Kesadaran dan Mati Batang Otak

Dr Khairul Ihsan Nasution SpBS

KESADARAN

Individu yang sadar adalah seseorang yang

terbangun serta waspada terhadap diri dan
lingkungannya.
dua bagian utama sistem saraf yang
mengatur kesadaran dan harus berfungsi
aktif :
1. formatio retikularis dibatang otak dan
2.cortex cerebri
LOCATION OF BRAIN STEM
BRAIN STEM
Formatio reticularis berperan dalam keadaan
bangun.
Cortex cerebri dibutuhkan untuk keadaan
waspada, yaitu keadaan yang
memungkinkan individu beraksi terhadap
stimulus dan berinteraksi dengan lingkungan.
Gerakan membuka mata merupakan fungsi
batang otak ; berbicara adalah fungsi cortex
cerebri. Secara selektif, obat-obatan yang
menyebabkan ketidaksadaran seperti
anestesia menekan mekanisme kesiagaan
reticular ( reticular alerting mechanism ),
sedangkan obat-obatan yang menyebabkan
keadaan sadar memiliki efek stimulasi pada
mekanisme ini.
Seorang dokter harus mampu mengenali
berbagai tanda dan gejala yang
ditimbulkan oleh berbagai tingkat
kesadaran:
Letargi
Stupor
Koma (tidak sadar).
Pada orang yang latergi, bicara
lambat, serta gerakan voluntar
berkurang dan lambat. Gerakan
mata lambat.
Pasien stupor hanya bicara jika diberikan
stimulus nyeri. Gerakan voluntar hampir
hilang, mata tertutup dan sangat sedikit
gerakan mata spontan. Pasien dengan
stupor dalam tidak akan berbicara ; terdapat
gerakan sekelompok otot pada bagian-
bagiantubuh yang berbeda sebagai respons
terhadap nyeri hebat. Gerakan spontan
mata sangat kurang.
Pasien yang tidak sadar tidak akan
berbicara dan hanya akan menimbulkan
refleks bila diberikan stimulus nyeri, atau
tidak bereaksi sama sekali ; mata tertutup
dan tidak bergerak.
Secara klinis, tidak jarang didapatkan
seorang pasien dengan, misalnya perdarahan
intrakranial, mengalami penurunan kesadaran
secara progresif menjadi letargi, stupor,
koma, kemudian mengalami keadaan
sebaliknya jika terjadi pemulihan.
Untuk menimbulkan perubahan atas
kesadaran, sistem talamokortikal dan
formatio reticularis harus berperan langsung
secara bilateral atau secara tidak langsung
melalui distorsi atau tekanan.
STATUS VEGETATIF PASIEN

Seseorang dapat memiliki formatio

reticularis yang utuh, tetapi kortek
serebrinya tidak berfungsi. Pasien tersebut
terbangun (mata terbuka dan bergerak) dan
memiliki siklus tidur bangun, namun pasien
tidak mempunyai kewaspadaan sehingga
tidak berekasi terhadap stimulus seperti
perintah verbal atau nyeri.
Keadaan ini disebut status vegetatif
persisten, biasanya terjadi setelah cedera
kepala berat atau akibat anoksia serebri.
Sayangnya, pengamat yang tidak
berpengalaman menganggap pasien
tersebut sadar .
Mungkin saja didapatkan keadaan
bangunan tanpa kewaspadaan ; namun,
tidak mungkin memiliki kewaspadaan tanpa
keadaan bangun. Cortex cerebri
membutuhkan input dari formatio reticularis
untuk dapat berfungsi.
 PERSISTENT PERMANENT VEGETATIVE
STATE
Function usually or often preserved:
Brainstem and autonomically controlled visceral
functions: homeothermia; osmolar homeostasis;
breathing; circulation; gastrointestinal functions
Pupillary and oculovestibular reflexes usually remain
and are accentuated
Brief, inconsistent shifting of head or eyes toward
new sounds or sights may occur
Smiles, tears, or rage reactions may occur either
spontaneously or to nonverbal sounds
Reflex postural responses to noxious stimuli remain
 FORMULATIONS OF BRAIN DEATH

Whole-brain: complete and irreversible

cessation of all brain function, including that
of the brain stem

Brain-stem formulation: complete and

irreversible cessation of brain-stem function
alone
 HARVARD CRITERIA (1968)

Unreceptivity and unresponsivity

No movements or breathing
No reflexes
Flat electroencephalogram (EEG)

All of the above four tests are to be repeated at, at least, 24 hrs
with no change.
Exclusion of hypothermia (below 90 F or 32.2 C) or
Central nervous system depressants
 American Academy of Neurology Guidelines
(1995)

Demonstration of coma
Evidence for the cause of coma
Absence of confounding factors, including hypothermia, drugs,
electrolyte, and endocrine disturbances
Absent brainstem reflexes
Absent motor responses
Apnea
A repeat evaluation in 6 hrs is advised, but the time period is
considered arbitrary
Confirmatory laboratory tests are only required when specific
components of the clinical testing cannot reliably be evaluated.
CONFIRMATORY TESTS OF BRAIN DEATH IN
ADULTS

Electroencephalography (EEG)
Cerebral Angiogram
Transcranial Doppler Sonography
Magnetic Resonance Imaging (MRI)
Single Photon Emission Computed Tomography
(SPECT)
Evoked Potentials
Brainstem Auditory Evoked Potentials (BAEP)
Somatosensory Evoked Potentials (SSEP)
Spiral Computed Tomography Scan (Spiral CT Scan)
 Test 1 - Pain
Cerebral motor response to pain
Supraorbital ridge, the nail beds, trapezius
Motor responses may occur spontaneously
during apnea testing (spinal reflexes)
Spinal reflex responses occur more often in
young
If pt had NMB, then test w/ train-of-four
Spinal arcs are intact!
 Test 2 - Pupils
Round, oval, or irregularly shaped
Midsize (4-6 mm), but may be totally dilated
Absent pupillary light reflex
Although drugs can influence pupillary size, the light
reflex remains intact only in the absence of brain death
IV atropine does not markedly affect response
Paralytics do not affect pupillary size
Topical administration of drugs and eye trauma may
influence pupillary size and reactivity
Pre-existing ocular anatomic abnormalities may also
confound pupillary assessment in brain death
 Test 2 - Pupils
Round, oval, or irregularly shaped
Midsize (4-6 mm), but may be totally dilated
Absent pupillary light reflex
Although drugs can influence pupillary size, the light
reflex remains intact only in the absence of brain death
IV atropine does not markedly affect response
Paralytics do not affect pupillary size
Topical administration of drugs and eye trauma may
influence pupillary size and reactivity
Pre-existing ocular anatomic abnormalities may also
confound pupillary assessment in brain death
 Test 3
Eye movement

Oculocephalic reflex = dolls eyes

Oculovestibular reflex = cold caloric test

 Oculocephalic reflex

Rapidly turn the head 90 on both sides

Normal response = deviation of the eyes to
the opposite side of head turning
Brain death = oculocephalic reflexes are
absent (no Dolls eyes) = no eye movement in
response to head movement
Not Barbie, but old fashioned type dolls
 Cold calorics

Elevate the HOB 30

Irrigate one tympanic membrane with iced
water
Observe pt for 1 minute after each ear
irrigation, with a 5 minute wait between testing
of each ear
Facial trauma involving the auditory canal and
petrous bone can also inhibit these reflexes
 Cold calorics interpretation
Not comatose
Nystagmus; both eyes slow toward cold, fast to midline
Coma with intact brainstem
Both eyes tonically deviate toward cold water
No eye movement
Brainstem injury / death
Movement only of eye on side of stimulus
Internuclear ophthalmoplegia
Suggests brainstem structural lesion
 Test 4
Facial sensory & motor responses
Corneal reflexes are absent in brain death
Corneal reflexes - tested by using a cotton-
tipped swab
Grimacing in response to pain can be tested
by applying deep pressure to the nail beds,
supraorbital ridge, TMJ, or swab in nose
Severe facial trauma can inhibit interpretation
of facial brain stem reflexes
 Test 5
Pharyngeal and tracheal reflexes
Both gag and cough reflexes are absent in
patients with brain death
Gag reflex can be evaluated by stimulating
the posterior pharynx with a tongue blade, but
the results can be difficult to evaluate in orally
intubated patients
Cough reflex can be tested by using ETT
suctioning, past end of ETT
 Test 6
Apnea

PaCO2 levels greater than 60 mmHg, 20

mmHg over baseline
Technique:
Pre-oxygenate with 100% oxygen several min
Allow baseline PaCO2 to be ~40 mmHg
Place pt on CPAP or bag-ETT
Observe for respirations for ~6-10 minutes
Get ABG to determine PaCO2
 Confirmatory testing
4 vessel angiography
EEG
30 minutes

Cerebral blood flow = perfusion scan

 NEUROLOGIC STATES RESEMBLING BRAIN
DEATH

Hypothermia
Acute Poisoning
Acute Metabolic Encephalopathies
Akinetic Mutism
Persistent Vegetative State
Locked-in-Syndrome
BRAIN DEATH DETERMINATION IN CHILDREN

No reports of children recovering neurological function who have

met adult brain death criteria on clinical examination
Guidelines for children emphasize history and clinical
examination in determining etiology of coma to eliminate
reversible conditions
Age-related observation periods and need for specific tests
recommended in guidelines for children under 1 year of age
7 days to 2 months: Two examinations and EEGs 48 hrs apart
2 months to 1 year: Two examinations and EEGs 24 hrs apart,
or one examination and an initial EEG showing ECS combined
with a radionuclide angiogram showing no CBF or both
More than 1 year: Two examinations 12-24 hrs apart, EEG and
isotope angiography are optional
 HYPOTHERMIA: CLINICAL FEATURES

Body Core Temperature

35 32 degrees C
Central Nervous System: apathy; dysarthria,
impaired judgment
Cardiovascular: tachycardia, then progressive
bradycardia; cardiac cycle prolongation;
vasoconstriction
Respiratory: tachypnia, to progressive bradypnea;
bronchorrhea; bronchospasm
 HYPOTHERMIA: CLINICAL FEATURES

32 28 degrees C
Central Nervous System: decreased level of
consciousness; hallucinations; papillary dilation
Cardiovascular: Progressive decrease in pulse and
cardiac output; increased cardiac arrhythmias;
Respiratory: Hypoventilation; 50% decrease in
carbon dioxide production per 8 degree C drop
in temperature; absence of protective airway
reflexes; 50% decrease in oxygen consumption
Neuromuscular: hyporeflexia; diminishing shivering,
rigidity
 HYPOTHERMIA: CLINICAL FEATURES

Under 28 degrees C
Central Nervous System: coma; absent
oculocephalic, corneal and bulbar reflexes
Cardiovascular: hypotension, bradycardia,
dysrhythmias, decreased ventricular arrhythmia,
asystole
Respiratory: pulmonic congestion and edema; apnea
Neuromuscular: amobile; areflexia
 RESEARCH DIRECTIONS FOR BRAIN DEATH

Improvements in use of MRI and MRI angiography

Use of multimodality evoked potentials (MEPs), which
test cerebral cortex as well as the brain stem, and
include:
brain-stem auditory evoked potentials (BAEP)
flash-visual evoked potentials (flash VEPs), and
median somatosensory evoked potentials
(median SEPs)
Refinements of imaging technologies (PET, MRI,
SPECT) to achieve greater sensitivity and specificity
Improvements in MEG (magnetoencephalography) to
detect cellular activity in the brain stem
 FUTURE DEVELOPMENTS AND BRAIN
DEATH

Use of electrodes on motor cortex to translate motor

control commands, opens possibilities of translating
and transferring ideas to a computer during process
of dying

Use of electrodes may also provide means for

determining that any organized activity doesnt exist,
which in the absence of mechanical disruption,
would demonstrate the brain is dead.

Understanding the process of neuronal death

(apoptosis) may provide opportunities for
intervention
SEKIAN & TERIMA KASIH