Kuliah Kesadaran Menurun UNTAR Mei 2012 (Presentasi)

KESADARAN MENURUN
Hartono Prabowo
Bagian Saraf Universitas Tarumanagara
Jakarta
10-05-2012
Kesadaran Menurun
Seorang pasien pria 65 th diantar ke UGD
oleh tetangga rumahnya oleh karena
ditemukan dalam keadaan tidak sadarkan
diri. Pada pemeriksaan dengan rangsang
nyeri didapatkan kelopak mata sedikit
terbuka, kedua lengan fleksi disertai kedua
tungkai ekstensi dan pasien terdengar
merintih kesakitan. TD 140/90 mmHg, S
37.20 C, N 88x/menit dan R 24 x/menit
Kesadaran Menurun
1. Dari data yang ada dapat disimpulkan

GCS (Glasgow Coma Scale) pasien
tersebut adalah :
A.
B.
C.
D.
E2 M2 V2 = 6
E2 M3 V2 = 7
E2 M4 V3 = 9
E3 M3 V2 = 8
Kesadaran Menurun
2. Pemeriksaan penunjang yang perlu

dipertimbangkan untuk pasien tersebut
adalah sebagai berikut, kecuali :
A.
B.
C.
D.
Kadar gula darah

Analisa gas darah
Fungsi ginjal
Kadar Potasium darah
Kesadaran Menurun
3. Apabila pada pemeriksaan fisik didapatkan

adanya kelemahan ekstremitas kiri, maka
pemeriksaan yang harus dipertimbangkan
A.
B.
C.
D.
Brain CT-Scan / MRI

Kadar glukosa darah
Kadar potasium darah
Analisa gas darah
Kesadaran Menurun
4. Tindakan yang harus dikerjakan pada
penderita dengan kesadaran menurun
A. Tindakan Neuroproteksi
B. Segera berikan Piracetam / citicholine
C. Koreksi kelainan sistemik penyebab
penurunan kesadaran
D. Jika perlu segera lakukan reperfusi
Kesadaran
Kesadaran
William James : consciousness as awareness

of one-self and the environment.
Phenomenal consciousness : otak dapat
mengenali dan memberikan respons yang sesuai
terhadap fenomena fenomena yang terjadi didalam
tubuh dan lingkungan
Definisi kesadaran
CONSCIOUS
NESS
awareness
AROUSAL
Kesadaran diartikan sebagai hasil

berbagai fungsi yang kompleks
dan berdasar pada alertness/
arousal dan awareness
(mengenali dan merespon dengan
adekuat terhadap proses dalam
diri dan lingkungan).
Bedside :
arousal eye opening.
External awareness reproducible command following
of non-reflex/voluntary movements
Thibaut et al, 2012
Anatomi Kesadaran
Integritas hubungan antara korteks serebri dengan
sistem formasio retikularis pada batang otak.
ARAS menyalurkan impuls dari midpons ke rostral melalui

tegmentum menuju nukleus intralaminaris (& nukleus
centromedial) thalamus untuk selanjutnya menuju korteks serebri.
CONSCIOUSNESS
Anatomi Kesadaran
MOVEMENTS
Appropriate
Localized
AWARENESS Abduction
LANGUAGE
AROUSAL
Brainstem reflexes
12
Laureys et al, 2002
TWO AWARENESS NETWORK
awareness (content of consciousness)

arousal (level of consciousness )
13
Adopted from Laureys, et al, 2007
Awareness
@
@
@
@
@
Sensasi
Persepsi
Fungsi memori
Atensi
Kognisi
Neurotransmiter pada alertness / arousal
1. Cholinergic (Ach)
2. Monoaminergic
a. noradrenergic
b. dopaminergic
c. serotonergic
3. GABA-nergic.
Neuron aminergik pada formasio retikularis

Neurotransmiter
Lokasi
Serotonin
Nucl. Raphe midbrain,

pons, medulla oblongata
Dopamine
Tegmentum midbrain.
Norepinephrine
Midbrain, pons, medulla

oblongata.
Epinephrine
Medulla oblongata.
Sistem Cholinergic
Jalur cholinergic berperan pada alertness /arousal
sebagai komponen ARAS.
Aktivasi thalamus mengurangi tonus inhibisi
nukleus retikularis thalamus
fasilitasi transmisi thalamokortikal.
Aktivasi struktur medial diencephalon
emosional erousal.
Noradrenergic
brainstem
dorsal thalamus
o locus ceruleus
hipothalamus
hipocampus
neokorteks
Brainstem
o Nukleus tegmental lateralis
Med. Spin.
Schematic diagram of the noradrenergic system

Anterior thalamic
nucleus
To neocortex
Locus
ceruleus
medula
oblongata.
Nukleus
tegmentu
m lateralis
pons dan
medula
oblongata.
Thalamus
Habenula
PAG
Amygdata
N. Iocus
coeruleus
(A6)
Hippocampus
N. Subcoeruleus (A7)
DLF
ILC
Trigeminal
spinal
nucleus
A5
A1
Terman & Bonica, 2001

Modifikasi Meliala, 2003
Serotonergic inhibisi
Nukleus raphe tegmentum brainstem proyeksi ke
korteks serebri dan sistem limbik termasuk korteks
pyriformis, hypothalamus, hippocampus dan
diencephalon.
Defisiensi serotonin (spt. Withdrawal alkohol)
impulsip, over-reaktip,insomnia
(ggn. Siklus tidur).
Diagram of the origin and projection of the serotonergic system

Cingulate gyrus
Fronix
Thalamus
Habenula
Hippocampus
Septum
PAG
Amygdata
N. Raphe
dorsalis (B7)
N. Iocus
coeruleus
Hippocampus
N. raphe
Magnus
(B3)
N. Central superior (B6. 8)

DLF
N. Raphe
Pallidus
(B1)
N. raphe
Obscurus
(B2)
Terman & Bonica, 2001

VM
Modifikasi Meliala, 2003
Sistem dopaminergic
Ventral tegmentum brainstem
neostriatal, mesolimbik
dan mesokortikal.
o tu. Fungsi kognitip (lihat
efek amphetamine dan obat
antipsikotik sbg. Dopamine
blocker).
o Peranan dalam arousal kecil
tetapi dapat meningkatkan
responsiveness.
GABA-nergic
Neuron GABA-nergic tersebar luas pada SSP
dengan fungsi pada kesadaran tidak jelas.
Inhibisi korteks cerebri, thalamus, ganglion
basalis, cerebellum dan med. Spinalis.
Peningkatan GABA-nergic alertness dan daya
konsentrasi menurun
Glutamat dan aspartat.
Sintesa pada korteks cerebri.

Eksitatorik.
Peranan pada kesadaran kecil.
Lebih berperan pada komunikasi
kortiko kortikal.
A summary diagram of the ascending arousal system
NA : Noradrenaline
5-HT : Serotonin
DA : Dopamine
His : Histamine
ORX : Orexin
MCH : Melanin
concentrating hormone
ACh : Acetylcholine
GABA : Gamma
aminobutyric acid
LC : locus coeruleus
vPAG : ventral
periaqueductal gray
matter
TMN : Tuberomammiullary nucleus
LH : lateral
hypothalamus
BF : basal forebrain
PPT : pedunculo
pontine3
The cholinergic system, shown in yellow, provides the main input to the
relay and reticular nuclei of the thalamus from the upper brainstem. This
inhibits the reticular nucleus and activates the thalamic relay nuclei,
putting them into transmission mode for relaying sensory information to
the cerebral cortex. The cortex is activated simultaneously by a series of
direct
shown in red
Pluminputs,
and Posners 2007
Kesadaran Menurun
Plum and Posners 2007
Kesadaran Menurun
Clouding of
consciousness
minimally reduced wakefulness or awareness, hyperexcitability and

irritability alternating with drowsiness
Delirium
Disoriented (rst to time, next to place, and then to persons in their

environment ), motor restlessness, hallucination bilateral
impairment of cortical function
Obtundation
a mild to moderate reduction in alertness, accompanied by a lesser

interest in the environment. Such patients have slower psychologic
responses to stimulation - increased number of hours of sleep
Stupor
condition of deep sleep or similar behavioral unresponsiveness from

which the subject can be aroused only with vigorous and continuous
stimulation. Even when maximally aroused, the level of cognitive
function may be impaired.
Coma
Deep sleep / Trance unresponsiveness in which the patient lies

with eyes closed and cannot be aroused to respond appropriately to
stimuli even with vigorous stimulation.

Huges. Neurological Emergencies. 4th ed. 2003
REDUCING CONSCIOUSNESS TO 2 D
28
Laureys, 2011
PLUMS DEFINITION
Coma
(unconsciousness)
is an unarousable/ unresponsiveness
condition in which , the patient is not
responsive to all stimuli
Coma is caused by disordered arousal rather than
impairment of the awareness
J Neurol Neurosurg Psychiatry 2001;71(suppl I):i13i17
Kesadaran Menurun
Gangguan
Kelainan bihemisfer
serebri
fungsi neuron
Bilateral
difus (infeksi,
korteks
serebri.
ggn sistemik spt hipoksia,
hipoglikemia, uremia
Gangguan
fungsi dll)
hiponatremia,
interkoneksi
Otakpada
UnilateralBatang
dampak
(ARAS)
dan korteks serebri.
midbrain
Gangguan fungsi Formatio
(ARAS)
padaotak
Retikularis
Kelainan pada
batang
tingkat batang otak.
Principles and Practice of Emergency Neurology, 2003

The Merck Manual for Health Care Professionals, 2008
Kesadaran Menurun
Ekstra kranial
Hipoksia / hipercapnea
Hipo/hiperglikemia.
Uremia.
Hepatik ensefalopati.
Gangguan elektrolit
(hipo Natremia).
Hipoperfusi.
Intoksikasi (CO, dll)
Asidosis
Drugs
Intra kranial
Trauma.
CVD stroke Iskemik /
hemoragik.
Infeksi (meningitis /
Ensefalitis.
Tekanan Intrakranial
Tumor / brain abscess
Kejang / status
konvulsivus

Cerebral blood flow (CBF)

%
100
CBF
ml/100 g/ menit
50
80
40
60
30
40
20
I
S
20 K
E
M
10
I
A
Nilai
normal
Oligemia
Dipertahankan dengan
autoregulasi
Peningkatan ekstraksi O2 untuk

pertahankan CMRO2
Ringan
Peningkatan glikolisis anaerobik

Moderat
Berat
ELECTRICAL FAILURE
Penumbra
IONIC FAILURE
Depolarisasi anoksik
Hiperglikemia kesadaran menurun
Hiperglikemia
Status Hiperglikemia
lain :
DKA
DM tidak terkontrol
Stress
hyperglycemia
HHS
Ketosis
Status ketosis lain :
Ketotic hypoglycemia
Ketosis alkoholik
Ketosis starvation
Isoprophyl alcohol
Hiperemesis
Endocrinol Metab Clin N Am 35 (2006) 725751
Status asidosis
Asidosis metabolik lain :
Laktat asidosis
Asidosis
hiperkloremia
Salicylsm
Asidosis uremikum
Sekresi insulin
Inefektivitas insulin
Pe hormon kontra insulin
(glucagon, catecholamine,
cortisol dan GH)
Hiperglikemia kesadaran menurun
Hiperglikemia
Asidosis
Ketosis
Osmolaritas
Dehidrasi neuron
serebral
pH serebral
Edema serebri
Metabolisme
neuron
serebral
Kesadaran
Endocrinol Metab Clin N Am 35 (2006) 725751
Hipoglikemia (<70 mg/dl)
Suppression / inhibition of insuline release

Pancreas : secretion of glucagon & pancreatic polypeptide
Adrenal medulla : secretion of epinephrine & norepinephrine (NE)
Adrenal cortex : secretion of cortisol
Sympathetic postganglionic nerve terminal : secretion of NE
Pituitary gland : secretion of GH
4 hrs
Glucogenolysis
Gluconeogenesis
Lipolysis
Reduces glucose uptake in peripheral tissue
CLINICAL DIABETES. Volume 24, Number 3, 2006
Hipoglikemia (<70 mg/dl)
Suppression / inhibition of insuline release

Pancreas : secretion of glucagon & pancreatic polypeptide
Adrenal medulla : secretion of epinephrine & norepinephrine (NE)
Adrenal cortex : secretion of cortisol
Sympathetic postganglionic nerve terminal : secretion of NE
Pituitary gland : secretion of GH
Glucogenolysis
Gluconeogenesis
Lipolysis
Reduces glucose uptake in peripheral tissue
Autonomic
symptoms
4 hrs
Brain
neuronal
glucose
deprivation
symptoms
Hipoglikemia
Neurogenic (ANS) symptoms
Neuroglycopenic symptoms
Shakiness (limbung)
Abnormal mentation
Trembling (gemetar)
Irritability
Anxiety (cemas)
Confusion
Nervousness (gelisah)
Difficulty in thinking
Palpitasion
Dissiculty speaking
Clamminess (tangan
basah/lembab)
Ataxia
Sweating (berkeringat dingin)
Paresthesia
Dry mouth
Headaches
Hunger
Stupor
Pallor (pucat)
Coma
Pupil dilation
Death (if untreated)
Ensefalopati Hepatikum
Metab Ammonia
dalam Astrosit
glutamin
Uptake ammonia
otak
Permeabilitas BBB
tanpa kerusakan
membran basal
Ggn fungsi hati
Ammonia darah
Edema serebri
Kesadaran
TIK
CBF
Ensefalopati hiper / hipo-Natremia

Hiponatremia
Hipernatremia
Obat-obat berpengaruh pada kesadaran
Sedativa
Barbiturates
Tranquilisers
Alkohol
Opiates
Anticholinergics
Lithium
Psikotropika
Paraldehyde

Kesadaran
Evaluasi penderita kesadaran menurun
B
C
Diagnosis
Diagnosis dan ABC koma

harus simultan
Ukur kadar Glucose darah
segera hipoglikemia?
Pada kasus trauma dengan
kesadaran menurun
imobilisasi leher sampai dapat
dibuktikan tidak ada kelainan
pada vertebra servikalis
Evaluasi penderita kesadaran menurun

Riwayat penyakit
Pemeriksaan fisik umum
Pemeriksaan neurologis termasuk (pemeriksaan
mata)
Pemeriksaan Laboratorium (darah, urin dan jika
perlu AGD )
Neuroimaging (Brain CTScan / MRI, Ro-Thorax)
Ukur tekanan intrakranial (jika perlu dan mungkin)
Bila diagnosa tidak jelas LP / EEG
Pemeriksaan fisik
Keadaan umum
Tanda vital
Pola pernafasan dan odor spesifik
Jantung / paru / abdomen
Pupils
RBO (Refleks batang otak)
Reaksi terhadap rangsang nyeri
Fungsi traktus piramidalis
Tanda rangsang meningeal
Tanda TIK
Observasi umum
Gerakan menelan brain function is still intact
Asterixis dan multifocal myoclonus ggn
metabolik (uremia, ensefalopati hepatikum,
encephalopati hipoksik, intoksikasi obat) ggn
fungsi otak difus
Psychogenic ? tonus otot / refleks fisiologis /
refleks batang otak normal (lateralisasi / refleks
patologis negatip)

Penilaian kesadaran
Kwalitatip
Kwantitatip
GCS
CM
Somnolen
Sopor
Soporokoma
Koma
(Glasgow Coma Scale)
Skala lain penilaian kesadaran
Innsbruck Coma Scale

Edinburgh-2 Coma Scale
Reaction Level Scale
Coma Recovery Scale Revised
FOUR Score (Full Outline of
Unresponsiveness)
AVPU
ACDU
Metoda rangsang nyeri pada kesadaran menurun
Eye opening
Spontaneous = 4
To speech = 3
To painful stimulation = 2
No response = 1
Glasgow Coma Scale
Motor response
Follows commands = 6
Makes localizing movements to pain = 5
Makes withdrawal movements to pain = 4
Flexor (decorticate) posturing to pain = 3
Extensor (decerebrate) posturing to pain = 2
No response = 1
Verbal response

Oriented to person, place, and date = 5

Converses but is disoriented = 4
Says inappropriate words = 3
Says incomprehensible sounds = 2
No response = 1
STEREOTYPED MOTOR RESPONSE

Decorticate hemispheric damage
with preservation of motor centers
in the upper portion of the brain
stem (eg, rubrospinal tract).
Decerebrate the upper brain

stem motor centers damage only
the lower brain stem centers (eg,
vestibulospinal tract, reticulospinal
tract), which facilitate extension,
are responding to sensory stimuli.
Flaccidity without movement the lower brain stem is not affecting
movement

Pola pernafasan dikaitkan lokasi lesi
Cheyne Stokes lesi pada hemisfer serebri /

batang otak bagian atas
Central neurogenic hyperventilaion

= 40-70/m (Kussmaul/ Biot ) lesi pada
tegmentum serebri / bagian atas pons

Apneustic lesi pada Pons

(bilateral)
Ataksik lesi pada bagian dorsomedial

formatio reticularis dan medula oblongata
Apnea lesi pada bagian

Ventrolateral Medulla (bilateral)
Pola pernafasan dikaitkan lokasi lesi

Cheyne Stokes lesi pada
hemisfer serebri / batang
otak bagian atas
Central neurogenic hyperventilaion
lesi pada tegmentum serebri /
bagian atas pons
Apneustic lesi pada Pons
(bilateral)
Ataksik lesi pada bagian
dorsomedial formatio
reticularis dan medula oblongata
Apnea lesi pada bagian

Ventrolateral Medulla (bilateral)
The Pupils
Lesion
Location
Eyes Position
Light
Reflexes
PUPIL
SIZE
Hemisphere
Conjugate
deviation to
destructive
lesion side
Normal
Normal
Thalamus
See to the nose
Negative
Small
Pons
Medial eyes
(Dolls eyes)
Negative
Small
Cerebellum
Medial eyes
Normal
Big

EYES PICTURE
Kelainan pupil dikaitkan lokasi lesi
Refleks Batang Otak (RBO)
Pupil reflexes
Dolls eye
phenomenon
Vomiting
reflexes
Corneal
reflexes
Oculovestibular reflexes/
cold-water calories testing

PYRAMIDAL -TRACT LESIONS
Motoric UMN paresis

/paralysis
Physiol Reflexes increase
Pathol Reflexes (+)
Muscle Tonus increase
Right
Left
Right Hemiparesis
(lesion of left internal capsule)
Crossed Paresis
(left midbrain lesion causing
left oculomotor nerve palsy
and right hemiparesis
Crossed Paresis
(lesion at the level of the
pyramidal decussation
causing paresis of right arm
and left leg
Intrakranial Herniasi
Tanda-Tanda awal herniasi unkus
Tanda-Tanda lanjut herniasi unkus
Tanda-Tanda awal herniasi sentral / trantentorial
Tanda-Tanda lanjut herniasi sentral / trantentorial
Tanda-Tanda herniasi sentral / trantentorial

(midbrain-upper pons)
Tanda-Tanda herniasi sentral / trantentorial

(lower pons med. oblongata)
DIAGNOSTIC TOOLS
Adopted from Laureys, 2011
Adopted from Laureys, 2011
Bruno et al, 2011
Bruno et al, 2011
Vegetative State / Coma Vigil / Apallic State

Responsiveness and
awareness negatip fungsi
kognitip (-)
Akibat disfungsi hemisfer
serebri dengan batang otak
dan diensefalon normal
Refleks Otonom, refleks
motorik dan siklus tidur
normal
> 1 bulan

Vegetative State / Coma Vigil / Apallic State
Etiologi : tu pasca hipoksia (ensefalopati) / trauma

Prognosis : dubia
Terapi : Suportip
Harapan hidup : 2 5 tahun
C.o.d : infeksi (paru / ISK)
Multi organ failure

LOCK-IN SYNDROME
The locked-in syndrome describes a state in which the
patient is de-efferented, resulting in paralysis of all four
limbs and the lower cranial nerves.

Demerti, 2010
LOCK-IN SYNDROME
Locked-in syndrome can be caused by
stroke at the level of the basilar artery
suppling denying blood to the Pons,
among other causes..
Unlike persistent vegetative state, in
which the upper portions of the brain
are damaged and the lower portions
are spared, locked-in syndrome is
caused by damage to specific
portions of the lower brain and
brainstem with no damage to the
upper brain.

Demerti, 2010
Agranoff, 2007
Brain death
1959 (Mollaret &
Goulon) Irreversible
coma
1971 (Mohandas & Chou)
a critical component of
severe brain damage
1979 (Model Brain Death
Kebutuhan penggunaan
Act / US) Irreversible
ventilator jangka panjang.
cessation of
Kemungkinan terjadinya
circulatory and
pemberian harapan yang tidak
respiratory function
All function of brain
tepat kepada keluarga penderita.
Diagnosa Brain death

perlu ditegakkan

Brain death
Death :
Irreversible end of
life.
Irreversible cessation
of heartbeat and
respiration.
Brain Death :

Death of the brain

without cessation of
the heart beat.
Kriteria MBO (Brain death)

Harvard Committee (1968).
The Minnesota Criteria (1971).
Presidents Commission for the study of Ethical Problem in
Medicine and Biomedical and Behavioral Research, USA (1981).
UK criteria (1995).
AAN 1995.
Brain Death is defined as the irreversible loss of the

capacity for consciousness combined with the
irreversible loss of all brainstem functions including
the capacity to breathe.

Brain Death
Eelco F.M. Wijdicks, M.D.
N Engl J Med, Vol. 344, No. 16 April 19, 2001
Singkirkan :
Gangguan
keseimbangan
asam-basa dan
elektrolit.
Otak
Hipothermia berat
Refleks okulosefalik.
( < 32o C).
Refleks pupil /
Hipotensi.
cahaya.
Intoksikasi
Refleks kornea.
neuromuscular
Test irigasi
inhibitor.
Refleks batuk /
muntah.
Test Sulfas Atropin.
Test apneu
Koma (GCS 3).

Pupil dilatasi
Refleks Batang
maksimal.
Ventilator
Should never be
diagnosed hurriedly
in the emergency
room.
NEGATIP
Brain Death (Eelco, 2001)
Should never be diagnosed hurriedly in the

emergency room
Evaluasi :
2x
< 2 mo
48 hrs
2 mo 1 y
24 hrs
1 18 y
Facultative.
> 18 y
Facultative
Guidelines for determination of death JAMA 246:333,393. 1978
Pemeriksaan tambahan Dx Brain death

Eelco, 2001
Pemeriksaan
Cerebral angiography
Keterangan
Absence of intra-cerebral filling of the
intracranial arteries at the entry into the
skull.
EEG
Transcranial Doppler
(TCD).
electro-cerebral silence
Small systolic peaks in early systole with
retrograde (reverberating, oscillation) or
absent flow during diastole
Cerebral Scintigraphy
Atropine test
Vagal component of 10th nerve
Jugular bulb oxygen saturation

SSEP / BAEP
Kesimpulan
Kesadaran menurun merupakan keadaan emergensi
Kesadaran menurun dapat disebabkan oleh berbagai
kelainan baik intra maupun ekstrakranial.
Diagnosis yang cepat dan tepat merupakan tantangan
utama guna penatalaksanaan yang edekuat.
Diagnosis dapat ditegakkan dengan pemeriksaan
fisik, neurologis dan dengan bantuan pemeriksaan
penunjang yang sesuai.

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Kuliah Kesadaran Menurun UNTAR Mei 2012 (Presentasi)

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KESADARAN MENURUN

1. Dari data yang ada dapat disimpulkan

2. Pemeriksaan penunjang yang perlu

Kadar gula darah

3. Apabila pada pemeriksaan fisik didapatkan

Brain CT-Scan / MRI

William James : consciousness as awareness

Kesadaran diartikan sebagai hasil

ARAS menyalurkan impuls dari midpons ke rostral melalui

Laureys et al, 2002

TWO AWARENESS NETWORK

awareness (content of consciousness)

Neurotransmiter pada alertness / arousal

Neuron aminergik pada formasio retikularis

Nucl. Raphe midbrain,

Midbrain, pons, medulla

Schematic diagram of the noradrenergic system

Terman & Bonica, 2001

Diagram of the origin and projection of the serotonergic system

N. Central superior (B6. 8)

Terman & Bonica, 2001

Modifikasi Meliala, 2003

Glutamat dan aspartat.

Sintesa pada korteks cerebri.

A summary diagram of the ascending arousal system

Plum and Posners 2007

minimally reduced wakefulness or awareness, hyperexcitability and

Disoriented (rst to time, next to place, and then to persons in their

a mild to moderate reduction in alertness, accompanied by a lesser

condition of deep sleep or similar behavioral unresponsiveness from

Deep sleep / Trance unresponsiveness in which the patient lies

Plum and Posners 2007

Principles and Practice of Emergency Neurology, 2003

Principles and Practice of Emergency Neurology, 2003

Cerebral blood flow (CBF)

Peningkatan ekstraksi O2 untuk

Peningkatan glikolisis anaerobik

Hiperglikemia kesadaran menurun

Hiperglikemia kesadaran menurun

Endocrinol Metab Clin N Am 35 (2006) 725751

Hipoglikemia (<70 mg/dl)

Suppression / inhibition of insuline release

Hipoglikemia (<70 mg/dl)

Suppression / inhibition of insuline release

Sweating (berkeringat dingin)

Death (if untreated)

CLINICAL DIABETES. Volume 24, Number 3, 2006

Ggn fungsi hati

Plum and Posners 2007

Ensefalopati hiper / hipo-Natremia

Plum and Posners 2007

Obat-obat berpengaruh pada kesadaran

Principles and Practice of Emergency Neurology, 2003

Evaluasi penderita kesadaran menurun

The Merck Manual for Health Care Professionals, 2008

Diagnosis dan ABC koma

Evaluasi penderita kesadaran menurun

Principles and Practice of Emergency Neurology, 2003

(Glasgow Coma Scale)

Skala lain penilaian kesadaran

Innsbruck Coma Scale

Metoda rangsang nyeri pada kesadaran menurun

Plum and Posners 2007