head injury (trauma kepala) dr.agus.ppt

• USA : Sering pada dekade pertama sampai keempat, usia produktif

• 49% KLLD• Laki-laki > wanita• Dapat terjadi sebagai

injury lokal scalp haematoma atau intracranial injury

• Luka terbuka vs luka tertutup

• Luka tembus

• USA : Sering pada dekade pertama sampai keempat, usia produktif

• 49% KLLD• Laki-laki > wanita• Dapat terjadi sebagai

injury lokal scalp haematoma atau intracranial injury

• Luka terbuka vs luka tertutup

• Luka tembus

• Simple vs complicated• Static forced (> 200 ms)

vs dynamic forced (< 200 ms)

• Impact loading (kekuatan benturan) injury lokal

• Impulsive loading (Acceleration-deceleration injury) non local or diffuse injury

• Simple vs complicated• Static forced (> 200 ms)

vs dynamic forced (< 200 ms)

• Impact loading (kekuatan benturan) injury lokal

• Impulsive loading (Acceleration-deceleration injury) non local or diffuse injury

CPP

ICP

CBV

Vasodilation

Vasodilatory CascadeVasodilatory Cascade

CPP

ICP

CBV

Vasodilation

Vasoconstriction CascadeVasoconstriction Cascade

• Primary brain injury1. Luka kulit kepala,

Subgaleal haematoma, linier #, depress #, skull base #

2. Perdarahan otak3. Diffuse axonal injury

• Secondary brain injury1. Systemic disorders2. Metabolic disorders

• Primary brain injury1. Luka kulit kepala,

Subgaleal haematoma, linier #, depress #, skull base #

2. Perdarahan otak3. Diffuse axonal injury

• Secondary brain injury1. Systemic disorders2. Metabolic disorders

Mekanisme :

• Tumpul : – Kec. tinggi (KLLD > 60 km/jam)– Kec. rendah (jatuh, dipukul)

• Tajam / Tembus : – Luka tembak – Luka tembus lainnya:

• bacok, panah, tombak

Klasifikasi Head Injury

• Eye opening (E)4. Spontaneous3. To speech2. To pain1. None

• Motor response (M) 6. Obeys command5. Localizes pain4. Normal flexion (Withdrawal) 3. Abnormal flexion (Decorticate)

2. Extension (Decerebrate) 1. None

• Eye opening (E)4. Spontaneous3. To speech2. To pain1. None

• Motor response (M) 6. Obeys command5. Localizes pain4. Normal flexion (Withdrawal) 3. Abnormal flexion (Decorticate)

2. Extension (Decerebrate) 1. None

• Verbal response (V)5. Oriented4. Confused conversation3. Inappropriate words2.Incomprehensible sound1. None

• Verbal response (V)5. Oriented4. Confused conversation3. Inappropriate words2.Incomprehensible sound1. None

– Cedera Kepala Ringan : GCS 14 - 15

– Cedera Kepala Sedang : GCS 9 - 13

– Cedera Kepala Berat : GCS 3 - 8

Beratnya :

Morphology :• Skull fracture :

– Atap tengkorak : • Linier / stellate• Depressed / nondepressed• terbuka / tertutup

– Dasar tengkorak :• Dengan / tanpa LCS bocor• Dengan / tanpa parese N VII

• Intracranial lesion : – Focal:

• Epidural• Subdural• Intracerebral

– Diffuse : • Mild concussion• Classic concussion• Diffuse axonal injury

CT Scan grading :1. Normal2. Non-evacuated mass less than 25 cc3. With cystern system compress4. With Midline shift more than 5 mm

CT Scan grading :1. Normal2. Non-evacuated mass less than 25 cc3. With cystern system compress4. With Midline shift more than 5 mm

• Brain Swelling• Ischemic brain damage• Brain damage secondary to elevated

intracranial pressure• Infection• Fat Embolism• Hydrocephalus

• Brain Swelling• Ischemic brain damage• Brain damage secondary to elevated

intracranial pressure• Infection• Fat Embolism• Hydrocephalus

• Intracranial mass– Gangguan

• CPP, autoregulation CBF and ICP

– Brain Shift and herniation

– Gangguan Hypofise• Pyrexia after head injury• Neurogenic Pulmonary

Edema (NPE)• Tachy / Bradicardia• Stress Ulcer• Hypoxemia and anemia• Electrolit imbalance

• Intracranial mass– Gangguan

• CPP, autoregulation CBF and ICP

– Brain Shift and herniation

– Gangguan Hypofise• Pyrexia after head injury• Neurogenic Pulmonary

Edema (NPE)• Tachy / Bradicardia• Stress Ulcer• Hypoxemia and anemia• Electrolit imbalance

KECELAKAAN PERTAMA PADA PERTOLONGAN

P3K KP3

•Airway management

•Transportation

•Properly trained professionals

•Prevention of secondary injury

•Airway management

•Transportation

•Properly trained professionals

•Prevention of secondary injury

• Primary surveyA. Airway, C-spine controlB. Breathing

managementC. CirculationD. Disability : Mini

neurologisE. Exposure and

environmental

control

• Secondary surveyHead to toe

5B (breath, blood, brain, bladder, bowel)

• Primary surveyA. Airway, C-spine controlB. Breathing

managementC. CirculationD. Disability : Mini

neurologisE. Exposure and

environmental

control

• Secondary surveyHead to toe

5B (breath, blood, brain, bladder, bowel)

Severity classification of head injury based On GCS :

– Cedera Kepala Ringan : GCS 14 - 15

– Cedera Kepala Sedang : GCS 9 - 13

– Cedera Kepala Berat : GCS 3 - 8

• Important for management and outcome

Severity classification of head injury based On GCS :

– Cedera Kepala Ringan : GCS 14 - 15

– Cedera Kepala Sedang : GCS 9 - 13

– Cedera Kepala Berat : GCS 3 - 8

• Important for management and outcome

Indikasi Rawat bila :1. No CT scanner available2. Abnormal CT Scan3. All penetrating head injuries4. History of loss of consciousness5. Moderate to severe headache6. Significant alcoholic or drug

intoxication7. Skull fracture8. CSF leak rhinorhea or otorrhea9. Severe vomiting10. Amnesia11. No reliable companion at home12. Unable to return promptly

Indikasi Rawat bila :1. No CT scanner available2. Abnormal CT Scan3. All penetrating head injuries4. History of loss of consciousness5. Moderate to severe headache6. Significant alcoholic or drug

intoxication7. Skull fracture8. CSF leak rhinorhea or otorrhea9. Severe vomiting10. Amnesia11. No reliable companion at home12. Unable to return promptly

History• Name, age, sex, race, occupation• Mechanism of injury• Time of injury• Loss of consciousness immediately •after injury

History• Name, age, sex, race, occupation• Mechanism of injury• Time of injury• Loss of consciousness immediately •after injury

• Subsequent level of alertness• Amnesia : retrograde, anterograde• Headache ; mild, moderate, severe• Seizures

• Subsequent level of alertness• Amnesia : retrograde, anterograde• Headache ; mild, moderate, severe• Seizures

General examination to exclude systemic injuriesLimited neurological examinationCervical spine and othe radiographs as indicatedBlood alcohol level and urine toxic screenCT scan of the head in all patients except completely asymptomatic and neurologically normal patients is ideal

General examination to exclude systemic injuriesLimited neurological examinationCervical spine and othe radiographs as indicatedBlood alcohol level and urine toxic screenCT scan of the head in all patients except completely asymptomatic and neurologically normal patients is ideal

Observe in/admit to hospital• No CT scanner available• Abnormal CT scan• All penetrating head injuries• History of loss of consciousness• Deteriorating level of consciousness• Moderate to severe headache• Significant alcholic/drug intoxication• Skull fracture• CSF leak rhiorrhea or otorrhea• Significant associated injuries• No reliable companion at home• Unable ton return promptly• Amnesia• History of loss of consciousness

Observe in/admit to hospital• No CT scanner available• Abnormal CT scan• All penetrating head injuries• History of loss of consciousness• Deteriorating level of consciousness• Moderate to severe headache• Significant alcholic/drug intoxication• Skull fracture• CSF leak rhiorrhea or otorrhea• Significant associated injuries• No reliable companion at home• Unable ton return promptly• Amnesia• History of loss of consciousness

Discharge from hospital• Patient does not meet any of the criteria for admiission• Discuss need to return if any problrms delevop and issue a “warning sheet”• Schedule follow-up clinic visit, usually within 1 week

Discharge from hospital• Patient does not meet any of the criteria for admiission• Discuss need to return if any problrms delevop and issue a “warning sheet”• Schedule follow-up clinic visit, usually within 1 week

1. Peurunan kesadaran atau sulit dibangunkan (bangunkan tiap 2 jam selama tidur)

2. Muntah-muntah3. Kejang4. Keluar darah atau cairan dari hiodung dan mulut5. Nyeri kepala hebat6. Kaki atau tangan menjadi lemah atau mati rasa7. Tampak kebingungan atau ada perubahan tingkah

laku8. Pupil besar sebelah atau ada gangguan

penglihatan lainnya9. Nadi menjadi sangat cepat atau sangat lambat10.Gambaran nafas yang tidak normal

1. Peurunan kesadaran atau sulit dibangunkan (bangunkan tiap 2 jam selama tidur)

2. Muntah-muntah3. Kejang4. Keluar darah atau cairan dari hiodung dan mulut5. Nyeri kepala hebat6. Kaki atau tangan menjadi lemah atau mati rasa7. Tampak kebingungan atau ada perubahan tingkah

laku8. Pupil besar sebelah atau ada gangguan

penglihatan lainnya9. Nadi menjadi sangat cepat atau sangat lambat10.Gambaran nafas yang tidak normal

•Observasi di ruang emergency•CT Scan serial•Cari penyebab penurunan

kesadaran : intra/ekstra cranial•Temukan trauma penyerta

lainnya

•Observasi di ruang emergency•CT Scan serial•Cari penyebab penurunan

kesadaran : intra/ekstra cranial•Temukan trauma penyerta

lainnya

Initial workup• Same as for mild head injury, plus baseline blood work• CT scan the head obtained in all cases• Admission for observation

After admission• Frequent neurological check• Follow-up CT scan if condition deteriorates or preferably before discharge

Initial workup• Same as for mild head injury, plus baseline blood work• CT scan the head obtained in all cases• Admission for observation

After admission• Frequent neurological check• Follow-up CT scan if condition deteriorates or preferably before discharge

If patient improves (90%)• Discharge when appropriate• Follow-up in clinic

If patient improves (90%)• Discharge when appropriate• Follow-up in clinic

If patient deteriorates (10%)• If the patients stop following simple commands, repeat CT scan and manage persevere head injury protocol

If patient deteriorates (10%)• If the patients stop following simple commands, repeat CT scan and manage persevere head injury protocol

• ICP monitoring• CVP line• Continuous pulse

oxymetry• Blood gas analyze • Hemodynamic

support• Volume expansion

• ICP monitoring• CVP line• Continuous pulse

oxymetry• Blood gas analyze • Hemodynamic

support• Volume expansion

• Sedation• Mannitol• Ventricular

drainage• Barbiturate therapy• Temperature

regulation• Steroids• Nutritional support• Electrolyte

derangements• Infection control• Gastrointestinal

hemorrhage

• Sedation• Mannitol• Ventricular

drainage• Barbiturate therapy• Temperature

regulation• Steroids• Nutritional support• Electrolyte

derangements• Infection control• Gastrointestinal

hemorrhage

GCS 14 or lessGCS 15 with :

- documented loss of consiousness- amnesia for injury- focal neurological deficit- signs of basal or calvarial skull fracture

GCS 14 or lessGCS 15 with :

- documented loss of consiousness- amnesia for injury- focal neurological deficit- signs of basal or calvarial skull fracture

- Intubation- Controlled ventilation to PaC0235 mmHg- Volume resuscitation- Establishment of normotension- Narcotic sedation / neuromuscular blockade- Bolus mannitol 1 gram/kg- Phenytoin 18 mg/kg

- Intubation- Controlled ventilation to PaC0235 mmHg- Volume resuscitation- Establishment of normotension- Narcotic sedation / neuromuscular blockade- Bolus mannitol 1 gram/kg- Phenytoin 18 mg/kg

Preemptive Measure• head elevation to 300, neutral aligment• mild hyperventilation (paco2 30 – 35 mmHg)• maintenance of euvolemia• maintenance of CPP 70 mmHg or higher• maintenance of normothremia (< 37.50C )• seizure prophylaxis (phenytoin)Primary Therapy• ventricular CSF drainage• sedation (narcotics, benzodiazepines)• neuromuscular blockadeSecondary Therapy• bolus mannitol administration• elevation of cerebral perfusion pressureTertiary Therapy• metabolic suppressive theraphy with high-dose barbiturates or propofel

Preemptive Measure• head elevation to 300, neutral aligment• mild hyperventilation (paco2 30 – 35 mmHg)• maintenance of euvolemia• maintenance of CPP 70 mmHg or higher• maintenance of normothremia (< 37.50C )• seizure prophylaxis (phenytoin)Primary Therapy• ventricular CSF drainage• sedation (narcotics, benzodiazepines)• neuromuscular blockadeSecondary Therapy• bolus mannitol administration• elevation of cerebral perfusion pressureTertiary Therapy• metabolic suppressive theraphy with high-dose barbiturates or propofel

Battle sign

Raccon`s eyes (brill haematoma

Otorrhea

Rhinorrhea

Evacuation surgery : - Mass effect- Midline shift

Evacuation surgery : - Mass effect- Midline shift

Linear Fracture

Linear Fracture

Diastases Fracture

Depressed Fracture

Depressed Fracture

Depressed Fracture

Depressed Fracture

Depressed Fracture

Epidural Hematoma

Epidural Hematoma

Subdural Hematoma

Intraserebral Hematoma

Intraventricular Hematoma

Cerebral Contusion

Pneumocephalus