DOCSLIB.ORG

Patofisiologi Kesadaran Menurun

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Patofisiologi Kesadaran Menurun PATOFISIOLOGI KESADARAN MENURUN Akina Maulidhany Tahir* *Bagian Anatomi Fakultas Kedokteran UMI Kesadaran adalah kondisi sadar kesadaran antara lain pada pemenuhan terhadap diri sendiri dan lingkungan. kebutuhan dasar yaitu gangguan pernafasan, Kesadaran terdiri dari dua aspek yaitu kerusakan mobilitas fisik, gangguan hidrasi, bangun (wakefulness) dan ketanggapan gangguan aktifitas menelan, kemampuan (awareness). (Avner,2006) Kesadaran diatur berkomunikasi, gangguan eliminasi (Hudak & oleh kedua hemisfer otak dan ascending Gallo, 2002). reticular activating system (ARAS), yang FISIOLOGI KESADARAN meluas dari midpons ke hipotalamus anterior. Formasi retikuler berperan penting RAS terdiri dari beberapa jaras saraf yang dalam menentukan tingkat kesadaran. RAS menghubungkan batang otak dengan korteks adalah jalur polysynaptic kompleks yang serebri. Batang otak terdiri dari medulla berasal dari batang otak (formasi retikuler) oblongata, pons, dan mesensefalon. Proyeksi dan hipotalamus dengan proyeksi ke neuronal berlanjut dari ARAS ke talamus, intalaminar dan nukleus retikular thalamus dimana mereka bersinaps dan diproyeksikan yang akan memproyeksi kembali secara ke korteks. (Ganong,2016) menyeluruh dan tidak spesifik pada area Ketidaksadaran adalah keadaan tidak luas dari korteks termasuk frontal, parietal, sadar terhadap diri sendiri dan lingkungan temporal, dan oksipital (Gambar 1). Jaras dan dapat bersifat fisiologis (tidur) ataupun kolateral ke dalamnya tidak hanya dari traktus patologis (koma atau keadaan vegetatif). sensoris, tetapi juga dari traktus trigeminal, (Avner,2006) Penyebab kesadaran menurun pendengaran, penglihatan, dan penciuman. beragam dengan karakteristik masing- (Ganong, 2016) Kelainan yang mengenai masing. Banyak penyebab dari penurunan lintasan RAS tersebut berada diantara kesadaran merupakan ancaman jiwa yang medulla, pons, mesencephalon menuju membutuhkan intervensi yang cepat, ke subthalamus, hipothalamus, thalamus karena berpotensi terhadap morbiditas dan dan akan menimbulkan penurunan derajat mortalitas yang tinggi. Perubahan fisiologis kesadaran. (Wijdicks, 2010) yang terjadi pada pasien dengan gangguan serebri merupakan bagian yang terbesar dari susunan saraf pusat di mana kedua korteks ini berperan dalam kesadaran akan diri terhadap lingkungan atau input-input rangsangan sensoris (awareness). Neurotransmiter yang berperan pada ARAS antara lain neurotransmiter kolinergik, monoaminergik dan Gamma Aminobutyric Acid (GABA). (Yeo, 2013) ETIOLOGI KESADARAN MENURUN Gambar 1. Gambaran ascending reticular activating Koma dapat disebabkan oleh penyakit system (ARAS) pada batang otak (brainstem) memperlihatkan proyeksi pada thalamus dan yang menyerang bagian otak secara fokal korteks serebral (Ganong, 2016) maupun seluruh otak secara difus. Penyebab Kesadaran ditentukan oleh interaksi koma secara umum diklasifikasikan dalam kontinu antara fungsi korteks serebri intrakranial dan ekstrakranial (tabel 1). (kualitas) dengan Ascending Reticular Selain itu, Koma juga dapat disebabkan oleh Activating System (ARAS) (kuantitas) yang penyebab traumatik dan non-traumatik. terletak mulai dari pertengahan bagian atas Penyebab traumatik yang sering terjadi pons. ARAS menerima serabut-serabut saraf adalah kecelakaan lalu lintas, kekerasan kolateral dari jaras-jaras sensoris dan melalui fisik, dan jatuh. Penyebab non-traumatik thalamic relay nuclei dipancarkan secara difus yang dapat membuat seseorang jatuh ke kedua korteks serebri. ARAS bertindak dalam keadaan koma antara lain gangguan sebagai suatu tombol off-on, untuk menjaga metabolik, intoksikasi obat, hipoksia global, korteks serebri tetap sadar (awake) (Wijdicks, iskemia global, stroke iskemik, perdarahan 2010). intraserebral, perdarahan subaraknoid, Respon gangguan kesadaran pada tumor otak, kondisi inflamasi, infeksi sistem kelainan di ARAS ini merupakan kelainan yang saraf pusat seperti meningitis, ensefalitis berpengaruh kepada sistem arousal yaitu dan abses serta gangguan psikogenik. (Greer, respon primitif yang merupakan manifestasi 2012) Keadaan koma dapat berlanjut menjadi rangkaian inti-inti di batang otak dan serabut- kematian batang otak jika tidak ada perbaikan serabut saraf pada susunan saraf. Korteks keadaan klinis. Tabel 1. Etiologi Penurunan Kesadaran (Howlett, 2012) Site/aetiology Disorder Intracranial Focal stroke infarct, ICH, SAH infections brain abscess trauma haematoma (ICH, EDH, SDH) tumours primary or secondary Diffuse infections HIV, meningitis, malaria, encephalitis seizures post ictal/status epilepticus trauma traumatic brain injury Extracranial hypoxia cardiac, respiratory, renal, shock, anaemia metabolic/toxic hyper-hypoglycaemia, organ failure, hyponatraemia overdose, opiates, alcohol hypertension encephalopathy, eclampsia Easy way to remember the causes of coma A = anoxia/apoplexy E = epilepsy I = injury/infection O = opiates U = uraemia PATOMEKANISME KESADARAN Pada penurunan kesadaran, gangguan MENURUN terbagi menjadi dua, yakni gangguan Perilaku normal membutuhkan derajat (kuantitas, arousal, wakefulness) Pengetahuan dan Afek yang sesuai, sehingga kesadaran dan gangguan isi (kualitas, seseorang mampu mengenali hubungan awareness, alertness) kesadaran. Adanya antara diri sendiri dan lingkungan. Komponen lesi yang dapat mengganggu interaksi perilaku ini di kontrol oleh hemisfer otak. Pada ARAS dengan korteks serebri, apakah lesi umumnya, tubuh mengikuti ritme kesadaran supratentorial, subtentorial dan metabolik yang normal. Dari kondisi kesadaran penuh akan mengakibatkan menurunnya kesadaran (wakefulness) menjadi mengantuk, dan pada (Taylor, 2006). akhirnya tertidur. Pada satu titik selama Pendekatan lain untuk menjelaskan tertidur (atau bahkan pada mengantuk), level kesadaran adalah analogi “tombol on- stimulus dari luar diproses melalui input off lampu”. Perilaku (yang dikontrol oleh sensoris untuk meningkatkan kondisi sadar hemisfer otak) sebagai Bohlam Lampu dan dan menyebabkan seseorang menjadi sadar Komponen kesadaran (dikontrol oleh ARAS) (bangun). Siklus ini dipicu secara predominan adalah tombol untuk menyalakan lampu. oleh ARAS, yang disebut sebagai pusat tidur. Untuk menyalakan lampu (kondisi seseorang (Avner, 2006) menjadi Sadar), Lampu harus berfungsi dan menyala. Ada tiga kemungkinan Lampu tersebut tidak menyala (dalam hal ini Kesadaran Terganggu), yaitu adanya defek kranial III, VI, VIII, dan fasciculus longitudinal pada lampu itu sendiri (Disfungsi menyeluruh medial). Pemeriksaan pada refleks ini pada hemisfer otak), defek pada tombol lampu mengindikasikan fungsi dari ARAS. (Avner, (abnormalistas dari ARAS), atau terdapat 2006) Adanya trauma pada area ARAS dapat defek pada kedua lampu dan tombol lampu menyebabkan hilangnya refleks batang otak (Disfungsi CNS secara umum). (Avner, 2006) dan gangguan kesadaran, meskipun hemisfer Model ini juga membantu membedakan otak tetap dalam kondisi normal. Disfungsi penyebab dari penurunan kesadaran. ARAS otak difus biasanya akibat riwayat penyakit di beberapa refleks batang otak, termasuk medis seperti keracunan, gangguan metabolik refleks cahaya pada pupil (nervus kranial II dan infeksi menyebabkan penekanan dan III) dan refleks pergerakan mata (nervus (kompresi) pada ARAS yang merupakan akibat gangguan struktural (Tabel 2). Tabel 2. Berbagai Penyakit Penyebab Penurunan Kesadaran (Avner, 2006) Gangguan Medis Gangguan Struktural (Toxic-Infeksi-Metabolik) • Kejadian cerebrovascular • Anoxia • Trombosis Vena Otak • Ketoasidosis Diabetes • Hidrocefalus • Abnormalitas elektrolit • Tumor Intraserebral • Encephalopathy • Empiema Subdural • Hipoglikemia • Trauma (Perdarahan Intrakranial, • Hipotermi / Hipertermi pembengkakan otak secara difus, shaken baby • Infeksi (sepsis) syndrome) • Meningitis dan encephalitis • Psikogenik • Intususepsi • Toksin • Uremia (Sinfrom uremi-hemolitik) Periode hilangnya kesadaran sesaat dapat menyebabkan koma sedangkan lesi berarti hilangnya kesadaran intermiten dan fokal terjadi di atas tentorium dalam satu muncul secara mendadak dari pasien yang hemisfer otak menyebabkan koma hanya sebelumnya telah sadar penuh. hal ini terdapat jika sisi kontralateral otak secara bersamaan pasien dengan penyakit kardiovaskular terlibat atau terkompresi (Gambar 2.B) Lesi dengan penurunan aliran darah ke otak menyebar (difus) otak, yang mempengaruhi secara akut (syncope) ataupun gangguan fungsi otak secara keseluruhan termasuk aktivitas elektrik pada otak (kejang). Lesi RAS dapat menyebabkan koma (Gambar 2.C). fokal otak yang terjadi di bawah tentorium (Howlett, 2012) (Gambar 2.A) akan mengganggu RAS sehingga Gambar 2. Gambaran Lesi yang menyebabkan Penurunan Kesadaran. Gbr A & B menunjukkan Lesi fokal. Gbr C. menunjukkan pada kondisi Encephalophaty Diffuse. (Howlet, 2012) PENILAIAN TINGKAT KESADARAN • Koma berarti kesadaran hilang, tidak Penilaian kesadaran secara kuantitatif memberikan reaksi walaupun dengan dapat menggunakan Tabel penilaian Glasgow semua rangsangan (verbal, taktil, dan Coma Scale (GCS) (Tabel 3) atau Four Score nyeri) dari luar. Pasien dalam keadaan (Tabel 4) (Huff,2012 dan Laureys, 2011). tidak sadar yang dalam, yang tidak dapat Tingkat kesadaran secara kualitatif dapat dibangunkan akibat disfungsi ARAS dibagi menjadi kompos mentis, apatis, di batang otak atau kedua hemisfer somnolen, stupor, dan koma. (Singhal, 2014) serebri. Karakteristik koma adalah tidak • Kompos mentis berarti keadaan adanya arousal dan awareness terhadap seseorang sadar penuh dan dapat diri sendiri dan lingkungannya. menjawab pertanyaan tentang dirinya Selain di atas terdapat
Load more

Recommended publications
  • Tactics of Family Doctors in Case of Syncopal States
    MINISTRY OF PUBLIC HEALTH OF UKRAINE ZAPORIZHZHIA STATE MEDICAL UNIVERSITY DEPARTMENT OF GENERAL PRACTICE – FAMILY MEDICINE AND INTERNAL DISEASES DEPARTMENT OF GENERAL PRACTICE – FAMILY MEDICINE, THERAPY, CARDIOLOGY AND NEUROLOGY OF THE POSTGRADUATE FACULTY TACTICS OF FAMILY DOCTORS IN CASE OF SYNCOPAL STATES STUDY GUIDE for the students of the specialty "Medicine" in the program of the educational discipline "General Practice - Family Medicine" Zaporizhzhia 2020 2 UDC 616.8-009.832-08(072) М 99 Аpproved by Central Methodical Council of Zaporizhzhia State Medical University as а study guide (Protocol № 3 of 27.02.2020) and recommended for use in the educational process Authors: N. S. Mykhailovska - Doctor of Medical Sciences, Professor, head of the Department of General practice – family medicine and internal diseases, Zaporizhzhia State Medical University; A. V. Grytsay - PhD, associated professor of the Department of General practice – family medicine and internal diseases, Zaporizhzhia State Medical University; І. S. Kachan - associated professor of the Department of Family medicine, therapy, cardiology and neurology of the Postgraduate faculty, Zaporizhzhia State Medical University. Readers: S. Y. Dotsenko – Doctor of Medical Sciences, Professor, Head of the Internal Medicine №3 Department, Zaporozhye State Medical University; S. M. Kiselev – Doctor of Medical Sciences, Professor, Professor of the Department of Internal diseases 1, Zaporizhzhia State Medical University. Mykhailovska N. S. M99 Tactics of family doctors in case of syncopal states = Тактика сімейного лікаря при синкопальних станах: study guide for the practical classes and individual work for 6th-years students of international faculty (speciality «General medicine»), discipline «General practice – family medicine» / N. S. Mykhailovska, A. V. Grytsay, I.S.
    [Show full text]
  • Sleep As a Problem of Localization
    SLEEP AS A PROBLEM OF LOCALIZATION Prof. C. von Economo Vienna, Austria The Journal of Nervous and Mental Disease march 1930, vol 71, n°3 An American Journal of Neuropsychiatry, Founded in 1874 Paper read before the College of Physicians and Surgeons Columbia University, New York, Dec. 3, 1929 The search for a so-called sleep center may at the ceasing of the activity of this organ, i.e., the ceasing first sight appear a paradoxical idea. In the same man- of consciousness bringing about sleep. Others conceived ner as the waking state, so also does sleep appear as the mechanism of interruption not in this delicate histological such a complex biological condition that the problem manner but somewhat more massively. Purkinje belie- makes us at first sit up and take notice. Indeed, our enti- ved that by the congestion of the grey mass of the sub- re life takes place in the alternating change of two bio- cortical ganglia the thalamus corpus striatum, etc., pres- logical conditions, the waking and sleeping state and in sure is excited upon the nervous fibers of the corona this way the problem might appear primarily of the same radiata which run through this ganglia and that due to category as the problem of the center of life itself. The this strangulation an interruption of conduction from problem of a center of life in the nervous system has and to the brain is effected thus bringing about sleep. often been discussed in past centuries. But it has been put away as life is a much too complex condition as to The Viennese ophthalmologist Mauthner assu- be localized.
    [Show full text]
  • Medical Studies in English Clinical Skills: Year 2
    MEDICAL STUDIES IN ENGLISH CLINICAL SKILLS: YEAR 2 STUDENT HANDOUT 2015 Contents: 1. General principles of history taking 2. Basic principles of physical examination 3. Overview of a patient consultation 4. Monitoring vital signs 5. Structured approach to the seriously injured 6. Shock 7. Acute heart and respiratory failure 8. Disturbances of consciousness 9. Life support in children 10. Newborn resuscitation 11. Resuscitation of adults 12. Medical care of the injured patient 13. Use of equipment during treatment of injured patients; transport positions Department of Clinical Skills University of Split School of Medicine 1. THE GENERAL PRINCIPLES OF HISTORY TAKING Irena Zakarija-Grković, MD, FRACGP, IBCLC, PhD A Brief Overview of Clinical Medicine From classical Greek times interrogation of the patient has been considered most important. However, the current emphasis on the use of history taking and physical examination for diagnosis developed only in the 19th century. Until the 19th century, diagnosis was empirical and based on the classical Greek beliefs that all disease had a single cause, an imbalance of the four humours or body fluids (yellow bile, black bile, blood and phlegm). In the 17th century physicians based their opinion on a history provided by an apothecary (assistant) and rarely saw the patients themselves. Thomas Sydenham (1624-1689) began to practise more modern bedside medicine basing his treatment on experience and not theory. A renaissance in clinical methods began with the concept of Battista Morgagni (1682-1771) that disease was not generalised but arose in organs, a conclusion published in 1761. Leopold Auenbrugger invented chest tapping (percussion) to detect disease in the same year.
    [Show full text]
  • SMART - Narzędzie Oceny Pacjentów Z Zaburzeniami Świadomościi Mocy Regulacji W Badaniu Wysiłkowym
    Rehabilitacja Postępy Rehabilitacji (1), 5 – 10, 2016 Rehabilitacja Postępy Rehabilitacji (1), 49 – 57, 2017 Poziom wydolności dorosłych kobiet urodzonych przedwcześnie na podstawie analizy mocy wejścia SMART - narzędzie oceny pacjentów z zaburzeniami świadomościi mocy regulacji w badaniu wysiłkowym A – opracowanie koncepcji The level of efficiency of adult women in premature i założeń (preparing SMART – a tool for assessing patients with disorders concepts) based on analysis of power input and power regula- B – opracowanie metod of consciousness (formulating methods) tion stress test C – przeprowadzenie badań (conducting 1,A,E,F 2,A,F research) Tomasz Waraksa1, A-F , Agnieszka Wójcik1, C-F 1, A,C,E D – opracowanie wyników Andrzej Magiera , Artur Jagodziński , Katarzyna Kaczmarczyk , 2, A,D,E (processing results) Ida1Centrum Wiszomirska Rehabilitacji Funkcjonalnej ORTHOS, Warszawa. Centre of Functional E – interpretacja i wnioski (nterpretation and KatedraRehabilitation Biologicznych ORTHOS, Podstaw Warsaw Rehabilitacji, Wydział Rehabilitacji AWF Warszawa 1 conclusions) Zakład Fizjologii 2 F – redakcja ostatecznej 2Akademia Zakład Anatomii Wychowania Fizycznego Józefa Piłsudskiego w Warszawie, Wydział wersji (editing the final Rehabilitacji, Katedra Fizjoterapii. Jozef Pilsudski University of Physical Education version) in Warsaw, Faculty of Rehabilitation, Department of Physiotherapy Streszczenie Streszczenie Wstęp: Liczba urodzeń przedwczesnych w Polsce, pomimo znacznego wzrostu poziomu medycynyTrafna ocenaoraz świadomości pacjentów zmatek, zaburzeniami w ostatnich świadomości latach utrzymuje wciąż sięstanowi na stałym poważne poziomie, wy- zwanieoscylującym medyczne. wokół Pomimo 7%. Wskaźnik zastosowania ten jest w podobny ostatnim w czasie innych nowoczesnych krajach Unii Europejskiej.technik neu- roobrazowaniaCelem niniejszej (EEG, pracy fMRI,jest ocena PET wpływu i innych) wcześniactwa prawidłowa na diagnoza moc wejścia wciąż i jestmoc znaczącoregulacji utrudniona.w badaniu wysiłkowym Brak precyzyjnego u kobiet dorosłych.
    [Show full text]
  • Unconsciousness Coma
    Unconsciousness Coma Z. Rozkydal Intracranial causes Vessels: head injury, bleeding haematoma, anomalies, ischemia Infection – meningitis, encefalitis, abscesus Tumors Epilepsy Extracranial causes Poisoning (CO, alcohol, drugs) Metabolic diseases (DM, hypothyreosis) Systemis failure- liver, kidney Stop of breathing and circulation - in 30 seconds Level of consciousness 1. Somnolence drowsiness 2. Sopor lower level of consciousness reaction to pain 3. Coma deep unconsciousness je neprobuditelný Level of consciousness A Alert, respond to questions eyes are open V Voice, respond to voice, obey commands P Pain, respond to pain U Unresponsive to any stimulus First aid Seek the cause Monitor vital signs Opening the airways- tilt his head back lift the chin Checking breathing Recovery position, injury- the same position AED CPR Avoid aspiration, nothing orally Transport Recovery position Faintness- syncope Short loss of consciousness Causes: bradycardia, arythmia postural hypotensis vasovagal faintness First aid Horizontal position Raising of legs Fresh air Fluids Extracranial unconsciousness Diabetic coma DM- insufficient production of insulin Hyperglycaemia, osmotic diuresis Loss of fluids Metabolic acidosis, aceton Loss of potassium and natrium Brain is depedent on plasmatic glucose Utilisation of glucose in brain is not controlled by insulin Signs Polyuria, polydypsia Dry, warm skin, dehydration Rapid pulse and breathing Excessive thirst Deep breath Fruity sweet breath- aceton in the breath Nausea and vomiting Unconsciousness Mortality 50
    [Show full text]
  • Unconsciousness Due to Internal Diseases - - Differential Diagnosis and Management
    Unconsciousness due to internal diseases - - differential diagnosis and management Tomáš Janota 3rd Department of Medicine Intensive Cardiac Care Unit Content • Definitions • Patophysiological mechanism • List of reasons • Dif. dg. approaches • Examinations • Manegement • Syncope (Guideliness ESC 2018) Definition of unconsciousness (coma) • The most severe quantitative disturbance of consciousness • Somnolence - sopor - coma. • Glasgow Coma Scale ≥ 7 Glasgow Coma Scale (adult) Classification of unconsciousness by duration • Transient lost of consciousness (TLOC) – lasting in seconds/minutes • Prolonged unconsciousness/coma - lasting tens of minutes or more Transient lost of consciousness (TLOC) • Short duration LOC • Lost of responsiveness • Lost of muscle tone • Amnesia ! TLOC regarding age 100 Classification of TLOC by mechanism cerebral abnormal excessive psychological process hypoperfusion brain activity of conversion frequency „Rare“ causes o TLOC Vertebrobasiliar TIA – focal neurological signs, LOC longer Subclavian steal sy – with arm excercises Subarachnid haemorrhage – extreme headache Cyanotic breath-holding spells - young child reacts to sudden pain or upset by not breathing, turning pale or blue and then fainting Psychogenic TLOC Psychogenic pseudosyncope (PPS)/pseudocoma – duration minutes to hours, up to several times a day Psychogenic non-epileptic seizures (PNES) Situations incorectly diagnosed as TLOC Falls – no unresponsiveness, no amnesia Absence epilepsy – no falls but amnesie …… Syncope • Definition: sudden temporary
    [Show full text]
  • Unconsciousness
    Consciousness • Vigilance • The ability to maintain attention and alertness over prolonged periods of time • Individual is fully responsive to stimuli, this is the condition of the person when awake. • Activity of ARAS (ascending reticular activating system) Unconsciousness A state of unawareness of self and environment. One shows no responsiveness to environmental stimuli but may respond to deep pain with involuntary movements. Unconsciousness • Somnolencia – ("drowsiness„) is a state of near-sleep, a strong desire for sleep, or sleeping for unusually long periods. • Sopor/stupor- is an unresponsive state from which a person can be aroused only briefly and with vigorous, repeated attempts. • Coma- is a profound state of unconsciousness. - a comatose patient cannot be awakened - fails to respond normally to pain or light - does not have sleep-wake cycles - does not take voluntary actions. - coma can last days, weeks, months, or indefinitely - the length of a coma cannot be accurately predicted or known - coma results from gross impairment of both cerebral hemispheres, and/or the ascending reticular activating system. Unconsciousness • Deep unconsciousness – absent brain stem reflexes (corneal, pupillar, pharyngeal), tendom reflexes, muscle hypotonia, spontaneous breathing is absent • Mild unconsciousness – brain stem reflexes +-, increases muscle tone, spontaneous breathing is present – different pathology Unconsciousness • Acute a/ lesion in brain stem b/ metabolic reason Unconsciousness 1. Consciousness 2. Breathing 3. Pupils 4. Position
    [Show full text]
  • Coma of Unknown Origin in the Emergency Department
    Braun et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:61 DOI 10.1186/s13049-016-0250-3 ORIGINAL RESEARCH Open Access Coma of unknown origin in the emergency department: implementation of an in- house management routine Mischa Braun1,2†, Wolf Ulrich Schmidt1,2*†, Martin Möckel3, Michael Römer4, Christoph J. Ploner1 and Tobias Lindner3 Abstract Background: Coma of unknown origin is an emergency caused by a variety of possibly life-threatening pathologies. Although lethality is high, there are currently no generally accepted management guidelines. Methods: We implemented a new interdisciplinary standard operating procedure (SOP) for patients presenting with non-traumatic coma of unknown origin. It includes a new in-house triage process, a new alert call, a new composition of the clinical response team and a new management algorithm (altogether termed “coma alarm”). It is triggered by two simple criteria to be checked with out-of-hospital emergency response teams before the patient arrives. A neurologist in collaboration with an internal specialist leads the in-hospital team. Collaboration with anaesthesiology, trauma surgery and neurosurgery is organised along structured pathways that include standardised laboratory tests and imaging. Patients were prospectively enrolled. We calculated response times as well as sensitivity and false positive rates, thus proportions of over- and undertriaged patients, as quality measures for the implementation in the SOP. Results: During 24 months after implementation, we identified 325 eligible patients. Sensitivity was 60 % initially (months 1–4), then fluctuated between 84 and 94 % (months 5–24). Overtriage never exceeded 15 % and undertriage could be kept low at a maximum of 11 % after a learning period.
    [Show full text]
  • Outcome and Prognosis of Hypoxic Brain Damage Patients Undergoing Neurological Early Rehabilitation Ute E Heinz and Jens D Rollnik*
    Heinz and Rollnik. BMC Res Notes (2015) 8:243 DOI 10.1186/s13104-015-1175-z RESEARCH ARTICLE Open Access Outcome and prognosis of hypoxic brain damage patients undergoing neurological early rehabilitation Ute E Heinz and Jens D Rollnik* Abstract Background: The prevalence of patients suffering from hypoxic brain damage is increasing. Long-term outcome data and prognostic factors for either poor or good outcome are lacking. Methods: This retrospective study included 93 patients with hypoxic brain damage undergoing neurological early rehabilitation [length of stay: 108.5 (81.9) days]. Clinical data, validated outcome scales (e.g. Barthel Index—BI, Early Rehabilitation Index—ERI, Glasgow Coma Scale—GCS, Coma Remission Scale—CRS), neuroimaging data, electroen- cephalography (EEG) and evoked potentials were analyzed. Results: 75.3% had a poor outcome (defined as BI <50). 38 (40.9%) patients were discharged to a nursing care facil- ity, 21 (22.6%) to subsequent rehabilitation, 17 (18.3%) returned home, 9 (9.7%) needed further acute-care hospital treatment and 8 (8.6%) died. Barthel Index on admission as well as coma length were strong predictors of outcome from hypoxic brain damage. In addition, duration of vegetative instability, prolongation of wave III in visual evoked potentials (flash VEP), theta and delta rhythm in EEG, ERI, GCS and CRS on admission were related to poor outcome. All patients with bilateral hypodensities of the basal ganglia belonged to the poor outcome group. Age had no inde- pendent influence on functional status at discharge. Conclusions: As with other studies on neurological rehabilitation, functional status on admission turned out to be a strong predictor of outcome from hypoxic brain damage.
    [Show full text]
  • A Randomized Clinical Trial
    Supplementary Online Content 2 Schmidt K, Worrack S, Von Korff M, et al. Effect of a primary care management intervention on mental health–related quality of life among survivors of sepsis: a randomized clinical trial. JAMA. doi:10.1001/jama.2016.7207. Sepsis Help Book Sepsis Monitoring Checklist Sepsis Case Manager Training Manual Sepsis PCP Manual Downloaded From: https://jamanetwork.com/ on 09/24/2021 Effect of a primary care management intervention on mental-health-related quality of life among survivors of sepsis: a randomized clinical trial Sepsis Help Book Sepsis survivors Monitoring and cOordination in OutpatienT Health care Study management: Prof. Dr. J. Gensichen (PI), Dr. med. Konrad Schmidt Patient manual Jena University Hospital, Institute of General Practice, Bachstr. 18, 07743 Jena. 2012_01_16_final rev. Telephone: +49 (0)3641/9395800; [email protected] 1 Downloaded From: https://jamanetwork.com/ on 09/24/2021 Table of Contents 1 Introduction ............................................................................................................................. 3 1.1 What is this manual about? ............................................................................................... 3 1.2 What is this manual good for? ........................................................................................... 3 1.3 The SMOOTH study at a glance........................................................................................ 4 2 Sepsis ....................................................................................................................................
    [Show full text]
  • Die Verwirrung Um Verwirrtheit, Stupor Und Koma Terminologische Bemerkungen Zu Den Bewusstseinsstörungen N C
    Originalarbeit Die Verwirrung um Verwirrtheit, Stupor und Koma Terminologische Bemerkungen zu den Bewusstseinsstörungen n C. W. Hess Neurologische Universitätsklinik und Poliklinik, Inselspital, Bern Summary (twilight state) are being discussed and related to the term “delirium” with its various definitions Hess CW. [Confusion over delirium, stupor and in recent years. coma.] Schweiz Arch Neurol Psychiatr. 2007;158: Keywords: sopor; stupor; delirium; acute con- 354–9. fusional state Taxonomy and nomenclature of normal and abnormal states of consciousness have been Einleitung highly variable, imprecise and sometimes con- fusing, because the terms used to describe them Begriffsverwirrungen gehören zur klinischen Me- have been given different meanings depending dizin wie das Wasser zum Fisch.Das liegt einerseits on medical field (e.g. neurology and psychiatry) sicher daran, dass die klinische Medizin, ähnlich and language. Compounding the difficulty is the etwa wie die Psychologie, keine exakte Wissen- fact that the terms continue to be changed in an schaft ist. Bereiche wie die Neurologie und Psych- attempt to reflect pathophysiology of disturbed iatrie sind wegen ihrer unübertroffenen Kom- consciousness which, however, is still not fully plexität besonders anfällig auf terminologische understood. In this article the terminological de- Verwirrungen. Verschiedene Schulen schufen in velopment and various definitions of the terms ihrer Sprache ihre eigene Systematik, mehr oder sopor, stupor, delirium, akinetic mutism and coma weniger ungeachtet anderer schon existierender vigile,“apallisches Syndrom” (“apallic syndrome”) terminologischer Regelwerke. or vegetative state are being described with spe- Heute versuchen internationale Expertengre- cial emphasis on the German and English medical mien eine einheitliche Nomenklatur zu schaffen, usage and some discrepant denotations.
    [Show full text]
  • Alterations in Consciousness, Coma Last Updated: May 8, 2019 DEFINITIONS
    ALTERATIONS IN LEVEL OF CONSCIOUSNESS, COMA S30 (1) Alterations in Consciousness, Coma Last updated: May 8, 2019 DEFINITIONS ............................................................................................................................................ 1 PATHOPHYSIOLOGY ................................................................................................................................. 2 ANATOMY OF AROUSAL ......................................................................................................................... 2 SUBSTRATE OF COMA ............................................................................................................................ 4 ANATOMY OF AWARENESS .................................................................................................................... 4 ANATOMY OF ATTENTION ...................................................................................................................... 5 ETIOLOGY ................................................................................................................................................ 5 INITIAL EXAMINATION AND STABILIZATION .......................................................................................... 5 SHORT HISTORY ..................................................................................................................................... 6 GLASGOW COMA SCALE ........................................................................................................................
    [Show full text]