12 strategi NS

Diagnostic:
GCS, Cushing response, neurologic deficit
Imaging:
Skull X-Ray, Head CT Scan, head MRI, Cervical X-ray
Skull X RAY INDICATIONS
* Open fracture, * Deformity, * Stab wound
* Corpus alienum , * Scraped wound
CERVICAL SPINE X RAY INDICATIONS
* Scraped wound on the neck, * Neck pain
* Traumatic mechanism ( wisplash injury )
* Cervical signs : tetra plegia / paralytis
* Unconscious patients
CT SCAN INDICATIONS
* Seizures * GCS < 15
* Decreased of GCS > 1 point
* Continuous cephalgi, vomiting and vertigo with medicine
* Corpus alienum or stab wound
* Lateralization ( anisocor / hemiparalysis )
* Cushing response : hypertension + bradicardy
* Brain + multiple organ injury
* Social indication
OUT PATIENTS CONDITION
* Conscious + good orientation
* No neurological deficit, * Decreased of complain
* No fracture
* Social Problems nobody care at home hospital
distance home / village from the hospital
NOTES : Back to the hospital if patient has :
* Seriously complain (severe complain)
* Restlessness, * Decreased of conscious ( GCS )
* Seizures, * Lateralization
1.Observation Of Consciousness (based on GCS Score)



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2. Observation of neurological deficit

3. Pernafasan
Mencegah hipoksia
Mbersihkan sal nafas dr sekret, Darah,muntahan & benda asing
menidurkan dg posisi miring & ekstensikepala
Posisi diubah tiap jam
Bila perlu trakheostomy
Sirkulasi:
Mencegah hipertensi , Mencegah hipotensi , Mencegah anemia
4. Position:
Head elevation (10-30
o
Not >30
o),
CBF :N, ICP : Mechanical
5. Fluid, electrolyte and nutrition imbalance
DAY 1 2 :* 2 liters isotonic fluid
* has an electrolyte : osmolar stabilization
DAY 3 :* nasogastric tube :
- no gastric retention (100 cc/day)
- good peristaltic
- no abdominal distension
- no nausea and vomiting
- start low go slow
Some factors need to be considered in fluid administration are:
1. Extra fluid 10 15% must be given for every increased 1C
2. Urinary production :
* diabetes insipidus : 1 ltr negative balance
* progressive urinary production and prolonged urine
production ( > days) vasopression administration is needed
and electrolytes is periodically examined
3. Its not recommended to give glucose 5% glucose rapidly
metabolize solution changes into hypotonic
6. Temperature
Rectal temperature
Hyperthermia brain Hypermetabolism
* Causes of hyperthermia
1. Intracranial : Primary
2. extracranial: Secondary infection
drug reaction
transfusion reaction
*Treatment
+ intracranial : without antipyretics + antibiotic
+ increasing of fluid : > 1 C (+) 10 15% (extra)
7. Restlessness
Factors : 1.Intracranial : +start to be alert
+ICP : intracranial
2.Extracranial :
Pain : + full bladder, bone fracture
+ uncomfortable feeling due to dirty bed/ clothing
+ patient is tightened, + hyperthermia
+ respiratory disturbance
Treatment :+ etiologic factors must be found and treated
+ medical :chlorpromazine : 25 mg
diazepam : 5 10 mg

8. Seizures
Occurred due to iritative of brain and Ca
2+,
IC
*Treatment :
1. Diazepam : 10 40 mg iv during attack
Phenitoin : 3 5 mg Kg/BW
Phenobarbital : 3 5 mg Kg/BW
2. In epileptic status : should be more intensively treated
3. Until EEG normal or 2 years seizures free
* Prevent :
- Severe BI, - ICH Traumatic, - Edema, - Depressed Fracture
- Foreign Bodies, - Acute Seizures
9. Urinary : micturation
Dauer catheter is inserted with the aim
* to monitor urinary production
* to calculate the fluid balance
* to keep the bed clean and dry
* to prevent restlessness due to full bladder
10. Skin care
* Skin area with continuous pressure decubitus
* Dangerous : - infection sepsis
- serum fluid hypoalbumin
* Treatment
- turning position periodically
- giving soft pillows beneath parts of the body which are under
continuos pressure

11. ICP monitoring
ICP : Monitoring
Out Come Prediction
Intraventricular Monitoring
< 20 mm H
2
O
CPP : MAP ICP ( Target CPP : + 75 mmHg)
MAP Slight Hypertension
ICP Mechanical : Position CSF
IC

Medical : Acetazolamic , Mannitol ,Corticosteroid

12. Drug medicine
Ca
2+
Blocker
Antioxidant
Dehydration Agent
Nootrophic : Nicholin
Piracetam :* Rheology
* CBF
SUMMARY
1. It is important to observe the changes of consciousness, especially
when the patient is firstly seen, during transportation to / at the
hospital
2. 17.5 20% patient expected to die before arriving in the hospital
3. In the hospital : ( recent management)
* primary survey : stabilization : A B C
* diagnostic
* definitive treatment
- operative
- conservative
- observation 12 points
4. Goal of brain injury treatment
a. curable
b. to prevent of SBI
c. to minimize invalidity and death
d. the end results of treatment is good outcome


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