Kegawatdaruratan

Sistem Persarafan
Ners. Feandi Putera, M.Kep
 Stroke
Brain Attack
Cerebrovascular Accident (CVA)
Cerebrovascular Disease (CVD)
Stroke: Incident
 Stroke: Defined

Kematian jaringan otak (infark serebral) yang

terjadi karena berkurangnya aliran darah dan
oksigen ke otak (WHO, 2010)
 Stroke: Defined

Medical emergency in which the blood supply

to any portion of the brain is interrupted or
reduced

Destruction of a portion of brain tissue as a result

of circulatory failure in the distribution of
a specific arterial vessel
Cerebral Blood Flow
Cerebral Blood Flow
 Klasifikasi Stroke
Acute Stroke

Ischemic Stroke Hemorrhage Stroke

Thrombotic Stroke Embolic Stroke Subarachnoid Intraventricular Intracerebral

(Lokal) (Travelling) Hemorrhage (SAH) Hemorrhage (IVH) Hemorrhage (ICH)

Occlusion Bleeding
 Ischemic Stroke: Types
Thrombotic
• Cause: Platelet
Aggregation/ Vessel
Occlusion
• Onset: During Sleep when
BP is lowest
• Risk Factors:
o Large Vessel Disease
• Atherosclerosis
• Dissection
• Arteritis
o Small Vessel Disease
• Chronic Hypertension
• Lacunar : small
subcortical infarcts
Embolic
• Cause: Fragments formed
outside the brain break off
and travel to a vessel in the
brain
• Onset: Abrupt, may occur
during exercise
• Risk Factors
o Afib
o Endocarditis
o Valve Disease
o Patent Foramen Ovale
(PFO)
Hemorrhagic Stroke: Types
• SAH (Subarachnoid Hemorrhage)
o Ruptured Aneurysm

• IVH (Intraventricular Hemorrhage)

o Usually an extension of ICH
o Rarely isolated

• ICH (Intracerebral Hemorrhage)

o Hypertension
o Cocaine
o Many other
 MANIFESTASI KLINIS
Kerusakan Otak Kiri
 Kelumpuhan sebelah kanan:
hemiplegia
 Aphasia
 Tidak dapat membedakan kiri-
kanan
 Cendrung menolak atau
mengabaikan
 Performanya lambat, berhati-hati
 Penurunan koping: depresi, cemas
 Kerusakan pemahaman b.d bahasa
dan berhitung
 Penurunan daya ingat
Kerusakan Otak Kanan
 Kelumpuhan sebelah kiri:
hemiplegia
 Penurunun respon stimulus
sebelah kiri
 Penurunan persepsi tempat, ruang,
dan waktu
 Cendrung menolak atau
mengabaikan
 Performanya cepat, terburu-buru
 Bersifat impulsif
 Tidak mampu mengambil
keputusan
 Penurunan daya ingat
 KOMUNIKASI VERBAL
Kerusakan Komunikasi Verbal

Aphasia Dysarthria
(Hemisfer Kiri) (Brainstem)

Fluent Nonfluent Disfungsi syaraf

kranial V, VII, IX,
X, dan XII
Broca’s Wernicke’s
(ekspresif) (receptif)
Gangguan pada kontrol
otot pembicaraan
Produksi pembicaraan Pemahaman pembicaraan
(motorik) (sensorik)

Mekanisme pembicaraan

Konduksi Global
 PROSEDUR DIAGNOSTIK
• CT-SCAN/ MRI
• ANGIOGRAFI
• ECG
• EEG
• MONITORING JANTUNG
• FUNGSI SEREBERAL (PRONATOR DRIFT, ROMBERG TEST, FINGER
TO NOSE TO FINGER TEST, & HEEL DOWN SHIN)
CT MRI CT MRI

Ischemic Stroke Hemorrhagic Stroke

STROKE TREATMENT
AHA/ASA Guidelines
 INFARCT

CLOT

ISCHEMIC STROKE
 EMS Management
DO’s
• Manage ABCs
• Cardiac monitoring
• Intravenous access
• Oxygen (as required O2
saturation <92%)
• Normothermia
• BP control – HTN
• Assess for hypoglycemia
• NPO
DON’T’S
• Dextrose-containing fluids in
nonhypoglycemic patients
• Hypotension/excessive blood
pressure reduction
• Excessive intravenous fluids
• Causing aspiration pneumonia
 Thrombolytics

Intravenous rtPA
(0.9 mg/kg, maximum dose 90 mg) is strongly
recommended for carefully selected patients who
can be treated within 3 hours of onset of ischemic
stroke

Intraarterial rtPA
< 6 hours for selected patients who are NOT eligible
for IV tPA
Intra-arterial Thrombolytics
 Antiplatelets
• Aspirin : initial dose 325 mg given within 24- 48
hours of stroke onset
• Clopidogrel
Anticoagulants/ Fibrinolytics
• Warfarin
• Heparin
 Endovascular Intervention
• Mechanical removal of clot
o Clinical trials have shown that thrombectomy with
mechanical thrombolysis devices is indeed feasible in the
treatment of acute stroke.
o Many devices have been discontinued
o MERCI Retriever has received FDA clearance.
 Surgical Intervention
• Immediate intervention
o Carotid Endarterectomy (CEA)
o Extracranial-intracranial arterial bypass (EC-IC
bypass)
o Angioplasty/ Stents
 BLEEDING

HEMORRHAGIC STROKE
 Terapi Stroke Perdarahan

ICU - Terapi 6 B Terapi Khusus :

(Breath, Bleed, - Hipertensi : - Terapi operatif
Brain, Bladder, - Kejang
Bowel, Bone and
Skin) - PTIK
- Hiperglikemia
- Hipertermia
- DVT & Emboli

27
 PENCEGAHAN PTIK
 Target: CPP > 70 mmHg & PaCO2 = 30 - 35 mmHg
 Berikan kenyamanan setiap melakukan intervensi
 Tinggikan kepala 15-300
 Hindari fleksi lutut
 Hindari penekanan pada penutup kepala yang
mengalami fraktur
 Cegah terjadinya luka dekubitus
 Hindari batuk dan konstipasi
 Kaji penggunaan PEEP
 PENCEGAHAN PTIK
 Atur posisi leher sesuai garis tubuh
 Hindari fiksasi plester ETT yang terlalu ketat
 Batasi stimulasi sensorik (lampu dan kebisingan)
 Berikan interval waktu 10 menit diantara 2
intervensi
 Atur siklus tidur dan istirahat
 Atur jadwal kunjungan
 PENCEGAHAN PTIK
 Hindari manipulasi yang berlebihan: berputar &
mandi di TT
 Lakukan pengisapan lendir trakeal
 lamanya tindakan: < 2 menit
 jeda waktu diantara pengisapan lendir: 60 detik
 Berikan preoksigenasi O2 100%: 1-5 menit
 Berikan bolus analgesia dan sedasi
 Berikan lokal anastesi (intratracheal lignocaine)
 PENCEGAHAN PTIK
 Obat-obatan:
 Osmotik diuretik : Manitol 20% 0,25-1 gr/kgBB
bolus, selama 20 menit dilanjutkan 0,25-0,50
gr/kgBB diulang setiap 4-6 jam sekali
 Loop diuretik: Forosemide 20 - 40 mg
 Koreksi natrium dan protein
 Antihipertensi, Antikonvulsan, & Antitusif
 Barbiturat koma
 Laxatif
 Anticoagulants/ Fibrinolytics

• Heparin - Biological
• Warfarin (Coumadin): Plants– Vitamin K IV (10mg)
with treatment to replace clotting factors (Vitamin
K Antagonist)
• When to restart anticoagulation after ICH??
- If low risk of thromboembolic event, may restart
antiplatelet instead of warfarin
- If warfarin must be restarted, wait 7-10 days after
ICH
 Specific Treatment

• Treat and decrease fever

• Glycemic control (treat > 140mg/dL)
• Early mobilization and rehabilitation
 Surgical Approaches

• Decompressive Craniectomy
• Cerebellar ICH > 3cm with neuro deterioration
/herniation or hydro should have removal of
hemorrhage
• Lobar clots within 1 cm of the surface may be
considered for standard craniotomy
Perawatan Mata
Pressure Ulcer
Oral Care
DVT Prevention
Thank you