Laki-laki 48 tahun dibawa ke Puskesmas dalam keadaan tidak sadar.

Setelah diletakkan di tempat tidur dan diperiksa, penderita tidak memberi respon dan tetap mendengkur dengan irama napas 32 kali/menit, nadi 100 kali/menit, lemah. Menurut keterangan keluarga yang mengantar, penderita tidak mengalami trauma.

A : Snoring B : RR : 32 kali/menit C : Nadi 100x/menit, lemah D : Kesadaran Menurun E:

Preparation

Definitive Care

Triage

Initial Assesment
Secondary Survey ( Head to toe evaluation ) Primary Survey ( ABCDE )

Resuscitation

1.0 Airway
LOOK Kesadaran menurun Agitasi pergerakan dinding dada

LISTEN

Suara Tambahan Snoring : Pangkal lidah jatuh Stridor : penyempitan larynx gurgle : sumbatan oleh cairan

FEEL

hembusan nafas

1.1 Airway Management

Chin lift/jaw thrust/Head tilt (tongue is attached to the jaw) Suction (if available) Guedel airway/nasopharyngeal airway Intubation; keep the neck immobilized in neutral position

2.0 Breathing

2.1 Breathing Management Artificial ventilation Decompression and drainage of tension pneumothorax/haemothorax Closure of open chest injury

3.0 Circulation Warna kulit (Pucat) Akral Dingin Nadi Tekanan darah Perdarahan CRT (Cappillary Refile Time) Normal : < 2 detik

3.1 Circulation Management

Stop external haemorrhage Establish 2 large-bore IV lines (14 or 16 G) if possible Administer fluids, if available

4. Disability

AVPU

A : Alert V : Verbal Stimulation P : Pain stimulation U : Unresponssive

Glasgow Coma Scale Normal : 15 Tidak sadar : < 8 Reaksi Pupil Tanda-tanda lateralisasi Spinal Injury

5. Exposure Hypovolemia Vasodilatation Loss of temperature Infection risk

Definition Clinical condition of the haemodynamic and metabolic disturbances that occur when there are failure of circulatory system for maintain the adequate perfusion of blood to the entire organs Etiology Massive bleeding Loss of plasma Loss of extracellular fluid

Clinical presentation Decrease of blood pressure drastically Decrease of consciousness

Pathophysiology
Internal/external fluid loss Decreased intravascular fluid volume Diminished venous return Reduced filling pressure

Decreased tissue perfussion

Reduced arterial blood pressure

Lowered cardiac output

Decreased stroke volume

Reduced oxygen and nutrient delivery cells

Multiple organ dysfunction syndrome

Management Trendelenburg position Fluid resuscitation with IV access

Definition Cardiogenic shock is a physiologic state in which inadequate tissue perfusion results from cardiac dysfunction, most often systolic Etiology Impaired myocardial contractility Abnormalities of cardiac rhythm Cardiac structural disorder

Pathophysiology
Myocardial infarction

hypotension

Decreased cardiac output and stroke volume

Decreased systemic perfusion

Decreased coronary perfusion pressure

Compensatory vasoconstriction

Ischemia

Progressive myocardial dysfunction

Management Fluid resuscitation Vasopressor (dopamine, epinephrine)

Anamnesis A : Allergy M: Medication P : Past illness L : Last meal E : Event / Environment

Physical examination Head to toe examination Pemeriksaan penunjang Lab test : urine and blood Radiology and CT scan Monitoring ABCDE TTV (Nadi, RR, BP, T)

S : Sirkulasi E : Epilepsi E: Ensefalitis

T : Trauma

S.E.M.E.N.I.T.E

M: Metabolik

I: Intoksikasi

E : Elektrolit N: Neoplasma / Neurologis

Ruptur Pembulu darah Otak

Tekanan intrakranial meningkat

Penurunan kesadaran

Penekanan otak

Sudden numbness or weakness of the leg, arm or face Sudden confusion or trouble understanding

Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

Nonhemorrhagic stroke was defined as an acute new neurological deficit resulting in death or lasting for >24 hours without hemorrhage on computed tomography or magnetic resonance imaging.

Keadan pembuluh darah ( stenosi, tersumbat oleh trombus/emboli)

Keadaan darah ( Viskositas darah yang meningkat, hematokrit yang meningkat ,aliran darah ke otak lambat sehingga oksigenasi menurun) Tekanan darah sistemik memegang peranan tekanan perfusi otak

STROKE NON HEMORRHAGIC

Kelainan Jantung (menurunya cardiac output, lepasnya embolus sehingga iskemia d otak)

Fase akut ( 0-14 hari sesudah onset penyakit) Pertahankan tekanan darah Jantung harus berfungsi baik pantau dengan EKG Pada penderita DM, turunkan kadar gula perlahan Jaga keseimbangan Elekrolit , cairan dan asam basa darah Obat :
- Anti edema otak

- Gliserol 10% - Kortikosteroid - Anti- agregasi trombosit - Aspirin - Anti - koagulant - Heparin

Fase Pasca-Akut - Rehabilitasi Fisioterapi Terapi Wicara Psikoterapi - Terapi prevenif Mencegah serangan kembali

Results from a relative or absolute insulin deficiency Characterized by hyperglycemia, ketoacidosis and osmotic diuresis induced dehydration Life threatening hyperglycemic syndromes: diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNK)

 Hypotension Weakness Nausea/vomitting Dehydration Abdominal pain Polyuria Polydipsia Altered mental status Coma Tachycardia Arrhythmias

Goal: to restore fluid & electrolyte balance,provide insulin & identify precipiting factor (infection,stroke,MI,pancreatitis) Normal saline: replenish IV volume & restore hemodynamis stability ( 1 L in 1st hour, 250500 mL/hr as needed) Urine output maintained at 1-3 mL/kg/hr to ensure adequate tissue perfusion & clearance of glucose

Invasive hemodynamic monitoring (arterial catheter, PA catheter) in patient with underlying CV disease Monitor glucose level: -glucose > 250 mg/dL (<13.8 mmol/L) switch to glucose containing fluid to avoid hypoglycemia -10 % Dextrose may be necessery to maintain glucose level > 150 mg/dL while continuing insulin infusion

Kehilangan air dan penambahan ion Na dengan kekurangan air

Kadar Na serum>145 mEq/L

Menyebabkan hiperosmolalitas (ECF)

Pengerutan sel

Dehidrasi ICF

Iritabilitas, Restlessness, Letargi, Kejang otot, Spastisitas, Hiperrefleks

Menurunkan ion Na serum, sebelum mencapai kadar kritis (>160 m Eq/L) Hypernatremia dengan normovolemia D5 per oral atau IV Hypernatremia dengan hypervolemikD5 dan diuretik Diabetes insipidus - desmopresin

Air yang berlebihan atau ion Na yang berkurang

(Na + serum <135 mEq/)

Perpindahan air dari ECF ke ICF

Cerebral edema (Jika terjadi di dalam otak)

Menyebabkan pembengkakan sel

Sakit kepala, Kebingungan atau keadaan mental yang berubah, Seizures Kesadaran yang berkurang yang dapat berlanjut pada koma dan ke matian. Kegelisahan atau keresahan, Spasme-spasme otot atau kejang-kejang otot, Kelemahan, dan kelelahan.

Hiponatremia berat: NaCl hipertonik yaitu NaCl 3% pada keadaan natrium <120 mEq/L

Pada kadar Na>125 mEq/L dan <130 mEq/L dapat diberikan sebanyak 0.9% Kadar natrium secara intravena harus diberikan secara lambat untuk mencegah central pontin myelinolysis

F(x) : important for maintenance of the resting membrane potential

Definition : level of potassium in blood <3.5mEq/L Pathophysiology :

K+ in blood ( intake, K+ loss, drugs use, etc) resting electrical membrane potential excitability of cells

cells response to normal stimuli

 K+ loss Transcellular shifts

Renal loss

Extrarenal loss Diarrhea Profuse sweating

K+ Intake Malnutrition Alcoholism Anorexia nervosa

Alkalosis Diuresis Hyperventilation Metabolic alkalos Insulin Renal tub -adrenergic defects agonists Diabetic ketoacid Drugs (diuretics, Hypomagnese

mia Vomiting

aminoglycosides, amphotericin B)

Mild hypokalemia : usually asymptomatic Cardiovascular system :

Arrythmia ECG changes : classical U-wave, low-

Neuromuscular system : GI system :

paralysis(severe)

amplitude/flattened T-wave

Malaise, muscle weakness, muscle twitch,

Abdominal cramps, constipation, paralytic

ileus(severe)

Goal of Tx :
Correct underlying disease/cause Administer potassium

K <3mEq/L & asymptomatic: K enterally (orally or NGT) (KCl 2040mEq every 4-6 hrs) K <2-2.5mEq/L (<3mEq/L if on digoxin) @ symptoms (+): K intravenously

Definition : high/increase of potassium level in blood (>5.0mEq/L) Pathophysiology :

K+ in blood transmembrane potential action potential

excitability of cells

Renal dysfunction Acidemia Hypoaldosteronism Drugs (potassium-sparing diuretics, ACE inhibitors, etc.) Excessive intake

Cell

death:

Rhabdomyolisis Tumor lysis Burns Hemolysis

Cardiovascular system :
Arrythmia ECG changes : diffuse peaked T-wave, QRS

prolongation(sine wave)

Neuromuscular system :
Muscle weakness, paralysis, paresthesias,

hypoactive reflexes

Goal of Tx :
Correct underlying disease/cause Limitation of potassium intake

ECG abnormalities :

CaCl 5-10 mL of a 10% solution IV over 5-10 mins

(the effect lasts only 30-60 mins & should be followed by additional treatment)

Redistribution of K :

Na bicarbonate 1 mEq/kg (1 mmol/kg) IV over 5-

10 mins Inhaled 2-agonists in high dose (albuterol 10-20 mg)

Removal of K :

loop diuretic Na polystyrene sulfonate 25-50 g in sarbitol,

enterally or by enema dialysis

Lesi supratentorial
Disfungsi difus kortikal dari korteks serebri, seperti

ensefalitis,Neoplasma,trauma kepala tertutup dgn perdarahan, empiema subdural Disfungsi subkortikal bilateral seperti trauma batang otak

Lesi infratentorial
Destruksi langsung pada ARAS Batang otak rusak akibat invasi langsung

Buku I EIMED DASAR Kegawat daruratan Penyakit Dalam halaman 350-360

(demielinasasi,Neoplasma,granuloma,abses,trau ma kapitis)

Kompresi ARAS :
Tek langsung pada pons dan midbrain

menyebabkan iskemia dan edema neuron Herniasi ke atas serebellum menekan atas dari midbrain dan diensefalon Herniasi ke bawah melalui foramen magnum

Buku I EIMED DASAR Kegawat daruratan Penyakit Dalam halaman 350-360

Gejala gejala neurologik fokal sesuai dgn lokasi lesi, neuropati cranial dengan gejala seperti diplopia, facial weakness, ataxia, headaches, hearing loss, weakness, hemiparesis.

Buku I EIMED DASAR Kegawat daruratan Penyakit Dalam halaman 350-360