HEAD INJURY

dr. Dasa Sariadi SpBS., M.Kes

Department of NeurosurgeryGunung Jati HospitalCirebon

PENDAHULUAN40% Cedera multipel dgn.cedera kepala.Anatomi dasar & fisiologi kepala/otak.Cedera kepala berat asumsi cedera servikal.

ANATOMISCALP : Skin, Connective tissue, Apponeurosis Galea, Loss Areolar Tissue, Pericranium.Bone :Tabula Eksterna,Tab Interna,diploic.Meningen : Duramater,Arachnoid,Piamater. Brain : Gray Matter (korteks serebri).White MatterSistem Ventrikel Vascular :Sistem carotisSistem vertebro baisiler

ANATOMI CALVARIA : - Os Frontal - Os Parietal - Os Occipital - Os Temporal - Os Sphenoidal

BASIS CRANII : - Fossa Anterior - Fossa Media - Fossa Posterior

OS FACIALIS

ANATOMI

ANATOMI

ANATOMI

ANATOMI

ANATOMI

CENTRAL NERVUS SYSTEMOTAK : - Telensefalon (Hemisfer Serebri). - Diensefalon. - Mesensefalon. - Metensefalon : Pons & Cerebellum. - Myelensefalon : Medulla Oblongata.

Medulla Spinalis.

Pada minggu ke4, otak dibagi jadi 3Pada minggu ke6 membelah lagiRhombencephalon kemudian menjadi metensefalon dan myelensefalon. Med. Oblongata berasal dari myelensefalon

ANATOMI

VASCULARISASICAROTID SYSTEM : - A. Cerebri Ant. - A. Cerebri Media.

VERTEBRO-BASILAR SYSTEM : - A. Cerebri Post. - A. Cerebelli Sup. - etc.

VASCULARISASI

- etc.

PATOFISIOLOGICedera deselerasi.Coup & contrecoup.

Tekanan intra kranial (TIK)TIK 15 mmHg = berbahaya.TIK > 25 mmHg = herniasi.Tekanan perfusi otak(TPO) = MAP TIKTPO = 70 mmHg.

SINDROMA HERNIASIPenurunan kesadaran yang progresif.Pupil anisokor ipsilateral.Hemiparese kontralateral.Postur deserebrasi.

DOKTRIN MONRO-KELLIEVolume intrakranial selalu konstan.

V otak + V darah + V lcs = konstan.

TEKANAN PERFUSI OTAK (TPO)TAR - TIK = TPO.Normal : 90 - 10 = 80Respon Cushing : 100 - 20 = 80Hipotensi : 50 - 20 = 30TPO tidak sama dengan ADOKuncinya adalah ADO.

AUTOREGULASIMempertahankan ADO dgn tekanan darah rata-rata 50 - 160 mmHg.Cedera kepala sedang atau berat sering menyebabkan autoregulasi terganggu.Otak sangat rentan terhadap cedera otak sekunder karena iskhemia sebagai akibat hipotensi yang tiba-tiba.

ALIRAN DARAH KE OTAK (ADO)50 mL/100 g/min = Normal.< 25 mL/100 g/min = aktivitas EEG menurun/hilang.< 5 mL/100 g/min = sel-sel otak mati.

ANATOMI IMAGING SKULL X-RAY. CT SCAN. MRI.

CT SCANMidline shifGyrusSulcusVentricleCysternaBoneSoft Tissue

Primary brain injuryLaceration of the scalp, Subgaleal haematoma, linier #, depress #, skull base #EDH, SDH, SAB, ICH, ContusionDiffuse axonal injurySecondary brain injurySystemic disordersMetabolic disorders

CLASSIFICATION

Vasogenic Edemamalfunction of the Na / K pumpsDamage to the phospholipid membraneexcitatory amino acids (EAA)Cytotoxic EdemaBBB breakdownProtein leakageIncreasing oncotic pressureWater accumulation EDEMA OTAK

HEAD INJURYClassification :Mechanism : Blunt High velocity (Automobile collision) Low velocity (Fall, assault) Penetrating Gunshot wound

Other penetrating injury.

Classification :Severity : Mild GCS 14 - 15

Moderate GCS 9 to 13

Severe GCS 3 to 8

Classification :Morphology : Skull Fracture Vault Linear/stellate. Depressed/nondepressed. Open / closed. Basilar With/without CSF leak. With/without nerve VII palsy Intracranial Lesions Focal Epidural Subdural Intracerebral

Diffuse Mild concussion. Classic concussion. Diffuse axonal injury.

Classification :Diffuse Head Injury Based on CT Scan:Category Initial CT findings Diffuse Injury I No vissible pathology. Diffuse injury II Cisterns are present; midline shift < 5mm and/or lesion densities present, no high or mixed density lesion > 25 ml, may include bone fragmens and foreign bodies. Diffuse injury III Cisterns are compressed or absent (swelling) midline shift 0-5 mm, no high or mixed density lesion > 25 ml. Diffuse injury IV Midline shift > 5 mm, no high or (Shift) mixed density lesion > 25 ml.

Evacuated mass Any lesion surgically evacuated.Nonevacuated mass High or mixed density lesion > 25 ml, not surgically evacuated.

Linear Fracture

Linear Fracture

Diastasis Fracture

Depressed Fracture

Depressed Fracture

Depressed Fracture

Depressed Fracture

Depressed Fracture

Epidural Hematoma

Epidural Hematoma

Subdural Hematoma

Intraserebral Hematoma

Intraventricular Hematoma

Cerebral Contusion

Pneumocephalus

PREHOSPITAL CAREAirway managementTransportationProperly trained professionalsPrevention of secondary injury

EMERGENCY ROOM CAREPrimary surveyAirway, C-spine controlBreathing managementCirculationDisability : Mini neurologisExposure and environmental controlSecondary surveyHead to toe5B (breath, blood, brain, bladder, bowel)

GLASGOW COMA SCALE ASSESEMENTEye opening (E)4.Spontaneous3.To speech2.To pain1.None

Motor response (M) 6. Obeys command5. Localizes pain4. Normal flexion (Withdrawal) 3. Abnormal lexion (Decorticate) 2. Extension (Decerebrate) 1. NoneVerbal response (V)5.Oriented4.Confused conversation3.Inappropriate words2.Incomprehensible sound1.None

Severity classification of head injury based On GCS :

Mild head injury (GCS 14 or 15)Moderate head injury (GCS 9 to 13)Severe head injury (GCS 3 to 8)

Important for management and outcome

MILD HEAD INJURYObserve in/admit to hospital if :

No CT scanner availableAbnormal CT ScanAll penetrating head injuriesHistory of loss of consciousnessModerate to severe headacheSignificant alcoholic or drug intoxicationSkull fractureCSF leak rhinorhea or otorrheaSevere vomiting Amnesia No reliable companion at home Unable to return promptly

History Name, age, sex, race, occupation Mechanism of injury Time of injury Loss of consciousness immediately after injurySubsequent 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 idealObserve 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 consciousnessDischarge 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

MANAGEMENT OF MILD HEAD INJURY

Head Injury Warning Discharge InstructionDrowsiness or increasing difficulty in awakening patient (awaken patient every 2 hours during period of sleep)Nausea or vomitingConvulsions or fitsBleeding or watery drainage from the nose or earSevere headacheWeakness or loss of feeling in the arm or legConfusion or strange behaviourOne pupil larger than the other or any visual disturbanceVery slow or very rapid pulseUnusual breathing pattern

Moderate to Severe Head InjuryObserve in emergency roomCT Scan serialFound the cause of LOC either extra cranial problem or intracranial problemFound another associated injuries

Management of Moderate Head InjuryInitial 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 clinicIf patient deteriorates (10%) If the patients stop following simple commands, repeat CT scan and manage persevere head injury protocol

INTENSIVE CAREICP monitoringCVP lineContinuous pulse oxymetryBlood gas analyze Hemodynamic supportVolume expansion

SedationMannitolVentricular drainageBarbiturate therapyTemperature regulationSteroidsNutritional supportElectrolyte derangementsInfection controlGastrointestinal hemorrhage

CAUSED OF REDUCED CEREBRAL PERFUSION PRESSUREArterial hypotensionHypovolemiaCardiodepressant drugs Sepsis

Intracranial hypertensionMass lesion (hematoma)Vascular engorgementCerebral edemaAcute hydrocephalus

CT SCANNING CRITERIA FOLLOWING CRANIOCEREBRAL TRAUMAGCS 14 or lessGCS 15 with :- documented loss of consiousness- amnesia for injury- focal neurological deficit- signs of basal or calvarial skull fracture

EMERGENT MANAGEMENT OF INTRACRANIAL HYPERTENSIONIntubation Controlled ventilation to PaC0235 mmHg Volume resuscitation Establishment of normotension Narcotic sedation / neuromuscular blockade Bolus mannitol 1 gram/kg Phenytoin 18 mg/kg

MEDICAL MANAGEMENT OF INTRACRANIAL HYPERTENSIONPreemptive 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

SKULL BASE FRACTURERaccon`s eyes (brill haematomaOtorrheaRhinorrheaBattle sign

OPERATION PROCEDURE

DEPRESSED FRACTUREDOUBLE CONTOUR SIGN

HEAD INJURY Mild Head Injury Observation Hospitalized Sent home

Moderat and severe head Injury

Hospitalized

HEAD INJURYIndication for hospitalized : Decrease of consciousness. Headache (moderat to severe). History of unconscious > 15 minute. Skull Fracture. Rhinorea otorhea. Penetration injury. Alkohol/drugs intoxication. Significant multiple trauma. Abnormal CT Scan. Amnesia. No family at home.

Indication for CT Scan : Decrease of consciousness(GCS

TREATMENT Assesment and management : Primary and secondary survey. Neurological Evaluation. Mini neurologis. Operative Conservative. Treat Increased Intracranial Pressure : - Position : Head up 30 o. - Mild hiperventilation. - Manitol. - Sedation. - Analgetic. Supportive : - Nutritional support. - Treat hyperthermia. - Early mobilization/physiotherapy. Other medication : - H2 antagonist. - Anticonvulsant.

PENATALAKSANAAN PASIEN CEDERA KEPALA ( DILAPANGAN)Bebaskan jalan nafas & beri oksigen.Stabilisasi : leher dgn kolar, papan spinal.Catat pengamatan awal : tanda vital.Pengamatan ulang & berurutan.Pasang 2 infus dg.iv kateter uk.besar

Antisipasi adanya cedera spinal.Kejang.Muntah.Perburukan yg cepat.Shock : perdarahan/spinal.Gangguan metabolik.

Indication of Surgery : Depressed # > 1 table (open/closed). Intracranial hematoma (EDH/SDH/ICH) > 25 cc. Midline Shift > 5 cm. Penetrating Injury.

KESIMPULANAntisipasi adanya cedera spinal.Kejang.Muntah.Perburukan yg cepat.Shock : perdarahan/spinal.Gangguan metabolik.

*************************************************************************