KEDARURATAN

NEUROLOGI

dr. I Nym. Bgs. Surya Antara, M.Biomed,

Sp.N
Neurologic Emergency Outline

• Change in Mental Status / Coma

• Stroke/TIA Syndromes
• Seizure & Status Epilepticus
• Infectious
PENURUNAN KESADARAN
 Etiologi

Non traumatic Stroke

(hypoxic-ischemic Cardiopulmonary arrest
Meningoencephalitis
neural injury) Final stage of certain
neurodegenerative disease
(Parkinson, Alzheimer)

VS Traumatic brain
injury
 Etiologi
Supratentorial mass lesions Structural
Infratentorial mass/destructive
lesions

VS
Metabolic

Hiperglikemia, hipoglikemia, uremia, ensefalopati anoksik, gangguan

elektrolit, ensefalopati Wernicke, intoksikasi
 Penegakkan Diagnosis

Physical
History
Taking + Examinatio
n

General

Neurologic

+ Diagnostic
Aids
Change in Mental Status / COMA

• Potential Causes – “AEIOU TIPS”

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

Level of
consciousness
Neurologic Pattern of breathing
Examination
Pupillary responses
Oculomotor
responses
Motor responses
Yang Dinilai pada GCS Nilai

MEMBUKA MATA / EYE (E)

Spontan 4
1. Atas Perintah 3
2. Dirangsang Nyeri 2
3. Tidak Ada Respon 1

VERBAL (V)
1. Orientasi Baik (Waktu, Tempat, Orang) 5
2. Berbicara Namun Disorientasi 4
3. Kata-kata Yang Tidak Tepat 3
4. Suara Yang Tidak Berarti 2
5. Tidak Ada Respon 1
MOTORIK (M)
1. Gerakan Mengikuti Perintah 6
2. Melokalisir Nyeri 5
3. Menarik Lengan atau Tungkai 4
4. Fleksi Abnormal (Dekortikasi) 3
5. Ekstensi Abnormal (Deserebrasi) 2
6. Tidak Ada Respon) 1
REFLEK PUPIL
 Cheyne-Stokes

Central Neurologic Hyperventilation

Apneusis

Cluster & Ataxic

Apnea
 GERAK DAN KEDUDUKAN BOLA MATA
Deviasi Konjugat
1. Kedua bola mata melirik ke
samping
2. Ke arah hemisfer yang terganggu
3. Ukuran dan bentuk pupil normal
4. Refleks cahaya positif
5. Deviasi terjadi pada area 8 lobus
frontalis
Proses di Pons
1. Kedua bola mata berada di tengah
2. Doll’s eye (-)
3. Pupil sangat kecil, reaksi cahaya
(+)
4. Kadang tampak ocular bobbing
Proses di Talamus
1. Kedua bola mata melirik ke hidung
2. Bola mata tidak dapat digerakkan
ke atas
3. Pupil kecil dan refleks cahaya (-)
Proses di
Serebelum
1. Pasien tidak dapat melihat
kesamping
2. Bentuk pupil normal (bentuk dan
reaksi terhadap cahaya)
3. Refleks cahaya (+)
Modul Penurunan Kesadaran, 2008
 ALGORITMA PASIEN KOMA
Pasien penurunan kesadaran

Pemeriksaan Neurologi Lengkap

Pemeriksaan Penunjang

Assesment Etiologi

Lesi Struktural (Dekstruktif Intrakranial) Toksik Metabolik (Diffuse Brain Disease)

Terdapat defisit neurologi fokal, dilatasi Pupil reaktif, neurologik fokal (-),
unreaktif pupil, TIK meningkat peningkatan TIK (-)

Supratentorial Infratentorial Eksogen Endogen

Trauma, Perdarahan intrakranial, Stroke Intoksikasi obat, Gangguan

Iskemik, Abnormalitas mikrovaskuler Napza, endokrin,
difus, Tumor intrakranial, dll insektisida, dll Gangguan
metabolik,
Psikogenik, dll

Modul Penurunan Kesadaran, 2008

PENANGANAN AWAL
STROKE
 Terminologi Stroke
“Suatu sindroma klinis yang ditandai oleh
gangguan fungsi otak fokal maupun global
mendadak berlangsung lebih dari 24 jam,
mempunyai kecenderungan perburukan
bahkan kematian yang diakibatkan oleh satu-
satunya gangguan vaskuler”

Terminologi Baru memasukkan juga stroke

spinal

17
 Jenis Stroke
Stroke Hemoragik Stroke Iskemik

Lacunar small vessel

Intracerebral disease (25%)
hemorrhage (59%)

Atherothrombotic
disease (20%)

SAH (41%)
Embolism (20%)

18 Cryptogenic (30%)
Albers GW et al. Chest. 1998;114:683S-698S.
Rosamond WD et al. Stroke. 1999;30:736-743.
 Deteksi dini Stroke:
Cincinnati Prehospital Stroke Scale (CPSS).

1. Facial droop. Suruh pasien tersenyum

atau memperlihatkan gigi.
2. Arm drift. Suruh pasien mengangkat
tangan 90º dari tubuh dan tahan 10 detik.
3. Slurred speech. Suruh pasien mengulang
kalimat sederhana.
4. Time. Segera mencari RS terdekat.

FAST
19
 Skor Stroke Siriraj

• (2.5 x S) + (2 x M) + (2 x N) + (0.1 D) – (3 x A) – 12
− S : kesadaran (0 = CM, 1 = somnolen, 2 = sopor/koma)
− M : muntah (0 = tidak ada, 1 = ada)
− N : nyeri kepala (0 = tidak ada, 1 = ada)
− D : tekanan darah diastolik
− A : ateroma (0 = tidak ada, 1 = salah satu/lebih : DM,
angina, penyakit pembuluh darah)

• Penilaian
− SSS > 1 = perdarahan supratentorial,
− SSS < -1 = infark serebri,
− SSS -1 s/d 1 = meragukan
 Treatment of Stroke

• AS ALWAYS – ABC’s FIRST

• What’s the Serum Glucose??
– Consider Thiamine 100mg IV, D 50 bolus if hypoglycemic.
– Treat Hyperglycemia if Serum Glucose > 300mg/dl
• Protect the “Penumbra”
– Keep SBP >90mm Hg
– Goal keep CPP > 60mm Hg (CPP=MAP-ICP)
– Treat Fever ( Mild Hypothermia beneficial)
• Acetaminophen 650mg po or pr, cooling blanket
– Oxygenate (Keep Sao2 >95%)
– Elevate head of bed 30 deg. (Clear c-spine)
• Frequent repeat Neuro checks!! Reassess GCS!
 Treatment of Stroke

• What type of stroke is Present??

– Hemorrhagic vs Ischemic
• Any signs of shift herniation?
• Neurosurgery evaluation or transfer necessary?
• Other management adjuncts:
• Ischemic strokes
– ASA 81-325mg
– Patients with Systolic BP >220 , Diastolic>120 need BP control with
Nitroprusside or Labetolol.
– DO NOT OVERTREAT BP or risk extending the infarct.
– Heparin not shown to be of benefit in recent studies, however, still
frequently used.
• Consult Neurologist before use
• If used, No bolus, just infusion.
• Risk of hemorrhagic transformation.
 Treatment of Strokes

• Strokes with Edema, Mass Effect or Shift

– Load with Phosphenytoin 1000mg for seizure prophylaxis
– Acute seizure prophylaxis still of benefit.
– Mannitol, Decadron??
• Recently shown to be of NO benefit, some Neurosurgeons still advocate,
so consult first.
– Hyperventilation??
• NOT beneficial and perhaps harmful, don’t do it!
• Thrombolytics???
– Ischemic strokes ONLY with large deficit NOT improving.
– Time from symptom onset <3 hours
– No ABSOLUTE Contraindications!!
– Inclusion and Exclusion Criteria
– Benefit Questionable
 Kriteria Operatif pada Stroke Hemoragik
Stroke Hemoragik
dibuktikan dengan
CT Scan kepala non kontras

Operatif: Non Operatif

•Perdarahan lobar ≥ 50 CC. •Selain kondisi yang
•Perdarahan serebelar >3 cm. menjadi
•Hidrosefalus akut indikasi operatif.
•Lesi struktural vaskuler tertentu •GCS ≤ 4
•IVH masif dengan ancaman
hidrosefalus
•Syarat : GCS > 4.
 Emergency Treatment of
Aneurysmal SAH
• Notify neurosurgery and neurointerventional team
immediately
• Prevent rebleeding
− Risk = 5-15% in 1st 24h; mortality 70-80%
− Treat hypertension: Keep SBP 110-150 mmHg
• IV Antihypertensives
– Prns: labetalol, hydralazine
– Nicradipine gtt
• Judicious analgesia
– Tylenol  Ultram  very low-dose IV fentanyl or
hydromorphone
− Antifibrinolytics (tranexamic acid) if securing is expected
to be delayed > 6h after arrival
 Emergency Treatment of
Aneurysmal SAH
• Secure aneurysm
− Goal: ASAP; within 18h of presentation
− Conventional angiogram from ED
• Operative planning
• Endovascular coils if possible
− Otherwise, surgical clipping
 STATUS EPILEPTIKUS
• Status epilepticus
− Any single seizure lasting > 5min
− ≥ 2 seizures without clearing of mental status between
them
Bahaya Status Konvulsif

Kejang lama akan menyebabkan

kerusakan otak permanen
s ia
Hipok si
en
Hipot emi
i po glik
H
gk a tan a
Peni n
li s me ai
b
Meta ak
o Supl
ot

u tu h an
Keb

Cedera
Otak
 Emergency Treatment of
Generalized Convulsive Status
Epilepticus
• Abort the seizure
− Lorazepam 4-6mg IV push
− diazepam 0,2 mg/kg (10-20 mg iv)
− Repeat 5 min later if seizure continues or
returns
• Prevent future seizures
− Phenytoin load: 20mg/kg IV infusion
− DO NOT just give 1g  only enough for a small,
50kg person
− Alternatives:
• IV valproic acid 20-30mg/kg
• IV levetiracetam 25-30mg/kg
 Algoritma
Urea & elektrolit
Resusitasi Kardiopulmoner DPL
Monitoring CK
IV line Glukosa
Ambil sampel darah LFT
Periksa glukosa Ca2+, PO4-, Mg2+
Toksikologi
AGD

Diazepam
0,2 mg/kg dg kec < 2mg/min

Ya
Bangkitan dan
faktor penyebab
dikoreksi?

Tidak
 Tidak
Fenitoin
20 mg/kg dg kec <50 mg/kg
ATAU
Fosfenitoin
Equivalen fenitoin20 mg/kg dg kec <150 mg/kg

Pertahankan keadaan
Ya
Penyembuhan tsb sambil
Bangkitan berhenti? Pemulihan kesadaran
Tidak
Fenitoin
Dosis tambahan 5-10mg/kg sampai total 30mg/kg
ATAU
Fosfenitoin
Equivalen fenitoin 5-10mg/kg sampai total 30mg/kg

Ya
Bangkitan berhenti?
Tidak
 Tidak

ICU atau adakah Ya

gangguan Anestesia umum
sistemik mayor? Propofol ATAU Thiopental

Tidak
60 menit
Bangkitan berhenti?
 Infectious Neurologic
Emergencies

• Meningitis: inflammation of the meninges

• History:
– Acute Bacterial Meningitis:
• Rapid onset of symptoms <24 hours
– Fever, Headache, Photophobia
– Stiff neck, Confusion
• Etiology By Age:
– 0-4 weeks: E. Coli, Group B Strep, Listeria
– 4-12 weeks: neotatal pathogens, S. pneumo, N.
meningitides, H. flu
– 3mos – 18 years: S.pneumo, N. menin.,H. flu
– >50/ alcholics: S. pneumo, Listeria, N. menin., Gram(-) bacilli
 Meningitis

• Lymphocytic Meningitis (Aseptic/Viral)

– Gradual onset of symptoms as previously listed
over 1-7 days.
– Etiology:
• Viral
• Atypical Meningitis
– History (medical/social/environmental) crucial
– Insidious onset of symptoms over 1-2 weeks
– Etiology:
• TB(#1)
• Coccidiomycosis, crytococcus
 Meningitis

• Physical Exam Pearls

– Infants and the elderly lack the usual signs and
symptoms, only clue may be AMS.
– Look for papilledema, focal neurologic signs,
ophthalmoplegia and rashes
– As always full exam
• Checking for above
• Brudzinski’s sign
• Kernigs sign
– KEY POINT: If you suspect meningococcemia do
NOT delay antibiotic therapy, MUST start within 20
minutes of arrival!!!!!
 Meningitis

• Emergent CT Prior to LP
– Those with profoundly depressed MS
– Seizure
– Head Injury
– Focal Neurologic signs
– Immunocompromised with CD4 count <500

• DO NOT DELAY ANTIBIOTIC THERAPY!!

 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
 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

• Always think of in the young/elderly or

immunocompromised with FEVER + AMS
• Common Etiologies:
• Viral
– West Nile
– Herpes Simplex Virus (HSV)
– Varicella Zoster Virus (VZV)
– Arboviruses
• Eastern Equine viruses
• St. Louis Encephalitis
 Encephalitis

• Always think of in the young/elderly or

immunocompromised with FEVER + AMS
• Common Etiologies:
• Viral
– West Nile
– Herpes Simplex Virus (HSV)
– Varicella Zoster Virus (VZV)
– Arboviruses
• Eastern Equine viruses
• St. Louis Encephalitis
 Encephalitis

• Defined as: inflammation of the brain itself

• Most cases are self limited, and unless virulent
strain, or immunocompromised, will resolve.
• The ONLY treatable forms of encephalitis are:
– HSV
– Zoster
 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.