KEGAWATDARURATAN

NEUROLOGI
 Neurologic Emergency Outline

• Change in Mental Status / Coma

• Stroke/TIA Syndromes
• Seizure & Status Epilepticus
• Head Trauma
• Infectious
• Vertigo/Headaches
• Peripheral Neuropathies
 The Neurologic Exam

• KEY!! Must do a complete thorough neuro exam to properly

identify and diagnose any neurologic abnormality.
• Exam should include 5 parts:
– Mental status, level of alertness (GCS)
– Cranial nerve exam
– Motor / Sensory exam
– Reflexes
– Cerebellar
– Consider ; MMSE if Psych components
 Change in Mental Status / COMA

Potential Causes – “TIPS AIUEO”

•T = Trauma, Temperature
•I = Infection
•P = Psychiatric disorder
•S = Seizure , Stroke, Shock, Space occupying lesion
•A = Alcohol ( Drugs & Toxins)
•I = Insulin
•U = Uremia
•E = Endocrine, Exocrine, Electrolyte
•O = Opiates, OD
 Penurunan Kesadaran

Dibagi 3 :
1. Penurunan kesadaran, tanpa kelainan fokal/lateralisasi, tanpa
kaku kuduk.
2. Penurunan kesadaran, tanpa kelainan fokal/lateralisasi, dengan
kaku kuduk.
3. Penurunan kesadaran, dg kelainan fokal/lateralisasi.
Penurunan kesadaran, tanpa kelainan
fokal/lateralisasi, tanpa kaku kuduk

1. Gg. Metabolik.
2. Gg. Iskemik.
3. Intoksikasi.
4. Infeksi Sistemik.
5. Hipertermia.
6. Epilepsi.
 Penurunan kesadaran, tanpa kelainan
fokal / lateralisasi, dg kaku kuduk

1. Perdarahan Subaraknoid.
2. Infeksi otak.
3. Infeksi Selaput otak.
Penurunan kesadaran dg kelainan fokal / lateralisasi

1. Stroke.
2. Tumor otak.
3. Abses otak.
-S for Stroke / Space Occupying
Lesions
Intracerebral Hemorrhage
Penilainan kesadaran scr kuantitatif dg
GCS ( Glasgow Coma Scale )

Respon buka mata ( E ) :

• Buka mata spontan (E4).
• Buka mata dg rangsang suara (E3).
• Buka mata dg rangsang nyeri (E2).
• Tidak buka mata da rangsang nyeri (E1).
Penilainan kesadaran scr kuantitatif dg
GCS ( Glasgow Coma Scale )

Respon Verbal :
• V1. Dg rangsang nyeri tdk ada respon.
• V2. Dg rangsang nyeri ada respon mengerang.
• V3. Dg rangsang nyeri ada respon kata.
• V4. Bicara dg kalimat tp disorientasi waktu dan tempat.
• V5. Bicara dg kalimat dg orientasi baik.
Penilainan kesadaran scr kuantitatif dg
GCS ( Glasgow Coma Scale )

Respon Motorik.
• M1. Dg rangsang nyeri tdk ada respon.
• M2. Dg rangsang nyeri reaksi deserebrasi.
• M3. Dg rangsang nyeri reaksi dekortikasi.
• M4. Dg rangsang nyeri reaksi mendekati nyeri tp tdk sampai.
• M5. Dg rangsang nyeri reaksi mendekati nyeri dan sampai sasaran.
• M6. Reaksi motorik sesuai perintah.
 Peningkatan
Tekanan Intra Kranial ( TIK )
TIK normal :
• Bayi : 1,5 – 6 mmHg.
• Anak : 3 – 7 mmHg.
• Dewasa : 10 – 15 mmHg.

Penyebab :
1. Peninggian ADO (Aliran Darah ke Otak).
2. Oedem serebri krn iskemik/infark.
3. Sumbatan aliran CSS (Cairan cerebrospinal).
4. Efek massa.
Gejala klinik :
1. Sakit kepala.
2. Muntah proyektil tanpa mual.
3. Papil edema.

Gejala efek massa :

1. Herniasi tentorial (Lateral) :
- Hemianopsia homonim.
- Gg. Kesadaran.
- Hemiparese ipsilateral.
- Ptosis n Gg. N. III.
2. Herniasi Tentorial (Sentral) :
- Gg. Gerakan bola mata.
- Gg. Kesadaran.
- Diabetes Insipidus.
3. Herniasi Tonsilar :
- Gg. Gerakan bola mata.
- Gg. Kesadaran makin dalam.
- Leher kaku n kepala condong ke depan.
 Penanganan :
• ABC
• Pasang intubasi.
• Kontrol ventilasi : PaCO2 35 mmHg.
• Pertahankan tek.darah normal.
• Beri sedasi Narkotika/Neuromuscular blok.
• Beri Manitol.
• Beri Anti kejang.
 Status epilepsi
Mrpkn suatu keadaan adanya serangan kejang yang
berulang dan berkepanjangan dan di antara kejang
penderita belum sempat sadar.

Penanganan awal :
1. Atur posisi penderita.
2. Jauhkan dari tempat berbahaya.
3. Longgarkan pakaian t.u bagian leher.
4. Jgn keluarkan dan masukan sesuatu dg kekerasan pada
mulut penderita.
Approach for 1st Seizure, New Seizure,
or Substance/ Trauma Induced Seizure
• As always ABC’s First
• IV, O2, Monitor.
– Send blood for CBC, Chem 20, Tox screen as appropriate
– Anticonvulsant levels
– Prolactin levels / Lactate level
• CXR / UA/ Head CT
• Is patient actively seizing? Post ictal? Pseudoseizure?
– Consider treatment options
• Complete History and Physical Exam
– Including detailed Neuro Exam
– Repeat Neuro evaluations a must!
 Penanganan Lanjutan :
• Miringkan kepala pada satu sisi.
• Pasang O2.
• Pasang IV line.
• Berikan Anti kejang per IV atau perectal.
• Berikan Thiamin 50 – 100 mg IV dan Glukosa 25 – 50 mg IV.
• Evaluasi penyebab kejang.
Terapi
Guidelines for Postictal Head CT
Scans
• Status Epilepticus ( a true emergency)
• Abnormal Neuro findings
• No return to GCS 15
• Prolonged HA
• History of malignancy
• CHI (Closed Head Injury)
• HIV infection or high risk for HIV
• Anticoagulant use
• Age > 40
Status Epilepticus Treatment

• FIRST LINE TREATMENT

– Lorazepam (Ativan) 2mg/min IV up to 10 mg max. OR
Diazepam(Valium) 5mg/min IV or PR up to 20mg
• SECOND LINE TREATMENT
– Phenytoin or Fosphenytoin (Cerebyx):
• 20mg/kg IV at rate of 50mg/min
• THIRD LINE TREATMENT
– Get Ready to intubate at this point!!
– Phenobarbitol 10-20mg/kg @ 60 mg/min
Status Epilepticus Treatment

• FINAL TREATMENT
– Barbiturate Coma
• Pentobarbitol 5mg/kg @ 25 mg/min
• Stat Neurology consult for evaluation and EEG
• Pentobarbitol titrated to EEG response.
• Always get a through HISTORY
– Possible trauma
– Medications in house
– Others sick, symptomatic
– Overall appearance of patient
Status Epilepticus Adjunctive
Treatment by History
• Thiamine 100mg IV, 1-2 amps D 50
– If suspect alcoholic, malnourished, hypoglycemia
• Magnesium Sulfate 20cc of 10% solution
– As above of if eclampsia (BP does NOT have to be 200/120!!)
• Pyridoxine 5 gms IV
– INH or B-6 deficiency
Algoritma tatalaksana pada status epileptikus
 Infeksi SSP

Bbrp keadaan yg dapat menyertai :

1. Penurunan Kesadaran.
2. Kejang.
3. TIK meningkat.
4. Syok Septik.
Gejala Infeksi SSP

• Tanda rangsang meningeal

 Manifestasi klinis

• demam tinggi yang akut

• tanda-tanda rangsang meningeal (nyeri kepala,
demam dan kaku kuduk)
• kelainan fokal neurologi (kejang, penurunan
kesadaran dari lethargy hingga koma)
• gejala-gejala spesifik lainnya yang disebabkan oleh
virus/bakteri.
Meningitis

• Lumbar Puncture Results

TEST NORMAL BACTERIAL VIRAL
Pressure <170 >300 200
Protein <50 >200 <200
Glucose >40 <40 >40
WBC’s <5 >1000 <1000
Cell type Monos >50% PMN’s Monos
Gram Stain Neg Pos Neg
 Penatalaksanaan

• Airway, hrs longgar.

• Breathing, hrs adekuat.
• Circulation, pasang IV line.
• Tirah baring.
• Pemberian nutrisi parenteral.
Meningitis Management

• Antibiotics By Age Group

– Neonates(<1month) = Ampicillin + Gent. or
Cefotaxime + Gent
- Infants (1-3mos) = Cefotaxime or Ceftriaxone
+ Ampicillin
- Children (3mos-18yrs) = Ceftriaxone
- Adults (18yr-up) = Ceftriaxone + Vancomycin
- Elderly/Immunocomp = Ceftriaxone +Ampicillin +
Vancomycin
Meningitis Management

• Steroids
– In children, dexamethasone has been shown to be of
benefit in reducing sensiorneural hearing loss, when given
before the first dose of antibiotic.
– Indications:
• Children> 6 weeks with meningitis due to H. flu or S. pneumo.
• Adults with positive CSF gram stain
– Dose: 0.15mg/kg IV
Encephalitis

• Management:
– Emergent CT : As indicated for meningitis
– ABC’s with supportive care.
– Lumbar puncture:
• Send for ELISA and PCR
– Acyclovir 10 mg/kg Q 8 hours IV for HSV and Zoster
– Steroids not shown to be of benefit.
• e/ virus :
• Asiklovir diberikan dengan dosis 10 mg/kgBB setiap 8 jam selama 10 hari atau peroral
200 mg/kgBB 5-6 kali sehari. Kadar Hemoglobin harus terus dipantau, bila Hb turun
sampai 9 g/dl maka dosis diturunkan menjadi 200 mg setiap 8 jam. Jika Hb turun
sampai 7 g/dl maka pengobatan dihentikan sementara waktu dan diberikan lagi
setelah kadar Hb normal kembali.

• e/ bakteri :
• Antibiotik ; Ceftriaxon inj 1x2gram

• Steroid (dexamethasone)
STROKE
 Pengertian

Penyakit yang terjadi akibat terganggunya aliran darah ke otak secara tiba-tiba
sehingga menyebabkan kerusakan neurologis

Tipe oklusif/ Tipe hemoragi/

penyumbatan perdarahan
stroke yang stroke yang
disebabkan disebabkan
karena adanya karena
penyumbatan perdarahan
pembuluh intrakranial
darah
Aliran darah otak dan pengaruhnya terhadap fungsi
sel saraf

50 cc/100 Normal
gram/mt

35-40 cc/100
Aliran Kehilangan fungsi
gram/mt
darah
ke otak
20 cc/100 Aktifitas listrik otak berhenti
gram/mt

< 10 cc/100
Kematian sel saraf
gram/mnt
 O2 & Glukose ↓ Pembentukan ATP ↓ Na-K ATPase ↓
iskemia

Aktifasi Saluran Depolarisasi Gangguan pompa Na/K

Ca++ & Na+ ( Pembengkakan Sel)

Pelepasan Glutamat Aktifasi Reseptor

ekstraseluler Glutamat
Matinya sel
pada
Inotropik :
Iskemia Otak
NMDA, AMPA, Kainate-R
Metabotropik

L-Arginin Aktifasi jalur NOS Mengaktifasi Enzim inti

Influks Ca++ & Na+
NO (Sintesa nitrit oksid) • Proteinkinase C
• Ca-Calmodulin dependent
proteinkinase II
Penumpukan Ca++ dalam sel • Protease
Keterangan • Endonuklease
•R : Reseptor
•NO : Nitrik Oksida • Omitin dekarboksilase
•Ca : Calsium • Fosfatase
Sel Mati
•Na : Natrium • Fosfolipase
•K : Kalium • NO sintetase
•ATP : Adenosin Triphosphate Fragmentasi DNA
•NMDA : N-methyl-D-Aspartate
•AMPA : α Amino-3-hydroxy—5methul-4-isoksazole propionate
• Jika CBF < 10 ml/100 mg/menit 
• kekurangan oksigen 
• proses fosforilasi oksidatif terhambat 
• produksi ATP (energi) berkurang 
• pompa Na-K-ATPase tidak berfungsi  depolarisasi membran sel saraf 
• pembukaan kanal ion Ca  kenaikan influks Ca secara cepat 
• gangguan Ca homeostasis  Ca merupakan signalling molekul yang
mengaktivasi berbagai enzim 
• memicu proses biokimia yang bersifat eksitotoksik 
• kematian sel saraf (nekrosis maupun apotosis) 
• gejala yang timbul tergantung pada saraf mana yang mengalami
kerusakan/kematian
 Gejala dan Tanda

• unilateral weaknesses biasanya hemiparesis (lumpuh separo)

• unilateral sensory complaints numbness,

paresthesia (mati rasa)

• Aphasia  language comprehension

• Monocular visual loss  gangguan penglihatan sebelah

PENATALAKSANAAN UMUM
STROKE AKUT

( di IGD )
1. PRINSIP
• ABC
• Rawat di RS  ruang saraf / ICU
• Fase akut  menyelamatkan jiwa
• Setelah fase akut  mencegah serangan ulang
• Lama perawatan :
• Stroke Infark  minimal 1 minggu
• Stroke perdarahan  sampai 3 minggu
Management of Stroke

Reproduced with permission, 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. ©2010, American Heart Association.
2. Terapi Umum (suportif)
A. Stabilisasi jalan nafas dan pernafasan
 02, pemasangan pipa orofaring

B. Stabilisasi hemodinamik
 cairan kristaloid atau koloid , iv
 optimalisasi TD **
 pemantauan jantung selama 24 jam onset
C. Pengendalian peningkatan TIK

• TTIK : nyeri kepala, muntah, penurunan

kesadaran
• Tinggikan posisi kepala 20 – 30 °
• Hindari pemberian cairan glukosa/hipotonik
• Hindari hipertermia
• Manitol 20% = 0,25 - 0,5 gr/kgBB , diguyur
• Furosemide 20 – 40 mg iv (bila perlu)
D. Pengendalian kejang
• Bila kejang  diazepam bolus lambat iv 5 – 20 mg
• Phenitoin loading dose 15-20 mg/kg bolus,
kecepatan max 50 mg/menit
• Belum teratasi  ICU

E. Pengendalian suhu tubuh

• Pasien stroke + febris  antipiretika + atasi
penyebabnya
 Penatalaksanaan umum

Beri oksigen
Pastikan jalan napas melalui nasal
bersih, kanul,
posisikan saturasi oksigen
kepala 30-45 derajat > 95 %

Perbaiki
TD sirkulasi dengan
bila terdapat pemasangan jalur IV
komplikasi hipertensi  cairan normal
edem pulmonary. salin 0,9% 20 ml/jam.

Atasi kejang
kondisi stabil lakukan dan demam 
(CT SCAN, LAB, diazepam 5-20 mg
chest X ray, EKG dll) IV(perlahan),
--konsul dgn ahli acetaminophen 650 mg.
Closed Head Injury

• Definitions :
– Concussion: refers to a transient LOC following head injury.
Often associated with retrograde amnesia that also
improves.
– “Coup” = injury beneath the site of trauma
– “Countrecoup” = injury to the side polar opposite to the
traumatized area.
– Diffuse Axonal Injury : tearing and shearing of nerve fibers at
the time of impact secondary to rapid
acceleration/deceleration forces. Causes prolonged coma,
injury, with normal initial head CT and poor outcome.
Closed head Injury Facts

• The single most important factor in the neurologic

assessment of the head injured patient is level of
consciousness. (LOC)
• Always assume multiple injuries with serious mechanism.
– ESPECIALLY C - SPINE!!!!
– Unless hypotensive WITH bradycardia and WARM extremities (spinal
cord injury); hypotension is ALWAYS secondary to hypovolemia from
blood loss in the trauma patient!
• The most common intracranial bleed in CHI is subarachnoid
hemorrhage.
Headache & Vertigo

• Headache
• Types of Headache:
– Migraine
• With aura
• Without aura
– Cluster Headache
– Subarachnoid hemorrhage
– Temporal arteritis
Vertigo

• History and PE exam again CRUCIAL!!

– History:
• Truly a vertiginous complaint?
– r/o syncope / near syncope??
• Acute onset of severe symptoms or more gradual course
– PE:
• Full exam paying particular attention to:
– HEENT : Eyes, TM’s
– Neuro : Cerebellar function
Emergent Peripheral Neuropathies

• Guillain-Barre Syndrome
– Most common acute polyneuropathy.
– 2/3’s of patients will have preceeding URI or
gastroenteritis 1-3 weeks prior to onset.
– Presents as: paresthesias followed by ascending paralysis
starting in legs and moving upwards.
• Remember Miller-Fischer variant: has minimal weakness and
presents with ataxia, arreflexia, and ophthalmoplegia.
– DX: LP will show cytochemical dissociation.
• Normal cells with HIGH protein.
– TX: Self limiting, Early and aggressive airway stabilization.
Emergent Peripheral Neuropathies

• Myasthenia Gravis
– Most common disorder of neuromuscular transmission.
– An autoimmune disease that destroys acetylcholine
receptors (AchR) which leads to poor neurotransmission
and weakness.
– Proximal >> Distal muscle weakness
– Commonly will present as:
• Muscle weakness exacerbated by activity, and is relieved by rest
– Clinically: ptosis, diplopia and blurred vision are the most
common complaints. Pupil is spared!
Emergent Peripheral Neuropathies

• Myasthenia Gravis
– Myasthenic crisis = A true emergency!!
– Occurs in undiagnosed or untreated patients
• Due to relative Ach (acetylcholine) deficiency
• Patients present with profound weakness and impending respiratory failure
– TX: Stabilize and manage airway
• Consider edrophonium 1 -2 mg IV
(AchE inhibitor)
FEBRILE SEIZURE
TERIMA KASIH
KEGAWATDARURATAN NEUROLOGI