head injury (trauma kepala) dr.agus.ppt
DESCRIPTION
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• 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