KEDARURATAN

NEUROLOGI
(Brain Emergencies)

DR Dr Anwar Wardy W, SpS,DFM

Maret 2015
anwar wardy w Dept.Neyrosain FKK.UMJ.2010
 The General Principle For Managing
Brain Emergencies

Principle I: (Kaidah I)
Kerusakan sistem saraf tidak menyebabkan
kematian organ yang disarafi. Jaringan dan
fungsi diharapkan dapat diperbaiki.

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Emergency Symptoms

Confusion
Drowsiness
Difficulty
speaking clearly
Numbness in any part of the body
One pupil that is larger than the other

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 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,
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 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

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 TRAUMA

Concussion
Cerebral contusion
Epidural hematoma
Subdural hematoma/effusion
Intracerebral hematoma
Diffuse axonal injury

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 EPIDURAL HEMATOMA

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Anwar Wardy W.FKK.UMJ
 SUBDURAL HEMATOMA

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Anwar Wardy W.FKK.UMJ
 Secondary Events
Edema Cerebri
TIK
Obstruksi dari Liquor CS. Anoxia
Vasospasme ICH
Ischemia
Kegagalan Autoregulasi Tumors
Trauma
Kegagalan Collateral supply
Gagal Jantung
Gagal Nafas.
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 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.

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 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 Total = E+V+M
2=No words......only sounds
1=None
Motor Response (M)
6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Decorticate posture
2=Decerebrate
1=None
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Principle III (Kaidah 3)
Stop perdarahan (Stop the Bleeding)

PRINCIPLE iv ( Kaidah 4)

Sirkulasiperedaran daraf keotak

dipertahankan.
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Principle V (kaidah 5)
Penyakit tersebut Struktural atau Non-
Structural.

Biasanya dilakukan dengan pemeriksaan

Rontgen / CT.Scan atau
Suspect N-Struktural dengan LP.

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 INFRATENTORIAL LESIONS
Brainstem symptoms are often seen
initially
Sudden onset of coma
Cranial nerve abnormalities
Alteration of the respiratory pattern

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 PROGRESSION OF MASS LESIONS

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 TYPES OF BRAIN HERNIATIONS

1= subfalcine
2 = uncus
3 = caudal
displacement
4 = cerebellar
tonsils

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Anwar Wardy W.FKK.UMJ
 HERNIATION SYNDROMES
Tonsillar or Foramen Magnum Herniation
Displacement of brainstem and cerebellar tonsils
into the foramen magnum
Progressive ALOC, hypertension, bradycardia and
irregular respirations (Cushing Triad)
Transtentorial herniation
Displacement of medial aspect of temporal lobe
into tentorial hiatus
ALOC, ipsilaterial pupillary dilatation, contralateral
hemiparesis
Upward tentoral herniation
Cerebellar vermis moves into incisura
Produces brain stem compression

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Anwar Wardy W.FKK.UMJ
 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.

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Bleeding or swelling in the brain can
cause pressure that forces the brain
downward in the skull.

Herniation: The Brain Under Pressure

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 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

Anwar Wardy W.FKK.UMJ

 r t
p o
S u p
Part I. Neurological Examination
stic
agn
o and Neurodiagnostic Testing
Di
n
ai
M

1. Neurological examination;
2. Neuroradiology;
3. Electroencephalography;
4. Lumbar puncture;
5. Electromyography;
6. Electronystagmography;
7. Evoked potentials;
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Part II. Common Neurological
Presentations

8. Altered level of consciousness;

9. Headache;
10. Weakness;
11. Dizziness;
12. Seizures;
13. Gait disturbance;
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Part III. Specific Neurological
Conditions:
14. CNS infections in adults; 22. Dementia;
15. Viral encephalitis; 23. Neurooncology;
16. Vascular disease; 24. Neuropsychiatric
17. Movement disorders;
25.Neuroanesthesiology;
18. Neuromuscular disorders; 26. TIK
19. Musculoskeletal and neurogenic pain;
20. Neuroophthalmological disorders;
21. Multiple sclerosis; 28. Sleep disorders;
27. Normal pressure hydrocephalus;
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

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 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

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 Part V. Pediatric Neurology

33. Hydrocephalus and shunts in

children;
34. Pediatric CNS infections;
35. Pediatric stroke;
36. Pediatric seizures;
37. The hypotonic infant;

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Anwar Wardy W.FKK.UMJ

 Part VI. Neurological Emergencies
of Pregnancy:

38. Neurological emergencies of

pregnancy;

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 Part VII. Brain Resuscitation and
Neurotoxicology:
39. General neurotoxicology;
40. Neurotoxicology of alcohol and
substances of abuse;
41. Brain resuscitation.

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

 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.
anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

anwar wardy w Dept.Neyrosain FKK.UMJ.2010

Anwar Wardy W.FKK.UMJ

Bahan Bacaan:
Gilroy John, Textbook Medical Neurology, MacMillan Publ. co.Inc. 5th Edition
London, 2009.
Surgery, and Internal Medicine, Neuroscience Intensive Care Unit, 2006.
Epstein, Owen, Clinical Examination on Neurology Emergency, Mosby 2005

TERIMA KASIH,
.Wassalam..//

a2w@telkom.net FKK.UMJ.Juni 2008

Anwar Wardy W.FKK.UMJ