LAPORAN

KASUS
Perdarahan intrakranial EC acquired
prothrombin complex deficiency
DHANI AKBAR
NUGRAHA
IDENTITAS PASIEN
Nama : By. Z

Usia : 2 Bulan

Jenis kelamin : Perempuan

Alamat : Sukanagara
ANAMNESIS

Dilakukan secara Alloanamnesis dengan

ibu pasien pada hari Kamis, 14 Juli 2016
pukul 13.30 WIB di Ruang ICU.

Keluhan Utama: Kejang

Riwayat Penyakit Sekarang :
Bayi Z, usia 2 bulan datang ke IGD RSUD
Kabupaten Tasikmlaya dengan keluhan kejang
sejak 5 jam SMRS, kejang terjadi sebanyak 2x,
kejang pertama terjadi kurang lebih selama 15
menit. Menurut ibu pasien kejang tersebut seperti
kelojotan dan matanya melirik kearah atas.
Setelah kejang berhenti pasien juga terlihat kejang
yang hanya berupa gerakan menghentak pada
tubuh sebelah kiri saja. Ibu pasien mengaku
setelah kejang yang pertama tiba-tiba mata
anaknya yang sebelah kanan tidak bisa membuka,
dan anaknya mulai tidak menangis.
 Lanjutan

. Keluhan disertai penurunan kesadaran. Ibu pasien juga

mengaku setelah itu leher anaknya dan tubuhnya menjadi
kaku, seerta tubuh kanannya kurang aktif. Keluhan tidak
disertai muntah yang menyemprot.. Keluhan kejang tersebut
tidak disertai dengan demam. Keluhan seperti mimisan dan
buang air berwarna kehitaman disangkal. Pasien juga terlihat
sangat pucat. Pasien belum diberikan obat apapun untun
meringankan kejangnya. Riwayat keluarga menderita kejang
disangkal. Keluhan juga disertai BAB cair lebih dari 5x.
Gangguan BAK disangkal. Riwayat trauma kepala
disangkal. .
 Riwayat penyakit dahulu
Penyakit Umur Penyakit Umur Penyakit Umur

Alergi - Difteria - Jantung -

Cacingan - Diare - Ginjal -

DBD - Kejang - Darah -

Thypoid - Maag - Radang -

paru
Otitis - Varicela - Tuberkulosi -
s
Parotis - Operasi - Morbili -
 Riwayat kehamilan dan
Persalinan

KEHAMILAN Morbiditas kehamilan Tidak ditemukan kelainan

Perawatan antenatal Tidak rutin periksa ke

dokter/bidan

KELAHIRAN Tempat kelahiran Rumah Sakit

Penolong persalinan Bidan

 Riwayat Pertumbuhan dan
Perkembangan
Pertumbuhan gigi I :-
Mengangkat kepala :-
Tengkurap :-
Duduk : -
Berdiri :-
Berjalan :-
Bicara :-
Kesan :-
 Riwayat Makanan
Umur (bulan) ASI/PASI Buah/biskuit Bubur susu Nasi tim

0-2 ASI - - -

2-4 - - - -

4-6 - - - -

6-8 - - - -

8-10 - - - -
Riwayat Imunisasi

Ibu pasien mengatakan riwayat imunisasi

pasien lengkap, namun ayah pasien tidak
mengetahui percis waktu dan tempat
dilakukan imunisasi pada pasien.
Pemeriksaan fisik

General appearance
Kondisi : Sakit berat
Kesadaran : somnolen
Keadaan umum : lemah
Tanda vital
Frekuensi nadi : 132x/menit
Tekanan darah : Tidak dihitung
Frekuensi pernapasan : 32x/menit
Suhu tubuh : 36,1C
Status Gizi
Berat badan : 4,4 kg
Panjang badan : tidak dilakukan
pengukuran
Status gizi menurut CDC :
BB/U = 4,4/2 x 100% = 25%
Kesan = gizi kurang
Kepala
Bentuk : Normocephali
Ubun-ubun besar menonjol.
Rambut : Hitam, tidak mudah dicabut,
distribusi cukup baik
Mata: Conjungtiva anemis +/+, sklera ikterik -/-,
pupil anisokor,
Pemeriksaan Reflex cahaya tidak dilakukan,
lakrimasi +/+, ptosis +/-
Telinga : Normotia, serumen -/-
Hidung : Septum deviasi (-), sekret -/- warna
kehijauan, nafas cuping hidung -/-
Mulut : Sianosis (-) ,Bibir tampak kering (-),
faring hiperemis (-),
 Leher
Tekanan Vena : tidak dilakukan pemeriksaan
KakuKuduk : (-)
Kelenjar Getah Bening : tidak teraba

Thorax

- Paru-paru

Inspeksi : bentuk dan gerak simetris

palpasi : vokal fremitus kanan = kiri

Perkusi : sonor pada kedua paru

Auskultasi : VBS ka=ki, ronkhi -/-, wheezing -/-

- Jantung

Auskultasi: BJ I-II murni reguler, gallop (-), murmur (-)

 Abdomen
Inspeksi : Perut datar,
Auskultasi : Bising usus (+)
Palpasi : Supel, turgor kulit baik, hepar dan lien tidak
teraba membesar
Perkusi : Timpani di seluruh lapang abdomen
Kulit : Ikterik (-), petechie (-),
Ekstremitas : Akral hangat pada keempat
ekstremitas, sianosis (+), edema (-), CRT < 2
atas : kiri: aktif, kanan: tidak aktif
bawah: kiri: aktif, kanan : tidak aktif
 Pemeriksaan Neurologis
Tanda Rangsang Selaput Otak
Kaku kuduk : -
Brudzinski I : -
Lasegue : tidak dilakukan pemeriksaan
Kernig : tidak dilakukan pemeriksaan
Brudzinski II : -/-
Nervus Kranialis
N. I : Tidak valid dinilai
N. II
Visus campus : Tidak dilakukan
Lihat warna : Tidak dilakukan
Funduskopi : Tidak dilakukan
N. III, N. IV, dan N. VI
Kedudukan bola mata : Ortoposisi +/+
Gerak bola mata : sulit dinilai
Ptosis : +/-
 Pemeriksaan laboratorium

Leukosit:19.800 /L
Eritrosit:1,1 juta/uL
Hb :3,9 g/dL
Leukosit: 12700/l
Ht :11 %
Trombosit: 522 ribu/ L Hb: 14,6 g/dl
GDS : 99 mg/dl Ht:47 %
Trombosit:310 ribu/ l
Elektrolit Eritrosit:4,9 juta/ uL
Na: 130
Ka: 4,7
Cl: 101
18
Tanggal 13 Juli 2016 Tanggal 14 Juli 2016
 USG kepala bayi
Pada 19 juli 2016
Kesan:
perdarahan subarachnoid region frontalis
Diagnosis
Diagnosis banding:
Perdarahan intrakranial ec APCD
Perdarahan intrakranial ec Penyakit Hati

Diagnosis Kerja:
Perdarahan intrakranial ec APCD
 Rencana terapi
Non Medicamentosa
Rawat ICU
Komunikasi-Informasi-Edukasi kepada orang tua pasien mengenai
keadaan pasien
Observasi tanda-tanda vital
Oksigenasi 1 liter/menit
Puasakan, pasang OGT

Medicamentosa
Fluid: KAEN 3B 8 tpm mikro
Vitamin K 1x1mg IV (selama 3 hari)
Fenitoin 2x 15 mg iv
Manitol 20% 10ml/8jam (selama 5 hari)
Ceftriaxone 2 x 110 mg IV
Transfusi PRC 50 cc
Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad malam
 FOLLOW UP
14 juli 2016 Terapi
Subjektif:
Diit: mulai intake Susu
kejang (-) Formula per OGT 8x20 cc
Objektif: Cairan intravena:
Somnolen I Kaen 3B
Ubun-ubun cembung II NaCl( post transfusi)
Mata konjungtiva Injek Vit K 1 mg IM selama 3
anemis +/+, ptosis +/- hari
Kulit pucat Manitol 20% 10 ml/ 8 jam
Fenitoin 2x15 mg IV
N:142
Ceftriaxone inj 2x 125 mg IV
RR: 28x/menit
SpO2 : 99 %
15 juli 2016 Terapi
Subjektif: Diit: mulai intake Susu
kejang (-) Formula per OGT 8x25
Anemia (-) cc
Objektif: Cairan intravena:
Somnolen I Kaen 3B
Injek Vit K 1 mg IM
Ubun-ubun cembung
selama 3 hari
Mata konjungtiva Manitol 20% 10 ml/ 8 jam
anemis +/+, ptosis +/-
Fenitoin 2x15 mg IV
Kulit pucat Ceftriaxone inj 2x 125
N:130 mg IV
RR: 30 x/menit
SpO2 : 99 %
Jan 17th, 2011 Plan:
Subjective: 02 nasal 2 lpm
Groan (-) Diet : fasting
Convulsion (+) IVF : Aminofuchsin ped
Cry (+) 100cc/hour, D5 %+
Objective: valium 15 mg 400 cc/24
hour
Sklera ikteric (+/+),
pupil anisokor
( diameter pupil Transfusi WB 50 cc
sinistra> dextra) Amoxillin 3 x 500 mg iv
Skin : ikteric (+) Garamisin 2 x 100 mg iv
Fontanel : tense Mannitol 3 x 10 cc, drip
SpO2 : 100 % Vit K : 1 mg IM, during 5
Nastril breath -/-, days
retraction -/-
Jan 18th, 2011 Plan:
Subjective: Craniotomy
Convulsion (+)
Objective: Diet : fasting
Sklera ikteric
IVF(+/+),
: Aminofuchsin ped
pupil anisokor
100cc/hour, D5 % 400
( diameter cc/24
pupil hour
sinistra> dextra)
Amoxillin 3 x 500 mg iv
Skin : ikteric (+)
Garamisin 2 x 100 mg iv
Fontanel : tense
Kalmethason 2x1 mg
SpO2 : 100
Mannitol 3 x 10 cc, drip
%,spontaneus
Phenitoin 2x 25 mg
breathing
Nastril breath -/-,
Diazepam 1 mg prn
retraction
-/-
Vit K : 1 mg IM
Jan 19th, 2011 Plan :
Subjective: Diet : D5 % 6 x 10 cc
Convulsion (+) KaEN 1 B 100 cc
Eyelash (+) Aminofucsin 100 cc
General condition :
improve Amoxillin 3 x 500 mg iv
Objective: Garamisin 2 x 100 mg iv
Sklera ikteric (+/+), Kalmethason 2x1 mg
pupil isokor , light Phenitoin 2x 25 mg
reflex +/+
Vit K : 1 mg IM
Skin : ikteric (+)
Novalgin 4x 50 mg
Fontanel : soft
Valium 1mg prn
spontaneus breathing
Nastril breath -/-,
retraction -/-
Discussion
The Diagnosis of based Intracranial Hemorrhage In the
Newborn
on :
Anamnesis :
Patient was 1 month year old
Convulsion wasnt preceded by fever
never cry again since seizures
vomitting
ikteric
had not been given Vitamin K injection when the baby was born.
The big brother of patient had experience the convulsion at the
age of 6 months old
Physical Diagnostic
Skin : pale (+), ikteric (+)
Fontanel : Tense
Eyes : conjungtiva anemic +/+, sklera ikteric +/+,
light reflex : -/-, pupil anisokor ; diameter pupil sinistra> dextra
Nose : Nostril breathing (+)
Thorax : retractions supraclavicle +

CT Scan :
subdural and intraserebral haemorrhage
Function Vit K
Vitamin K is one of the essential vitamins.
The letter K in vitamin K actually comes from the word
"Koagulations", that means coagulation or clotting.

Without vitamin K, blood would be unable to clot.

Deficiencies in vitamin K lead to clotting disorders,
bruising, and other blood disorders.
Haemorrhagic disease of the newborn

a coagulation disturbance in newborns due to vitamin K

deficiency. As a consequence of vitamin K deficiency
there is an impaired production of coagulation factors II,
VII, IX, X, by the liver

Causes
Newborns are relatively vitamin K deficient for a variety
of reasons. They have low vitamin K stores at birth,
vitamin K passes the placenta poorly, the levels of
vitamin K in breast milk are low and the gut flora has not
yet been developed (vitamin K is normally produced by
bacteria in the intestines).
Craniotomy

Brain tumors
Bleeding (hemorrhage) or blood clots (hematomas) from
injuries (subdural hematoma or epidural hematomas)
Weaknesses in blood vessels (cerebral aneurysms)
Damage to tissues covering the brain (dura)
Pockets of infection in the brain (brain abscesses)
Epilepsy
 Intracranial Hemorrhage In the Newborn
Definition
Bleeding in the cranial cavity and its contents in infants
from birth until age 4 weeks.

Intracranial Hemorrhage includes epidural, subdural,

subarachnoid, intra serebral/parenkim dan
intraventrikuler hemorrhage
Epidemiology
from 5 to 15 %, with a mortality of from 40 to 50 %
low birth weight infants, weighing less than 1500 g)

Etiology

The chief cause is trauma

Breech extraction, in which rapid or forceful delivery of the after-
coming head produces the injury.
Precipitate labors, where there is sudden compression of the
head.
Very difficult or prolonged labors, where there is excessive
molding of the head with injury.
Instrumental deliveries

Cause not trauma

Prematurity of the infant
KLasifikasi
patogenesis

Epidural hemorrhage (extradural hemorrhage) which occur

between the durameter and the skull, is caused by trauma
It may result from laceration of an artery, most commonly
the middle meningeal artery dangerous type of injury
because the bleed is from a high-pressure system and
deadly increases in intracranial pressure can result rapidly

Subdural hemorrhage results from tearing of the bridging

veins in the subdural space between the dura and
arachnoid mater

Subarachnoid hemorrhage which occur between the

arachnoid and pia meningeal layers, can result either from
trauma or from ruptures of aneurysms or arteriovenous
malformations
 Intraventrikuler hemorrhage

hypoxia

vasodilatation blood vessel of the brain and venous
congestion

increase blood flow

elevated pressure of the brain blood

Easily Ruptur
Sign and symptoms
Onset of symptoms of intracerebral hemorrhage is usually
during daytime activity, with progressive :

Alteration in level of consciousness (approximately 50%)

Nausea and vomiting (approximately 40-50%)
Headache (approximately 40%)
Seizures
Focal neurological deficits
Cephalic cry
Snake like flicking of the tongue
Expiratory grunting
 Physical exam:

unconscious individual should quickly assess the

adequacy of the airway, breathing, pulse, and blood
pressure before beginning a more detailed neurological
and physical exam.

The latter includes an evaluation of level of

consciousness, pupil response and vital signs, motor
function, reflexes, and memory.
SUGGESTED FURTHER
STUDIES
Serial Lumbar Punctures
Blood gas analysis
CT Scan
USG
Management
Treated in the incubator that allows continuous
observation and O2 delivery
It should be observed carefully: body temperature,
degree of consciousness, pupil size and reaction, motor
activity, respiratory frequency, heart frequency, pulse rate
and diuresis.
Keeping the airway to remain free.The baby lies on his
side
Vitamin K and blood transfusions may be considered.
Management
Valium / luminal if convulsion, valium dose from 0.3 to 0,
5 mg / kgBB
Corticosteroids such as dexamethasone 0.5 to 1
mg/kgBB/24 hours that have good effect against hypoxia
and brain edema
Antibiotics can be given to prevent secondary infection
Lumbar puncture to reduce intracranial pressure,
bleeding, prevent obstruction likuor flow and reduce the
effects of irritation on the surface of the cortex
Emergency surgery Craniotomy
prognosis
Staging I, II : mild
Staging III, IV : severe

Intracranial hemorrhage is a serious medical emergency

because the build up of blood within the skull can lead to
increases in intracranial pressure
Severe increases in intracranial pressure can cause
potentially deadly brain herniationin
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