PENURUNAN KESADARAN

Dept.Neurosains FK.UMJ.2015Dept.Neurosains FK.UMJ.2015

KEDARURATAN KEDARURATAN NEUROLOGINEUROLOGI

((Level Of ConciousnessLevel Of Conciousness))

Anwar Wardy WAnwar Wardy WJuni 2015Juni 2015

Anwar Wardy W. FK.UMJ

NEURAL BASIS OF NEURAL BASIS OF CONSCIOUSNESSCONSCIOUSNESS

ConsciousnessConsciousness cannot be readily cannot be readily defined in terms of anything elsedefined in terms of anything else

A state of awareness of A state of awareness of self self and and surroundingsurrounding



Mental StatusMental Status = =

Arousal + ContentArousal + Content



ANATOMYANATOMY OF MENTAL STATUS OF MENTAL STATUS

Ascending reticular activating system (ARAS)Ascending reticular activating system (ARAS) Activating systems of upper brainstem, hypothalamus, Activating systems of upper brainstem, hypothalamus,

thalamusthalamus Determines the level of Determines the level of arousalarousal

Cerebral hemispheres and interaction Cerebral hemispheres and interaction between functional areas in cerebral between functional areas in cerebral hemisphereshemispheres Determines the Determines the intellectual and emotional intellectual and emotional functioningfunctioning

Interaction betweenInteraction between cerebral hemispheres and cerebral hemispheres and activating systemsactivating systems



Sum of patient’s Sum of patient’s intellectualintellectual (cognitive) (cognitive) functions and functions and emotionsemotions (affect) (affect)

Sensations, emotions, memories, images, Sensations, emotions, memories, images, ideas (SEMII)ideas (SEMII)

Depends upon the activities of the Depends upon the activities of the cerebral cerebral cortexcortex, the , the thalamusthalamus & their interrelationship & their interrelationship

THE CONTENT OF CONSCIOUSNESS

Lesions of these structures will diminish the content of consciousness (without changing the state of consciousness)



The The ascending RASascending RAS, from the lower border , from the lower border of the of the ponspons to the to the ventromedial thalamusventromedial thalamus

The cells of origin of this system occupy a The cells of origin of this system occupy a paramedian area in the brainstem paramedian area in the brainstem

THE STATE OF CONSCIOUSNESS (AROUSAL)



LESION OBJECTIVESLESION OBJECTIVES

◦Describe the common causes of a deteriorating Describe the common causes of a deteriorating conscious level.conscious level.

◦Describe how to assess a patient with a altered Describe how to assess a patient with a altered conscious level using the Glasgow coma scale.conscious level using the Glasgow coma scale.

◦Describe the emergency management of a Describe the emergency management of a patient with a decreasing conscious level.patient with a decreasing conscious level.



RAPID ASSESSMENTRAPID ASSESSMENT

A A AAlertlert

V V responds to responds to VVoiceoice

P P responds to responds to PPainain

U U UUnresponsivenresponsive



GLASGOW COMA SCALEGLASGOW COMA SCALE

Assesses patient’s neurological conditionAssesses patient’s neurological condition

Value range 3 to 15Value range 3 to 15

3 totally comatose patient3 totally comatose patient

15 fully alert patient15 fully alert patient



CLASSIFICATION OF BRAIN INJURYCLASSIFICATION OF BRAIN INJURYACCORDING TO GLASGOW COMA SCALEACCORDING TO GLASGOW COMA SCALE

(GCS) (GCS) (HICKEY 2003)(HICKEY 2003)

MILD

GCS 13-15

MODERATE

GCS 9-12

SEVERE

GCS 3-8



NEUROLOGICAL GUIDENEUROLOGICAL GUIDE

GCS top sectionGCS top section

Temperature/BP/pulse/respiratory rateTemperature/BP/pulse/respiratory rate

Pupil size / reaction to lightPupil size / reaction to light

Limb movement – arms and legs Limb movement – arms and legs



EYE OPENINGEYE OPENING

Spontaneous = 4Spontaneous = 4

To speech = 3To speech = 3

To pain = 2To pain = 2

None = 1None = 1



VERBAL RESPONSEVERBAL RESPONSE

◦Orientated = 5Orientated = 5

◦Disorientated = 4Disorientated = 4

◦Monosyllabic = 3Monosyllabic = 3

◦ Incomprehensive = 2Incomprehensive = 2

◦None = 1None = 1



MOTOR RESPONSEMOTOR RESPONSE◦Obeys commands = 6Obeys commands = 6

◦Localises pain = 5Localises pain = 5

◦Withdrawal to pain = 4Withdrawal to pain = 4

◦Flexion to pain = 3Flexion to pain = 3

◦Extension to pain = 2Extension to pain = 2

◦None = 1None = 1 Dept.Neurosains FK.UMJ.2015Dept.Neurosains FK.UMJ.2015


Posturing




The General Principle For Managing The General Principle For Managing Neurologic EmergenciesNeurologic Emergencies

Principle I:Principle I: (Kaidah I)(Kaidah I)

Kerusakan sistem saraf tidak menyebabkanKerusakan sistem saraf tidak menyebabkan

kematian organ yang disarafi. Jaringan dan kematian organ yang disarafi. Jaringan dan fungsi diharapkan dapat diperbaiki.fungsi diharapkan dapat diperbaiki.



Emergency SymptomsEmergency Symptoms

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



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, hyperthermia



Primary EventsPrimary Events::

Cell, Axonal atau Myelin (Transmisi terganggu)Cell, Axonal atau Myelin (Transmisi terganggu)

PenyebabnyaPenyebabnya::

1. Anoxia 1. Anoxia 7. Toxin/7. Toxin/InfeksiInfeksi

2. Intracranial Hemorrhage. 2. Intracranial Hemorrhage. 8. Metabolic8. Metabolic

3. Ischemia3. Ischemia

4. Trauma4. Trauma

5. Hypoglicemia5. Hypoglicemia

6. Tumors6. Tumors



TumorsTumors



Brain Abscess



Symptoms of Brain Tumors?Symptoms of Brain Tumors?

nausea nausea - impaired sense of smell- impaired sense of smell

Vomiting Vomiting - memory loss- memory loss

headaches headaches - seizures- seizures

behavioral and emotional changes behavioral and emotional changes - muscle weakness- muscle weakness

impaired judgment impaired judgment -paralysis on one side of the body-paralysis on one side of the body

loss of hearing loss of hearing -reduced mental capacity-reduced mental capacity

vision lossvision loss



Secondary EventsSecondary Events• Edema CerebriEdema Cerebri• TIKTIK• Obstruksi dari Liquor CS.Obstruksi dari Liquor CS.• VasospasmeVasospasme• Kegagalan AutoregulasiKegagalan Autoregulasi• Kegagalan Collateral supplyKegagalan Collateral supply• Gagal JantungGagal Jantung• Gagal Nafas.Gagal Nafas.

AnoxiaICH

IschemiaTumorsTrauma





Principle IIPrinciple II (Kaidah 2)(Kaidah 2)

Selalu memerlukan intubasi Selalu memerlukan intubasi

Agar pernapasan terjamin dan Agar pernapasan terjamin dan oksigenasi ke otak terjamin baik.oksigenasi ke otak terjamin baik.

Cegah terjadinya:Cegah terjadinya:

1. Coma hypoventilasi.1. Coma hypoventilasi.

2. Hypoxia otak dan acidosis / 2. Hypoxia otak dan acidosis / hypercarbia.hypercarbia.



Glasgow Coma ScoreGlasgow Coma Score Eye Opening (E) Eye Opening (E) 4=Spontaneous4=Spontaneous

3=To voice3=To voice2=To pain2=To pain1=None 1=None

Verbal Response (V)Verbal Response (V) 5=Normal conversation5=Normal conversation

4=Disoriented conversation4=Disoriented conversation

3=Words, but not coherent 3=Words, but not coherent Total = E+V+MTotal = E+V+M 2=No words......only sounds2=No words......only sounds

1=None1=None Motor Response (M)Motor Response (M) 6=Normal6=Normal

5=Localizes to pain5=Localizes to pain4=Withdraws to pain4=Withdraws to pain3=Decorticate posture3=Decorticate posture2=Decerebrate2=Decerebrate1=None1=None



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

PRINCIPLE iv PRINCIPLE iv ( Kaidah 4)( Kaidah 4)

Sirkulasi peredaran daraf keotak Sirkulasi peredaran daraf keotak dipertahankan.dipertahankan.





Principle V Principle V (kaidah 5)(kaidah 5)

Penyakit tersebut Struktural atau Non- Penyakit tersebut Struktural atau Non- Structural.Structural.

Biasanya dilakukan dengan pemeriksaan Biasanya dilakukan dengan pemeriksaan Rontgen / CT.Scan atauRontgen / CT.Scan atau

Suspect N-Struktural dengan LP.Suspect N-Struktural dengan LP.





Principle VI Principle VI (Kaidah 6)(Kaidah 6)

Diagnosis cepat dan sederhanaDiagnosis cepat dan sederhana (Simple & Spot Diagnosis) : yaitu (Simple & Spot Diagnosis) : yaitu dengan menggunakan pengetahuan dengan menggunakan pengetahuan Anatomi saraf (Topis Diagnostic) untuk Anatomi saraf (Topis Diagnostic) untuk mengetahui letak lesi di Otak.mengetahui letak lesi di Otak.



Herniation:Herniation: The Brain Under Pressure The Brain Under PressureBleeding or swelling in the brain can Bleeding or swelling in the brain can

cause pressure that forces the brain cause pressure that forces the brain downward in the skull.downward in the skull.



WHEN SPECIFIC AREAS OF THE WHEN SPECIFIC AREAS OF THE BRAIN ARE DAMAGEDBRAIN ARE DAMAGED



EmboliEmboli (Perifer) (Perifer)



Part Part I.I. Neurological Examination Neurological Examination and Neurodiagnostic Testingand Neurodiagnostic Testing

1. 1. Neurological examination; Neurological examination; 2. Neuroradiology; 2. Neuroradiology; 3. Electroencephalography; 3. Electroencephalography; 4. Lumbar puncture; 4. Lumbar puncture; 5. Electromyography; 5. Electromyography; 6. Electronystagmography; 6. Electronystagmography; 7. Evoked potentials; 7. Evoked potentials;

Main Diagnostic

Support



Part II.Part II. Common Neurological Common Neurological PresentationsPresentations

8.8. Altered level of consciousness; Altered level of consciousness;

9. Headache; 9. Headache;

10. Weakness; 10. Weakness;

11. Dizziness; 11. Dizziness;

12. Seizures; 12. Seizures;

13. Gait disturbance; 13. Gait disturbance;



Part III.Part III. Specific Neurological Specific Neurological Conditions:Conditions:

14. CNS infections in adults; 14. CNS infections in adults; 15. Viral encephalitis; 15. Viral encephalitis; 16. Vascular disease; 16. Vascular disease; 17. Movement disorders; 17. Movement disorders; 18. Neuromuscular disorders; 18. Neuromuscular disorders; 19. Musculoskeletal and neurogenic pain; 19. Musculoskeletal and neurogenic pain; 20. Neuroophthalmological disorders; 20. Neuroophthalmological disorders; 21. Multiple sclerosis21. Multiple sclerosis; ;


Specific Neurological Specific Neurological Conditions:Conditions:

22. Dementia;22. Dementia; 23. Neurooncology;23. Neurooncology; 24. Neuropsychiatric24. Neuropsychiatric 25. Neuroanesthesiology;25. Neuroanesthesiology; 26. TIK (Tekanan Intra Kranial)26. TIK (Tekanan Intra Kranial) 27. Normal pressure hydrocephalus; 27. Normal pressure hydrocephalus; 28. Sleep disorders;28. Sleep disorders;




Part IV.Part IV. Neurological Trauma and Neurological Trauma and Environmental EmergenciesEnvironmental Emergencies

29.29. Traumatic brain injury; Traumatic brain injury;

30. Spinal cord injury; 30. Spinal cord injury;

31. Peripheral nerve injury; 31. Peripheral nerve injury;

32. Neurological complications of 32. Neurological complications of environmental emergencies environmental emergencies



Part V.Part V. Pediatric Neurology Pediatric Neurology

33. Hydrocephalus and shunts in 33. Hydrocephalus and shunts in children; children;

34. Pediatric CNS infections; 34. Pediatric CNS infections;

35. Pediatric stroke; 35. Pediatric stroke;

36. Pediatric seizures; 36. Pediatric seizures;

37. The hypotonic infant; 37. The hypotonic infant;



Part VI.Part VI. Neurological Emergencies Neurological Emergencies of Pregnancy:of Pregnancy:

38. Neurological emergencies of 38. Neurological emergencies of pregnancy; pregnancy;



Part VII.Part VII. Brain Resuscitation and Brain Resuscitation and Neurotoxicology:Neurotoxicology:

39. General neurotoxicology; 39. General neurotoxicology;

40. Neurotoxicology of alcohol and 40. Neurotoxicology of alcohol and substances of abuse; substances of abuse;

41. Brain resuscitation.41. Brain resuscitation.



PERUBAHAN KESADARAN PERUBAHAN KESADARAN

Dizziness Dizziness (pening / pusing?)(pening / pusing?)Fainting Fainting (menjadi pinsan)(menjadi pinsan)Dissociation Dissociation (pemisahan diri)(pemisahan diri)Confusion or delirium Confusion or delirium (ingauan / kacau)(ingauan / kacau)Dementia Dementia Seizures Seizures Coma Coma Stupor Stupor



CONSCIOUSNESSCONSCIOUSNESS is defined by levels is defined by levels of behavior in response to stimuli of behavior in response to stimuli asas: :

1) alertness 1) alertness (kesiagaan)(kesiagaan)

2) drowsiness or lethargy 2) drowsiness or lethargy (kelesuan)(kelesuan)

3) stupor (3) stupor (keadaan pinsan / dengkurkeadaan pinsan / dengkur))

4) coma. 4) coma.









CONSCIOUSNESS IS A MANIFESTATION CONSCIOUSNESS IS A MANIFESTATION OFOF HOLISTIC INFORMATION HOLISTIC INFORMATION PROCESSINGPROCESSING, THE MAJOR POINTS OF , THE MAJOR POINTS OF WHICH ARE:WHICH ARE:

1.1. Consciousness involves simultaneous activity Consciousness involves simultaneous activity of large areas of the cerebral cortex.of large areas of the cerebral cortex.

2.2. Consciousness is superimposed on other types Consciousness is superimposed on other types of neural activity, so that they are not only of neural activity, so that they are not only involved with their specific activity.involved with their specific activity.

3.3. Consciousness is totally interconnected. Consciousness is totally interconnected.

Thought occurs in many areas of the cerebrum Thought occurs in many areas of the cerebrum simultaneously.simultaneously.



FaintingFainting, or , or syncopsesyncopse, is a temporary , is a temporary loss of consciousness that is usually due loss of consciousness that is usually due to inadequate blood flow to the brain. to inadequate blood flow to the brain.

It may also be due to head injury, edema, It may also be due to head injury, edema, hemorrhaging, or sudden emotional hemorrhaging, or sudden emotional stress. stress.

ComaComa is loss of consciousness in which is loss of consciousness in which the victim is unresponsive to stimuli.the victim is unresponsive to stimuli.



EvaluationEvaluationICP monitoring is most often used in head trauma in ICP monitoring is most often used in head trauma in

the following situations:the following situations: 1) GCS less than 81) GCS less than 8 2) Drowsy with CT findings 2) Drowsy with CT findings (operative or non (operative or non

operative)operative) 3) Post op hematoma evacuation3) Post op hematoma evacuation 4) High risk patients (a) Above 40 yrs. (b) Low BP 4) High risk patients (a) Above 40 yrs. (b) Low BP

(c) Those who require ventilation.(c) Those who require ventilation. There is nothing to achieve in monitoring ICP in There is nothing to achieve in monitoring ICP in

the patients with GCS of less than 3.the patients with GCS of less than 3.

Daftar Bacaan;Daftar Bacaan; J. A. Fodor, "The big idea: can there be science of the mind," Times

Literary Supplement, pp. 5-7, July 2012. J. Norden, Understanding the brain, Video lecture series. M. Velmans, "Where experiences are: Dualist, physicalist, enactive and

reflexive accounts of phenomenal consciousness," Phenomenology and the Cognitive Sciences, vol. 6, pp. 547-563, 2014

A. Sloman, "Developing concept of consciousness," Behavioral and Brain Sciences, vol. 14 (4), pp. 694-695, Dec 2014.

W. H. Calvin and G. A. Ojemann, Conversation with Neil's brain: the neural nature of thought and language: Addison-Wesley, 2014.

J. Hawkins and S. Blakeslee, On intelligence. New York: Henry Holt & Company, LLC., 2014.

S. Greenfield, The private life of the brain. New York: John Wiley & Sons, Inc., 2003

D. C. Dennett, Consciousness Explained, Penguin Press 2013. D. M. Rosenthal, The nature of Mind, Oxford University Press, 2011. B. J. Baars “A cognitive theory of consciousness,” Cambridge

University Press, 2014.



Jakarta, 17 Juni 2015Jakarta, 17 Juni 2015

FKK-UMJFKK-UMJ

Wassalamu’Alaikum Wr, Wassalamu’Alaikum Wr, Wbr.Wbr.

Anwar Wardy WAnwar Wardy W

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