EMERGENCY NURSING CARE

OF

R. Isnawan Risqi Rakhman, S.Kep., Ners, M.Kep

 R. Isnawan Risqi Rakhman
[email protected]
081280304884

• 2022 M.Kep., FIK UI

• 2008 S.Kep., Ners, FIK UI

● 2010-2012 IGD RSCM – Staff

● 2012-2017 IGD RS PON- Head Nurse
● 2017-2020 IBS RS PON- Head Nurse
● 2020-recent Yankep RS PON- Spv. Ruang
Khusus
● 2013 DPK RS PON– Ketua
● 2014 HIPGABI DKI - Diklat
● 2014 HIPENI Pusat- Sekretaris Anggota
● 2019 HIPENI Pusat - Sekretaris
OUTLINE

Overview

Basic Concept

Emergency Management
 Epidemiology Traumatic Brain
Brain Tumors Vascular Lessions
Injury
• 50 % • 25 % cavernous • 20% traumatic ICH
-ganglioglioma malformation • 19% Concussion
• 46% • 22% AVM • 19% contusion
-oligodendrogliom • 8% SAH • 6% chronic SDH
a • 6% infark • 3% CKR
• 33% -low grade • 4% SH
astrocytoma
• 21%- high grade
astrocytoma
• 14% -Meningioma
• 9% -ependimoma
Hamasaki, T., Yamada, K., & Kuratsu, J. (2013). Seizures as a presenting symptom in neurosurgical
patients: A retrospective single-institution analysis. Clinical Neurology and Neurosurgery, 115(11), 2336-40.
doi:http://dx.doi.org/10.1016/j.clineuro.2013.08.016
Epidemiology

3.1 % pasien stroke mengalami kejang Faktor risiko kejang :

Pada 24 jam pertama setelah • Stroke perdarahan
serangan • Usia muda
8.4% pasien ICH/SAH mengalami • Prestroke Rankin stroke ≥1
kejang
Pasien stroke dengan kejang
mortalitasnya > disbanding yang •Szaflarski, J. P., Rackley, A. Y., Kleindorfer, D. O., Khoury, J., Woo, D., Miller, R., Alwell,
K., Broderick, J. P., & Kissela, B. M. (2008). Incidence of seizures in the acute phase of
tanpa kejang stroke: A population‐based study. Epilepsia (Copenhagen), 49(6),
974-981. https://doi.org/10.1111/j.1528-1167.2007.01513.x
Hamasaki, T., Yamada, K., & Kuratsu, J. (2013). Seizures as a presenting symptom in neurosurgical patients: A
retrospective single-institution analysis. Clinical Neurology and Neurosurgery, 115(11), 2336-40.
doi:http://dx.doi.org/10.1016/j.clineuro.2013.08.016
 SEIZURE

Definition • Is a clinical presentation of the CNS characterized

by ABNORMAL CEREBRAL ELECTRICAL
Patophysiology
DISCHARGES (ANNA, 2009)

Classification

Clinical Signs and

“Seizure is a transient occurence of signs and/or symptoms due to
Symtoms
abnormal excessice or synchronous neuronal activity in the brain
(ILAE, 2014)
 STATUS EPILEPTICUS

Definition • Continuous state of Seizure/ multiple seizures without

return to baseline, resulting in observable or even
subjectively perceived sensory, motor, and/or cognitive
Patophysiology dysfunction for at least 30 minutes

Classification STATUS
EPILEPTICUS

Clinical Signs and

Symtoms
30’ 20’ 5’
 SEIZURE vs STATUS EPILEPTICUS vs EPILEPSY

Definition

Patophysiology Seizure Status Ep Epilepsy

Classification Seizure is an • Continuous • the disease

event, state of involving
Clinical Signs and
Seizure/ recurrent
Symtoms multiple unprovoked
seizures seizures
 Definition

Patophysiology

Classification

Clinical Signs and

Symtoms
Ketidakstabilan membrane sel saraf 🡻 mudah aktif
• Neuron hipersensitif 🡻 mudah terangsang
• Terjadinya polarisasi abnormal
 Definition

Patophysiology

Classification

Clinical Signs and

Symtoms
• ketidakseimbangan antara pengaruh inhibisi dan eksitatori
pada otak
⦿ Kurangnya transmisi inhibitori
⦿ Meningkatnya aksi eksitatori
 Hipoksia/
iskemia

Paska
Definition pembedahan Massa

Patophysiology

Classification

Infeksi dan Gangguan

Etiology and
Clinical demam elektolit
Presentation

Toksisitas
obat
 SEIZURE CLASSIFICATION (ILAE, 2016)
FOKAL GENERALIZED Unknown onset

MOTOR MOTOR MOTOR

tonik tonic-clonic tonic-clonic
Definition tonic
atonik tonic
myoclonic atonic atonic
clonic myoclonic epileptic spasm
Patophysiology epileptic spasm myoclonic-atonic
hypermotor clonic NON MOTOR
NON- MOTOR clonic-tonic-clonic
Classification
Sensory epileptic spasm
aware impaired unknown
cognitive ABSENCE awareness awareness
Clinical Signs and emotional typical
Symtoms autonomic atypical
myoclonic unclassified

aware impaired unknown eyelid myoclonia

awareness awareness
Operational Classification of Seizure Types by the International League
Against Epilepsy.
to bilateral tonic-clonic
http://www.ilae.org/visitors/centre/documents/ClassificationSeizureILAE-2
016.pdf 13
 Sympathetic Parasympathetic
Responses Responses
Definition
• Tachycardi • Hypersalivasi
Patophysiology • Tachypnea • Secretion of
• BP 🡻 gastric acid
Classification
• Dilatation of pupil • Peristalsis
Etiology and • Diaphoresis • Myosis
Clinical
Presentation • Facial flushing • BP and HR 🡻
https://synapse.koreamed.org/ArticleImage/0176BN/bn-7-10-g002-l.jpg
 MANAGEMENT OF CARE
• Penanganan kedaruratan
1 Actively Observation

• Terminasi kejang
2
Direct Nursing
• Pencegahan berulangnya Intervention
3 kejang

• Penanganan dan Collaboration

4 pencegahan komplikasi
 PRE-HOSPITAL

• JANGAN!!
• Memasukkan sesuatu ke dalam
mulut pasien
• Merestrain pasien
• Memberikan instruksi verbal
• Memberikan medikasi PER ORAL
• Stabilisasi pasien (airway, Breathing, circulation,
disability-pemeriksaan neurologis)
• Catat waktu onset kejang, monitor TTV
• Kaji Oksigenasi, berikan oksigen per NK/sungkup, pertimbangkan
intubasi jika dibutuhkan
• Monitor EKG
• Cek GDS. Jika <60 mg/dl:
• Dewasa : 100 mg thiamine IV, kemudian 50 ml D50W IV
• Anak ≥ 2 th 2ml/kg D25W IV,
• anak <2 tahun : 4ml/kg D12,5W IV

• Pasang akses IV access

 AIRWAY BREATHING CIRCULATION

• Proteksi • Berikan Oksigen tinggi: • Pasang emergency IV Line

• Cegah Aspirasi : miringkan, NRM • Pantau Nadi : Frekuensi
suction • Pantau SaO2 dan Irama
• Intubasi • Pantau TD

• Lakukan penanganan Basic Life Support (BLS)

• Monitoring berkala : TD, EKG, SaO2, suhu
• Peningkatan TD pada kejang fase akut, tidak memerlukan penanganan kecuali
mengalami peningkatan TD yang ekstrim sistolik >230 mmHg
• Lab studies: DPL, glukosa, elektrolit, enzim hati, AGD, dan kadar OAE jika memungkinkan
• Atasi hipoglikemi jika terjadi, monitoring GDS POCT (stick)
Benzodiazepine pada terapi inisial (Level A)
Pilih 1 dari 3 opsi lini pertama berikut:
• IM midazolam (1o mg, BB>40 kg, 5 m BB 13-40 kg) dosis tunggal
• IV Lorazepam (0.1 mg/kg/dose, max 4 mg/dose, dapat diulang
1x)
• IV diazepam (0.15-0.2 mg/kg/dose, max : 10mg/dose, dapat
diulang 1x)
Jika tidak dapat diberikan 3 opsi diatas, maka dapat:
• IV phenobarbital (15mg/kg/dose, single dose)
• Rectal diazepam (0.2-0.5 mg/kg, max 20 mg/dose, single dose)
• Intranasal midazolam, buccal midazolam)
 Diazepam administration

• 1 ampul : 2 ml = 10 mg (1 strip syringe = 0.5 mg)

• Bolus pelan
• Tidak perlu diencerkan
• Stop jika kejang berhenti
• Maksimal 2x dengan interval 5 menit
• SIAPKAN BAG VALVE MASK
Pilih satu dari beberapa terapi lini kedua, berikan sbg dosis
tunggal
Pilih 1 dari 3 opsi lini pertama berikut:
• IV fosphenitoin (20mg/kg, max 1500 mg/dose, dosis
tunggal)
• IV Valproic acid (40 mg.kg, max 3000 mg/dose, single dose)
• IV levetiracetam (60 mg.kg, max 4500,g/dose, single dose)
Jika tidak tersedia pilihan diatas, dapat menggunakan (jika
sebelumnya belum diberikan)
• IV phenobarbital (15mg/kg, single dose)
 Phenytoin Administration

• 1 ampul = 2 ml = 100 mg
• Kecepatan infus : < 25-50 mg/menit
• Diencerkan dengan NaCl 0.9% (1 ml/1-10 mg)
• Jangan diencerkan dengan pelarut lain karena akan menimbulkan
endapan
• Pastikan TIDAK ADA ARITMIA sebelum pemberian
• Pasang monitor EKG selama pemberian, HENTIKAN infusan jika
muncul aritmia
 Penanganan dan Pencegahan Komplikasi
ssp Kardiovaskular Respirasi Metabolik

• Hipoksia serebral • Infark miokard • Apnea/hypopnea • Dehidrasi

• Edema Serebral • Hipo/hipertensi • Gagal Napas • Gangguan
• Perdarahan • Aritmia • Pneumonia elektrolit:
serebral • Henti jantung aspirasi hiponatremia,
• Trombosis vena • Syok Kardiogenik • Hipertensi hipoglikemia,
serebral pulmoner hiperkalemia
• Emboli paru • Asidosis metabolik
• Nekrosis tubular
asidosis
• Nekrosis hepatik
akut
• Pankreatitis akuT
 SDKI SLKI SIKI
D. 0001. L.01001 Utama :
Bersihan jalan nafas tidak efektif Bersihan jalan nafas meningkat : I.14542 Pencegahan kejang
b.d Sianosis menurun (5) I.01011 Manajemen jalan nafas
Spasme jalan nafas Frekuensi nafas membaik (5) I.01014 Pemantauan respirasi
Hipersekresi jalan napas Pola nafas membaik (5)
Disfungsi neuromuscular dd Pendukung:
I.01012 Manajemen jalan nafas
Mayor: buatan
Tidak mampu batuk I.01018 Pencegahan aspirasi
Sputum berlebih I.010120 Penghisapan jalan nafas
I.010125 Stabilasi jalan nafas
Minor: I.010126Terapi Oksigen
Sianosis
Pola nafas berubah
 SDKI SLKI SIKI
D.0066 Penurunan kapasitas L.06049 Kapasitas adaptif Utama
adaptif intracranial b.d intracranial meningkat I.06194 Manajemen PTIK
Lesi desak ruang • Tingkat kesadaran meningkat (5) I. 06198 Pemantauan TIK
Gangguan metabolism • Gelisah menurun (5)
Edema serebral • Agitasi menurun (5) Pendukung:
Obstruksi aliran cairan serbrospinal • Tekanan darah membaik (5) Manajemen cairan
d.d • Pola nafas membaik (5) Manajemen elektrolit
TD meningkat • Respon pupil membaik (5) Manajemen medikasi
Bradikardi • Refleks neurologis membaik (5) Pemantauan neurologis
Pola nafas irregular • Tekanan intracranial membaik
Kesadaran menurun (5)
Repon pupil melambat
28
TERIMAKASIH

29
Referensi
• Berg, Anne T & Millichap, Jhon.2013. “The 2010 Revised Classification of Seizure & Epilepsy”. Continuum
Vol 19 Number 3 June 2013. American Acedemy of Neurology
• Devinsky, Orrin. 2004. “Effects of Seizures on Autonomic and Cardiovascular Function”.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC531654/ diakses pada tanggal 4 April 2016
• Deglin, Judith Hopver&Vallerand, April Hazard. 1996.”Pedoman Obat Untuk Perawat”. Jakarta: EGC
• Fisher, Rebecca & Long, Lucretia. 2009. “Care of The Patient with Seizures”, Second Edition. Glenview:
American Association of Neuroscience Nurse.
• Fisher, Robert S. 2014.”Epilepsy: A New Definition”. Epilepsy Foundation
http://www.epilepsy.com/article/2014/4/revised-definition-epilepsy diakses pada tanggal 5 April 2016
• Hickey, Joane V. 2014.”The Clinical Practice of Neurological and Neurosurgical Nursing”. Philadelphia:
Lippincot Williams & Wilkins
• Sunaryo, Utoyo. 2006. “Diagnosis Epilepsi”. Jurnal Ilmiah kedokteran Wijaya Kusuma Volume 1 Nomor 1
Januari 2007. Surabaya: FK Universitas Wijaya Kusuma Surabaya
• Varelas, PN. Seizures in Critical Care, A guide to Diagnosis and Therapeutics