4a.pptx

KEJANG STATUS EPILEPTIKUS

• Definisi Konseptual Bangkitan yang berlangsung lebih dari 30 menit, atau adanya dua bangkitan atau lebih di mana di antara bangkitanbangkitan tadi tidak terdapat pemulihan kesadaran. • Definisi operasional status epileptikus konvulsif Adalah bangkitan dengan durasi lebih dari 5 menit, atau bangkitan berulang 2 kali atau lebih tanpa pulihnya kesadaran diantara bangkitan.

• Tatalaksana Stadium 1 (0−10 menit) • • • • •

Diazepam 10 mg IV bolus lambat dalam 5 menit, stop jika kejang berhenti, bila masih kejang dapat diulang 1 kali lagi atau Midazolam 0.2 mg/kgBB IM Pertahankan patensi jalan napas dan resusitasi Berikan oksigen Periksa fungsi kardiorespirasi Pasang infus

• Stadium 2 (0−30 menit) • • • • •

Monitor pasien Pertimbangkan kemungkinan kondisi non epileptik Pemeriksaan emergensi laboratorium Berikan glukosa (D50% 50 ml) dan/atau thiamine 250 mg i.v bila ada kecurigaan penyalahgunaan alkohol atau defisiensi nutrisi Terapi asidosis bila terdapat asidosis berat

• Stadium 3 (0−60 menit) • • • • •

Pastikan etiologi Siapkan untuk rujuk ke ICU Identifikasi dan terapi komplikasi medis yang terjadi Vasopressor bila diperlukan Phenytoin i.v dosis of 15–18 mg/kg dengan kecepatan pemberian 50 mg/menit dan/atau bolus Phenobarbital 10–15 mg/kg i.v.dengan kecepatan pemberian100 mg/menit

• Stadium 4 (30−90 menit) • • • • •

Pindah ke ICU Anestesi umum dengan salah satu obat di bawah ini : - Propofol 1–2 mg/kgBB bolus, dilanjutkan 2–10 mg/kg/jam dititrasi naik sampai SE terkontrol - Midazolam 0.1–0.2 mg/kg bolus, dilanjutkan 0.05–0.5 mg/kg/jam dititrasi naik sampai SE terkontrol - Thiopental sodium 3–5 mg/kg bolus, dilanjut 3–5 mg/kg/jam dititrasi naik sampai terkontrol Perawatan intensif dan monitor EEG Monitor tekanan intrakranial bila dibutuhkan Berikan antiepilepsi rumatan jangka panjang

a. Terdapat serangan bangkitan berulang tanpa diikuti pulihnya kesadaran b. Gejala dan tanda sebelum, selama, dan pasca bangkitan : • •

Sebelum bangkitan/gejala prodromal: Selama bangkitan/iktal:

• Apakah terdapat aura, gejala yang dirasakan pada awal bangkitan? • Bagaimana pola/bentuk bangkitan, mulai dari deviasi mata, gerakan kepala, gerakan tubuh, vokalisasi, otomatisasi, gerakan pada salah satu atau kedua lengan dan tungkai, bangkitan tonik/klonik, inkontinensia, lidah tergigit, pucat, berkeringat, dan lain-lain. (Akan lebih baik bila keluarga dapat diminta untuk menirukan gerakan bangkitan atau merekam video saat bangkitan) • Apakah terdapat lebih dari satu pola bangkitan? o Apakah terdapat perubahan pola dari bangkitan sebelumnya? o Aktivitas penyandang saat terjadi bangkitan, misalnya saat tidur, saat terjaga, bermain video game, berkemih, dan lain-lain. •

Pasca bangkitan/ post iktal: o Bingung, langsung sadar, nyeri kepala, tidur, gaduh gelisah, Todd’s paresis.

c. Faktor pencetus : kelelahan, kurang tidur, hormonal, stress psikologis, alkohol. d. Usia awitan, durasi bangkitan, frekuensi bangkitan, interval terpanjang antar bangkitan, kesadaran antar bangkitan. e. Terapi epilepsi sebelumnya f. Penyakit yang diderita sekarang, riwayat penyakit neurologik, psikiatrik maupun sistemik yang mungkin menjadi penyebab maupun komorbiditas. g. Riwayat epilepsi dan penyakit lain dalam keluarga

h. Riwayat saat berada dalam kandungan, kelahiran, dan tumbuh kembang i. Riwayat bangkitan neonatal/ kejang deman j. Riwayat trauma kepala, stroke, infeksi susunan saraf pusat (SSP), dll.

PRE HOSPITAL CARE • Supportive care, including ABCs, must be addressed in the prehospital setting. • If the seizure fails to stop within 4-5 minutes or if the patient is continuing to seize at the time of emergency medical system (EMS) personnel arrival, prompt administration of anticonvulsants may be necessary. • Because of the refrigeration requirements and the infrequent use of most anticonvulsants, diazepam (Valium) is often the only anticonvulsant available in the prehospital setting. Diazepam may be administered intravenously (IV) or per rectum. Midazolam (Versed) is available in some EMS systems and is currently the subject of study because of the option for intramuscular and intranasal administration. • If persons who know the patient, or who witnessed the onset of the seizures, are present at the scene, EMS providers may be able to collect information that offers clues to the cause of the SE.

TENSION HEADACHE

• Episodic tension headache usually is associated with a stressful event. This headache type is of moderate intensity, self-limited, and usually responsive to nonprescription drugs. • Chronic tension headache often recurs daily and is associated with contracted muscles of the neck and scalp. This type of headache is bilateral and usually occipitofrontal.

•

two of the following characteristics must be present : • • • •

Pressing or tightening (nonpulsatile quality) Frontal-occipital location Bilateral - Mild/moderate intensity Not aggravated by physical activity

• Tension-type headache history is as follows: • • • • • • • • • • • • •

Duration of 30 minutes to 7 days No nausea or vomiting (anorexia may occur) [11] Photophobia and/or phonophobia [11] Minimum of 10 previous headache episodes; [11] fewer than 180 days per year with headache to be considered "infrequent" Bilateral and occipitonuchal or bifrontal pain Pain described as "fullness, tightness/squeezing, pressure," or "bandlike/viselike" May occur acutely under emotional distress or intense worry Insomnia Often present upon rising or shortly thereafter Muscular tightness or stiffness in neck, occipital, and frontal regions Duration of more than 5 years in 75% of patients with chronic headaches Difficulty concentrating No prodrome

PF • Vital signs should be normal. • Normal neurologic examination. • Tenderness may be elicited in the scalp or neck, but no other positive physical exam findings should be noted. • Pain should not be elicited over temporal arteries or positive trigger zones. • Some patients with occipital tension headaches may be very tender when upper cervical muscles are palpated. • Pain associated with neck flexion and stretching of paracervical muscles must be distinguished from nuchal rigidity associated with meningeal irritation.

TX • Various modalities are used in the treatment of tension headaches. These include hot or cold packs, ultrasound, electrical stimulation, improvement of posture, trigger point injections, occipital nerve blocks, stretching, and relaxation techniques. • Regular exercise, stretching, balanced meals, and adequate sleep may be part of a headache treatment program. [12]

• Non-pharmacological treatments for headache include behavioral treatments such as cognitive-behavioral therapy, relaxation, biofeedback as well as acupuncture and massage. • Massage can relieve tight muscles in the back of the head, neck, and shoulders, which may in turn relieve headache pain. [15, 16]

Pharmacologic • Ibuprofen • OTC: 200-400 mg PO q4-6hr; not to exceed 1.2 g unless directed by physician • Prescription: 400-800 mg PO q6hr = 4 dd tab 1

• Difenhidramin • 25-50 mg PO q6-8 hr = 3 dd tab 1

MIGRAIN

• Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with visual or sensory symptoms—collectively known as an aura—that arise most often before the head pain but that may occur during or afterward. Migraine is most common in women and has a strong genetic component.

SYMPTOMS • Throbbing or pulsatile headache, with moderate to severe pain that intensifies with movement or physical activity • Unilateral and localized pain in the frontotemporal and ocular area, but the pain may be felt anywhere around the head or neck • Pain builds up over a period of 1-2 hours, progressing posteriorly and becoming diffuse • Headache lasts 4-72 hours • Nausea (80%) and vomiting (50%), including anorexia and food intolerance, and light-headedness • Sensitivity to light and sound

PF • Cranial/cervical muscle tenderness • Horner syndrome (ie, relative miosis with 1-2 mm of ptosis on the same side as the headache) • Conjunctival injection • Tachycardia or bradycardia • Hypertension or hypotension • Hemisensory or hemiparetic neurologic deficits (ie, complicated migraine) • Adie-type pupil (ie, poor light reactivity, with near dissociation from light)

• The diagnosis of migraine is based on patient history. International Headache Society diagnostic criteria are that patients must have had at least 5 headache attacks that lasted 4-72 hours (untreated or unsuccessfully treated) and that the headache must have had at least 2 of the following characteristics [1] : • • • •

Unilateral location Pulsating quality Moderate or severe pain intensity Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

• In addition, during the headache the patient must have had at least 1 of the following: • Nausea and/or vomiting • Photophobia and phonophobia

• Emergency medical services personnel should transport patients in a way that minimizes visual and auditory stimulation. • providing symptomatic relief should be a priority. Rest in a darkened, quiet room is helpful. Some patients find cool compresses to painful areas helpful. • Migraine-specific medications and analgesia are key elements of ED care. • Hospital admission for migraine may be indicated for the following: • Treatment of severe nausea, vomiting, and subsequent dehydration • Treatment of severe, refractory migraine pain (ie, status migrainosus) • Detoxification from overuse of combination analgesics, ergots, or opioids

• Terapi abortif migrain:

• a. Abortif non spesifik : • analgetik, obat anti-inflamasi non steroid (OAINS) • • • •

Aspirin 500 - 1000 mg per 4-6 jam (Level of evidence : A). Ibuprofen 400 – 800 mg per 6 jam (A). Parasetamol 500 -1000 mg per 6-8 jam untuk terapi migrain akut ringan sampai sedang (B). Kalium diklofenak (powder) 50 -100 mg per hari dosis tunggal.

• b. Abortif spesifik : triptan, dihidroergotamin, ergotamin, diberikan jika analgetik atau OAINS tidak ada respon. Risiko medication overuse headache (MOH) harus dijelaskan ke pasien, ketika memulai terapi migrain akut

• • Antimuntah

• a. Antimuntah oral atau per rektal dapat digunakan untuk mengurangi gejala mual dan muntah dan meningkatkan pengosongan lambung • b. Metokloperamid 10mg atau donperidone 10mg oral dan 30mg rektal.

• • Triptan

• a. Triptan oral dapat digunakan pada semua migran berat jika serangan sebelumnya belum dapat dikendalikan dengan analgesik sederhana • b. Sumatriptan 30mg, Eletriptan 40-80 mg atau Rizatriptan 10 mg

VERTIGO

• Vertigo adalah persepsi yang salah dari gerakan seseorang atau lingkungan sekitarnya. Persepsi gerakan bisa berupa: • a. Vertigo vestibular adalah rasa berputar yang timbul pada gangguan vestibular. • b. Vertigo non vestibular adalah rasa goyang, melayang, mengambang yang timbul pada gangguan sistem proprioseptif atau sistem visual

• Pada anamnesis perlu digali penjelasan mengenai: Deskripsi jelas keluhan pasien. Pusing yang dikeluhkan dapat berupa sakit kepala, rasa goyang, pusing berputar, rasa tidak stabil atau melayang. a. Bentuk serangan vertigo: Pusing berputar atau rasa goyang atau melayang. b. Sifat serangan vertigo: Periodik. kontinu, ringan atau berat. c. Faktor pencetus atau situasi pencetus dapat berupa: -‐ Perubahan gerakan kepala atau posisi. -‐ Situasi: keramaian dan emosional -‐ Suara

• The Dix-Hallpike maneuver is the standard clinical test for BPPV. The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless except to indicate that active canalithiasis is not present at that moment. • The Dix-Hallpike maneuver is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

• 1. Antihistamin (dimenhidrinat, difenhidramin, meksilin, siklisin) • Dimenhidrinat lama kerja obat ini ialah 4 – 6 jam po/im/iv dengan dosis 25 mg – 50 mg (1 tablet), 4 kali sehari. • Difenhidramin HCl. Lama aktivitas obat ini ialah 4 – 6 jam, diberikan dengan dosis 25 mg (1 kapsul) – 50 mg, 4 kali sehari per oral. • Senyawa Betahistin (suatu analog histamin): • a) Betahistin Mesylate dengan dosis 12 mg, 3 kali sehari per oral. • b) Betahistin HCl dengan dosis 8-24 mg, 3 kali sehari. Maksimum 6 tablet dibagi dalam beberapa dosis.

2. Kalsium Antagonis • Cinnarizine, mempunyai khasiat menekan fungsi vestibular dan dapat mengurangi respons terhadap akselerasi angular dan linier. Dosis biasanya ialah 15-30 mg, 3 kali sehari atau 1x75 mg sehari.

ASMA BRONCHIALE

• Asthma is a common chronic disease involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness. • Episodic symptoms of airflow obstruction are present • Airflow obstruction or symptoms are at least partially reversible • Exclusion of alternative diagnoses.

batuk, mengi, sesak napas episodik bronkitis / pneumonia berulang Riwayat atopi Riwayat faktor pencetus

Tanpa serangan : dapat normal Penyakit penyerta Saat serangan • sesak • mengi • otot bantu napas • pulsus paradoksus

• A detailed assessment of the medical history should address the following: • • • • •

Whether symptoms are attributable to asthma Whether findings support the likelihood of asthma (eg, family history) Asthma severity Identification of possible precipitating factors Family history may be pertinent for asthma, allergy, sinusitis, rhinitis, eczema, and nasal polyps. The social history may include home characteristics, smoking, workplace or school characteristics, educational level, employment, social support, factors that may contribute to nonadherence of asthma medications, and illicit drug use.

• Wheezing, a musical, high-pitched, whistling sound produced by airflow turbulence, is one of the most common symptoms. In the mildest form, wheezing is only end expiratory. As severity increases, the wheeze lasts throughout expiration. In a more severe asthmatic episode, wheezing is also present during inspiration. During a most severe episode, wheezing may be absent because of the severe limitation of airflow associated with airway narrowing and respiratory muscle fatigue. • Asthma can occur without wheezing when obstruction involves predominantly the small airways. In exercise-induced bronchoconstriction, wheezing may be present after exercise, and in nocturnal asthma, wheezing is present during the night.

Gejala dan Tanda

Berat Serangan Akut Ringan

Keadaan Mengancam Jiwa

Sedang

Berat

Sesak napas

berjalan

Posisi

Dapat tidur terlentang

Duduk

Duduk membungkuk

Cara berbicara

Satu kalimat

Beberapa kata

Kata demi kata

Kesadaran

Mungkin gelisah

Gelisah

Gelisah

Frekuensi napas

<20/menit

20-30/menit

>30/menit

Nadi

<100

100-120

>120

Bradikardia

Pulsus paradoksus

10 mmHg

+/10-20 mmHg

+ >25 mmHg

Kelelahan otot

Otot bantu napas dan retraksi suprasternal

-

+

+

Torakoabdominal paradoksimal

Mengi

Akhir ekspirasi paksa

Akhir ekspirasi

Inspirasi dan ekspirasi

‘silent chest’

APE

>80%

60-80%

<60%

PaO2

N

>60 mmHg

<60 mmHg

PaCO2

<45 mmHg

<45 mmHg

>45 mmHg

SaO2

>95%

91-95%

<90%

Mengantuk, gelisah, kesadaran menurun

Daftar 2-5. TIngkat Kontrol Asma Karakteristik

Terkontrol (semua dari daftar berikut)

Terkontrol Sebagian(bebera pa didapatkan dalam seminggu)

Tidak Terkontrol

Gejala harian

Tidak ada (dua atau kurang dalam seminggu)

Lebih dari dua kali/seminggu

Keterbatasan aktifitas

Tidak ada

Ada

Tiga atau lebih gambaran dalam asma terkontrol sebagian muncul dalam seminggu

Gejala malam hari/terbangun

Tidak ada

Ada

Kebutuhan terapi pelega

Tidak ada (dua kali atau kurang dalam seminggu)

Lebih dari dua kali/seminggu

Fungsi paru (VEP1 atau APE)

Normal

< 80% prediksi atau nilai terbaik yang diketahui

DYSPEPSIA

GERD

DIARE & GASTROENTERITIS

CORPUS ALIENUM

CONJUNCTIVITIS

DRY EYES

EPISTAKSIS

RHINITIS

INFLUENZA

FARINGITIS

TONSILITIS

APHTOUS ULCER

PAROTITIS

INTOLERANSI MAKANAN

ALERGI MAKANAN

KERACUNAN MAKANAN

ISK

ADB

HIPOGLIKEMIA

TINEA

REAKSI GIGITAN SERANGGA

DERMATITIS ATOPIK

URTIKARIA

VULNUS LACERATUM

LUKA BAKAR

HEAT RELATED ILLNESS

HIPOTERMIA

DEHIDRASI

TERSEDAK

SYNCOPE