Ped Praktis Stat Gizi Dewasa

ADVANCED NEUROLOGY LIFE SUPPORT
Management of
Headache
ANLS, 2017
JAKARTA, 2 – 3 DESEMBER 2017
Objektif
• Algoritma utk menilai dan mengobati pasien

yg datang ke Unit Gawat Darurat dgn keluhan
utama Sefalgia (Headache) atau rasa berputar
(vertigo)
Pendahuluan
Sakit kepala ungkapan pasien beraneka ragam tapi
dapat dibedakan dalam dua kelompok yaitu : pusing
(dizziness/vertigo) dan sakit Kepala (headache)
1. Headache 2. Dizziness (Vertigo)

- sakit kepala - pusing
- nyeri kepala - tujuh keliling
- kepala berdenyut - kepala terasa enteng
cekot-cekot - kepala terasa goyang
ADVANCED NEUROLOGY LIFE SUPPORT Headache (Sefalgia)
Pain or discomfort between the orbits
and occiput arising from pain sensitive structures.
Struktur Kranial/Kepala
yang Peka Nyeri
Peka Nyeri Tidak Peka Nyeri
• Cranial : venous sinuses • Parenchyma otak
dgn v. aferent • Ependyma
• Arteri pd basis serebri & • Choroid
cabang2 arteri besar. • Piamater
• Arteri duramater. • Arachnoid
• Dura dekat basis otak • Dura permukaan convex
dan cabang arteri besar
• Tulang kepala/skull
• Semua struktur extra
kranial.
Mekanisme Umum
Nyeri Kepala
• Traksi pd pembuluh darah besar intrakranial.
• Distensi, dilatasi pd arteri intrakranial
• Inflammasi dekat struktur peka nyeri
• Tekanan langsung pd n. cranialis atau cervical
• Kontraksi otot penopang kepala atau leher
• Stimulasi karena penyakit mata, telinga, hidung
dan sinus.
Epidemiologi
• 60-75% orang dewasa mengalami nyeri kepala
1x per tahun.
• 5-10% akan meminta evaluasi dari Dokter
• 2.8 juta orang/thn ke UGD krn nyeri kepala
• Kurang dari 10% pasien UGD dgn keluhan utama
nyeri kepala karena kausa sekunder emergensi.
CLASSIFICATION of HEADACHE
International Headache Society (IHS)
2004 (WHO ICD-10NA)
I. Primary Headache
II. Secondary Headache
III. Cranial neuralgias central and primary
facial pain and other headaches
Major Causes of Headache
Primer Headache Secondary Headache

1.Migraine 1.Head trauma
a. migraine w/o aura 2. Vascular disorder
b. migraine w/ aura 3. Nonvascular disorder
c. opthalmoplegic 4. H from substance or their with-
d. migraine complication drawal (acute or chronic)
2. Tension type headache 5. H from noncephalic infection
a. episodic 6. Metabolic
b. chronic 7. H referred from cranium, neck, etc
3. Cluster headache 8. Cranial neuralgia, nerve trunk
a. episodic pain, or deafferentation pain
b. chronic a. trigeminal neuralgia
c. chronic paroxysmal hemicrania b. glossopharyngeal neuralgia
4. Miscellaneous c. occipital neuralgia
a. idiophatic stabbing H d. superior laryngeal neuralgia
b. H associated w/ sexual activities e. n. intermedius neuralgia
Nyeri Kepala Primer
Tension
Cluster
Migraine
Algoritma Headache
Keluhan Utama: Headache
Headache Alarms
Anamnesa & Pem Fisik Riwayat Gangguan
Sakit Kepala yang Serius
No Ya
Diagnosa Identifikasi/Singkirkan
Gangguan Sefalgia Primer Etiologi Sefalgia Sekunder
Ya No
Terapi :Sefalgia Primer Identifikasi Sefalgia

Sekunder
Headache Red Flags (SNOOPS)

Systemic Symptoms (fever, weight loss)
Neurologic Symptoms or abnormal signs
(confusion, impaire alertness or conciousness)
Onset : sudden, abrupt, or split second
Older : new on set or progressive headache,
especially in patients > 50 (GCA)
Previous Headache history : 1st H or new or different
Headache (change in attack frequency, severity or
clinical feature)
Secondary risk factors (HIV, systemic cancer)
ADVANCED NEUROLOGY LIFE SUPPORT Headache yang
mengancam Nyawa
• Sub-arachnoid hemorrhage :
perdarahan krn aneurisma sub-arachnoid pecah dan
dapat terjadi rebleeding yang fatal.
• Infeksi susunan saraf pusat :
meningitis bakterialis harus dapat dikenal lebih dini,
supaya terapi antibiotika dapat mencegah kematian
dan mengurangi cacat.
• Edema serebri dan Peninggian TIK : emergensi krn
struktur tengkorak yang keras, sehingga toleransi isi
tengkorak terbatas (hanya 30-50ml). edema atau ↑
TIK dpt menyebabkan herniasi menekan batang otak
dan medula oblongata lalu kematian.
Diagnosa Sefalgia
A. Anamnesa
1. Kapan serangan nyeri kepala yang pertama ?
- akut : SAH, a. carotis diseksi, ruptura AVM,
meningitis, pasca sanggama
- kronik : chronic cluster headache
- serangan pertama kali pd usia > 50 thn : tumor
2. Frekuensi ?
3. Lama serangan ?
4. Berapa kali serangan per hari ?
Diagnosa Sefalgia .. (2)

5. Sifat nyeri kepala ? tajam, tumpul, berdenyut, dll
- tumor : nyeri tumpul dan konstan
- tension H : nyeri tumpul, konstan spt diikat di
frontal
- cluster H : nyeri tajam berdenyut.
6. Lokasi nyeri ?
- cluster H : retroorbital, unilateral.
- trigeminal N : nyeri spt terstrom didaerah V2, V3
- temporal artritis, tension & cluster : di pelipis

7. Faktor memperberat ?
- migraine : trigger stereotipe - lelah, stress, kurang
tidur, mens, alkohol, dll
8. Faktor meringankan ?
- migraine : tempat tenang dan redup.
9. Faktor predisposisi timbulnya nyeri ?
- kehamilan/dehidrasi : venous trombosis
- HIV/immunosupressan : meningitis
- polimyalgia rheumatica: giant cell arteritis (GCA)
- sinusitis, glaucoma, caries, hipertensi, dll

B. Pemeriksaan fisik
- umum; kurus (anoreksia), atau gemuk, dll.
- tanda vital; suhu, tensi, nadi, pernafasan, VAS
- kepala dan THT; scalp tenderness, sinusitis,
keringat di wajah, dan rhinorrhea (cluster H)
- mata; lakrimasi, tekanan bola-mata (glaucoma),
fotophobia, dll
- muskulo-skeletal; myalgia, arthralgia (GCA)
- kulit; rash, herpes, dll

C. Pemeriksaan neurologik
- kesadaran/keadaan mental; tingkat kesadaran,
iritabel, depressi, dll.
- saraf kranial; papiledema, visus↓, ukuran pupil,
lapang pandang, diplopia, dll.
- sensorimotor; ggn neurologik fokal (hemiparese)
D. Pemeriksaan penunjang
- Lab : DPL, cairan otak, urine toksikologi (obat)
- Foto : foto panorama, foto leher, CTScan, MRI
- EKG (utk th/ triptan).
Pendahuluan
• Definisi : nyeri kepala episodik yang berlangsung
4 sp 72 jam, dengan gejala yang khas.
• Karakteristik nyeri kepala disertai gejala neurologik
gastrointestinal, dan gejala otonom.
• Insiden wanita 18%, dan pria 6 % .
• Frekwensi, durasi dan disabiliti bervariasi antara
penderita dan di antara serangan.
• Migraine kausa ? diduga gangguan neurobiologik.
• Berhubungan dgn perubahan sensitivitas sistem
saraf dan aktivasi sistem trigeminal-vaskuler.
The new Basic Concept of
Migraine Pathogenesis
Common Triggers of Migraine

- Stress
- Tiredness
- Anxiety
- Glare flashing/flickering light
- Irregular eating patterns
- Contraceptive pills
- Menstruation.
- Food containing tyramine
- Food not containing tyramine
Women and Migraine
• Menstrual cycle (cyclic↓estrogen levels)
– 60% to 70% report related attacks
– ≈ 60% experience ↑ frequency of attack
• Pregnancy (noncyclic↑ levels of estrogen)
– 55% to 90% report ↓frequency or absence
• Perimenopause (↓estrogen production)
– Many report exacerbation of migraine
• After menopause (noncyclic ↓levels of estrogen)
– Two thirds report marked improvement
Foods that can trigger Headache

Food Foods Containing Tyramine
Avocados Especially when overripe
Bananas If eaten in large quantities
Bean curd Made by the fermentation of the soy bean, found in many Asian
foods. Miso soup has caused reaction
Beer and ale Can be caused by nonalcoholic brand also. Mainly associated with
imported brands with higher levels of tyramine.
Caviar Safe if vacuum packed or fresh
Cheese All are potential headache triggers except the unfermented
cheeses such as cottage cheese
Figs Especially if overripe
Fish Safe if fresh; dried products are potential triggers caution in resto
Liver Safe only if very fresh; accumulates tyramine very rapidly

Food Foods Containing Tyramin
Yeast extract In dietary supplements avoid; safe in baked goods
Protein extra Liquid and powdered protein supplements are potential triggers
Meat Safe if fresh; caution in restaurants
Sausage Avoid aged varieties such as pepperoni
Shrimp paste Avoid; high levels of tyramine
Soups May contain protein extracts, should be avoided
Soy sauce Should be avoided; contains high levels of tyramine; this includes
teriyaki
Wines Generally safe, but red wine may be trigger
Milk May be trigger; ingredient in many prepared foods

Food Foods not Containing Tyramine
Caffeine Large amounts will trigger headache
Chocolate Can cause headaches because of the phenolic compounds
Fava beans Especially when overripe
Ginseng Certain preparations cause headache
Liqueurs More common with chatreuse and drambuie; cause unknown
Whiskey Cause unknown
Incidence: Age of First Migraine
Migraine With Aura Migraine Without Aura

20 20
Boys Girls
15 15
10 10
5 5
0 10 20 30 0 10 20 30
Years of Age at Onset Years of Age at Onset

[Axis: Incidence (per 1,000 Person-Years)]
Stewart W, et al. Am J Epidemiol. 1991;134:1111-20.
Diagnosis Migraine (SULTANS)

• Criteria 1 :
- Severe
- UniLateral
- Throbbing
- Activity Worsens Headache
• Criteria 2
- Nausea
- Sensitivity to light/sound
Gejala Migraine
• Migraine :
1. sederhana (tanpa aura)
2. klasik (migraine dengan aura)
• Aura : gejala fokal neurologi yang komplek men-
dahului/bersamaan dgn serangan nyeri kepala.
1. aura visual : zigzag lines, scintillating scotomas,
bright flashes of light, alteration in the size or
shape of objects in the visual field
2. others : paresethesias, aphasia, motor weakness
(unilateral), dysarthria.
Aura Visual Migraine Classic

DD/ of Primary Headaches

Difrensial Diagnosa Sefalgia Primer

Klinik Migraine Tension H. Cluster H.
L:P 25 : 75% 40 : 60% 90 : 10%
Lateralisasi 60% unilat Difuse bilateral 100% unilateral
Lokasi Frontal, periorbital, Difus Periorbital
temporal, hemicrani
Frekuensi 1-4/bln 1-30/bln 1-3/hr at 3-12/bln
Derajat nyeri Sedang/berat ringan/sedang Sangat berat
Durasi 4-72 jam Variasi 15menit-3jam
Sifat nyeri Berdenyut Tumpul Tajam, bosan
Periodisitas (±) (-) (+++)
Riw keluarga (+++) (±) (±)
Difrensial Diagnosa Sefalgia Primer .. 2

Klinik Migraine Tension H. Cluster H.
Gejala lain
Aura (+++) (-) (-)
Ggn otonom (±) (-) (+++)
Nausea/vomitus (+++) (-) (±)
Foto/fonophobia (+++) (-) (±)
exsaserbasi dgn
gerakan (+++) (-) (-)
Terapi Non-medikamentosa
Dapat diberikan tersendiri atau bersama terapi
pencegahan utk meningkatkan perbaikan klinik
- Latihan relaksasi
- Kombinasi biofeedback termal & terapi
relaksasi
- EMG biofeedback
- Terapi cognitive-behavioral
Terapi Medikamentosa .. 1
Tatalaksana Migraine Akut dibagi 4 tipe :
A. Ringan (mild)
- analgesik sederhana
- NSAIDs
- metoclopramide, kalau perlu jika ada mual
atau muntah
B. Sedang (moderate)
- NSAIDs - ergotamine : oral, nasal
- metoclopramide - sumatriptan : oral, nasal
- DHE (Dehidroergotamine) : nasal
Terapi Medikamentosa .. 2
Tatalaksana Migraine Akut dibagi 4 tipe :
C. Berat (severe)
- ergotamine rectal (kadar plasma 20x dari oral)
ditambah anti emetic rectal,
- sumatriptan : sc 6mg, nasal spray 5 dan 20mg,
oral 25, 50mg (eropa 100mg)
- DHE : im, nasal
D. Sangat berat (extremely severe)
- ketoralac : im 60 mg
- DHE : iv, ditambah dengan  metoclopramide,
- dopamine antagonists,
- opioid
Algoritma Th/ migraine Akut
migraine Pts edukasi : diet, OR, rokok , hindari faktor pen-

cetus nilai derajat disabiliti, derajat serangan dan
Intensitas nyeri berdasarkan catatan buku harian
ringan sp sedang ada mual muntah diare berat
aspirin, acetaminofen + antiemetik, anti- Triptans

NSAID (± antiemetik) migraine non oral DHE nasal-spray
Kombinasi analgesik Frek >3/bln, lamanya opioid (codein + analgesik

>48 jam, aura lama, ringan), butorphanol
Respon tdk adekuat Th/ tdk efektif
opioid > kuat, meperidine,
propoxyphene, oxycodone
Th/ = migraine berat Pertimbangkan
Th/ pencegahan
corticosteroid : prednison
PENCEGAHAN
* Banyak bukti data klinis bahwa migraine timbul
karena hipereksitabilitas sistem saraf sentral
* Tujuan Terapi Pencegahan :
- Mengurangi frekuensi, derajat, dan durasi
serangan nyeri kepala
- Meningkatkan keberhasilan terapi akut
- Meningkatan fungsi dan mengurangi disabiliti
Indikasi Terapi Pencegahan

1. Serangan migraine > 2x/bulan dan menimbulkan
disabiliti > 3 hari.
2. Dengan terapi simptomatik ada kontra indikasi
atau tidak efektif.
3. Pemberian terapi abortif > 2 minggu
4. Keadaan khusus migraine misalnya :
serangan migraine menimbulkan hemiplegi atau
gangguan neurologis lainnya.
5. Lama terapi pencegahan (?), biasanya ≥ 6 bln pd
migraine khronik th/ pencegahan terus menerus.
Medikamentosa utk Terapi
Pencegahan Migraine
Drug Dosis Drug Dosis
 Blocker TCA
Propanolol 60-240 mg/hr Amitriptilin 10-200 mg/hr
Timolol 10-20 mg/hr Imipramine 10-150 mg/hr
NSAIDs SSRIs
Aspirin 325 mg/hr Fluoxetine 10-80 mg/hr
Naproxen 250-500 mg/hr sertraline 50-200 mg/hr
Ca antagonist 120-480 mg/hr OXC 150-300 mg/hr
Verapamil divalproex sod 500-2000mg/hr
Methysergide/ 2-8 mg/hr Cyprohepta- 2-4mg mg qid
serotonin antag din
Terapi Pencegahan Migraine

dengan ggn penyerta
Coexisting disorder Suggeted agents
Hypertension/angina  blocker, Ca channel antagonist
Depression TCA, SSRIs
Refractory depression MAO inhibitors
Mania Divalproex sodium
Epilepsy AED
Anxiety Idem, TCA, SSRIs,  blocker
Insomnia Sedating TCA
Arthritis NSAIDs
Asthma Ca channel antagonist, divalproat Na
Terapi Pencegahan
• Kegagalan terapi pencegahan :
– Diagnosis tidak tepat
– Dosis obat tidak adekuat
– Waktu pemberian tidak adekuat
– Tidak mengenal komorbiditas (depresi, axietas,dll)
– Harapan yg tidak realistik
• Upaya menekan kegagalan th/ pencegahan :
– Kenal komorbiditas
– Kenal rebound efek obat
– Terapi kombinasi farmasi dan non farmasi
Terapi Headache di UGD
Terapi Primary Headache :

Tension
Oral Analgesics (NSAIDS, Acetaminophen)
Migraine
Serotonin agonists : Sumitriptan 50 mg PO or
6.0 mg SQ
Narcotics IV or IM
Cluster
100% oxygen
Intranasal lidocaine ?
NSAIDS
Migraine specific therapies
ADVANCED NEUROLOGY LIFE SUPPORT Pendahuluan
I am Dizziness
Vertigo Syncope Disequilibrium ill-defined giddiness

(Sensation of (Sensation of other than vertigo,
motion) Impending faint) syncope or
disequilibrium
Disturbance of Disturbance of Neurologic Psychiatric

vestibular cardiovascular Disorders Disorders
function function
-multiple sensory -hyperventilation
disorders. syndrome
-peripheral -cardiac
-cerebellar dysfunction -anxietas neurosis
-central -vascular orthostatic
-nonfunctioning labyrinths -hysterical idem
hypotension
-extrapyramidal disorders -affective disorder
-drug intoxication -etc
-posterior fossa tumor, etc
ADVANCED NEUROLOGY LIFE SUPPORT Etiologi Dizziness
• Gangguan sistem vestibuler perifer
– Telinga luar : serumen, benda asing
– Telinga tengah : retraksi memb timpani, OMPA, OM
dgn efusi, labirintis, kolesteatom, rudapaksa dgn
perdarahan.
– Telinga dalam : labirintis akut toksi, trauma, ggn
vaskuler, alergi, hidrops labirin (morbus Meniere),
mabuk gerakan, vertigo postural
– N. VIII: infeksi, trauma, atau tumor
– Inti vestibuler : infeksi, trauma, perdrhan, trombosis
a. serebeli post inferior, tumor, MS
Etiologi Dizziness .. 2
• Gangguan Susunan Saraf Pusat
– TIA, stroke.
– Infeksi : meningitis, ensefalitis, abses, lues
– Trauma : kepala, labirin
– Tumor
– Migraine
– Epilepsi
– Dll.
• Gangguan kardiovaskuler
– Syncope, hipertensi kronis, arteriosklerosis, anemia,
AF paroksismal, stenosis aorta dan insufisiensi, dll
– Hipotensi ortostatik: perbedaan tensi pada posisi
baring dgn duduk > 10-15mmHg
– Aritmia cordis: pd pem EKG monitor ditemukan ggn
irama (sinus bradikardi, AF, dll)
– Presyncope vasodepressor: khas anamnesa tdk ada
ggn jantung dan saraf.
• Kelainan endokrin:
– hipoparatiroid, hipotiroid, hipoglikemi, tumor
medula adrenal, keadaan menstruasi, hamil atau
menopause.
• Kelainan mata:
– Kelainan propioseptik
• Intoksikasi:
• Kelainan Psikiatri
– Depresi, neurosa cemas, sindroma hiperventilasi,
dan fobia.
Practical Diagnostic Dizziness
• Psychologis
– Berhubungan dgn gejala akut atau kronik anxietas
– Pasien fokus pada gejala somatik(dizzinya & gejala
otonom) dibanding rasa cemas krn anxietasnya
• Disequilibrium
– Berjalan langkah lebar dan ataxia, dpt dibedakan
ggn ringan berjalan pada keadaan ggn vestibuler
atau ggn sensorik
– Ggn vestibular bilateral mungkin/tidak disertai ggn
pendengaran, D/timbul ggn pd stimulasi kalori dan
stimulasi putar.
Practical Diagnostic Dizziness .. 2
• Vertigo
– BPV: Timbul nystagmus vertikal pd tes Dix-Hallpike,
jika diulang serangan nystagmus berkurang
– Vestibular neuritis: gambaran klinis yg khas timbul
vertigo spontan berlangsung lama, tapi bbrp hari
berangsur ↓, pada pemeriksaan ada ggn vestibular
perifer unilat (nystagmus spontan) tdk ada gejala
neurologi.
– Synd Meniere: vertigo dgn ggn pendengaran nada
rendah yg fluktuatif.
– Migraine: sefalgia dgn vertigo, ggn pendengaran (-)
Practical Diagnostic Dizziness .. 3
– VBI:serangan tiba2 tanpa faktur pencetus dalam

waktu bbrp menit hilang, disertai dgn keluhan lain
ggn penglihatan, diplopia, disartri, parese atau ke-
semutan.
– Infark brainstem: sindrom stroke krn lesi sirkulasi
posterior, mudah dikenal krn ada gejala neurologi.
– Infark Cerebeller: dpt samar dgn gejala ggn telinga
bag dlm, biasanya ada gejala ataxia tubuh waktu
berganti posisi, dan gaze evoked nystagmus sbg
indikasi ggn sentral
– C-P angle tumor: diagnosa periksa audiometri dan
MRI dgn kontras utk deteksi tumor yg masih baru
Vertigo
• Vertigo (giddy, dizzy, pusing): berasal dari
bahasa Latin “vertere = memutar” makna
masalah keseimbangan.
• Keluhan nomor 3 terbanyak setelah sefalgi
dan nyeri pinggang.
• Vertigo : adanya sensasi gerakan atau rasa
gerak dr tubuh atau lingkungan sekitarnya
dpt disertai gejala otonom (pucat, keringat
dingin, mual, muntah dan pusing).
Patofisiologi
Alat Keseimbangan Tubuh (AKT)
A. Organ vestibuler (> 50%)
B
1. Statis labirin
- utriculus
- sacculus
2. Kinetik labirin
- canalis semicircularis A
- ampula
3. n. vestibularis & gg Scarpa
B. Optokinetik:
retina, otot bola mata, dll
C. Somatokinetik: C
kulit, persendian, otot, dll
Nerve Acusticus
Membranous Labyrinth
Kausa Vertigo
• Vertigo Perifer • Vertigo Central
– BPV – Brainstem infark
– Meniere Disease – Vertebro-Basilar TIA
– Vestibular labyrinthis – Cerebello-pontine angle
– Perilympahtic fistula tumor.
– Ototoxic medication : – Basilar migraine
antibiotik, lasix. – Meningitis
– Acoustic neuroma – Trauma
– Otitis media – Lesi cerebeller
– kejang
DD/ Vertigo Perifer dan Sentral

Vertigo Perifer Vertigo Sentral
Keluhan nausea dan vertigo cenderung lebih berat Serangan gradual
Serangan tiba-tiba Keluhan konstan/menetap
Episodik Gejala rasa goyang dan
ataxia lebih menonjol
Gangguan pendengaran atau tinnitus Diplopia
Berhubungan dengan perubahan posisi Disartria
Nyeri telinga atau rasa penuh Ada gejala batang otak yg
berdekatan
Rasa lemah pada wajah Gejala spt diayun kuat
Seperti baru terserang flu atau demam (oscillopsia)
Gejala bertambahn berat jika mengedan atau bising
Riwayat minum obat ototoksik
Seperti baru menyelam atau naik pesawat udara
ADVANCED NEUROLOGY LIFE SUPPORT Pemeriksaan Fisik
dan Neurologi
• Fisik umum
– Perhatikan posture, posisi kepala (cendrung miring kesisi
vestibuler yg fungsi hilang), tdk nyaman.
• Tanda vital
– Cek hipotensi ortostatik, periksa tensi kanan-kiri (ggn a.
subcalvian), cek suhu tubuh.
• THT
– Mata: visus, gerakan bola mata, nystagmus (tes provokasi),
reflek vestibulo-okuler, dll.
– Telinga: memb timpani, pendengaran, dll.
– Cervical: cek pembuluh darah leher (bruits)
dan Neurologi .. 2
• cardiovasculer
– Cek denyut jantung, irama jantung, murmur
• Traktus GI
– Keluhan perdarahan lambung, ggn pencernaan.
• Neurologi
– Saraf kranialis: diplopia, disartri, nystagmus, dll
– Sensori-motor: cek fungsi propioseptik, rasa raba, rasa
getar, parese, hipotonia (ggn serebeller).
– koordinasi: cek past pointing, finger to nose, rebound.
– Langkah (gaya berjalan): tes jalan lurus buka/tutup mata,
tandem, tes Romberg
Tatalaksana dan Terapi
• Terapi kausal
• Terapi simptomatik
– Gol Ca channel blocker (flunarizin)
– Gol antihistamin : sinarizin, prometazin,
difenhidrinat
– Gol fenotiazin : prokloperazin, klorpromazin
– Gol histaminic : betahistine
• Latihan vestibuler
Latihan
Vestibuler
Latihan Vestibuler
dan Neurologi .. 3
Provokasi tes :
-pem garpu tala
-Dix Hallpike maneuver
-Tes kalori
-Reflex vestibulo-ocular
Skema impuls
keseimbangan tubuh
reseptor
gerak posisi - vestibularis bulu
endolymp
tubuh/kepala - visual getar
- propioseptik
Nucl. Vestibular
Serebellum saraf pelepasan NT influx
Kortek serebri vestibular (glutamat)* Ca**
Hipotalamus
Form. retikularis
depolarisasi
NT eksitator (impul aferen) : glutamat, aspartat, asetilkolin,

histamin, substan P. Impul eferent : NT inhibitor antara lain
GABA, glisin, NA, dopamin, serotonin
Terapi simptomatik
Generic Trade name Dosis oral dewasa Durasi Sedasi
diphenhydramine Benadryl 25-50 mg/6 jam 4-6 jam ++
Dimenhydrinate Dramamine 25-50 mg/6 jam 4-6 jam ++
Promethazine Phenergan 25mg/6 jam 4-6 jam ++
Scopolamine Transderm scop 72 jam/transderm - +
Ephedrine - 25mg/6 jam -
Headache Red Flags
• Headache that awaken the pts from sleep
• Headache with particularly sudden onset & explosive
character.
• New onset headache in pts > 50 years.
• Headache associated with focal neurologic deficits,
papiledema, or seizures.
• Headache that worsen with valsalva maneuver or
changes in posture.
• Any significant change in headache pattern :
– Increased intensity - Change in quality
– Increased frequency
Headache Red Flags .. 2
• Headache in the context of recent trauma or cervical

manipulation.
• Headache occuring in immunocompromised pts (HIV)
• Meningeal sign or symptoms
• Symptoms of increased ICP: nause, vomiting, blurry
vision, decreased sensorium
• headache that are particulary worse in the morning
or with prolonged recumbency
• Any mental status changes
• Headache with sudden onset during sexual activities
Aneurysm
Jadwal ANLS KPPIK

Tgl Jam Topik
Kelompok 1.
Senin 7/3-11 10.30-11.05 Approach to the unconcious patient
Selasa 8/3-11 07.30-08.15 Vertigo and emergency headache
Kelompok 2.
Selasa 8/3/11 10.30-11.05 Approach to the unconcious patient
Rabu 9/3/11 08.15-09.00 Vertigo and emergency headache
09.15-10.00 ICP as emergency
Headache (Sefalgia)
Pain or discomfort between the orbits
and occiput arising from pain sensitive structures.
Patofisiologi Migraine
Dizziness : Practical Diagnostic
Onset of dizziness sudden

yes no
Exertional vertigo labyrin- No, it’s chronic

thitis, vascular disorder of
inner ear it’s episodic
yes No, it’s unremitting
yes no
Are there ear symp
no Acoustic neurinoma it’s associated
yes
Other CPA tumor with fainting
yes no
Otitis/mastoiditis it’s positional
Meniere”s disease VBI, cardiac disease Phychoneurosis, HT
Acoustic neurinoma Carotid sclerosis anemia, DM, thyro
Carotid sinus sensitivity toxicosis, blood dys
yes no crasia.
BPV, cervical Drugs, hyperventilation
Spine osteophytes Cervical trauma, meno-
Pause, migraine.

Ped Praktis Stat Gizi Dewasa

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Ped Praktis Stat Gizi Dewasa

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ADVANCED NEUROLOGY LIFE SUPPORT

• Algoritma utk menilai dan mengobati pasien

1. Headache 2. Dizziness (Vertigo)

Primer Headache Secondary Headache

Nyeri Kepala Primer

Terapi :Sefalgia Primer Identifikasi Sefalgia

Headache Red Flags (SNOOPS)

Diagnosa Sefalgia .. (2)

Diagnosa Sefalgia .. (3)

Diagnosa Sefalgia .. (4)

Diagnosa Sefalgia .. (5)

Common Triggers of Migraine

Foods that can trigger Headache

Foods that can trigger Headache

Foods that can trigger Headache

Migraine With Aura Migraine Without Aura

Years of Age at Onset Years of Age at Onset

Diagnosis Migraine (SULTANS)

Aura Visual Migraine Classic

DD/ of Primary Headaches

Difrensial Diagnosa Sefalgia Primer

Difrensial Diagnosa Sefalgia Primer .. 2

migraine Pts edukasi : diet, OR, rokok , hindari faktor pen-

ringan sp sedang ada mual muntah diare berat

aspirin, acetaminofen + antiemetik, anti- Triptans

Kombinasi analgesik Frek >3/bln, lamanya opioid (codein + analgesik

Indikasi Terapi Pencegahan

Terapi Pencegahan Migraine

Terapi Primary Headache :

Vertigo Syncope Disequilibrium ill-defined giddiness

Disturbance of Disturbance of Neurologic Psychiatric

– VBI:serangan tiba2 tanpa faktur pencetus dalam

DD/ Vertigo Perifer dan Sentral

NT eksitator (impul aferen) : glutamat, aspartat, asetilkolin,

• Headache in the context of recent trauma or cervical

Jadwal ANLS KPPIK

Onset of dizziness sudden

Exertional vertigo labyrin- No, it’s chronic

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