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TRAUMA KEPALA

TUJUAN
Setelah menyelesaikan bab ini peserta diharapkan dapat menjelaskan: 1.Anatomi kepala & otak. 2.Patofisiologi cedera kepala. 3.Pemeriksaan pasien cedera kepala. 4.Penatalaksanaan pasien cedera kepala.

PENDAHULUAN
PREVENTING SECONDARY BRAIN INJURY IS THE MOST IMPORTANT ASPECT OF TRAUMA TO THE BRAIN

EPIDEMIOLOGI
Data di Bagian Syaraf RSUPNCM tahun 2000, dari 929 penderita cedera kepala : - CKR 570 orang - CKS 231 dengan kematian 3 % - CKB 128 dengan kematian 50%. Di US 2 juta insiden kasus trauma kepala per tahun, 52 ribu meninggal , 220 ribu MRS dan 100 ribu terdapat kecacatan temporer/permanen (Data tahun 1993). Sejak mulai diberlakukannya Safety On The Road terjadi penurunan hingga 22% lebih terhadap angka kematian trauma kepala. 34 ribu meninggal dalam perjalanan ke UGD RS (data tahun 1995)

EPIDEMIOLOGI
Angka Survival di UGD ( US tahun 1993) adalah : 80% pada Cedera kepala ringan (GCS 13 15) 10% Cedera Kepala Sedang (GCS 9 12) 10% pada Cedera Kepala Berat (GCS 8 )

PENYEBAB

ANATOMI

Kulit kepala. Tulang tengkorak. Selaput otak/meningen, Jaringan otak. Cairan serebro spinal. Kompartemen vaskuler.

1.Kulit Kepala (SCALP) S kin atau kulit C onnective Tissue A poneurosis L oose areolar tissue P erikranium

ANATOMI
Tulang Tengkorak : 1. Calvaria 2. Basis Cranium

Lapisan Meningen 1. Duramater 2. Arachnoid Mater 3. Pia mater

MECHANISME OF BRAIN INJURY


2 Mekanisme yaitu : A. Direct (Langsung ) B. Indirect (Tidak Langsung) Direct --- initial impact tulang kepala dengan obyek Indirect - Robekan pembuluh darah dan terganggunya integritas akson, shg terjadi subdural hematoma, diffus axonal injury dan gegar otak.

Cedera Primer dan Sekunder Primer (timbul segera pada saat terjadinya trauma): 1. Lokal 2. Difus Sekunder (Timbul dan berkembang beberapa waktu setelah trauma) 1. Lokal 2. Difus

DIAGRAM MOI
CEDERA OTAK

TRAUMA

SKULL FRACTURE

CEDERA PRIMER

CEDERA SEKUNDER

LOKAL :
DAI Kontusio Laserasi, HSD akut

DIFUS : Komosio PSA EDH

LOKAL : HSD subakut/kronik Infeksi Infark Batang Otak

DIFUS : Iskemi, Hipoksi Edema,TIK naik Difus Vaskuler Injury

COUP VS CONTRA COUP COUP -- Direct Lacerasi SCALP Fraktur tulang tengkorak Epidural Hematoma Contusio Otak Contra Coup - Direct & Indirect

PENYEBAB CEDERA OTAK SEKUNDER


ISCHEMIA Cerebral Perfusion Pressure. Another simple but vital principal that must be kept in mind when dealing with intracranial pathologies. The CPP is just as important as the intracranial pressure. CPP 70mmHg> is generally associated with a poorer outcome following head injury. Hyperventilation and low C02 are no longer recommended. Causes arterial vasoconstriction that reduces the ICP but also the CPP. EXCITOTOXICITY

CEDERA OTAK SEKUNDER Sistemik : Hipoxemia Anemia Hipotensi Hiperthermia Hiper/hipocapnea Komplikasi respirasi Elektrolyte imbalance Intracranial TIK Edema cerebri Lesi massa Kejang

KARAKTERISTIK CEDERA KEPALA

GCS
E + M + V = 3 to 15 Less than or equal to 8 at 6 hours - 50% die Initial "postresuscitation" score most accurate predictor of future outcome.

KARAKTERISTIK CEDERA KEPALA

CONT

PENATALAKSANAAN

CASE 1
Ditemukan seorang laki laki muda terbaring dibawah tangga, mengerang kesakitan, lupa ingatan, tidak ada yang mengetahui insidennya . Korban tampak pucat dan dingin dengan muka penuh darah, dan terdapat lacerasi dan udem di bagian kiri kepala.

What do yo do now ?
ABCs AIRWAY / BREATHING

Most important and the primary concern is if the patient is able to maintain an airway. How do you assess the airway? Rapid assessment of the neurological state. How do you assess the neurological state?

Korban suara hanya mengerang dan respon menghindari rangsangan nyeri. Mata tidak membuka What is his GCS ? GCS = 7 What do you need to now ? GCS < 8 --- Intubasi pasien

What do you want to check next ?


Breathing: Exclude conditions that will impair breating and rapidly correct. look for: exposure inspection of chest chest wall movement tracheal deviation. percussion may be helpful but Auscultation Conditions that have to be excluded: tension pneumothorax flail chest massive haemothorax open pneumothorax

CIRCULATION
Now you can finally deal with the head laceration. How do you deal with it? In this category you also need to look for: Blood volume and cardiac output. Level of consciousness Skin color Pulse. Bleeding: expose patient fully.

C - SPINE
What do you do to protect the C-spine? All patients with head trauma or maxillofacial trauma should be presumed to have an unstable cervical spine injury until positively excluded. Absence of neurological deficit does not exclude cervical spine injury. Examination of the c-spine is impaired in a comatosed patients. Decubitus ulcers may develope quickly. Waiting for several hours to exclude c-spine injury is poor management. leaving patient in hard color and on spinal board for several hours is very poor management. Serious full thickness skin ulcers will develope. Early attention to excluding c-spine injuries is important. What are the investigations you would do?

FOTO CERVICAL
This injury is known as a extension teardrop fracture. This injury is secondary to a hyperextension mechanism and usually involves the second cervical vertebrae. It is seen most often in the elderly. This injury is potentially unstable.

This is known as a hangman's fracture and consists of fractures through the pedicles of C-2 (traumatic spondylolithisis of the axis). The injury occurs with hyperextension and commonly occurs following car accidents. In this patient with little dispacement, the anterior and longitudinal ligaments are intact and the injury is relatively stable. With marked anterior displacement, the ligaments are ruptured and the injury is unstable

THE PATIENT IS NOW STABLE


Good oxygen saturation, Breathing 100% oxygen and on ventilator. Abdomen is soft (but this may be misleading in head trauma) There is no x-ray finding of fracture or any clinical signs of fracture. What is your next step? Reassess the GCS. pupillary changes - (fixed, dilated) - a late finding due to brainstem compression. Continuous Neuro OBS is vital the detect early changes in the patient.

The patient is now intubated and paralysed, you did not get a chance to do the neurological examination prior to intubation. Your findings at this stage: Slightly dilated pupil on the right but reactiv. Previously equal pupils. GCS of 3T More brisk reflexes on the left.

What is the next step ?


Patient needs urgent CT scan. Neurosurgeon needs to be contacted at an early stage.

TEKANAN INTRA KRANIAL


Many Intracranial pathologies affects intracranial pressure Normal ICP <10mmHg (136 mm water) 20 mmHg < is abnormal. 40 mmHg < severe elevation. The higher the ICP after head injury the worst the outcome

DOKTRIN MONROE-KELLIE

ICP value gets elevated at point of decompensation. When ICP starts going up the patient will rapidly decompensate and herniation is imminent Every effort should therefore be made to keep the patient on the flat part of the curve

Signs of increased ICP: Headache: Worse on waking in the morning, relieved by vomiting. (Intracranial pressure increases during sleep, some carbon dioxide retention?) Nausea and vomiting, usually worse in the morning. Drowsiness. Important clinical sign not to be dismissed. Papilloedema.

CONCLUSION

TREATMENT STRATEGIES

DEFINITIVE TREATMENT

CT SCAN