PARKINSON'S

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">It is important to realize that not every person with Parkinson's develops all signs or symptoms of the disease. For example, some people experience tremor as the primary symptom, while others may not have tremor but do have balance problems. Also, for some people the disease progresses quickly, and in others it does not. The following are descriptions of the most common primary symptoms of Parkinson's disease.<br /> Tremor: In the early stages of the disease, about 70 percent of people experience a slight tremor in the hand or foot on one side of the body, or less commonly in the jaw or face. It appears as a "beating" or oscillating movement. Because the Parkinson's tremor usually appears when a person's muscles are relaxed, it is called "resting tremor." This means that the affected body part trembles when it is not doing work, and it usually subsides when a person begins an action. The tremor often spreads to the other side of the body as the disease progresses, but remains most apparent on the original side of occurrence.<br /> Rigidity: Rigidity, also called increased muscle tone, means stiffness or inflexibility of the muscles. Muscles normally stretch when they move, and then relax when they are at rest. In rigidity, the muscle tone of an affected limb is always stiff and does not relax, sometimes resulting in a decreased range of motion. For example, a person who has rigidity may not be able to swing his or her arms when walking because the muscles are too tight. Rigidity can cause pain and cramping.<br /> Bradykinesia: Bradykinesia is the phenomenon of a person experiencing slow movements. In addition to slow movements, a person with bradykinesia will probably also have incomplete movement, difficulty initiating movements and sudden stopping of ongoing movement. People who have bradykinesia may walk with short, shuffling steps (this is called festination). Bradykinesia and rigidity can occur in the facial muscles, reducing a person's range of facial expressions and resulting in a "mask-like" appearance.<br /> Postural instability or impaired balance and coordination: People with Parkinson's disease often experience instability when standing or impaired balance and coordination. These symptoms, combined with other symptoms such as bradykinesia, increase the probability of falling. People with balance problems may have difficulty making turns or abrupt movements. They may go through periods of "freezing," which is when a person feels stuck to the ground and finds it difficult to start walking. The slowness and incompleteness of movement can also affect speaking and swallowing.<br /> <br /> <b><span style="color: orange; font-size: large;">What causes Parkinson's?</span></b><br /> Why an individual develops Parkinson's disease remains unclear. The cause is probably a combination of genetic and environmental factors, and may vary from person to person. Although the cause of Parkinson's remains unknown, scientists have identified factors that contribute to Parkinson's in some patients. For example, people over age 60 have a two-to-four percent risk of developing Parkinson's disease, compared with the one-to-two percent risk in the general population. <br /> Below is information on the two factors that scientists think are most likely to cause Parkinson's disease. <br /> Genetics About 15 to 25 percent of people with Parkinson's report having a relative with the disease. In large epidemiological studies (studies that deal with incidence, distribution and control of disease in a population), researchers have found that people with an affected first-degree relative, such as a parent or sibling, have a two-to-three fold increased risk of developing Parkinson's, as compared to the general population. This means that if your parent has Parkinson's, your chances of developing the disease are slightly higher than the risk in the general population.<br /> The vast majority of Parkinson's cases are not directly inherited, but researchers have discovered several genes that can cause the disease in a small number of families. Some of these genes involve proteins that play a role in dopamine cell functions. Because genetic forms of a disease can be studied in great detail in the laboratory, and because understanding the rare genetic forms of Parkinson's disease may help to understand more common forms of the disease, genetic aspects of PD are currently the subject of intense research. <br /> Environmental Factors Some scientists have suggested that Parkinson's disease may result from exposure to an environmental toxin or injury. Epidemiological research has identified several factors that may be linked to PD, including rural living, well water, herbicide use and exposure to pesticides. Also, a synthetic narcotic agent called MPTP can cause immediate and permanent parkinsonism if injected. These environmental factors are not useful in diagnosing the cause of Parkinson's disease in individual people. In fact, there is no conclusive evidence that any environmental factor, alone, can be considered a cause of the disease. However, these environmental factors have been helpful in studying laboratory models of Parkinson's disease. Scientists are continuing to pursue these clues to establish more concrete linkages.<br /> <br /> <span style="font-size: large;"><b><span style="color: orange;">Parkinson’s Medications</span></b></span><br /> People with Parkinson’s disease often take a variety of medications in different doses in order to manage the symptoms of the disease.  These factors, combined with the frequency with which one must take their medicines, can be confusing.  People with Parkinson’s and their caregivers should become familiar with their medications in order to use them most effectively and avoid possible interactions. Understanding a medication regime and sticking to it will provide the greatest benefit from the drug and avoid unpleasant “off” periods due to missed doses or confusion. <br /> Although there are general guidelines that doctors use to choose a treatment regimen, each patient must be individually evaluated to determine which drug or combination of drugs is best for them.  For some, a “first choice” drug might be one of the levodopa preparations, and for others, an initial prescription may be given for one of the agonists, an MAO inhibitor or an anticholinergic.  The choice of drug treatment depends on many variables including symptom presentation, other concurrent health issues (and the medications being used to treat them) and a person’s age.  And while the suggested starting dosages (as indicated by the package insert) are listed here, remember that they too can vary greatly depending on a person’s needs and metabolism.<br /> <br /> <span style="font-size: large;"><b><span style="color: orange;">Surgical Treatment for Parkinson's</span></b></span><br /> Surgery for Parkinson's disease has come a long way since it was first developed more than 50 years ago. The newest version of this surgery, deep brain stimulation or DBS, was developed in the 1990s and is now a standard treatment. Although it is certainly the most important therapeutic advance since the development of levodopa, it is not for every person with Parkinson's. It is most effective - sometimes, dramatically so - for individuals who experience disabling tremors, wearing-off spells and medication-induced dyskinesias.<br /> During deep brain stimulation surgery, electrodes are inserted into the targeted brain region using MRI and neurophysiological mapping to ensure that they are implanted in the right place. A device called an impulse generator or IPG (similar to a pacemaker) is implanted under the collarbone to provide an electrical impulse to a part of the brain involved in motor function. Patients have a controller, which allows them to check the battery and to turn the device on or off. An IPG battery lasts for about 3 to 5 years and is relatively easy to replace under local anesthesia.<br /> <br /> <span style="font-size: large;"><b><span style="color: orange;">The Role of the Patient</span></b></span><br /> Treating Parkinson's disease is not exclusively the doctor's job; there are many things a person with Parkinson's can do to contribute. Regular exercise, joining a support group, maintaining a healthy diet and taking part in a clinical trial are just some of the things you might consider.<br /> •    Exercise <br /> •    Support Groups <br /> •    Diet <br /> •    A Healthy Patient / Doctor Relationship <br /> •    Physical, Speech and / or Occupational Therapy <br /> •    Clinical Trials <br /> <b>Exercise</b>: For people with Parkinson's, regular exercise or physical therapy is crucial for maintaining and improving mobility, flexibility, balance, range of motion and for warding off many of the disease's secondary symptoms such as depression and constipation. PDF offers Motivating Moves for People with Parkinson's, a unique program of 24 seated and stimulating exercises that were created especially for people with Parkinson's. Copies are available for ordering through the website, or you can call or email PDF for more information. As with every aspect of your care, always consult your doctor before starting an exercise program.<br /> <b>Support groups</b>: For many people, support groups play an important role in the emotional well-being of patients and families. They can provide a caring environment for asking questions about Parkinson's, for sharing stories and advice and for creating friendships with people who have experienced similar problems. To find a support group in your area, please call or email PDF. In addition to in-person support groups, many people also find online groups and list servs helpful. For a listing of list servs that serve the Parkinson's community, please request our publication, Web Resources for People with Parkinson's Disease.<br /> <b>Diet</b>: Many people with Parkinson's lose weight because of poor appetite and inadequate food intake. It is recommended to maintain a full diet that contains all the daily nutritional requirements, including extra fresh fruits and vegetables for fiber to help prevent constipation and plenty of fluids to keep hydrated.<br /> Some people who take levodopa find that protein may interfere with the medication's effect. Limiting protein intake or staggering the medication dosing to avoid conflicts with meals can help this problem. However, adjustments in protein intake are only worthwhile for those very few people whose response to levodopa is indeed sensitive to dietary protein.<br /> People with Parkinson's who lose weight for no clear reason should discuss this with a physician.<br /> <b>A Healthy Patient/Doctor Relationship</b>: Making an accurate diagnosis of Parkinson's - specifically in its early stages - is difficult, but a skilled practitioner can come to a reasoned conclusion that it is Parkinson's. Every person diagnosed with Parkinson's should consider getting a second opinion from a neurologist who specializes in movement disorders and is up-to-date on research and approaches to therapy. <br /> Locating a qualified physician is a first step; next is considering whether the physician is the right one. A person with Parkinson's will work with a physician for many years. Consider these questions: <br /> •    Are you comfortable speaking with your physician? <br /> •    Do you feel respected by your doctor? <br /> •    Are questions answered to your satisfaction or do you come away from a visit feeling that you have not been taken seriously? <br /> •    Can you get in touch with the doctor between visits? <br /> To find a neurologist or movement disorder specialist in your area: <br /> •    Ask your primary care physician for a referral <br /> •    Seek referrals from other living with Parkinson's <br /> •    Contact your insurance provider for a list of neurologists or movement disorder specialists in your network <br /> •    Contact PDF for a referral. <br /> <b>Physical, Speech and/or Occupational Therapy</b>: These therapies can help Parkinson's patients control their symptoms and make daily life easier. Physical therapy may increase muscle strength and flexibility and decrease the incidence of falls. Speech therapy can increase voice volume and assist with word pronunciation. The Lee Silverman technique is a special speech therapy that can be very beneficial to people with Parkinson's - for further information see www.lsvt.org.<br /> Occupational therapy gives people alternative methods of doing tasks that they can no longer perform with ease. These options may provide a stronger sense of control when living with Parkinson's disease. A neurologist should be able to provide recommendations for these therapies and, if needed, a referral. These therapies may or may not be covered by insurance.<br /> <b>Clinical Trials</b>: Clinical trials (also called medical research, clinical research or a clinical study) help researchers answer specific questions about the safety and efficacy of new treatments by studying its effects in people. They are an essential and necessary component of the scientific research process. Simply put, there is no other way for research to show that a proposed treatment works. In addition to contributing to research, joining a clinical trial can provide a person with early access to potentially-helpful Parkinson's treatments and drugs that are not yet on the market.</div>

By Deden Sura AgungIt is important to realize that not every person with Parkinson's develops all signs or symptoms of the disease. For example, some people experience tremor as the primary symptom, while others may not have tremor but do have balance problems. Also, for some people the disease …

COMA is a state of unconsciousness

<div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;">Coma is a medical condition that needs treatment sooner, because the basic course of the disease was the cause of 'coma' and direction of development of the disease can cause severe brain damage and irreversible. So rapid and systematic examination is needed to provide appropriate therapy and diagnostic work properly. <span class="hps"><span lang="EN">Neurologic</span></span><span lang="EN"> <span class="hps">evaluation</span> <span class="hps">and management</span> <span class="hps">of</span> <span class="hps">patients</span> <span class="hps">'</span>coma' or <span class="hps">loss of consciousness</span> <span class="hps">is very</span> <span class="hps">difficult</span>, <span class="hps">because patients</span> <span class="hps">in such conditions</span> <span class="hps">usually</span> <span class="hps">in critical condition</span> <span class="hps">and</span> <span class="hps">need help</span> <span class="hps">fast</span></span>. 'Coma' is the result of brain dysfunction that can cause damage rekticular activation system such as loss of consciousness. </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;">In formulating a diagnosis of 'coma', there are two axioms that must be followed: (1) that found a single clue about the causes of 'coma' is not meant to prove the cause, (2) a complete Neurology examination itself is not efficient, because the examination of other organ systems should also be done . <span class="hps"><span lang="EN">Disturbance</span></span><span lang="EN"> <span class="hps">of consciousness</span> <span class="hps">is a</span> <span class="hps">marker</span> <span class="hps">of</span> <span class="hps">nervous system disorders</span>. <span class="hps">In the examination</span> <span class="hps">must</span> <span class="hps">be</span> <span class="hps">distinguished from</span> <span class="hps">abnormalities in the</span> <span class="hps">level of consciousness</span> <span class="hps">(</span>somnolence, <span class="hps">stupor</span>, <span class="hps">coma</span>) <span class="hps">and</span> <span class="hps">/</span> <span class="hps">or</span> <span class="hps">the contents</span> <span class="hps">of</span> <span class="hps">consciousness</span> <span class="hps">(</span>confuse, <span class="hps">hallucinations</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">DEFINITION</span></b></span><b><span style="font-size: 12pt;"></span></b></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Coma</span></span><span lang="EN"> <span class="hps">is</span> <span class="hps">a state of</span> <span class="hps">'</span>unresponsiveness' <span class="hps">in which</span> <span class="hps">a person can not</span> <span class="hps">feel or</span> <span class="hps">react</span> <span class="hps">in the environment</span>. <span class="hps">Circumstances</span> <span class="hps">where a person</span> <span class="hps">looks</span> <span class="hps">like</span> <span class="hps">falling asleep</span> <span class="hps">and at the</span> <span class="hps">same time</span> <span class="hps">can not be</span> <span class="hps">awakened</span> <span class="hps">by</span> <span class="hps">external stimuli</span> <span class="hps">and</span> <span class="hps">the needs</span> <span class="hps">of</span> <span class="hps">the body</span> <span class="hps">in a state</span> <span class="hps">referred to as</span> <span class="hps">'</span>coma'.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">ANATOMY AND PHYSIOLOGY</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">State of</span></span><span lang="EN"> <span class="hps">human consciousness</span> <span class="hps">is a</span> <span class="hps">reflection</span> <span class="hps">of the</span> <span class="hps">level of '</span>arousal' <span class="hps">and</span> <span class="hps">combined</span> <span class="hps">cognitive</span> <span class="hps">brain</span> <span class="hps">functions</span>. <span class="hps">'</span>Arousal' <span class="hps">played by</span> <span class="hps">the integrity of</span> <span class="hps">the physiological</span> <span class="hps">mechanisms</span> <span class="hps">of</span> <span class="hps">formation</span> <span class="hps">rektikularis</span> <span class="hps">and structures</span> <span class="hps">located at the</span> <span class="hps">top of the brainstem</span>, <span class="hps">starting</span> <span class="hps">from</span> <span class="hps">the front</span> <span class="hps">until</span> <span class="hps">the mid-</span>pons <span class="hps">to</span> <span class="hps">the hypothalamus</span>. <span class="hps">Behavior</span> <span class="hps">'</span>conscious' tend <span class="hps">in</span> <span class="hps">played</span> <span class="hps">by</span> <span class="hps">functional</span> <span class="hps">areas of</span> <span class="hps">the</span> <span class="hps">hemisphere</span> <span class="hps">cerebri</span> <span class="hps">each other</span> <span class="hps">and</span> <span class="hps">interact with each other</span> <span class="hps">is widely</span> <span class="hps">associated with the</span> <span class="hps">activation system</span> <span class="hps">that</span> <span class="hps">is more</span> <span class="hps">noble</span> <span class="hps">than</span> <span class="hps">the upper brain</span> <span class="hps">stem</span>, <span class="hps">hypothalamus</span>, <span class="hps">and</span> <span class="hps">thalamus</span>. <span class="hps">Moruzzi</span> <span class="hps">and</span> <span class="hps">Mogoun</span> <span class="hps">(1949)</span>, argued <span class="hps">that</span> <span class="hps">the</span> <span class="hps">rektikularis</span> <span class="hps">formasio</span> <span class="hps">area</span> <span class="hps">located at the</span> <span class="hps">rostral</span> <span class="hps">brain stem</span>, <span class="hps">which when</span> <span class="hps">stimulated</span> <span class="hps">will cause</span> <span class="hps">a general</span> <span class="hps">activation of</span> <span class="hps">the</span> <span class="hps">non</span><span class="atn">-</span>specific <span class="hps">in the</span> <span class="hps">cortex</span> <span class="hps">cerebri</span>, <span class="hps">which</span> <span class="hps">is referred to as</span> <span class="hps">'</span>Ascending <span class="hps">Recticular</span> <span class="hps">Activating</span> <span class="hps">System'</span>. <span class="hps">This system</span> <span class="hps">includes areas</span> <span class="hps">in the middle of</span> <span class="hps">the brain stem</span>, extending <span class="hps">from</span> <span class="hps">the midbrain</span> <span class="hps">to</span> <span class="hps">the hypothalamus</span> <span class="hps">and</span> <span class="hps">thalamus</span>, <span class="hps">and</span> <span class="hps">describe</span> <span class="hps">these structures</span> <span class="hps">in</span> <span class="hps">transmitting</span> <span class="hps">the physiological</span> <span class="hps">effects of</span> <span class="hps">a diffuse</span> <span class="hps">to the cortex</span> <span class="hps">either directly</span> <span class="hps">or indirectly</span>, <span class="hps">in the role</span> <span class="hps">of the</span> <span class="hps">arousal</span> <span class="hps">of consciousness</span>. <span class="hps">Gellhorn</span> <span class="hps">(1953)</span>, <span class="hps">suggests</span> <span class="hps">thinking</span> <span class="hps">about the</span> <span class="hps">process of '</span>consciousness', <span class="hps">which is</span> <span class="hps">known</span> <span class="hps">as</span> <span class="hps">the hypothalamus</span> <span class="hps">or</span> <span class="hps">hypothalamic</span> <span class="hps">activation</span> <span class="hps">system</span> <span class="hps">controle</span> <span class="hps">system</span>, which is <span class="hps">composed of</span> <span class="hps">fibers of</span> <span class="hps">the projection</span> <span class="hps">between the</span> <span class="hps">hypothalamus</span> <span class="hps">with the front</span> <span class="hps">lobe of</span> <span class="hps">the piriformis</span>, <span class="hps">nucleus of</span> <span class="hps">the amygdala</span> <span class="hps">and</span> <span class="hps">hippocampus</span> <span class="hps">formasio</span> <span class="hps">rear</span>, <span class="hps">to</span> <span class="hps">deliver</span> <span class="hps">visceral</span> <span class="hps">feelings</span> <span class="hps">and</span> <span class="hps">impulses</span> <span class="hps">of organic</span> <span class="hps">sensations</span> <span class="hps">through</span> <span class="hps">the neocortex</span> <span class="hps">without</span> <span class="hps">direct contact with</span> <span class="hps">formasio</span> <span class="hps">rektikularis</span>. <span class="hps">In this case the</span> <span class="hps">activation of</span> <span class="hps">the cortex</span> <span class="hps">cerebri</span> <span class="hps">is controlled</span> <span class="hps">by a</span> <span class="hps">two-</span>way <span class="hps">through</span> <span class="hps">the hypothalamus</span>, <span class="hps">the</span> <span class="hps">activation</span> <span class="hps">/</span> <span class="hps">facilitation</span> <span class="hps">and</span> <span class="hps">inhibition</span> <span class="hps">systems</span>. <span class="hps">And</span> <span class="hps">this system</span> <span class="hps">is closely related to</span> <span class="hps">the setting</span> <span class="hps">instinktuil</span>, <span class="hps">emotional</span>, <span class="hps">autonomic</span>, <span class="hps">and</span> <span class="hps">hormonal</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Formasio</span></span><span lang="EN"> <span class="hps">rektikularis</span> <span class="hps">extends</span> <span class="hps">from the</span> <span class="hps">caudal</span> <span class="hps">medulla</span> <span class="hps">oblongata</span> <span class="hps">to the</span> <span class="hps">midbrain</span> <span class="hps">rostal</span>, <span class="hps">with</span> <span class="hps">no</span> <span class="hps">clear</span> <span class="hps">boundaries</span>. <span class="hps">In it</span> <span class="hps">lie</span> <span class="hps">many</span> <span class="hps">vital</span> <span class="hps">centers</span> <span class="hps">such as</span> <span class="hps">the respiratory center</span>, <span class="hps">blood</span> <span class="hps">pressure</span>, <span class="hps">heart rate</span>, <span class="hps">and</span> <span class="hps">other</span> <span class="hps">vegetative</span> <span class="hps">functions</span>, and also <span class="hps">contain</span> <span class="hps">components of</span> <span class="hps">ascending</span> <span class="hps">and</span> <span class="hps">descending</span> <span class="hps">pathways</span> <span class="hps">that</span> <span class="hps">play an important role</span> <span class="hps">in the regulation of</span> <span class="hps">endocrine</span> <span class="hps">secretion</span>, <span class="hps">reflex</span>, <span class="hps">sensory</span> <span class="hps">input</span>, <span class="hps">and</span> <span class="hps">awareness</span>. <span class="hps">'</span>Ascending Recticular Activating System' <span class="hps">receiving</span> <span class="hps">stimulation</span> <span class="hps">by</span> <span class="hps">all</span> <span class="hps">the general</span> <span class="hps">somatic</span> <span class="hps">sensory</span> <span class="hps">pathways</span> <span class="hps">and specific</span>. <span class="hps">Rektikularis</span> <span class="hps">excitation</span> <span class="hps">system</span> <span class="hps">is</span> <span class="hps">a complex</span> <span class="hps">trajectory</span> <span class="hps">polisinaps</span>, <span class="hps">because apart</span> <span class="hps">from</span> <span class="hps">the sensory</span> <span class="hps">tract</span>, <span class="hps">also derived</span> <span class="hps">from the</span> <span class="hps">trigeminal</span> <span class="hps">system</span>, <span class="hps">hearing</span>, sight, <span class="hps">and</span> <span class="hps">smell.</span> <span class="hps">Conductive</span> <span class="hps">pathway</span> <span class="hps">talamikus</span> <span class="hps">spino</span><span class="atn">-</span>walk <span class="hps">toward the</span> <span class="hps">medulla</span> <span class="hps">and</span> <span class="hps">pons</span> <span class="hps">tegmentum</span> <span class="hps">is a</span> <span class="hps">morphological</span> <span class="hps">pathway</span> <span class="hps">of the</span> <span class="hps">excitatory</span> <span class="hps">noksius</span> <span class="hps">of</span> <span class="hps">'</span>consciousness'. <span class="hps">Some</span> <span class="hps">pathways</span> <span class="hps">of</span> <span class="hps">formasio</span> <span class="hps">rektikularis</span> <span class="hps">routed through</span> <span class="hps">the thalamus</span> <span class="hps">to</span> <span class="hps">the next</span> <span class="hps">projected</span> <span class="hps">evenly on</span> <span class="hps">the cortex</span> <span class="hps">cerebri</span> <span class="hps">(</span>specific <span class="hps">projections</span>), <span class="hps">while others</span> <span class="hps">will end up in</span> <span class="hps">nuckleus</span> <span class="hps">specific</span> <span class="hps">thalamus</span> <span class="hps">to then</span> <span class="hps">projected</span> <span class="hps">diffusely</span> <span class="hps">to the cortex</span> <span class="hps">(</span>the projection <span class="hps">of non</span><span class="atn">-</span>specific).</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Broadly speaking</span></span><span lang="EN">, <span class="hps">the causes of</span> <span class="hps">'</span>coma' could be <span class="hps">in</span> <span class="hps">for</span> <span class="hps">two</span>, <span class="hps">namely</span> <span class="hps">intracranial</span> <span class="hps">and</span> <span class="hps">metabolic</span>. <span class="hps">The cause of</span> <span class="hps">intracranial</span> <span class="hps">such as head trauma</span>, <span class="hps">infections</span>, <span class="hps">neoplastic</span>, <span class="hps">and</span> <span class="hps">vascular</span> <span class="hps">disorders</span>. <span class="hps">On</span> <span class="hps">the causes</span> <span class="hps">can</span> <span class="hps">be</span> <span class="hps">metabolic</span> <span class="hps">imbalance</span> <span class="hps">of electrolytes</span> <span class="hps">and</span> <span class="hps">acid</span>-base, <span class="hps">endocrine</span> <span class="hps">disorders</span>, <span class="hps">hepatic</span> <span class="hps">coma</span>, <span class="hps">uremic</span> <span class="hps">coma</span>, <span class="hps">anoxia</span> <span class="hps">encephalopathy</span>, vitamin deficiency <span class="hps">(</span>thiamine, <span class="hps">niacin</span>, <span class="hps">vitamin</span> <span class="hps">B12</span>), <span class="hps">toxins</span> <span class="hps">and</span> <span class="hps">intoksikan</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">The causes of</span></span><span lang="EN"> <span class="hps">'</span>coma' can be <span class="hps">categorized</span> <span class="hps">into:</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">a.</span></span>      <span class="hps"><span lang="EN">Dysfunction of</span></span><span lang="EN"> <span class="hps">the cerebral cortex</span> <span class="hps">of</span> <span class="hps">bilateral</span> <span class="hps">multifocal</span> <span class="hps">or</span> <span class="hps">diffuse</span>, <span class="hps">where the</span> <span class="hps">substantia</span> <span class="hps">grisea</span> <span class="hps">cortex</span> <span class="hps">is destroyed or</span> <span class="hps">depressed</span> <span class="hps">by</span> <span class="hps">acute</span> <span class="hps">and</span> <span class="hps">diffuse</span> <span class="hps">so that</span> <span class="hps">the curved</span> <span class="hps">trajectory of</span> <span class="hps">physiological</span> <span class="hps">feedback</span> <span class="hps">cortical</span><span class="atn">-</span>subcortical <span class="hps">damage</span>, <span class="hps">the mechanism</span> <span class="hps">of autonomic</span> <span class="hps">arousal</span> <span class="hps">of</span> <span class="hps">the brain</span> <span class="hps">stem</span> <span class="hps">and cause</span> <span class="hps">shock</span> <span class="hps">terinhibisi</span> <span class="hps">acute</span> <span class="hps">rektikulaer</span> <span class="hps">below the level of</span> <span class="hps">lesion</span> <span class="hps">(</span>eg <span class="hps">:</span> <span class="hps">necrosis</span> <span class="hps">due to</span> <span class="hps">hypoxia</span><span class="atn">-</span>iskhaemia <span class="hps">heavy</span>, <span class="hps">prolonged</span> <span class="hps">hipol</span></span><span class="hps">eu</span><span lang="EN">khaemia, <span class="hps">metabolic</span> <span class="hps">depression</span> <span class="hps">in</span> <span class="hps">ensefalopatia</span> <span class="hps">hepatica</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">b.</span>     </span><span class="hps"><span lang="EN">Direct damage</span></span><span lang="EN"> <span class="hps">to the</span> <span class="hps">paramedian</span> <span class="hps">upper brain</span> <span class="hps">stem</span> <span class="hps">and</span> <span class="hps">posterior</span>-inferior <span class="hps">diencephalic</span> <span class="hps">ascending</span> <span class="hps">arousal</span> <span class="hps">system that is</span> <span class="hps">blocking</span> <span class="hps">the normal</span> <span class="hps">cortical</span> <span class="hps">activity</span> <span class="hps">(ie</span>: <span class="hps">encephalitis</span> <span class="hps">infrak</span> <span class="hps">or</span> <span class="hps">certain</span> <span class="hps">inflammatory</span> <span class="hps">lesions</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">c.</span>    </span><span class="hps"><span lang="EN">Wide</span></span><span lang="EN"> <span class="hps">disconnection</span> <span class="hps">between</span> <span class="hps">the cortex</span> <span class="hps">and</span> <span class="hps">subcortical</span> <span class="hps">mechanisms of</span> <span class="hps">activity</span> <span class="hps">similar to</span> <span class="hps">the above</span> <span class="hps">two</span> <span class="hps">conditions</span> <span class="hps">(</span>for example: <span class="hps">dismielinisasi</span> <span class="hps">or</span> <span class="hps">extensive</span> <span class="hps">damage</span> <span class="hps">of the</span> <span class="hps">substantia</span> <span class="hps">alba</span> <span class="hps">severe</span> <span class="hps">cerebral</span> <span class="hps">hemisphere</span> <span class="hps">pascahipoperfusi</span><span class="atn">-</span>old <span class="hps">cerebral</span> <span class="hps">hypoxemia</span> <span class="hps">due to</span> <span class="hps">CO poisoning</span>).<br /> <span class="hps">d.</span> <span class="hps">Diffuse</span> <span class="hps">abnormalities</span> <span class="hps">are</span> <span class="hps">usually</span> <span class="hps">caused</span> <span class="hps">by a</span> <span class="hps">metabolic</span> <span class="hps">disorder</span> <span class="hps">affecting</span> <span class="hps">competing</span> <span class="hps">cortical</span> <span class="hps">and</span> <span class="hps">subcortical</span> <span class="hps">arousal</span> <span class="hps">mechanisms</span> <span class="hps">(</span>eg <span class="hps">metabolic</span> <span class="hps">encephalopathy</span>).</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">CLINICAL APPROACH</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">As the</span></span><span lang="EN"> <span class="hps">algorithm</span> <span class="hps">approaches</span> <span class="hps">the patients</span> <span class="hps">'</span>coma' or <span class="hps">loss of consciousness</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">1.</span></span>   <span class="hps"><span lang="EN">ABC</span></span><span lang="EN">: <span class="hps">in patients</span> <span class="hps">who experienced</span> <span class="hps">loss of consciousness</span>, <span class="hps">carried out</span> <span class="hps">the liberation</span> <span class="hps">of the airway</span>, <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">circulation</span> <span class="hps">should be</span> <span class="hps">checked</span> <span class="hps">and</span> <span class="hps">maintained</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">2.</span></span>   <span class="hps"><span lang="EN">Look for</span></span><span lang="EN"> <span class="hps">signs or</span> <span class="hps">clues</span> <span class="hps">about the</span> <span class="hps">cause of the</span> <span class="hps">decline in</span> <span class="hps">consciousness</span> <span class="hps">through</span> <span class="hps">anamnesa</span> <span class="hps">(</span>a history of <span class="hps">hereditary diseases</span>, <span class="hps">the state</span> <span class="hps">and</span> <span class="hps">condition of the patient</span> <span class="hps">is found</span>, <span class="hps">etc.</span>), <span class="hps">physical examination</span> <span class="hps">(</span>odor <span class="hps">breathing</span>, signs of <span class="hps">meningeal</span> <span class="hps">perangsagan</span>, scar <span class="hps">injections</span>, <span class="hps">etc.</span>), <span class="hps">laboratory</span> <span class="hps">and</span> <span class="hps">radiological</span> <span class="hps">examinations.</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">3.</span></span>      <span class="hps"><span lang="EN">Addressing</span></span><span lang="EN"> <span class="hps">a common cause</span> <span class="hps">of</span> <span class="hps">reversible</span>: <span class="hps">giving</span> <span class="hps">naloxone</span>, <span class="hps">thiamine</span>, and <span class="hps">dextrose</span> <span class="hps">50%</span> <span class="hps">in patients</span> <span class="hps">with decreased</span> <span class="hps">consciousness and</span> <span class="hps">the cause is unknown</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">4.</span></span>      <span class="hps"><span lang="EN">Neurology</span></span><span lang="EN"> <span class="hps">examination</span>: <span class="hps">check the</span> <span class="hps">brainstem and the</span> <span class="hps">search for</span> <span class="hps">focal lesions</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">DIAGNOSIS</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Physical </span>E</span><span class="hps"><span lang="EN">xamination</span></span><span lang="EN">:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Note</span></span><span lang="EN"> <span class="hps">vital signs</span> <span class="hps">like</span> <span class="hps">blood</span> <span class="hps">pressure</span>, pulse, respiration and <span class="hps">temperature</span>, <span class="hps">whether</span> <span class="hps">there are abnormalities</span> <span class="hps">or</span> <span class="hps">not</span>. <span class="hps">In</span> <span class="hps">general</span> <span class="hps">observations</span> <span class="hps">views</span> <span class="hps">posture</span>, patient age, <span class="hps">stigmata</span> <span class="hps">of chronic</span> <span class="hps">disease</span>, <span class="hps">breathing patterns</span>, <span class="hps">and skin color</span> <span class="hps">(</span>jaundice, <span class="hps">cyanosis</span>, pallor, <span class="hps">red</span> <span class="hps">cherry</span>). <span class="hps">Looking for</span> <span class="hps">signs of</span> <span class="hps">trauma to the</span> <span class="hps">head</span> <span class="hps">(</span>skull <span class="hps">fracture</span>, <span class="hps">laceration</span>), seizures <span class="hps">(</span>myoclonic, <span class="hps">deserebrasi</span>), <span class="hps">the smell</span> <span class="hps">of</span> <span class="hps">breathing</span> <span class="hps">(</span>alcohol, <span class="hps">acetone</span>, <span class="hps">ammonia</span>), <span class="hps">check the</span> <span class="hps">ears</span> <span class="hps">and</span> <span class="hps">nose</span> <span class="hps">(</span>bleeding <span class="hps">or discharge of</span> <span class="hps">cerebrospinal</span> <span class="hps">fluid</span>), <span class="hps">check the</span> <span class="hps">extremities</span> <span class="hps">body</span> <span class="hps">if there is</span> <span class="hps">a fracture</span> <span class="hps">or</span> <span class="hps">not,</span> <span class="hps">and</span> <span class="hps">palpation</span> <span class="hps">-</span> <span class="hps">percussion</span> <span class="hps">and</span> <span class="hps">auscultation</span> <span class="hps">of the thorax</span> <span class="hps">area</span>, heart <span class="hps">and</span> <span class="hps">abdomen</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Examination</span></span><span lang="EN"> </span><span class="hps">N</span><span class="hps"><span lang="EN">eurolgi</span>c</span><span lang="EN">:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">First of all</span></span><span lang="EN"> <span class="hps">examined</span> <span class="hps">the level of</span> <span class="hps">consciousness</span> <span class="hps">using the</span> <span class="hps">GCS</span> <span class="hps">-</span> <span class="hps">Glasgow</span> <span class="hps">Coma Scale</span> <span class="hps">which consists</span> <span class="hps">of</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><i><u><span lang="EN">EYE</span></u></i></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Opening</span></span><span lang="EN"> <span class="hps">eyes</span> <span class="hps">spontaneously.</span> <span class="hps">(</span>4)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Open the</span></span><span lang="EN"> <span class="hps">eyes with</span> <span class="hps">the sound</span> <span class="hps">stimuli</span>. <span class="hps">(</span>3)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Open the</span></span><span lang="EN"> <span class="hps">eye</span> <span class="hps">with</span> <span class="hps">painful</span> <span class="hps">stimuli</span>. <span class="hps">(</span>2)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Unable to open</span></span><span lang="EN"> <span class="hps">the eyes</span>. <span class="hps">(</span>1)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><i><u>MOTORIC</u></i></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Moving</span></span><span lang="EN"> <span class="hps">according to</span> <span class="hps">the command</span>. <span class="hps">(</span>6)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">It can</span></span><span lang="EN"> <span class="hps">locate</span> <span class="hps">pain.</span> <span class="hps">(</span>5)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">avoidance</span></span><span lang="EN"> <span class="hps">reaction</span>. <span class="hps">(</span>4)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Reaction</span></span><span lang="EN"> <span class="hps">dekortikasi</span> <span class="hps">/</span> <span class="hps">flexion</span>. <span class="hps">(</span>3)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-</span>        <span class="hps"><span lang="EN">Directors</span></span><span lang="EN"> <span class="hps">deserebrasi</span> <span class="hps">/</span> <span class="hps">extension</span>. <span class="hps">(</span>2)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">There was no</span></span><span lang="EN"> <span class="hps">reaction</span>. <span class="hps">(</span>1)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><i><u><span lang="EN">VERBAL</span></u></i></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">Good</span></span><span lang="EN"> <span class="hps">and no</span> <span class="hps">disorientation</span>. <span class="hps">(</span>5)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">'</span></span>C<span lang="EN">onfuse'. <span class="hps">(</span>4)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">Talk is not</span></span><span lang="EN"> <span class="hps">appropriate</span>. <span class="hps">(</span>3)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">Can only</span></span><span lang="EN"> <span class="hps">groaned</span>. <span class="hps">(</span>2)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0.0001pt 21.25pt; text-align: justify; text-indent: -21.25pt;"><span class="hps">-        </span><span class="hps"><span lang="EN">There is no sound</span></span><span lang="EN">. <span class="hps">(</span>1)</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">As a</span></span><span lang="EN"> <span class="hps">benchmark</span> <span class="hps">for</span> <span class="hps">'</span>coma' <span class="hps">then according to</span> <span class="hps">GCS</span> <span class="hps">equal to</span> <span class="hps">3,</span> <span class="hps">where</span> <span class="hps">there were no</span> <span class="hps">eye-opening</span> <span class="hps">response</span>, <span class="hps">verbal</span> <span class="hps">and motor</span></span><span class="hps">ic</span><span lang="EN">.</span><span lang="EN"> </span><span class="hps"><span lang="EN">Then note</span></span><span lang="EN"> <span class="hps">the pattern of</span> <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">motor</span></span><span class="hps">ic</span> <span class="hps"><span lang="EN">examination</span></span><span lang="EN">. </span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">On</span></span><span lang="EN"> <span class="hps">motor</span></span><span class="hps">ic</span> <span class="hps"><span lang="EN">examination</span></span><span lang="EN">, which is seen <span class="hps">is the</span> <span class="hps">patient's</span> <span class="hps">posture</span> <span class="hps">and</span> <span class="hps">if there are</span> <span class="hps">seizures</span> <span class="hps">or</span> <span class="hps">not</span>. <span class="hps">Cranial</span> <span class="hps">nerves</span> <span class="hps">examination</span> <span class="hps">was conducted to assess</span> <span class="hps">the function</span> <span class="hps">of the brain stem</span>. <span class="hps">Where</span> <span class="hps">in the patients</span> <span class="hps">who experienced</span> <span class="hps">loss of consciousness</span> <span class="hps">or '</span>coma' will <span class="hps">happen</span> <span class="hps">some</span> <span class="hps">decline in</span> <span class="hps">brain</span> <span class="hps">stem</span> <span class="hps">reflexes</span>, <span class="hps">then</span> <span class="hps">examined</span> <span class="hps">the</span> <span class="hps">pupillary</span> <span class="hps">reflex</span>, <span class="hps">corneal</span>, <span class="hps">okulocefalik</span> <span class="hps">(</span>doll's <span class="hps">eye</span>), and <span class="hps">vomiting</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><span lang="EN">To help find out the causes of 'coma', then the examination can be performed with CT-scan or MRI, was conducted to determine abnormalities in the brain are like a tumor mass or increased intracranial fluid. If meningitis is suspected, then examination lumbar puncture. In laboratory tests that examined the levels of blood glucose, iodine, calcium, and urea nitrogen or creatinine; arterial pH, pO</span><span lang="EN" style="font-size: 8pt; position: relative; top: 3pt;">2</span><span lang="EN">, and PCO</span><span lang="EN" style="font-size: 8pt; position: relative; top: 3pt;">2</span><span lang="EN">; the concentration of ethanol in blood and urine; blood cultures and cerebrospinal fluid; and liver function.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">TREATMENT</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">The principle of</span></span><span lang="EN"> <span class="hps">treatment</span> <span class="hps">is generally</span> <span class="hps">required to</span> <span class="hps">be applied</span> <span class="hps">immediately</span> <span class="hps">although the</span> <span class="hps">diagnosis of</span> <span class="hps">the cause</span> <span class="hps">has not been</span> <span class="hps">enforced.</span> <span class="hps">Starting</span> <span class="hps">from</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">1.</span></span>      <span class="hps"><span lang="EN">ABC</span></span><span lang="EN">: <span class="hps">the liberation</span> <span class="hps">of the airway</span>, <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">circulation</span> <span class="hps">maintenance</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">2.</span>      </span><span class="hps"><span lang="EN">Overcome</span></span><span lang="EN"> <span class="hps">state of</span> <span class="hps">shock</span>, <span class="hps">if any.</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">3.</span>      </span><span class="hps"><span lang="EN">Provision of</span></span><span lang="EN"> <span class="hps">naloxone</span> <span class="hps">0.5 mg</span> <span class="hps">iv</span> <span class="hps">(</span>if <span class="hps">the cause is</span> <span class="hps">an overdose</span> <span class="hps">of narcotics</span>), <span class="hps">infusion</span> <span class="hps">of glucose</span> <span class="hps">50</span>% 25 <span class="hps">50ml</span>. <span class="hps">And</span> <span class="hps">given the</span> <span class="hps">thiamine</span> <span class="hps">50 -</span> <span class="hps">100mg</span> <span class="hps">after administration of</span> <span class="hps">a bolus</span> <span class="hps">injection of</span> <span class="hps">glucose</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">4.</span></span>      <span class="hps"><span lang="EN">Giving</span></span><span lang="EN"> <span class="hps">Mannitol</span> <span class="hps">50gr</span> <span class="hps">in a solution</span> <span class="hps">of 20%</span> <span class="hps">iv</span> <span class="hps">every</span> <span class="hps">10 -20</span> <span class="hps">minutes</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">5.</span></span>      <span class="hps"><span lang="EN">Perform</span></span><span lang="EN"> <span class="hps">lumbar</span> <span class="hps">puncture</span> <span class="hps">if</span> <span class="hps">meningitis</span> <span class="hps">is suspected</span> <span class="hps">or</span> <span class="hps">subarakhnoi</span> <span class="hps">hemorrhage,</span> <span class="hps">or</span> <span class="hps">perform</span> <span class="hps">a CT</span><span class="atn">-</span>scan.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">6.</span></span>      <span class="hps"><span lang="EN">Giving</span></span><span lang="EN"> <span class="hps">anticonvulsant</span> <span class="hps">such as</span> <span class="hps">phenytoin</span> <span class="hps">500 -</span> <span class="hps">1000mg</span> <span class="hps">iv</span>, <span class="hps">doses</span> <span class="hps"><</span>50mg/mnt.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">7.</span></span>      <span class="hps"><span lang="EN">Rinse</span></span><span lang="EN"> <span class="hps">and</span> <span class="hps">gastric</span> <span class="hps">lavage</span> <span class="hps">with normal saline</span> <span class="hps">is very</span> <span class="hps">useful</span> <span class="hps">if the</span> <span class="hps">coma</span> <span class="hps">is because</span> <span class="hps">taking</span> <span class="hps">drugs.</span></span><span class="hps"></span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">8.</span></span>      <span class="hps"><span lang="EN">The use of</span></span><span lang="EN"> <span class="hps">cooling</span> <span class="hps">mat</span> <span class="hps">to</span> <span class="hps">cope with</span> <span class="hps">hyperthermia</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">9.</span></span>      <span class="hps"><span lang="EN">Installation of</span></span><span lang="EN"> <span class="hps">a catheter to</span> <span class="hps">help the</span> <span class="hps">urine output</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">10.</span></span>   <span class="hps"><span lang="EN">Installation of</span></span><span lang="EN"> <span class="hps">stomach</span> <span class="hps">tube</span> <span class="hps">to</span> <span class="hps">assist</span> <span class="hps">the provision</span> <span class="hps">of food and drink</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 21.3pt; text-align: justify; text-indent: -21.3pt;"><span class="hps"><span lang="EN">11.</span></span>   <span class="hps"><span lang="EN">Changing the</span></span><span lang="EN"> <span class="hps">sleeping position</span> <span class="hps">of patients</span> <span class="hps">and</span> <span class="hps">restriction</span> <span class="hps">of</span> <span class="hps">oral</span> <span class="hps">fluids</span>. <span class="hps">Patient's legs</span> <span class="hps">should</span> <span class="hps">be checked</span> <span class="hps">to prevent</span> <span class="hps">phlebothrombosis</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 0.0001pt; text-align: justify;"><br /> </div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><b><span style="font-size: 12pt;">CONCLUSION</span></b></span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">'</span></span><span lang="EN">Coma' <span class="hps">is</span> <span class="hps">a state of</span> <span class="hps">reduced consciousness</span> <span class="hps">that</span> <span class="hps">causes people to</span> <span class="hps">look like</span> <span class="hps">falling asleep</span> <span class="hps">but can not be</span> <span class="hps">aroused</span> <span class="hps">by</span> <span class="hps">stimuli</span> <span class="hps">from the outside</span> <span class="hps">or</span> <span class="hps">the surrounding</span> <span class="hps">environment</span> <span class="hps">and</span> <span class="hps">by</span> <span class="hps">stimulation</span> <span class="hps">of</span> <span class="hps">the body</span>. <span class="hps">The causes of</span> <span class="hps">'</span>coma' <span class="hps">can be divided</span> <span class="hps">into </span></span><span class="hps">two</span><span lang="EN">, <span class="hps">the first</span> <span class="hps">of</span> <span class="hps">abnormalities</span> <span class="hps">in the</span> <span class="hps">intracranial</span> <span class="hps">and</span> <span class="hps">the second</span> <span class="hps">by</span> <span class="hps">metabolic abnormalities.</span> </span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">What makes</span></span><span lang="EN"> <span class="hps">'</span>coma' <span class="hps">as</span> <span class="hps">a state</span> <span class="hps">of</span> <span class="hps">emergency</span> <span class="hps">is</span> <span class="hps">the cause of</span> <span class="hps">the disease course</span> <span class="hps">and</span> <span class="hps">progression</span> <span class="hps">of the disease</span> <span class="hps">that can cause</span> <span class="hps">severe</span> <span class="hps">brain</span> <span class="hps">damage</span> <span class="hps">and</span> <span class="hps">irreversible</span>, <span class="hps">and usually</span> <span class="hps">patients</span> <span class="hps">with a</span> <span class="hps">'</span>coma' <span class="hps">was in</span> <span class="hps">critical condition</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span class="hps"><span lang="EN">Therefore</span></span><span lang="EN">, <span class="hps">in</span> <span class="hps">treating patients</span> <span class="hps">with decreased</span> <span class="hps">consciousness</span> <span class="hps">or</span> <span class="hps">'</span>coma' should be <span class="hps">quick</span> <span class="hps">and</span> <span class="hps">systematic</span>, <span class="hps">is intended</span> <span class="hps">to provide</span> <span class="hps">appropriate therapies</span> <span class="hps">and</span> <span class="hps">diagnostics</span> <span class="hps">work</span> <span class="hps">properly</span>. <span class="hps">In an effort</span> <span class="hps">to</span> <span class="hps">provide</span> <span class="hps">relief</span>, <span class="hps">then the</span> <span class="hps">following steps</span> <span class="hps">can be followed</span>:</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">1.</span></span>   <span class="hps"><span lang="EN">Remember</span></span><span lang="EN"> <span class="hps">ABC</span>: <span class="hps">the liberation</span> <span class="hps">of the airway</span>, <span class="hps">breathing</span> <span class="hps">and</span> <span class="hps">circulation</span> <span class="hps">maintenance</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">2.</span></span>   <span class="hps"><span lang="EN">Find</span></span><span lang="EN"> <span class="hps">the clues</span> <span class="hps">of</span> <span class="hps">the cause of the</span> <span class="hps">reduction</span> <span class="hps">state of</span> <span class="hps">awareness.</span> <span class="hps">In this case</span>, <span class="hps">do</span> <span class="hps">diagnose</span>, <span class="hps">checking</span> <span class="hps">vital signs</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">3.</span></span>   <span class="hps"><span lang="EN">The management</span></span><span lang="EN"> <span class="hps">of</span> <span class="hps">circumstances</span> <span class="hps">that are still</span> <span class="hps">reversible</span>, <span class="hps">such as</span> <span class="hps">provision of</span> <span class="hps">naloxone</span>, <span class="hps">thiamine</span>, and <span class="hps">dextrose</span> <span class="hps">to patients</span> <span class="hps">with decreased</span> <span class="hps">awareness of</span> <span class="hps">the</span> <span class="hps">cause is unknown</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 6pt 14.2pt; text-align: justify; text-indent: -14.2pt;"><span class="hps"><span lang="EN">4.</span></span>   <span class="hps"><span lang="EN">Check your</span></span><span lang="EN"> <span class="hps">brain stem</span> <span class="hps">reflexes</span> <span class="hps">and</span> <span class="hps">look for</span> <span class="hps">the symptoms</span> <span class="hps">/</span> <span class="hps">signs of</span> <span class="hps">focal lesions</span>.</span></div><div class="MsoNormal" style="line-height: normal; margin-bottom: 6pt; text-align: justify;"><span lang="EN"><br /> </span><span class="hps"><b><span style="font-size: 12pt;">LITERATUR</span></b></span></div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">1.<span style="font: 7pt "Times New Roman";">         </span>Adams R.D, Maurice V. Coma and Related Disorders of Consciousness, Principles of Neurology, 5^th edition. McGraw-Hill Co,Inc. 1993: 300 – 318;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">2.<span style="font: 7pt "Times New Roman";">         </span>Drislane F.W, Benatar M, Chang B.S, et all. The Approach to Coma and Altered Consciousness, Blueprints Neurology, 2^nd edition. Lippincott Williams & Wilkins. 2002: 20 – 26;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">3.<span style="font: 7pt "Times New Roman";">         </span>LeBlond R.F, DeGowin R.L, Brown D.D. Coma, DeGowin’s Diagnostic Examination The Complete Guide to Assessment Examination Differential Diagnosis, 8^th edition, International edition. McGraw-Hill Co,Inc. 2004: 865 – 868;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">4.<span style="font: 7pt "Times New Roman";">         </span>Kasper D.L, Braunwald E, Fauci A.S, et all. Confusion, Stupor, and Coma, Harrison’s Manual of Medicine, 16^th edition, International edition. McGraw-Hill Co,Inc. 2005: 54 – 58;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">5.<span style="font: 7pt "Times New Roman";">         </span>Gilroy J. Coma, Basic Neurology, 3^rd edition, International edition. McGraw-Hill Co,Inc. 61 – 70;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">6.<span style="font: 7pt "Times New Roman";">         </span>Listiono D. Koma dan Gangguan Kesadaran, Ilmu Bedah Saraf Satyanegara, edisi Ketiga. PT.Gramedia Pustaka Utama, Jakarta, 1998 : 130 – 143;</div><div class="MsoNormal" style="line-height: 150%; margin: 0cm 0cm 0.0001pt 21.3pt; text-align: justify; text-indent: -21.3pt;">7.<span style="font: 7pt "Times New Roman";">         </span>Brust  J.C.M. Coma, Current Diagnosis & Treatment in Neurology, International edition. Lange Medical Books/McGraw-Hill Co,Inc. 2007: 29 – 34.</div>

By Deden Sura AgungComa is a medical condition that needs treatment sooner, because the basic course of the disease was the cause of 'coma' and direction of development of the disease can cause severe brain damage and irreversible. So rapid and systematic examination is needed to provide appropriate…

SALMONELLA PARATYPHI - TYPHOID (TYPUS)

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">Demam Enterik (Tifoid) adalah penyakit sistemik yang ditandai dengan demam dan nyeri pada abdomen yang disebabkan oleh penyebaran  Salmonella typhi atau Salmonella paratyphi. Pada awalnya penyakit ini disebut demam tifoid karena memiliki gejala klinis yang sama dengan typhus. Namun pada awal tahun 1800-an, demam typhoid secara jelas didefinisikan sebagai kelainan patologis berupa suatu penyakit yang berbeda (unik) dikarenakan dasar penegakan penyakit yang berhubungan dengan pembesaran Plak Peyeri dan nodus limfatikus mesenterik. Pada tahun 1869, berdasarkan tempat infeksi, istilah demam enterik diajukan sebagai istilah alternatif untuk membedakan demam tifoid dari tifus. Namun pada saat ini kedua istilah tersebut sering bertukar tempat.</div><b style="color: orange;">Epidemiologi</b><br /> <div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"></div>Beberapa hal yang mempengaruhi terjadinya penyebaran demam tifoid di negara sedang berkembang adalah kepadatan penduduk, sumber air minum, produksi makanan, strain resisten antibiotik, kesulitan menentukan identifikasi dan penatalaksanaan karier, keterlambatan membuat diagnosis pasti, patogenesis dan virulensi yang belum diketahui sepenuhnya, serta belum adanya vaksin, efektif aman dan murah.</div><div style="text-align: justify;">Bakteri S. typhi dapat bertahan hidup di lingkungan kering dan beku, peka terhadap proses klorinasi dan pasteurisasi pada suhu 630 C. Organisme ini mampu bertahan beberapa minggu di es, debu, sampah kering, dan pakaian, mampu bertahan di tempat sampah selama satu minggu dan dapat berkembang biak dalam susu, daging atau produknya tanpa merubah warna atau bentuknya.<br /> Manusia merupakan satu-satunya sumber penularan alami melalui kontak langsung maupun tidak langsung dengan seorang penderita tifoid atau karier kronis. Transmisi kuman terutama dengan cara menelan makanan atau air yang tercemar tinja manusia. Transmisi secara kongenital dapat terjadi dari seorang ibu yang mengalami bakteriemia kepada bayi dalam kandungan, atau tertular pada saat dilahirkan oleh seorang ibu merupakan karier tifoid dengan rute fekal oral.</div><br /> <b style="color: orange;">Etiologi</b><br /> <div style="text-align: justify;">Salmonella Typhi adalah bakteri Gram negatif, mempunyai flagela, tidak berkapsul, tidak membentuk spora fakultatif anaerob. Mempunyai antigen somatik (O) yang terdiri dari oligosakarida, flagelar antigen (H) yang terdiri dari protein dan envelope antigen (K) yang terdiri dari polisakarida. Mempunyai makromolekular lipopolisakarida kompleks yang membentuk lapis luar dari dinding sel dan dinamakan endotoksin. Salmonella typhii juga dapat memperoleh plasmid faktor-R yang berkaitan dengan resistensi terhadap multipel antibiotik.</div><br /> <b><span style="color: orange;">Patogenesis</span></b><br /> <i>Jalur Masuknya Bakteri ke Dalam Tubuh</i><br /> <div style="text-align: justify;">Infeksi didapat dengan cara menelan makanan atau minuman yang terkontaminasi dan dapat pula dengan kontak langsung jari tangan yang terkontaminasi tinja, urin, sekret saluran nafas, atau dengan pus penderita yang terinfeksi. Agar dapat menimbulkan gejala klinis, diperlukan S. typhi dalam dosis 106 - 109 . Pada fase awal demam tifoid biasa ditemukan adanya gejala saluran nafas atas. Ada kemungkinan sebagian kuman ini masuk ke dalam peredaran darah melalui jaringan limfoid di faring. Pada tahap awal ini penderita juga sering mengeluh nyeri telan. Lidah tampak kotor tertutup selaput berwarna putih sampai berwarna putih sampai kecoklatan yang merupakan akibat sel epitel mati oleh bakteri S. typhi. Bila terjadi infeksi dari nasofaring melalui saluran tuba eustachi ke telingah tengah dan hal ini dapat terjadi otitis media.</div><div style="text-align: justify;">Di lambung, organisme menemui suasana asam dengan pH dengan rendah dalam kuman dimusnahkan. Pengosongan lambung yang bersifat lambat merupakan pelindung fisiologis. Setelah melalui barier asam lambung mikroorganiusme sampai ke usus halus dan menemui dua mekanisme pertahanan tubuh, yaitu motilitas dan flora normal usus. Penurunan motilitas usus karena obat-obatan atau faktor anatomis meningkatkan derajat beratnya penyakit dan timbulnya komplikasi, serta memperpanjang keadaan karier konvalesens. </div><div style="text-align: justify;">Sebuah penelitian menunjukkan bahwa apabila kuman yang masuk sebanyak 103 atau kurang, belum dapat menimbulkan gejala pada penderita, tetapi jika jumlahnya lebih dari 105 atau lebih menimbulkan gejala pada 27% sukarelawan. Semakin tinggi jumlah kuman yang masuk, semakin besar kemungkinan seseorang terkena deman typhoid, apalagi apabila kuman tersebut termasuk jenis yang menghasilkan gen polisakarida kapsul atau Vi.<br /> Selanjutnya kuman akan menembus dinding usus halus, masuk ke kelenjar mesentrika, lalu ke duktus thoracicus dan masuk ke dalam peredaran darah, dan menimbulkan bakteriemi I.<br /> Kuman-kuman ini kemudian akan ditangkap oleh sel-sel RES dari limpa hati dan organ-organ lainnya. Setelah beberapa lama, kuman-kuman tersebut kembali masuk ke peredaran darah, dan menimbulkan bakteriemi II dan menyebar ke seluruh tubuh, termasuk melalui kantung empedu dan aliran empedu, masuk ke lumen usus lalu menembus hingga ke  plaque peyeri.</div><br /> <b style="color: orange;">Manifestasi Klinis</b><br /> <div style="text-align: justify;">Pada anak, periode inkubasi demam tifoid antara 5-40 hari dengan rata-rata 10 – 14 hari. Gejala klinis demam tifoid sangat bervariasi, dari gejala klinis ringan dan tidak memerlukan perawatan khusus sampai dengan berat sehingga harus dirawat. Variasi gejala ini  disebabkan faktor galur Salmonella, status nutrisi, imunologi dan lama sakit di rumahnya. </div><div style="text-align: justify;">Semua pasien demam tifoid selalu menderita demam pada awal penyakit. Pada era pemakaian antibiotik belum seperti saat ini, penampilan demam pada kasus demam tifoid mempunyai istilah khusus yaitu step ladder temperature chart yang ditandai dengan demam timbul insidius, kemudian naik secara bertahap tiap harinya dan mencapai titik tertinggi pada akhir minggu pertama, setelah itu demam akan bertahan tinggi dan pada minggu ke-4 demam turun perlahan secara lisis, kecuali apabila terjadi fokus infeksi seperti kolesistitis, abses jaringan lunak maka demam akan menetap. Banyak orang tua pasien demam tifoid melaporkan bahwa demam lebih tinggi saat sore dan malam hari dibandingkan denga pagi harinya. Pada saat demam sudah tinggi, pada kasus demam tifoid dapat disertai gejala sistem saraf pusat; seperti kesadaran berkabut atau delirium atau obtundasi, atau penurunan kesadaran mulai apati sampai koma.</div><div style="text-align: justify;">Gejala sistemik lain yang menyertai timbulnya demam adalah nyeri kepala, malaise, anoreksia, nausea, mialgia, nyeri perut, dan radang tenggorokan. Pada kasus yang berpenampilan klinis berat, pada saat demam tinggi akan nampak toksik/sakit berat. Bahkan dapat juga ijumpai penderita demam tifoid yang datang dengan syok hipovolemik sebagai akibat kurang masukan cairan dan makanan. Gejala gastrointestinal pada kasus demam tifoid sangat bervariasi. Pasien dapat mengeluh obstipasi, obstipasi kemudian disusul episode diare, pada sebagian pasien lidah tampak kotor dengan putih di tengah sedang tepi dan ujungnya kemerahan. Banyak dijumpai gejala meteorismus, berbeda dengan buku bacaan Barat pada anak Indonesia lebih banyak dijumpai hepatomegali dibandingkan splenomegali.<br /> Rose spot suatu ruam makulopapular yang berwarna merah dengan ukuran 2-4 sering kali dijumpai pada daerah abdomen, toraks, ekstremitas dan punggung pada orang tua kulit putih, tidak pernah dilaporkan ditemukan pada anak Indonesia. Bronkhitis banyak dijumpai pada demam tifoid sehingga buku ajar lama bahkan menganggap sebagai bagian dari penyakit demam tifoid. Bradikardi relatif jarang dijumpai pada anak.<br /> <br /> <b><span style="color: orange;">Penyulit (Komplikasi)</span></b><br /> Perforasi usus halus dilaporkan dapat terjadi pada 0,5-3 %, sedangkan perdarahan usus pada 1-10% kasus demam tifoid anak. Penyulit ini biasanya terjadi pada minggu ke-3 sakit, walau pernah dilaporkan terjadi pada minggu pertama. Komplikasi didahului dengan penurunan suhu, tekanan darah dan peningkatan frekuensi nadi. Pada perforasi usus halus ditandai oleh nyeri abdomen lokal pada kuadran kanan bawah akan tetapi dilaporkan juga nyeri yang menyelubung. Kemudian akan diikuti muntah, nyeri pada perabaan abdomen, dan hilangnya keredupan hepar.</div><div style="text-align: justify;">Pada komplikasi neuropsikiatri sebagian besar bermanifestasi gangguan kesadaran, disorientasi, delirium, obtudansi, stupor bahkan koma. Hepatitis tifosa asimtomatik dapat dijumpai pada kasus demam tifoid dengan ditandai peningkatan kadar transaminase yang tidak mencolok. Ikterus dengan atau tanpa disertai kenaikan kadar transaminase, maupun kolesistitis akut juga dapat dijumpai, sedang kolesistitis kronik yang terjadi pada penderita setelah mengalami demam tifoid dapat dikaitkan dengan adanya batu empedu dan fenomena pembawa kuman (karier).<br /> Sebagian kasus demam tifoid mengeluarkan bakteri Salmonella typhi melalui urin pada saat sakit maupun setelah sembuh. Sistitis bahkan pielonefritis dapat juga merupakan penyulit demam tifoid. Proteinuria transien sering dijumpai, sedangkan glomerunefritis yang dapat bermani9festasi sebagai gagal ginjal maupun sindrom nefrotik mempunyai prognosis yang buruk.<br /> Relaps yang didapat pada 5-10% kasus demam tifoid saat era pre antibiotik, sekarang lebih jarang ditemukan. Apabila terjadi relaps, demam timbul kembali seminggu setelah penghentian antibiotik. Pada umumnya relaps lebih ringan dibandingkan gejala demam tifoid sebelumnya.<br /> <br /> <b><span style="color: orange;">Gambaran Darah Tepi </span></b><br /> Anemia normokrom normositik terjadi sebagai akibat perdarahan usus atau supresi pada sumsum tulang. Jumlah leukosit rendah, namun jarang di bawah 3.000/l3. Apabila terjadi abses piogenik maka jumlah leukosit dapat meningkat mencapai 20.000 – 25.000/l3. Trombositopenia sering dijumpai, kadang-kadang berlangsung beberapa minggu.<br /> <br /> <b><span style="color: orange;">Diagnosa dan Deteksi Pembawa Kuman</span></b><br /> Diagnosis ditegakkan berdasarkan gejala klinis berupa demam, gangguan gastrointestinal dan mungkin disertai perubahan atau gangguan kesadaran, maka seorang klinisi dapat dapat membuat diagnosis tersangka demam typhoid. Diagnosis pasti ditegakkan melalui isolasi S. typhi dari darah, atau dapat pula dari feces atau urine. Pada dua minggu pertama sakit, kemungkinan mengisolasi S. typhi dari dalam darah pasien lebih besar dari pada minggu berikutnya. Biakan yang dilakukan pada urin dan feses, kemungkinan keberhasilan lebih kecil. Biakan spesimen yang berasal dari aspirasi sumsum tulang mempunyai sensitivitas tertinggi, hasil positif didapat pada 90% kasus. Akan tetapi prcsedur ini sangat invasif, sehingga tidak dipakai dalam praktek sehari-hari. Pada keadaan tertentu dapat dilakukan biakan spesimen empedu yang diambil dari duodenum dan memberikan hasil yang cukup baik.</div><div style="text-align: justify;">Uji serologi Widal suatu metode serologik yang memeriksa antibodi aglutinasi terhadap antigen somatik (O), flagela (H) banyak dipakai untuk membuat diagnosis demam tifoid. Di Indonesia pengambilan angka titer O aglutinin > 1/40 dengan memakai uji Widal slide aglutination (prosedur pemeriksaan membutuhkan waktu 45 menit) menuniukkan nilai ramal positif 96%. Artinya apabila hasil tes positif, 96% kasus benar sakit demam tifoid, akan tetapi apabila negatif tidak menyingkirkan. Banyak pendapat apabila titer O aglutinin sekaii periksa > 1/200 atau pada titer sepasang terjadi kenaikan 4 kali maka diagnosis demam tit'oid dapat ditegakkan. Aglutinin H banyak dikaitkan dengan pasca imunisasi atau infeksi masa lampau, sedang Vi aglutinin dipakai pada deteksi pembawa kuman S. typhi (karier). Banyak peneliti mengemukakan bahwa uji serologik Widal kurang dapat dipercaya sebab dapat timbul positif palsu pada daerah endemis, dan sebaliknya dapat timbul negatif palsu pada kasus demam tifoid yang terbukti biakan darah positif.<br /> Akhir-akhir ini banyak dimunculkan beberapa jenis pemeriksaan untuk mendeteksi antibodi S.typhi dalam serum, antigen terhadap S. typhi dalam darah, serum dan urin bahkan DNA S. typhi dalam darah dan faeces. Walaupun laporan-laporan pendahuluan menunjukkan hasil yang baik namun sampai sekarang tidak salah satupun dipakai secara luas. Sampai sekarang belum disepakati adanya pemeriksaan yang dapat menggantikan uji serologi Widal.<br /> <br /> <b><span style="color: orange;">Diagnosis Banding</span></b>Pada stadium dini demam tifoid beberapa penyakit kadang-kadang secara klinis dapat merupakan diagnosis banding yaitu influenza, gastroenteritis, bronkitis dan bronkopneumonia. Beberapa penyakit yang disebabkan oleh mikroorganisme intraselular seperti tuberkulosis, infeksi Jamur sistemik, bruselosis, tularemia, shigelosis dan malaria juga perlu dipikirkan. Pada demam typhoid yang berat, sepsis, leukemia, limfoma, dan penyakit hodgkin dapat sebagai diagnosis banding.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b style="color: orange;">Tatalaksana</b><br /> Sebagian besar pasien demam tifoid dapat diobati di rumah dengan tirah baring, isolasi yang memadai, pemenuhan kebutuhan cairan, nutrisi serta pemberian antibiotik. Sedangkan untuk kasus berat harus dirawat di rumah sakit agar pemenuhan cairan, elektrolit serta nutrisi disamping observasi kemungkinan timbul penyulit dapat dilakukan seksama.</div><div style="text-align: justify;">Kloramfenikol masih merupakn pilihan pertama pada pengobatan penderita demam tifoid. Dosis yang diberikan adalah 100 mg/kg Berat Badan/hari dibagi dalam 4 kali pemberian selama 10 sampai 14 hari sedang pada kasus dengan malnutrisi atau penyakit, pengobatan dapat diperpanjang sampai 21 hari. Salah satu kelemahan kloramfenikol adalah tingginya angka relaps dan karier. Namun pada anak hal hal tersebut jarang dilaporkan.</div><div style="text-align: justify;">Ampisilin memberikan respons perbaikan klinis kurang apabila dibandingkan dengan kloramfenikol. Dosis yang dianjurkan adalah 100-200 mg/kg Berat Badan/hari dibagi 4 kali  pemberian secara oral atau suntikan intravena. Amoksilin dengan dosis 100 mg/kg Berat Badan/hari dibagi 4 kali pemberian memberikan hasil yang setara dengan kloramfenikol walaupun penurunan demam lebih lama. Kombinasi trimetophin sulfametoksazol memberikan hasil yang kurang baik dibanding kloramfenikol. Di beberapa negara sudah dilaporkan kasus demam tifoid yang resisten terhadap kloramfenikol. Seftriakson dan sefoperazon dapat memberikan angka kesembuhan 90% dan relaps 0-4%. Akhir-akhir ini cefixime oral 15-20 mg/kgBB/hari pertama 10 kali dapat diberikan sebagai alternatif, terutama apabila jumlah leukosit <2000/ atau dijumpai resistensi terhadap S.typhi.</div><div style="text-align: justify;">Pada demam tifoid kasus berat seperti delirium, koma atau syok, deksametason dosis tinggi 1 – 3 mg/kg Berat Badan/hari disamping antibiotik yang memadai dapat menurunkan angka kematian. Demam tifoid edngan tifoid denga npenyulit perdarahan usus kadang-kadang memerlukan tranfusi darah. Sedangkan apabila diduga terjadi perforasi, adanya cairan pada peritoneum dan udara bebas pada foto abdomen dapat membantu menegakan diagnosis. Laparotomi segera harus dilakukan pada perfusi usus didertai penambahan antibiotik metronidazol dapat memperbaiki prognosis.<br /> Tiga persen penderita demam typhoid akan menjadi karier, kejadiannya meningkat sesuai dengan bertambahnya umur. Terjadinya penderita dengan karier biasanya disebabkan oloh infeksi kandung empedu yang kronis akibat batu empedu dan penderita mengeluarkan kumannya melalui kotoran ( kandung empedu dan saluran empedu  sebagai sumber infeksi),<br /> sehingga kolesistektomi dapal dipertimbangkan pada > 8 % karier, bahkan tanpa pemberian antibiotika. Pengobatan Karier tergantung ada tidaknya kelainan kandung empedu<br /> kantung empedu normal<br /> •    Ampisilin 500 mg (tiap 6 jam) selama 6 minggu, atau <br /> •    Ampisilin 200 mg (tiap 6 jam) selama 6 minggu, intravena, atau<br /> •    Ampsilin 100 - 200 mg/kg/hari, untuk 3 - 4 minggu.<br /> •    Amoksisilin 40 mg/kg/hari, peroral  (tiap 8 jam) + Probenezid 25 mg/kg dosis pertama (selanjutnya 40 mg), peroral (tiap 6 jam), selama 4 - 6 minggu.<br /> •    TMP 8 mg/kg/hari, SMZ 40 mg/kg/hari, uintuk 3 - 4 minggu.<br /> •    Norfloxazin / Ciprofloxacin.<br /> Merupakan golongnn quinolon, telah berhasil baik pada penderita dewasa. <br /> Karena pengaruhnya lerhadap perkeimbangan Tulang rawan, sehingga tidak dianjurkani untuk anakyang lebih muda dari 18 tahun.<br /> Disfungsi kandung empedu<br /> Obat dan dosis sama dengan untuk kandung empedu normal + Kolesistektomi + Amoksisilin untuk 30 hari kemudian.<br /> <br /> Kasus demam tifoid yang mengalami relaps diberi pengobatan sebagai kasus demam tifoid serangan pertama.<br /> Pencegahan<br /> Secara umum, untuk memperkecil kemungkinan tercemar S.typlii, maka setiap individu harus memperhatikan kualitas makanan dan minuman yang mereka konsumsi. Salmonella typhi di dalam air akan mati apabila dipanasi seting 57°C untuk beberapa menit atau dengan proses iodinasi/klorinasi.<br /> Untuk rnakanan, pemanasan sampai suhu 57°C beberapa menit dan secara merata juga dapat mematikan kuman Salmonella typhi. Penurunan endemisitas suatu negara/daerah tergantung pada baik buruknya pengadaan sarana air dan pengaturan pembuangan sampah serta tingkat kesadaran individu terhadap higiene pribadi. Imunisasi aktif dapat membantu menekan angka kejadian demam tifoid.<br /> Vaksin Demam Tifoid<br /> Saat sekarang dikenal (tiga macam vaksin untuk penyakit demam tifoid, yaitu yang berisi kuman yang dimatikan, kuman hidup dan komponen Vi dari Salmonella typhi. Vaksin yang berisi kuman Salmonella typhi, S. paratyphi A,  S. paratyphi B yang dimatikan (TAB vaccine) telah puluhan tahun digunakan dengan cara pemberian suntikan subkutan namun vaksin ini hanya memberikan daya kekebalan yang terbatas, disamping efek samping lokal pada tempat suntikan yang cukup sering. Vaksin yang berisi kuman Salmonella typhi hidup yang dilemahkan (Ty-21a) diberikan per oral tiga kali dengan interval pemberian selang sehari, memberi daya perlindungan 6 tahun. Vaksin Ty-21a diberikan pada anak berumur di atas 2 tahun. Pada penelitian di lapangan didapat hasil efikasi proteksi yang berbanding terbalik dengan derajat transmisi penyakit. Vaksin yang berisi komponen Vi dari Salmonella typhi diberikan secara suntikan intramuskular memberikan perlindungan 60 – 70 %.</div><div style="text-align: justify;"><a href="http://www.blogger.com/goog_1419315295"><br /> </a></div><div style="text-align: justify;"><a href="http://adf.ly/104369/salmonella-paratyphi">Download artikel Salmonella Paratyphi - Typhoid (Typus) dalam bentuk Microsoft Word secara lengkap.</a></div><div style="text-align: justify;"><br /> <b style="color: #e06666;">DAFTAR PUSTAKA</b><br /> 1.Harrison’s Principles of Internal Medicine 16th edition .McGraw-Hill.2005 <br /> 2.Behrman KE. Kliegman RM, Nelson WE, Vaughan HI VC Typhoid fever. Nelson textbook of pediatrics, edisi ke-14 Philadelphia: WB Saunders Co, lS92.h.731-34.<br /> 3.Butier T Typhoid fever. Dalanu Warren KS, Mahmoud AF (penyunting). Tropical<br /> and geographical medicine, edisi ke-2. New York: Me Graw-HiU Information<br /> Services Co, 1990 Ji.753-7.<br /> 4.Hayani CH, Picketing LK. Salmonella infections. Dalam: Feigin RD, Cherry JD (penyunting). Textbook of pediatric infectious diseases, edisi ke-3, Tokyo: V/B Saunders Co, 1992.K620-33.<br /> 5.Hoffman SL. Typhoid fever. Dalatn: Strickland GT penyunting. Hunter's tropical medicine, edisi ke-7. Philadelphia: WB Saunders Co. 1991.h.344-58.<br /> <br /> Article Source:  <a href="http://djendral-berbagi.blogspot.com/2011/02/salmonella-paratyphi-typhoid-typus.html">http://djendral-berbagi.blogspot.com/2011/02/salmonella-paratyphi-typhoid-typus.html</a></div>

By Deden Sura AgungDemam Enterik (Tifoid) adalah penyakit sistemik yang ditandai dengan demam dan nyeri pada abdomen yang disebabkan oleh penyebaran  Salmonella typhi atau Salmonella paratyphi. Pada awalnya penyakit ini disebut demam tifoid karena memiliki gejala klinis yang sama dengan typhus. Namu…