Evaluasi dan

Penatalaksanaan
Kesadaran Menurun
Mercy Tobing
Bagian Neurologi RSU Bekasi
PENDAHULUAN
 Penyebab kesadaran menurun
40% Hipoksia Iskemik : karena jantung, tindakan anastesi,
stroke
18% Over dosis obat-obatan
21% Lesi masa
21% Metabolik
 Perlu waktu cepat untuk tindakan efektif dan diagnosis
 Pada tiap perubahan kesadaran dianggap akut dan
emergency
 Menemukan penyebab menstabilkan fungsi vital tubuh
 Perbaikan yang cepat untuk memulihkan gangguan yang
reversible
 Kesadaran terdiri dari
komponen
 AROUSE (bangun/bangkit diri)
 AWARE (sadar situasi)

Definisi : Suatu keadaan proses aktif

sebagai sadar akan diri dan
lingkungan/situasi/orientasi
Gambar Anatomi Kesadaran

Korteks

Talamus

Formasi retikularis
Penyebab Kesadaran Menurun

 Lesi masa supra atau infratentorium

 Lesi destruktif pada subtentorium atau

efek toksik

 Lesi difuse pada korteks serebri

Klasifikasi

1. Gangguan kesadaran

2. Gangguan kesadaran + kelainan fokal

/ lateralisasi + kaku kuduk

3. Gangguan kesadaran + kelainan fokal

Gangguan kesadaran umum

1. Gangguan vaskular
2. Gangguan metabolik
3. Intoksikasi
4. Infeksi sistemis
5. Hipertermia
6. Epilepsi
7. Trauma kepala
Tingkat Kesadaran 1

 UMUM

- Komposmentis
- Apatis
- Somnolen
- Soporos
- Koma - Vigil
- Vegetatif
- Lock in
Tingkat Kesadaran 2

 KWANTITATIF

- Skala Koma Glasgow (SKG)

- Mata (E) = 4
- Verbal (V) = 5
- Motorik (M) = 6
Tertinggi 15, terendah 3
Diagnosis 1

 Anamnesis

 Pemeriksaan fisik umum

 Pemeriksaan fisik neurologis

 Pemeriksaan penunjang
Diagnosis 2

 Anamnesis

- Proses kejadian
- Demam ?
- Riwayat penyakit dahulu ?
Diagnosis 3

 Pemeriksaan fisik umum

- Tanda-tanda vital
- Bau napas
- Pemeriksaan kulit
- Kepala
- Leher
- Toraks, abdomen, ektremitas
Diagnosis 4

 Pemeriksaan fisik neurologis

- Derajat kesadaran
- Periksa mata
- Periksa motorik
- Rangsang nyeri
- Pemeriksaan reflex
Pemeriksaan Penunjang 1

LABORATORIUM
 Darah perifer lengkap
 Gula darah
 Ureum, Kreatinin
 SGOT, SGPT
 Analisa Gas Darah
 Elektrolit
 Toksikologi
Pemeriksaan Penunjang 2

RADIOLOGIS
 Foto kepala
 Foto toraks
 CT Sken otak
LAIN-LAIN
 EKG
 LP
Terapi 1

UMUM

 Tirah baring posisi kepala > tinggi

300
 Resusitasi ABC
 Imobilisasi (Fraktur servikal)
 NGT
 Kateter
Terapi 2

KHUSUS
Pada TIK meninggi / herniasi
 Manitol 20%
 Kortikosteroid
 Indikasi operasi Konsul Bedah Saraf
 Antibiotik
 Neurotropik
 Citicholin
 Piracetam
 Vitamin B1, B6, B12
Terapi 3

KHUSUS
Tanpa TIK meninggi / herniasi
 Observasi pemeriksaan
neurologis ulang

 LP
 Classification
and Major
Causes of Coma
 STRUCTURAL BRAIN INJURY

 Hemisphere
 Unilateral (with displacement)
 Intraparenchymal hematoma
 Middle cerebral artery (MCA) occlusion with
swelling
 Hemorrhagic contusion

 Cerebral abscess

 Brain tumor
STRUCTURAL BRAIN INJURY
 Bilateral
 Penetrating traumatic injury
 Multiple traumatic brain contusions

 Multiple cerebral cortical infarcts (vasculitis,

coagulopathy, cardiac thrombus)
 Bilateral thalamic infarcts

 Lymphoma

 Encephalitis (viral, paraneoplastic)

STRUCTURAL BRAIN INJURY

 Gliomatosis

 Acute disseminated encephalomyelitis

 Anoxic-ischemic encephalopathy

 Cerebral edema

 Multiple brain metastases

 Acute hydrocephalus

 Leukoencephalopathy (chemotherapy or
radiation)
 STRUCTURAL BRAIN INJURY

 Brainstem
 Pontine hemorrhage
 Basilar artery occlusion

 Central pontine myelinolysis

 Brainstem hemorrhagic contusion

 STRUCTURAL BRAIN INJURY

 Cerebellum (with displacement)

 Cerebellar infarct
 Cerebellar hematoma

 Cerebellar abscess

 Cerebellar glioma
 ACUTE METABOLIC-
ENDOCRINE DERANGEMENT
 Hypoglycemia
 Hyperglycemia (nonketotic hyperosmolar)
 Hyponatremia
 Hypernatremia
 Addison’s disease
 Hypercalcemia
 Acute panhypopituitarism
 Acute uremia
 Hyperbilirubinemia
 Hypercapnia
DIFFUSE PHYSIOLOGIC BRAIN
DYSFUNCTION

 Generalized tonic-clonic seizures

 Poisoning, illicit drug use

 Hypothermia

 Gas inhalation

 Basilar migraine

 Idiopathic recurrent stupor

 PSYCHOGENIC
UNRESPONSIVENESS

 Acute (lethal) catatonia, malignant

neuroleptic syndrome
 Hysterical coma

 Malingering
Diagnostic Workup
of Comatose
Patient
LABORATORY STUDIES CAUSE OF COMA
Glucose Hypoglycemia
Nonketotic hyperglycemia
Diabetic ketoacidosis
Complete blood count Sepsis
Urinalysis Urosepsis
Natrium Hyponatremia
Hypernatremia
Calcium Hypercalcemia
Hypocalcemia
Magnesium Hypermagnesemia
Liver function tests Hyperbilirubinemia
Hyperammonemia
Renal function tests Acute uremia
Thyroid function tests Acute hypothyroidism
Urine toxicology screen Intoxication
Arterial blood gas analysis Hypoxia
Hypercapnia
Lactate Lactic acidosis
Physical Examination for Coma
Treatment
1. Airway, breathing, and circulation – initial resuscitation
2. Respiration – upper and lower airway dysfunction
3. Overall level of consciousness
4. Cranial nerve examination: eye movements; pupillary
responses; oculocephalic and vestibuloocular reflex;
corneal, cough and gag reflex
5. Motor examination: resting posture, spontaneous
motor activity, response to stimulation
6. Systemic examination: temperature; funduscopic;
ear,nose, and throat; integument; cardiac and
vascular; abdomen
Clinical Features with
Special Significance
FINDING SIGNIFICANCE

ODORS
Musty Uremia
Fruity Ketoacidosis
Fishy Hepatic failure

SKIN LESIONS
Bullae, blister Barbiturate overdose
Rash, purpura, petechiae Meningitis, DIC, sepsis, endocarditis
Maculopapular rash Viral meningocephalitis, endocarditis, fungal infection
Vesicular rash Herpes simplex virus or varicella infection
Needle track marks Intravenous drug abuse
Wet skin Cholinergic overdose
Dry skin Anticholinergic overdose
Ecchymosis, petechiae Trauma, steroids, liver disease, anticoagulants, DIC, TTP
Hyperpigmentation Addison’s disease, porphyria, malignant melanoma, chemotherapy
FINDING SIGNIFICANCE

FUNDAL EXAMINATION
Retinopathy Hypertention, diabetes
Papilledema Raised intracranial pressure, hypertensive
retinopathy, carbon dioxide retention
Subhyaloid hemorrhage Subarachnoid hemorrhage

ENT EXAMINATION
Otorrhea, hemotympanum, mastoid or Basal skull fracture
periorbital
Glasgow Coma Scale
 SCORE
EYE OPENING
Spontaneous 4
To speech 3
To pain 2
None 1
BEST MOTOR RESPONSE
Obeys 6
Localizes to pain 5
Withdraws to pain 4
Flexor (decorticate) 3
Extensor (decerebrate) 2
None 1
BEST VERBAL RESPONSE
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
None 1
 Other Investigations
STUDY INDICATION

Computed tomography (CT) Almost any unconscious patient, especially with focal signs
brain scan
Lumbar puncture Suspected meningitis, encephalitis, or occult subarachnoid
hemorrhage
Angiogram Suspected basilar artery thrombosis
Electroencephalogram Suspected nonconvulsive status epilepticus and for monitoring
of patient’s seizures during treatment
Magnetic resonance imaging Suspected cerebral venous sinus thrombosis, basilar artery
or magnetic resonance occlusion, cerebellar or brainstem infarction not well visualized
venography (MRV) on CT; adjunctive test for herpes simplex encephalitis