Basic Management of

Loss of Consciousness in
Adult
Hasanul Arifin

Medan Emergency Meeting 2013

Minggu , 8 Desember 2013

Penderita Gawat
Darurat
Penderita yang oleh karena suatu penyebab
(penyakit, tindakan, kecelakaan)
bila tidak segera ditolong akan cacat,
kehilangan anggota tubuh atau meninggal

Silent epidemic

So I said Hey Yallwatch this

4/12/16

The Golden Hour

is the time in which resuscitation of severely

injured patients must begin to achieve maximal
survive
R. Adams Cowley, MD

The lethal factor in shock is inadequate cellular oxygen

delivery, leads to irreversible anoxic cellullar injury that
kills a critical mass of cells

THE GOLDEN
Probability
of Survival
HOUR

R. Adams Cowley, MD

100
80
%
survival

60
40
20
0

30

60

90

Survival is related to severity

and duration
6

minutes

Percent of trauma deaths

The Trimodal Distribution of

Traumatic Disease
50

40
30
20
10
//
0
1
2
3
4.hrs
1-2
5-6
Time after injury
weeks
IMMEDIATE : CNS injury or Heart and great vessel
injury
EARLY : Major
hemorrhage
LATE : Infection and Multi Organ failure
0

Time Saving is Life Saving

Waktu untuk bertindak terbatas
Data dasar untuk bertindak
terbatas

Konsep dasar berfikir yang

sederhana, tindakan yang
sistematik, dan ketrampilan yang
memadai.

Handling trauma patients requires

different mindset

TIME SAVING is LIFE SAVING

Prognosis pasien trauma paling baik pada jam pertama.

Dalam waktu satu jam terapi definitip harus sudah dikerjakan

The Golden Hour

Pasien Trauma
Life Support
Resusitasi,
Stabilisasi
Terapi Definitif,
Spesialistik

A = airway
B = breathing
C = circulation
D = disability

Initial
Assessment !!!!

Sistematika
Triase
Survei Primer
Survei Sekunder
Stabilisasi
Rujukan
Terapi Definitif

Triage
Sorting of patients according to:
ABCDEs
available resources

Multiple casualties
Mass casualties

> 200 DEAD & more than 500 INJURED

TRIAGE & LABEL

Merah

Segera Ditanggulangi terlebih dahulu :

Mengancam Jiwa
Cacat

Kuning

Boleh Ditangguhkan :
Keadaan tidak mengancam Jiwa
Segera ditangani bila yang
mengancam Jiwa sudah teratasi

Hijau

Hitam

Boleh ditunda & Rawat Jalan :

Tidak Membahayakan Jiwa
Boleh Diabaikan & Ditinggalkan :
Diurus paling akhir
Sudah tidak ada tanda- tanda vital
Usaha usaha pertolongan amat
sangat kecil keberhasilannya

TRIASE

Survei primer,
Survei sekunder

Terapi Definitif,
Rujukan

KLINIK

RUMAH SAKIT
TERDEKAT

Quick Dx, Quick RX

RUMAH SAKIT
LENGKAP,

Resusitasi

KAMAR OPERASI,

& Stabilisasi

ICU

PTC

Hanya 50% pasien

trauma yang perlu
operasi

Survei Primer
dewasa/pediatrik/ wanita hamil
prioritas yang sama

Periksa cepat berurutan

Selesai dalam 2 menit
Terapi segera apa yang ditemukan
( treat as you find )

A
B
C
D
E

Survei Primer
Airway

Jalan nafas

Breathing

Pernafasan

Circulation

Sirkulasi

Disability

Kesadaran

Exposure

Pemaparan

Primary Survey
A airway with C-spine protection
B breathing
C circulation with hemorrhage
control
D disability
E exposure/environment

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure

Primary Survey
A
Establish patent airway
assume C-spine trauma

Pitfalls

equipment failure
inability to intubate
occult airway injury
progressive loss of airway

Airway
menilai jalan nafas
Bisa bicara ?
Look, listen, and feel
Gerak dada
Gerak otot nafas tambahan
Warna kulit, mukosa, kuku

Airway
waspada
Obstruksi jalan nafas
Cedera dada dengan gangguan nafas
Cedera tulang leher

Primary Survey

Suspect C-spine injury

spinal protection
C-spine X-ray when appropriate

Pasien tidak sadar

Sumbatan jalan nafas

paling sering oleh karena
jatuhnya pangkal lidah

Airway

mengatasi sumbatan jalan nafas

Chin lift, jaw thrust

Bersihkan rongga mulut
Oro atau nasopharyngeal tube
Lindungi tulang leher
Intubasi trakhea

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure

Primary Survey
B

Assess
Oxygenate
Ventilate
Pitfalls:
Airway vs ventilation problem
iatrogenic pneumothorax/tension
pneumothorax

Breathing
menilai pernafasan
Apakah ada udara keluar masuk
Frekwensi nafas
Cuping hidung
Cekungan sela iga

Breathing
waspada
ada jejas didada

Tension pneumothorax
Open pneumothorax
Fracture costa, Flail chest
Hematothorax
Kontusio paru

Breathing

membantu pernafasan

Beri oksigen ( jika ada )

Pernafasan buatan (AMBU)
Dekompressi pneumothorax
Drain thorax

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure

Primary Survey
C
Assessment of organ perfusion
Level of Consciousness
Skin color and temperature
Pulse rate and character

Primary Survey
C
Circulatory Management
Control Hemorrhage
Restore Volume
Reassess

Pitfalls:

elderly, athletes, children

medications

Circulation
menilai sirkulasi
Cardiac output
Volume darah
Perdarahan (external,internal)

Circulation

waspda dan cari lokasi perdarahan

Cedera intra abdominal

Cedera dada
Patah tulang panjang
Patah tulang pinggul
Luka tusuk, tembus
Luka kulit kepala

Circulation
shock ?
Perfusi : pucat, dingin, basah,
capillary refill time lambat
Nadi >100x/m
Tekanan darah <100 mmHg
Jika shock(+) posisi shock

Estimasi tekanan darah

Jika teraba nadi di :

Radialis systolik > 80 mmHg

Femoralis systolik > 70 mmHg
Carotis systolik > 60 mmHg

Circulation

mengatasi perdarahan
Hentikan perdarahan
Posisi shock
pasang infus besar (2)
ambil sampel darah
cross-match & periksa Hb
Beri infus cairan :
RL, RA, NaCl 0.9% 1000
ml guyur cepat, hangat

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure

Primary Survey
D
Disability
Baseline neurologic evaluation
GCS Scoring
Pupillary response

Continuously reassess for

deterioration/changes

Disability
menilai kesadaran
Periksa pupil (besar, simetri, refleks cahaya)
Periksa kesadaran
A = Awake (sadar penuh)
V = respond to Verbal command (ada reaksi
terhadap perintah)
P = respond to Pain (reaksi thdp nyeri)
U = Unresponsive (tidak ada reaksi)

Survei Primer
Airway
Breathing
Circulation
Disability
Exposure

Primary Survey
E
Exposure
Completely undress the patient

Environment
core temperature
prevent hypothermia

Exposure
pemaparan

Lepaskan semua pakaian untuk pemeriksaan

teliti menyeluruh, ada jejas apa saja.
Periksa punggung,(miringkan pasien dengan
cara Log Roll)
Cegah hypothermia (jangan kedinginan)

X foto
(kalau ada)

Tulang leher
Dada
Panggul

Alur Pasien

Pasien datang
Survei primer
stabil

Tidak stabil

Survei sekunder

Survei primer &

stabilisasi

stabil
Tidak stabil lagi
Survei primer lagi

Survei Sekunder

Lanjutan survei primer

Hanya bila ABC sudah stabil
Teliti kepala sampai kaki
Kembali survei primer bila pasien
menjadi tidak stabil atau kondisi
memburuk

Setelah survei sekunder

Pasien stabil
Rujukan
Definitive care

ingat !!!!
Periksa ulang ABCDE
Jika pasien kembali tidak
stabil

a
d
a
p
i
t
d
a
a
j
r
r
u
e ar
t
g td
n
a wa
y
n ga
a
a isi
d
a nd
e
K ko

Penurunan Kesadaran
Penyebab :
Intrakranial
Trauma kepala
( traumatic brain
injury)
SOL ( tumor otak)
Brain edema
Infection
dll

Extra kranial :
Kelainan metabolik
:
Elektrolit
Hypoglikemia
Hyperglikemia

Ginjal
Liver
Sepsis
dll

Penurunan Kesadaran
ok Proses Intrakranial

Penyebab tersering adalah TBI

TIK yg meningkat
CPP = MAP ICP
CPP 70 mmHg.
MAP =

1Syst + 2 Diast
3

Causes of ICP: Epidural Hematomas

Slides from Haines:Fundamental Neuroscience for Basic and Clinical Applications 3e -www.studentconsult.com

EDH
Formed when the outer layer of the dura is
stripped from the skull
Always traumatic, usually with skull
fracture
80% temporal or parietal as fracture tears
middle meningeal artery
Usually abrupt
Sudden loss of consciousness
Respiratory arrest

EDH
10% posterior fossa where fracture tears a sinus
10% frontal where fracture tears a small
meningeal artery
Insidious (72 hr) onset of headache and late coma

5% have lucid interval

Initial loss of consciousness due to concussion
The patient awakens after the concussion wears off
Second LOC occurs later due to the EDH

Radiography
Potential space
Dissects the outer layer of the dura from the
inner table of the skull
The dura is permanently fused to the skull
at suture lines
Blood is limited to the space between the
sutures and assumes a convex shape

Causes of ICP: Epidural Hematomas

Slides from Haines:Fundamental Neuroscience for Basic and Clinical Applications 3e -www.studentconsult.com

TIK
sebagai kata kunci
Primary Brain injury

Secondary Brain injury

Cegah peningkatan TIK

Ventilasi & Oksigenasi

Posisi head up 30 450
Kepala leher lurus jangan tertekuk
MAP 90 mmHg
Cegah / terapi Shivering
30 45
Cegah/ terapi Kejang
Cairan infus dgn osmolaritas > 295
mOsm/L
0

Keep the airway clear

Jika pasien sadar, ajak bicara

Berikan oksigen (jika ada)

masker 6 lpm

Jaga tulang leher

bicara jelas = tak ada sumbatan

baring datar, wajah ke depan, leher

posisi netral

Nilai apakah jalan nafas bebas

adakah suara snoring,64 gargling,

crowing

Tanda sumbatan / obstruksi

mendengkur : pangkal lidah (snoring)
suara berkumur : cairan (gargling)
stridor : kejang / edema pita suara
(crowing)
MAKIN
PARAH

gelisah (karena hipoksia)

gerak otot nafas tambahan
(tracheal tug, retraksi sela iga)

gerak dada & perut paradoksal

sianosis (tanda lambat)
65

Membebaskan jalan nafas

Sumbatan pangkal
lidah
jaw thrust
chin lift
jalan nafas oropharynx
jalan nafas
nasopharynx
intubasi trachea / LMA

Bersihkan cairan
penghisap / suction

Sumbatan66 di plica
vocalis

X
NECK LIFT

CHIN LIFT

X
X

HEAD TILT jangan dilakukan pada

67 trauma

HEAD TILT

68Cara

paling aman : JAW THRUST

Oro-pharyngeal tube

Jangan dipasang jika reflex muntah masih (+)

(Derajat A dan V dari AVPU atau GCS > 10)
69

Oropharyngeal airway
insertion

4/12/16

70

Simple airway adjuncts

4/12/16

71

Naso-pharyngeal tube

Tidak merangsang muntah

Hati-hati pasien dengan fraktura basis cranii
U/ dewasa 7 mm atau jari kelingking kanan
72

Nasopharyngeal tube

4/12/16

73

Ventilasi - Oksigenasi
PaCO2 35-40 mmHg ( GCS 8 Ventilasi
mekanik)
Oksigenasi keep airway clear SpO2 96
%.
PaCO2 < 28 mmHg vasokonstriksi
PaCO2 > 45 mmHg vasodilatasi

TIK

Nasal Cannula

Salter Oxy-Frame

Face Masks

Approximate FIO2 Delivered by Nasal

Cannula
Flow Rate (L/min)

Approximate FIO2*

1
2
3
4
5
6 inspired oxygen
FIO2, Fraction of

0.24
0.28
0.32
0.36
0.40
0.44

Simple Face Mask

Approximate FiO22 Delivered by Simple Face Mask

Flow Rate (L/min)

FiO2*

56
67
78

0.4
0.5
0.6

FiO2, Fraction of inspired oxygen

Posisi kepala leher

30 450

Aliran darah bolak

balik lancar

Tertekuk
Rata atau
head
down

TIK

MAP 90 mmHg
Pada TBI TIK bisa naik s/d 20 mmHg
CPP normal 70 mmHg

CPP = MAP TIK

Hemodynamic tree

PRE-LOAD

CONTRACTILITY

STROKE VOLUME

CARDIAC OUTPUT

4/12/16

Hasanul, 2006

BLOOD
PRESSURE

AFTERLOAD

HEART-RATE

SYSTEMIC
VASCULAR
RESISTANCE
Tissue
Perfusion
81

DO2 = CO x Hb x SaO2 x 1,34

Shivering,
Kejang

Hangatkan
Infus hangat
Anti kejang
R/ Petidin

Oxygen consumption (VO2)

( 5-6 x )

Osmolaritas Cairan Infus

Perpindahan cairan di jaringan otak
ditentukan oleh osmolaritas cairan
Hypoosmolar ( <295 mOsm/L) masuk
ke ISF dan ICF edema otak TIK naik
Hyperosmolar (> 295 mOsm/L) tarik
air dari ISF dan ICF ke IVF TIK turun

Kristalloid
Equi(iso)osmolar to normal plasma (290-295 mOsm/L)
F l

Osmolarity
(mOsm/L)

Lactated Ringers Solution

273

Acetate Ringers Solution

273

Ringers Solution

310

0.9% Saline

308

0.45% Saline

154

20% Mannitol

1098

Tumor Otak
dgn penurunan kesadaran

TIK naik
Ventilasi oksigenasi
Posisi, MAP, Cairan Hyperosmolar
( Mannitol), Steroid, Operatif

Penurunan Kesadaran
ok ggn Elektrolit
Hyponatremia

Replacement dgn
NaCl hypertonic

HYPONATREMIA

definition

Na

< 135 mmol/L

Clinical Manifestation
CNS dysfuntion
( large or rapidly)
headache, nausea, vomiting, muscle cramps,
lethargy, restlessness, disorientation.
severe and rapidly seizure, coma, brain
damage, respiratory arrest, brain stem
herniation, death

management
The optimal treatment of
hypotonic hyponatremia requires
balancing the risks of
hypotonicity against those of
therapy
There is no consensus about the
optimal treatment of symptomatic
hyponatremia

Management (cont)
Reverse the manifestation of hypotonicity, but not be so
rapid and large as to pose a risk of the development of
osmotic demyelination (CPM)
Recommend :
The initial rate of correction can still be 1 to 2
mmol/L/hr for several hours in patients with severe
symptoms
A targeted rate of correction that does not exceed 8
mmol/L/day.

Case
Symptomatic Hypotonic Hyponatremia

Concentrated urine (> 200 mOsm/kg.H2O)

Euvolemia or hypervolemia
Th/ hypertonic saline + Furosemide
Electrolyte free water intake must be witheld

Dilute urine (< 200 mOsm/kg.H2O)

Less serious symptoms
Th/ only water restriction and close observation
Severe symptoms
Th/ call for infusion of hypertonic saline

Formula
Change in serum Na+
Infusate Na+ - serum
= Na+
Total body water +1

Clinical use :
Estimate the effect 1 liter of any infusate on
serum Na+

case : a 32 year-old woman,

hyponatremia (serum Na+: 112 mmol/L), BW :

46 kg,

1L of NaCl 3% 513 mmol Na+

Retention 1L of NaCl 3% formula
(513-112) : (23+1) = 16.7 mmol/L
to raise the serum Na+ concentration by 3 mmol /L
over the next three hours =( 3:16.7)x1000ml = 180
ml
= 60 ml NaCl 3%/hr

Na+, 115 mmol/L, dalam 24 jam

kedepan akan dinaikkan menjadi 125
mmol/L

(513-115) : (23+1) = 16.6 mmol/L

(10 :16.6) x 1000 mL = 600
ml/24jam = 25ml/jam = 8
tetes/menit

hank you for listeni