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Introduction to Clinical Medicine II

Sudden Paralysis & Unconsciousness

HEAD INJURY

HARSAN
Eka JW, Jesaja Y, Julius J, Lutfi H, Binsar N, M Inggas, Firdaus M,
Lilik W, Ferry S, Willy A, Onie W, Ronnie S, Eko P,
Maximillian O, Eveline, Budhi S
Neuroscience Center Siloam Hospitals
Faculty of Medicine-Pelita Harapan University
STANDAR KOMPETENSI DOKTER
INDONESIA
TINGKAT KEMAMPUAN :
1. MENGENALI DAN MENJELASKAN
2. MENDIAGNOSIS DAN MERUJUK
3. DIAGNOSIS, PENETALAKSANAAN AWAL, RUJUK
A. BUKAN GAWAT DARURAT B. GAWAT DARURAT
4. DIAGNOSIS, PENATALAKSANAAN MANDIRI DAN TUNTAS
RISKESDAS 2013
 PREVALENSI CEDERA : 8,2 % (2007 = 7,5 %)
 Penyebab terbanyak : jatuh (40,9%),
kecelakaan sepeda motor (40,6%)
 kecenderungan peningkatan proporsi cedera
transportasi darat (sepeda motor dan darat
lain) dari 25,9 % menjadi 47,7 %
 Tiga urutan terbanyak jenis cedera yang dialami
penduduk adalah luka lecet/memar (70,9%),
terkilir (27,5%) dan luka robek (23,2%). Gegar
otak : 0,4 persen
 tempat terjadinya cedera : jalan raya (42,8%),
rumah (36,5%), area pertanian (6,9%) dan
sekolah (5,4%)
 Amerika : cedera kepala
62 JUTA/th.
 Penyebab kematian
terbesar bagi usia < 45
th SALAH SATU
 10% meninggal KASUS YG SERING
ditempat.
DIJUMPAI
 90% tertolong smp. RS.
 80% ced. kepala ringan
 10% ced. kepala sedang
 10% ced kepala berat
 20% CACAT !!!
CEDERA KEPALA  MASALAH :
KESAKITAN  (BIAYA) PERAWATAN
KECACATAN
KEMATIAN

BISA DICEGAH !!!


Anatomy
 SCALP.
• S: Skin
• C: Connective tissue
• A: Aponeurosis / galea
aponeurotica
• L: Loose areolar tissue
• P: Pericranium

 RICH
VASCULARIZATION
Bleeding from Scalp laceration
will result in shock (in
children !!!)
Anatomy
Anatomy
 Tentorium
Doktrin Monroe Kellie

Volume intra kranial


= tetap.
CLASSIFICATION
PREVENTABLE

 PRIMARY BRAIN INJURY


1. SCALP LACERATION, SUBGALEAL
HEMATOMA, LENEAR / DEPRESSED /
SKULL BASE FRACTURE
2. EDH, SDH, SAB, CONTUSION
3. DIFFUSE AXONAL INJURY
PREVENTABLE

 SECONDARY BRAIN INJURY


1. SYSTEMIC DISORDERS
2. METABOLIC DISORDER
Klasifikasi cedera kepala
MECHANISM
ACCELERATION – DECELERATION
INJURY
Tekanan Perfusi Otak (TPO)
 TPO = TAR – TIK.
 TPO < 70 mmHg prognosis jelek.
 Prioritas yang penting
mempertahankan TPO.
Tekanan intra kranial (TIK)
 TIK normal 10 mmHg.
 TIK > 20 mmHg tidak normal.
 TIK > 40 berat.
Aliran Darah ke Otak (ADO)
 ADO normal 50ml/100 gr. Jaringan
otak/menit.
 ADO < 20 – 25 ml/100gr/mt sel-sel
otak mati & terjadi kerusakan yg
menetap.
TIDAK BOLEH !!!
 HIPOKSIA
 HIPOTENSI
 ANEMIA
INITIAL EXAMINATION
(MINI NEUROLOGIST)
 LoC
 PUPIL
 MOTORIC

 (RESPIRATORY PATTERN)
 Eye opening (E)  Verbal response (V)
4. Spontaneous 5. Oriented
3. To speech 4. Confused conversation
2. To pain 3. Inappropriate words
1. None 2. Incomprehensible
sound
 Motor response (M) 1. None
6. Obeys command
5. Localizes pain
4. Normal flexion (Withdrawal)
3. Abnormal lexion
(Decorticate)
2. Extension (Decerebrate)
1. None
SKULL FRACTURE

LINEAR DEPRESSED
FRAKTUR DASAR
TENGKORAK
 Rhinorrhea : FDT
anterior.
 Otorrhea : FDT medial.
 Hemotympanum.
 Ekimosis periorbital.
 Ekimosis retroaurikuler.
 Cedera N.Fasialis.
 Hilang pendengaran.
 Pneumosefalus.
KLASIFIKASI CEDERA KEPALA
LESI INTRA KRANIAL
EPIDURAL HEMATOMA
 Associated with
skull fracture.
 Classic : Middle
meningeal artery
tear.
 Lenticular/biconvex
due to dural
adherence to skull.
 Lucid interval.
EPIDURAL HEMATOMA
 Can be rapidly
fatal.
 Early evacuation
good prognosis.
 Venous epidurals,
Possible
nonsurgical
management.
SUBDURAL HEMATOMA
 Venous tear/brain
laceration.
 Covers entire cerebral
surface.
 Morbidity/mortality due
to underlying brain
injury.
 Rapid surgical
evacuation
recommended
especially if > 5mm
shift of midline.
CONTUSION/HEMATOMA
 Coup/contrecoup
injuries.
 Most common :
frontal/temporal lobes.
 “Salt & pepper”
appearance on CT.
 CT changes usually
progressive.
 Most conscious
patients : no operation.
CONCUSSION
 Transient loss of consciousness.
 Normal head CT.
 Nausea, vomiting.
 Headache : If severe, repeat CT.
 Symptoms may worsen before improvement.
 Sequelae common.
DIFFUSE AXONAL INJURY
 Prolonged deep coma ( not due to
mass lesion ).
 Diffuse Brain injury.
 Motor posturing.
 Frequent autonomic disfunction
BALLOON EMBOLIZATION
Penatalaksanaan Cedera Kepala Ringan

 Anamnesa.
 Pemeriksaan umum.
 Pemeriksaan neurologis.
 Pemeriksaan Radiologis.
 Pemeriksaan Laboratorium.
History
• Name, age, sex, race, occupation • Subsequent level of alertness
• Mechanism of injury • Amnesia : retrograde, anterograde
• Time of injury • Headache ; mild, moderate, severe
• Loss of consciousness immediately • Seizures
•after injury
General examination to exclude systemic injuries
Limited neurological examination
Cervical spine and othe radiographs as indicated
Blood alcohol level and urine toxic screen
CT scan of the head in all patients except completely asymptomatic and neurologically
normal patients is ideal

Observe in/admit to hospital Discharge from hospital


• No CT scanner available • Patient does not meet any of the
• Abnormal CT scan criteria for admiission
• All penetrating head injuries • Discuss need to return if any problrms
• History of loss of consciousness delevop and issue a “warning sheet”
• Deteriorating level of consciousness • Schedule follow-up clinic visit,
• Moderate to severe headache usually within 1 week
• 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
Observasi/dirawat bila :
 CT-scan abnormal.
 Cedera tembus.
 Riwayat hilang kesadaran.
 Kesadaran menurun.
 Sakit kepala sedang sampai berat.
 Intoksikasi alkohol/obat.
 Fraktur tulang kepala.
 Rhinorhoe/otorhoe.
 Cedera penyerta bermakna.
 Tak ada keluarga dirumah.
 Tempat tinggal jauh.
 Amnesia.
Dipulangkan :
 Tidak memenuhi kriteria rawat.
 Berikan informasi kemungkinan
kembali ke RS segera bila keadaan
memburuk.
 Berikan jadwal ke Poliklinik
( ±1 minggu ).
1. Drowsiness or increasing difficulty in awakening patient
(awaken patient every 2 hours during period of sleep)
2. Nausea or vomiting
3. Convulsions or fits
4. Bleeding or watery drainage from the nose or ear
5. Severe headache
6. Weakness or loss of feeling in the arm or leg
7. Confusion or strange behaviour
8. One pupil larger than the other or any visual disturbance
9. Very slow or very rapid pulse
10. Unusual breathing pattern
Penatalaksanaan Cedera Kepala Sedang

 Perhatikan jalan nafas.


 Pem.awal : sama dengan CKR,
pem CT scan, MRS observasi.
 Pem.neurologis.
 CT scan ulang bila keadaan
memburuk, penatalaksanaan
sesuai dgn. CKB.
 Kondisi membaik : pulang,
kontrol Poliklinik.
Penatalaksanaan Cedera Kepala Berat

 Lakukan A,B,C,D,E.
 Pem. Awal dan resusitasi.
 Pem.lanjutan.
 Re-evaluasi neurologis : GCS, pupil &
refleks.
 Obat-obatan.
 Tes diagnostik.
Jalan Nafas/Pernafasan.
 Intubasi.
 Ventilasi.
Sirkulasi
 Cegah hipotensi.
 CK tidak pernah hipotensi, bila ada
cari sumber tempat lain.
Pemeriksaan neurologis
 GCS.
 Pupil
 Motorik
 Pem. Serial dan observasi.
Prosedur diagnosis
 Pem.CT scan kepala.
 Pergeseran garis tengah > 5mm,
indikasi operasi.
PENANGANAN
 Rawat intensif, cegah cedera otak sekunder.
 Cairan intra vena : normovolemi (NaCl/RL)
 Ventilasi : oksigen adekuat, 10 – 12 lt.
 (Mannitol 20% : menurunkan TTIK, ¼ - 1
gr/kg.BB IV bolus)
 (Furosemid)
 Steroid : tidak ada gunanya.
 Anti konvulsan (KONTROVERSI) : epilepsi 15%
CKB, pencegahan tidak bermanfaat
Penatalaksanaan Pembedahan
 Luka kulit kepala.
 Fraktur depresi tulang kepala.
 Lesi/masa intra kranial.
Prognosis
 WAKTU MENENTUKAN
 TERAPI INTENSIF DAN AGRESIF
(MONITOR KETAT)
 USIA MUDA : PROGNOSIS BAIK
SUMMARY
 ACCELERATION – DECELERATION
INJURY
 COUP – COUNTER COUP INJURY
 ICP / MAINTAIN ICP  MANITAIN
CEREBRAL PERFUSION PRESSURE
 CLOSED OBSERVATION
THANK YOU