42 22

Area 28
Smell N.Olfactorius Bulb.Olfact. Stria Olfact
Area 35 25

postcentral
Taste Lemnic.Medial Nu.Solitar. Rad.Gustat gyrus and
insula
Area 123 INPUT of Conciousness 10
Somato Sensorys
SPESIFIC
cortical

Thalamus Thalamo-Cortical

Spinothalamikus Lat.

Pain , temperature
Proprioseptif
Awareness of Somato Sensory 11
cortical
TERTIARY Area cortical PRIMARY Area 123
cortical
Secondary Area 5
Awareness of VISUAL VISUAL INPUT 12

SPESIFIC

Retina
Tractus Opticus
Corpus Genic.Lateral
Radiatio Optica

cortical Primer Area 17


Knows

cortical Secondary Area 18


Synthesis

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18 cortical Tertier Area 19
17 Analysis
Awareness of AUDITORY INPUT AUDITORY 13
SPESIFIC

Cohlea Labirin
Nn.VIII
Nuc.Nn.VIII
Lemnisc.Medialis

cortical Primer Area 41


Knows

cortical Secondary Area 42


Synthesis

cortical Tertier Area 22


Analysis
INPUT Conciousness 14
The 5th Sense
NON SPESIFIC

Inter Neuron Reticular

ARAS
A sending
R eticular
A ctivating
S ystem

Activating of Conciousness
ON / OFF Cortical System
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Disturbances of Conciousness
I. Grading of Conciousness :
1. Awareness of the 5 Sense Conciousness
2. Reaction Open of Eyes
Speech
Movement
II. Quality of Conciousness :
1. Perception and Orientation Agnosia
2. Intelectuality/ Thought / Reasoning Amnesia
3. Affect and Emotion
4. Desire
5. Psychomotor Apraxia
Aphasia

Psychiatry Neurology
Quality and Content of Conciousness 16

I. PERCEPTION:
1. Orientation : - Self - Person - Time - Surrounding
2. Gnosis : - Visual - Tactil - Auditory - Smell - Taste
II. INTELECTUALITY :
3. Memory : - Atention - Retention - Recall
- Counting - Knowledge
4. Thought / Imagination / Abstraction
5. Reasoning : - Similarity - Interpretation - Appraisal
- Disparity - Judgment
III. FEELING : 6. Affect dan Emotion
IV. DESIRE : 7. Desire of - Eat -Drink Sex
V. PSYCHOMOTOR : 8. Psikomotor / Motor Skill
9. Praxis
10. Speech = Fluent = Fasih
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Quality Disturbances of Conciousness
Organic Brain Syndromes
Disturbances of : 1. Concentration Capacity
2. Perception Capacity
3. Memory Capacity
4. Intelectual Capacity
5. Judgment, Value Capacity
6. Self Controle
CLASIFICATION :
1. D. Kognition Global : - Delirium Confusion State
- Dementia
- Amnesic Confusion State
2. D. Kognition Selectif : - Hallusination
- Frontal Lobe S
- Temporal Lobe S
3. D. Mental others : - Schizophrenia
- Paranoid state
- Depressive state
- Manic state
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Examination of Grading COMA

I. GLASGOW COMA SCALE = G.C.S


1. Open of Eyes 4 Scale
2. Speech 5 Scale
3. Motoric 6 Scale

II. Brainstem Scale = ( PITTBURG ) P.B.S.S


1. Eyelash Reflex 2 Scale
2. Corneal Reflex 2
3. Pupils Reflexes D/S 4
4. Caloric/ Dolls Eyes Reflex 5
5. Vomiting Reflex 2

Jumlah 15
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Decerebrate
Rigidity

Decorticate
Rigidity
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CLASIFICATION of COMA
A. Topical Lesion Clasification :
I. Cortical Bi Hemispher Coma
II. Diensefalic Coma

B. Anatomical Lesion Clasification :


I. Supra Tentorial Lesion
II Infra Tentorial Lesion

C. Etiological Clasification :
I. Neurological Coma
II. Non Neurological Coma
/ Metabolic Coma
/ Encephalopaty
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Clasification of COMA
I. Pathophysiology + Anatomical
1. Cortical Bi-Hemispheric COMA :
Disturbances of fungtion
Structural Lesion
L R
Vascular general
Hipoxia-anoxia
Metabolic / Toxic
Elektrolit
Hyperthermia
Encephalitis / Meningitis
2. Diencephalic COMA Space Occupying Process 23

Supra Tentorial

disturbances ARAS

Infra Tentorial
CVA Hemorrhage
Tumor
Abscess
Epidural B
Sub Epidural B
Brain Edema
Hidrosefalus
Cerebral Contution

3. Combination of ARAS + Cortical Bihemispheric


Cortical Bi HEMISPHERIC COMA 24
= METABOLIC COMA / EncephalopathY
Anoxic
1. Hipoxia : < 12 ml / mnt / 100 gr
Anoxia Anemic
2. Hipoglycemia : < 31 46 Mgr %
3. Hiperglycemia : >1100 mg%
< 1,7-2,6 mol Tek.Osmose
4. Temperature : < 36o / > 41,5 o C
5. Toxic substances
@ DM Keton Bodies : Ketonuria + > 400 mg%
@ Uremia NH3 : > 5 - 6 X Normal
@ Acidosis : Ph < 7.0 / Alkalosis
@ Hipo / Hiper Na : < 126 mmol or > 156 mmol
@ Vit B1 : < 100 g%
@ Toxin
6. Hipnotic : Barbiturat, Bromob, Alkohol, Anestesia
7. Blood Pressure / SHOCK : < 70 mmHg
8. Infection
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BRAIN ANOXIA
1. ANOXIC ANOXIA :
@ O2 Saturation
@ disturbances of Respiration Tract
@ Lung diseases
@ Toxic with CO2 , Anestesia
2. ANEMIC ANOXIA :
@ Anemia
@ Hb level
@ Hipotension / Shock
@ Cardiac Arrest
3. HISTOTOXIC ANOXIA :
@ Toxic with CO / Cyanide
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SYNCOPE
Transient of
Unconciousness
Transient of
Unconciousness
S irculation
1. EPILEPSY Y Psychiatry
2. C.V.A. / STROKE N eurogenic
3. SYNCOPE
4. HIPOGLYCEMIA
C ardiac
5. SHOCK O rtho static/Other
6. HYSTERIC P osture
E xresi
SHOCK 27

Shock is the clinical syndrome that results from inadequate


tissue perfusion (in CNS). Irrespective of cause, the
hypoperfusion-induced imbalance between the delivery of
and requirements for oxygen and substrate (glucose)
leads to cellular dysfunction

Causes :
1. Hipovolemic : @ Bleeding @ Dehidrasi
2. Anaphylactic : @ Allergic
3. Cardiogenic
4. Neurogenic : @ Severe pain @ Vagal Reflek
@ Heat stroke
5. Septic : @ Sistemic Infection
6. Histeric
Clinical Clasification of COMA 28

1. COMA + Focal Neurologic DEFISIT /


+ NEUROLOGIC Lateralitation

Hemiparese/plegi
Anisocori Pupil CVA
nn. Cranial Palsy Tumor
Asimetri Reflex Abscess NEUROLOGIC
Aphasia Encefalitis Coma
Rigiditas Epi / Subdural B
Brain Herniation C. Contution
Hidrosephalus

2. COMA + Meningeal Sign Meningitis


+ Abnormal LCS SAH ( Sub Arachnoid H )
+/- LATERALISASI Meningo-ensefalitis
Clinical Clasification of COMA 29

3. COMA + Without Focal Neurologic DEFISIT /


KLINIS:
+ Without NEUROLOGIC Lateralitation
+ Without Meningeal Sign

Uremia
Hepaticum
Diabetic Ketosidosis
Hipoglicemia Coma Non Neurologic
Anoxia / Coma Metabolic
Syncope / Ensephalopaty
Shcok
Disturbances Electrolyt
Intoxication
Clinical Clasification of COMA 30

C Circulation , Cardiac
I Infection : Encephalitis, Meningitis
M Metabolic
E Endockrinologic
N Neurologic
T Toxic
E Exretion
D Drug
Proses Desak Ruang SUPRA TENTORIAL 31

Supra Tentorial disturbances of ARAS

BRAIN HERNIASI
UNCAL Type
ARAS
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Proses Desak Ruang SUPRA TENTORIAL
Supra Tentorial disturbances of ARAS

HERNIASI OTAK
Tipe Central
Simetris
ARAS
Reticular System Brainstem 33

ARAS
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Change in Rhytme Respiration in
Brain Herniation UNCAL Type

APNEA
Change in Diameter Pupil 35
Brain Herniation UNCAL Type
Pattern of TONE 36
Gegenhalten / Motor Negativism
Brain Herniaion
Decorticate Rigidity UNCAL Type

Decerebrate Rigidity

FLAKSID
Staging Brain Herniation UNCAL Type SUPRA TENTORIAL Lesion

Exam. Diensefalon Mesencefalon Pons Med.


Oblongata
Conciousness Stupor Semi Coma Coma Coma
Respiration Cheyne Stoke CNH Ataxia Apneustik
Pulse Bradikardi Bradicardy -
Blood Pres. Normal BP ++ BP ++++
Temperature Normal / Hiperthermia
Eye Movement Moving MPF MPF MPF
Pupil Miosis Anisocor Midriasis
Midriasis Ipsi. Pin Point ODS
R. Pupil +/+ +/- -/- -/-
Cornea +/+ +/+ -/- -/-
Doll eye +/+ +/+ -/- -/-
Decorticate Decerebrate
Extremities Arm Flexion Arm Ext. Flaccid
Decerebrate
Leg Exten. Leg Ext. Atonic

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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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DDx COMA
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PEMERIKSAAN KOMA

I. ANAMNESA : Semua Klinis


Teliti Topis
Sisematis Etiologis
II. FISIK : Seluruh tubuh - Resp
Vital sign - Nadi
Interna - Tensi
III. NEUROLOGIS :
1. Kesadaran : GCS Reflek Batang Otak
2. Status Neuro : a. Neuro Fokal (+)
b. Tanda Meningeal
c. Tanda Defisit Neuro
d. Tanda Herniasi Otak
IV. PEMERIKSAAN KHUSUS :
Lab. Darah cito/urine ECG LP
X Foto Skull / Thorac
Oftalmoskopi Papil Edema
CT scan KPL / Arteriografi
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REFLEK BATANG OTAK

Aferen Eferen
Reflex Pusat
Nerve Nerve

R.Cahaya II CGL/ Mesen III

R.Bulu Mta
V Pons VII
R.Cornea

R.Doll Eye
VIII Pons III VI
R.Calorik

R.Muntah IX Med.Oblo IX X
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Px KOMA

BANTUAN HIDUP AWAL


Breath Blood Brain Bladder Bowel

Tanda Tanda Tanpa


Meningeal (+) Neuro Fokal (+) Tanda meningeal
Neuro Fokal
- Hemiparese
- Pupil Anisocori
- Reflex Asimetri
- Kejang 2 Fokal/General
- Parese NN.Cranialis
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PENATALAKSANAAN KOMA
I. BANTUAN HIDUP AWAL ( Basic Life Support )
Adalah tahap menyelamatkan hidup (life saving)
dikerjakan di U.G.D secepatnya sebelum
penanganan spesialis
Prinsip 5B : Breath Blood Brain Bladder Bowel

B1 BREATH:
1. Bersihkan & Lancarkan jalan nafas
2. Pasang oksigen
3. Bila gagal nafas:
Pasang mayo tube atau intubasi endo trachea
Pasang Ambu Bag
Resusitasi Kardio Pulmonal
4. Ambil darah arteri analisa gas darah
5. Kalau perlu X foto thorac
6. Monitor terus : Freq, ritme, sesak nafas
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Prinsip 5B : Breath Blood Brain Bladder Bowel


B2 BLOOD
1. Ambil darah vena Lab cito yang sesuai
2. Pasang infus N.S.
3. Pertahankan & Monitor Tensi & Nadi adekuat
Dehidrasi BJ Plasma ganti defisit
Tensi Rendah IV Dopamine 3 gr/kg IV
Drip 50 500 gr/500
4. ECG
Prinsip 5B : Breath Blood Brain Bladder Bowel 57
B3 BRAIN
1. Koma dengan tidak diketahui penyebab:
- Glukose 50% 50 cc IV
- Thiamine 100 mg IV
- Naloloxe 0,6 0,8 mg IV
2. Kejang-kejang
Diazepam 10 mg /Ivulangi tiap 15 menit
Phenytoin 10 18 mg/kg
50 mg / 100 cc NS IV / Drip PELAN
3. Tanda Herniasi Otak / TIK meningkat
Konsul cito neurologi / bedah saraf
Dexa methasone 10 mg / IV, diulangi 5 mg / 6 jam
Infus Drip Manittol 20 % 0,5 1 gr / Kg BB
Drip 15 30 menit, diulangi tiap 4 jam
+ Furosemide 0,5 1 mg / Kg IV
Prinsip 5B : Breath Blood Brain Bladder Bowel 58
B3 BRAIN
4. Trauma Kepala :
X foto cranium AP / Lat / Basis Cranii
X foto vertebra cervical AP / Lat / Obliq
Dexametasone 4 x 5 mg / IV
Piracetam
5. Kaku kuduk K. Neuro / LP
6. Suhu tinggi Injeksi xylomidon
Kompres dingin
7. Gelisah : Diazepam 10 mg IV
Chlorpromazine 25 mg / IM
Prinsip 5B : Breath Blood Brain Bladder Bowel 59

B4 BLADDER:
1. Pasang daner catheter foley & Urobag
2. Ambil urine Lab cito
3. Monitor urine tampung 24 jam
4. Perhatikan balance cairan & elektrolit

B5 BOWEL
1. Pasang NGT : mulai hari 2
2. Posisi diubah tiap 2 jam
3. Perhatikan : - Decubitus
- Hipostatik pneumonia
- Aspirasi
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SKALA DIAGNOSA KLINIS STROKE
Djoenaedi W Skor Skor

1. TIA sebelum serangan 1


2. Onset :
Sangat mendadak (1-2) menit 6,5
Mendadak (beberapa menit jam) 6,5
Pelan/bertahap 1
3. Waktu Onset:
Waktu bekerja / aktivitas 6,5
Waktu istirahat / tidur 1
Bangun tidur 1
4. Sakit Kepala saat serangan:
Sangat hebat 10
Hebat 7,5
Pelan (bbrp hari / lebih) 1
Tidak ada 0
5. Muntah
Langsung sehabis serangan 10
Mendadak (menit-jam) 7,5
Tidak ada 0
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SKALA DIAGNOSA KLINIS STROKE
Djoenaedi W Skor

6. Kesadaran:
Hilang waktu serangan 10
Hilang mendadak (menit-jam) 10
Pelan (beberapa hari/lebih) 1
Hilang sesaat, sadar lagi 1
Tetap sadar 0
7. Tekanan darah:
Waktu serangan > 200/110 mmHg 7,5
Waktu MRS > 200/110 mmHg 7,5
Waktu serangan 140/110 200/110 mmHg 1
Waktu MRS 1
8. Tanda Meningeal:
Kaku kuduk hebat 10
Kaku kuduk ringan 5
Tidak ada 1
9. Fundus Oculi :
Perdarahan Subhyaloid 10
Perdarahan retina 5
Normal 0
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10. Pupil :
Kecil + Reaktif 10
Kecil + Reaktif lambat 10
Midriasis Ka/Ki 10
Pin Point Ka/Ki 10
Anisokori 5
Isokori Normal 0
11. Darah:
Leukositosis > 10.00 1
CPK Meningkat 1
12. Panas :
Panas < 1 hari 1
Panas > 1 hari 1
JUMLAH
KESIMPULAN:
Skor < 15 : Stroke Iskhemic
Skor >= 20 : Stroke Perdarahan
Skor 15 19 : Ragu-ragu

Sensitivitas
Stroke Perdarahan : 91,3%
Stroke 87,5%
Stroke Iskhemik : 82,4%
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Tanda Meningeal (+)

LP

Abnormal Normal

Meningitis CVA SAH Metabolit


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NEUROLOGIS FOKAL (+)

Proses Desak Tanpa


Herniasi Otak Proses Desak
Herniasi Otak
CT Scan

Tumor (+) / Tumor (-)


CVA ICH CVA ICH (-)

LP
Tumor CVA
Abscess ICH CVA CVA
Hidrosefalus Tombosis - Arteritis
Emboli - F. Steal
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Tanpa tanda meningeal
Tanpa Neuro Fokal

Anamnesa
Laboratorium
Khusus

KOMA METABOLIT
- Hipoglikemia
- Uremia diabetik
- Hepatik
- Intoksikasi
- Contusio
- Ensefalopati
- Epilepsi