ENLS Day 1

Motor Function

Breathing Pattern : bantu lokalisasi neurogenic hyperventilation, encephalopathy, bilateral pontine

lesion, pontomedullary junction lesion, lesions affecting ventrolateral medulla

Pendekatan pada pasien koma  head CT buat eliminasi structural cause, historical, comorb, med,
exposures

Kasus

Laki-laki 60 th ditemukan di hotel, tidak responsive

Vitals

Hypothermic

Initial Formulation

Causes of coma kalo yakin structural yaudah lgsg order CT aja gausah acc dpjp,

Causes of coma bisa neurologic (trauma neurovasc, cns, neoplasm, seizure, NAE, ADEM, PRES, HIE),
bisa toxic metabolic causes

Brain Imaging

Kalo penyebab unclear atau focal exam

Non contrast head CT STAT

Case conclusion

CT head with diffuse intraventricular hemorrhage, SAH and hydrocephalus

Farmasi notifikasi urgent need dan dosing PCC

Kalau masih belum jelas juga?

Kadang pasien kejang tp gakeliatan  nonconvulsive seizure  EEG

Comm

Clinical presentation

Relevant past medical/surgical history

Findings on neurological exam

Intracranial hypertension and herniation

Phenobarb effects: hypotension, arrythmia, refleks batang otak kadang gaada, kesan braindead,
kadang jadi butuh EEG untuk memastikan dia ga braindead

Questions:

Durasi target pemberian mannitol berdasarkan ICP? Memantau dari klinis: pupil anisokor jadi isokor,
refleks perbaikan, evaluasi side effects  pertimbangan mannitol stop
Kasus: pasien on fenobarbital. EEG shows burst suppression in 8-10 second range

ICP diturunkan ke 16 mmHg

Maintenance on fenobarbital lalu 48 jam lalu weaning

ICP di range 100-15 mmHg, lalu EVD diremove

Consider additional monitoring

Kasus lagi

Pria 60 th jadi pasien baru di neuro ICU karena ICH, beratnya 75 kg, butuh 1g/kgBB mannitol, butuh
berapa cc?

Gram dikali 5: cc mannitol, kan mannitol pakenya yg 20%

75gx5: 225 cc butuhnya

Steroid administration

Boleh kasih start Dexamethasone 10 mg

Penurunan TIK dengan hiperventilasi  cerebral vasoconstriction lower blood flow  TIK turun,
tapi kalo kebablasan bisa iskemia

Usahakan jangan sampe 30 menit

Monitoring dengan AGD serial, lebih baik lagi dengan POCT AGD, target pCO2 25-35 (?)

Di venti bisa set RR di 18 dulu,

Bisa juga pasiennya diminta hiperventilasi sendiri kalo sadar  tapi praktiknya agak sulit

Pasien GCS 8 or under intubasi? Secara umum tetap kalo ada kemungkinan compromised airway,
hypoxe <94%, weakness diafragma (?), dan kecurigaan perburukan di masa depan (anticipated
progression).

Airway and Ventilation Management

Case: 70 yo male in traffic accident, obesity

Difficult bag mask vent  obesity, age, lack of teeth, the large laceration  all of the above

Target on neuro patient: Maintain ox, optimize cer phys, preserve cer perf, prevent aspiration

Airway, Ventilation and Sedation Protocol -> read

Four commonly accepted indications to intubate: Failure to oxygenate, ventilate, protecting the
airway, anticipated neurological or cardiopulmonary decline

M ask seal

O besity

A ge >55

N o teeth
LEMON: Yaknow

MACOCHA: mallampati, apne syndrome, cervical spine limitation, opening mouth, coma, hypoxia
<80%, satu lagi apaya

Intubation algorithm with elevated ICP  READ THE PARAMETERS

ICP <22 mmHG and so on

Patient intubation w Brain Ischemia

Avoid hypotension untuk preserve ischemic penumbra, avoid hyperventilation due tu cer
vascoconstriction, use iv fluid bolus or vasopressor if needed, induction pk ketamine atau etomidate,
consider sedasi conscious.

Intubasi dengan malformasi vascular unsecured atau hematoma

Avoid sever hypertension to prevent bleeding, consider fentanyl prior to intubation

Intubating patient with neuromuscular weakness

ABG measurement, asesmen fungsi respirasi serial

Intubasi pasien dengan cervical spine injury

Hindari head tilt chin lift, bmv, cricoid pressure, dan direct laryngoscopy

Consider fiberoptic intubation if there’s stable oxygenation and ICP

Perform jaw thrust, prefer video laryngoscopy

Manual in line stabilization (MILS), dan bagian anterior collar dibuka

RSI medications: read

Lanryngos and intub

Up to three attempts, jangan lupa ganti operator/technique, consider video laryngoscopy

Failed Airway

Can’t intubate or ventilate: Ineffective BMV, unsuccessful single, best attempt intubation

Cant intubate, can ventilate: unsuccessful three attempts at intubation, BMV effective

Post intubation management

Secure ett

Confirm position

Set cuff press to 20-30 cmh20

Pulse ox and capnography

Abg measurement

Deep sedation while neuromuscular blockade is in effect

Counsel next of kin on change in patient status

Analgesia for Sedation

Analgesia read

Sedatives read

Anatomical: Pediatric vs adults

Children: larger tongue, more compliant upper airway tissues, longer, narrower, floppier epiglottis,
shorter tracheal distance, prominent occiput, the narrowest portion falls in subglottic area at the
level of cricoid ring

Regarding the anatomical airway difference between pediatric and adult patients, is there any
maneuver or tips that we can do to make the intubation procedure easier, according to your clinical
experience?

Manuever the prominent occiput, consider hyperextension, avoid trauma

Take home message:

Deteriorasi, perburukan, butuh invasive therapies bisa consider intubasi, ga harus berpatokan ke
GCS