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Disturbances of
Conciousness
Contributor:
M.Dalhar
Farhad Balatif
Achdiat Agoes
2
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
6
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
7
Central Nervous System
CONCIOUSNESS 8
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
19
18 cortical Tertier Area 19
17 Analysis
Awareness of AUDITORY INPUT AUDITORY 13
SPESIFIC
Cohlea Labirin
Nn.VIII
Nuc.Nn.VIII
Lemnisc.Medialis
ARAS
A sending
R eticular
A ctivating
S ystem
Activating of Conciousness
ON / OFF Cortical System
15
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
17
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
18
Examination of Grading COMA
Jumlah 15
19
14
20
Decerebrate
Rigidity
Decorticate
Rigidity
21
CLASIFICATION of COMA
A. Topical Lesion Clasification :
I. Cortical Bi Hemispher Coma
II. Diensefalic Coma
C. Etiological Clasification :
I. Neurological Coma
II. Non Neurological Coma
/ Metabolic Coma
/ Encephalopaty
22
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
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
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
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
BRAIN HERNIASI
UNCAL Type
ARAS
32
Proses Desak Ruang SUPRA TENTORIAL
Supra Tentorial disturbances of ARAS
HERNIASI OTAK
Tipe Central
Simetris
ARAS
Reticular System Brainstem 33
ARAS
34
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
37
38
DDx COMA
39
DDx COMA
40
DDx COMA
41
DDx COMA
42
DDx COMA
43
DDx COMA
44
DDx COMA
45
DDx COMA
46
DDx COMA
47
DDx COMA
48
DDx COMA
49
DDx COMA
50
DDx COMA
51
DDx COMA
52
PEMERIKSAAN KOMA
Aferen Eferen
Reflex Pusat
Nerve Nerve
R.Bulu Mta
V Pons VII
R.Cornea
R.Doll Eye
VIII Pons III VI
R.Calorik
R.Muntah IX Med.Oblo IX X
54
Px KOMA
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
56
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
60
SKALA DIAGNOSA KLINIS STROKE
Djoenaedi W Skor 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
62
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%
63
LP
Abnormal Normal
LP
Tumor CVA
Abscess ICH CVA CVA
Hidrosefalus Tombosis - Arteritis
Emboli - F. Steal
65
Tanpa tanda meningeal
Tanpa Neuro Fokal
Anamnesa
Laboratorium
Khusus
KOMA METABOLIT
- Hipoglikemia
- Uremia diabetik
- Hepatik
- Intoksikasi
- Contusio
- Ensefalopati
- Epilepsi