Suspek Fraktur Basis Cranii

Cedera Kepala dengan Otorrhea, Suspek Fraktur Basis CraniiDr Erwin SantosoPendahuluanKasus AsliAlasan Kasus diajukan : mengetahui penanganan kasus cedera kepala pada situasi kedaruratanYang menarik dari kasus ini : Kondisi pasien yang dalam pengaruh alkoholKeterbatasan alat pencitraan

PendahuluanFokus pembicaraan : penanganan awal pasien CK sebelum dirujukMasalah pada kasus iniTujuan presentasi ini :Mendiskusikan penatalaksanaan pada pasien cedera kepala pada kondisi di UGD, kriteria merujuk pasien, indikasi merawat inap.

Kasus

Nama : Tn A. PJenis Kelamin: PriaUsia : 21 TahunAlamat : DumogaAgama : Islam

Anamnesis

Pasien mengalami kecelakaan lalu lintas saat mengendarai motor dengan helmPasien dalam keadaan mabuk, sempat muntah 1x di tempat kejadian, pingsan -Keluar perdarahan dari telinga pasienPemeriksaan FisikAirway & Breathing : pasien masih dapat berbicara clearCirculation : nadi teraba 80x/menit, kuat, teratur penuhDisability : Motorik ekstremitas baikEnvirontment : tidak ada kelainanPemeriksaan FisikKeadaan Umum : Dalam pengaruh alkoholKesadaran : GCS E4M6V5Tanda vitalTD : 110/80 mmHgNadi 72 x/menitRR 14x/menitSB 36,6oCPemeriksaan FisikStatus Lokalis :Kepala : tidak tampak adanya lukaTelinga : perdarahan aktif dari telinga kanan, dilakukan halo test dengan menggunakan tissue dan setetes darah dari telinga, hasil

Pemeriksaan Thorax dan abdomen tidak ditemukan kelainanPenangananPemasangan colar neckIVFD RL 20 tetes / menitCetriaxone 1 g / 12 jamRanitidin 50 mg / 12 jamAsam Tranexamat 1 ampul / 8 jamPiracetam 1 g / 8 jamPenangananPasien direncanakan untuk dirujuk ke Manado untuk melakukan CT Scan

TeoriCedera KepalaFocal injuriesFraktur tengkorakKontusio parenkimLaserasi parenkimKerusakan vaskulerDiffuse injuriesDiffuse axonal injuryDiffuse vascular injury

Tanda-Tanda Traumatic Brain InjuryPerubahan status mentalGangguan orientasiGangguan kepribadianAmnesiaRetrogradeAntegradeCushings Reflex (tanda peningkatan TIK)Peningkatan TDBradikardiaPernafasan irregulerBledsoe et al., Essentials of Paramedic Care: Division 1II 2006.Tanda-Tanda Traumatic Brain InjuryMuntah proyektilPerubahan suhu tubuhPerubahan refleks pupilDekortikasiBledsoe et al., Essentials of Paramedic Care: Division 1II 2006.Cushings ReflexPenurunan tingkat kesadaranGCS 100km/jam Kecelakaan dengan kendaraan terguling Terlontar dari kursi penumpang

1. Pemasangan Cervical Collar

Kemampuan untuk merotasikan leher sebesar 45 derajat ke kanan dan ke kiri merupakan metode efektif untuk mengeksklusi adanya cedera cervcial yang signifikanGuideline on the management of alert, adult patients with potential cervical spine injury in the Emergency Department . London 2010TataLaksanaTidak menunjukkan perbedaan signifikan dalam mengurangi risiko meningitis bakterial pada kasus fraktur basis kranialAntibiotik yang dipilih berdasarkan flora normal daerah nasofaringeal sebagai sumber infeksi. Antibiotik yang digunakan antara lain :Cephalosporin generasi ke 3 (ceftriaxone 1-2 gram)Ampicilin / SulfadiazinePenicillin

2. Pemberian antibiotikVillalobos T, Arango C, Kubilis P, Rathore M. Clin Infec Dis 1998 ; 27 : 364 9.Ratilal BO, Costa J, Sampaio C, et al. Cochrane Database Syst Rev 2011 ;(8) :CD004884

TataLaksanaMencegah terjadinya Cushing UlcerPeningkatan TIK stimulasi nucleus vagus sekresi asetilkolin stimulasi receptor parietal cell stimulasi pompa H/K ATPase sekresi asam lambungRanitidine memblokade pengikatan asetilkolin di reseptor H2 sel parietal

3. Pemberian RanitidinTataLaksanaPemberian ondansetron untuk muntah pada pasien cedera kepala yang tidak dilakukan CT scan tidak meningkatkan risiko misdiagnosis akibat efek masking terhadap cedera yang serius

4. Pemberian OndansetronSturm JJ, et al. Am J Emergency 2013 ; 31 (1) : 166-72TataLaksanaPemberian Piracetam pada pasien dengan traumatic brain injury tertutup memberikan efek positif pada fungsi kognitif (memori, atensi, dan fungsi eksekutif) dan motorik (koordinasi) Dosis 40-50 mg/kgBB (1600-2400 mg perhari) selama 1 bulan

5. Pemberian PiracetamZavadenko NN et al. Neurosci Behav Physiol 2009 ; 39 (4) : 323 - 8TataLaksanaPemberian Citicoline pada pasien traumatic brain injury tidak memberikan peningkatan signifikan pada status fungsional dan kognitif

6. Pemberian CiticolineZafonte RD et al. JAMA 2012 ; 308 (19) : 1993-2000TataLaksanaPemberian Asam tranexamat dapat mengurangi perdarahan pada pasien TBI, namun efeknya tidak terlalu signifikan dibandingkan plaseboDosis 1 gram dalam 10 menit dilanjutkan dengan 1 gram selama 8 jam

7. Pemberian Asam TranexamatCRASH-2 Collaborators, Intracranial Bleeding Study. BMJ 2011 ; 343 : d3958Indikasi pemeriksaan penunjang CT Scan1. Anamnesis Adanya pingsan selama > 5 menit Amnesia (antegrade atau retrograde) selama > 5 menit Rasa kantuk yang abnormal Muntah sebanyak 3 kali atau lebih setelah terjadinya cedera kepalaAdanya kejang setelah cedera kepala pada pasien tanpa riwayat epilepsiNational Collaborating Centre for Acute Care. London : 2007Indikasi pemeriksaan penunjang CT Scan2. Pemeriksaan FisikGCS < 14, atau GCS 5 cm pada anak usia > 1 tahun. National Collaborating Centre for Acute Care. London : 2007Indikasi rawatPasien dengan kelainan pada pemeriksaan pencitraanPasien dengan GCS < 15Pasien dengan indikasi pemeriksaan CT scan namun tidak dapat melakukannyaPasien dengan gejala muntah persisten atau sakit kepala yang hebatAdanya masalah lain yang perlu diperhatikan (intoksikasi obat/alkohol, syok, adanya kebocoran CSF, adanya luka lain yang perlu penanganan)

National Collaborating Centre for Acute Care. London : 2007Pasien boleh pulang setelah observasi minimal 2 jam dan GCS = 15ObservasiGCS, ukuran pupil dan refleks cahaya, pergerakan anggota gerak, laju nafas, nadi, tekanan darah, temperatur, dan saturasi oksigen.Frekuensi observasi pada pasien dengan GCS 15 :Setiap 30 menit pada 2 jam pertamaSetiap 1 jam pada 4 jam berikutnyaSetiap 2 jam untuk seterusnya.Pasien boleh pulang bila GCS tetap 15

National Collaborating Centre for Acute Care. London : 2007ReferensiThe College of Emergency Medicine. Guideline on the management of alert, adult patients with potential cervical spine injury in the Emergency Department . London 2010Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006. Pearson Education, Inc. Upper Saddle River, NJDula DJ, Fales W. The ring sign: Is it a reliable indicator for cerebral spinal fluid? Ann Emerg Med 1993;22:718-20Ratilal BO, Costa J, Sampaio C, et al. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2011;(8):CD004884

ReferensiVillalobos T, Arango C, Kubilis P, Rathore M. Antibiotic Prophylaxis After Basilar Skull Fracture : A Meta Analysis. Clin Infec Dis 1998 ; 27 : 364 9.National Collaborating Centre for Acute Care. Head Injury: triage, assessment, investigation and early management of head injury in infants, children and adults. London : 2007Sturm JJ, et al. The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED. Am J Emergency 2013 ; 31 (1) : 166-72

ReferensiZavadenko NN et al. Sequelae of closed craniocerebral trauma and the efficacy of piracetam in its treatment in adolescent. Neurosci Behav Physiol 2009 ; 39 (4) : 323 - 8Zafonte RD et al. Effect of citicoline on functional and cognitive status among patient with traumatic brain injury : Citicoline Brain Injury Treatment Trial (COBRIT) . JAMA 2012 ; 308 (19) : 1993-2000CRASH-2 Collaborators, Intracranial Bleeding Study. Effect of tranexamic acid in traumatic brain injury : a nested randomised, placebo controlled trial (CRASH-2 Intracranial Bleeding Study). BMJ 2011 ; 343 : d3958

Terima KasihThe Ring SignAnn Emerg Med. 1993 Apr;22(4):718-20.The 'ring sign': is it a reliable indicator for cerebral spinal fluid?

Dula DJ, Fales W.

Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania.

STUDY OBJECTIVE: To study the development of a ring sign when blood is mixed with various fluids. METHODS: One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. RESULTS: All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. The type of filter paper did not affect the development of a ring. CONCLUSION: In this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid.

Upper Brainstem CompressionIncreasing blood pressureReflex bradycardiaVagus nerve stimulationCheyne-Stokes respirationsPupils become small and reactiveDecorticate posturingNeural pathway disruptionBledsoe et al., Essentials of Paramedic Care: Division 1II 2006.Signs and Symptoms of Brainstem InjuryMiddle Brainstem CompressionWidening pulse pressureIncreasing bradycardiaCNS hyperventilationDeep and rapidBilateral pupil sluggishness or inactivityDecerebrate posturingBledsoe et al., Essentials of Paramedic Care: Division 1II 2006.Signs and Symptoms of Brainstem InjurySigns and Symptoms of Brainstem InjuryLower Brainstem InjuryPupils dilated and unreactiveAtaxic respirationsErratic with no patternIrregular and erratic pulse rateECG changesHypotensionLoss of response to painful stimuli

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006.Intracerebral PressureNormal 20-25 mm Hg Increases morbidity and mortalityICP monitoring rarely available in the EDMust use physical findingsNeurologic deteriorationUnilaterally dilated pupil

HemiparesisPosturing

Increased ICP-ManagementHypertonic SalineImproves CPP and brain tissue O2 levelsDecreased ICP by 35% (8-10 mm HG)CPP increased by 14%MAP remained stableGreatest benefit in those with higher ICP and lower CPPRepeated doses were not associated with rebound, hypovolemia or HTN30 mL of 23.4% over 15 minutes

A. Defillo, Hennepin County Medical CenterIncreased ICP-ManagementMannitolOsmotic agentEffects ICP, CBF, CPP and brain metabolismFree radical scavengerReduces ICP within 30 minutes, last 6-8 hoursVolume expansion, reduces hypotensionDosage0.25-1 gm/kg bolusIncreased ICP-ManagementHyperventilationNot recommended as prophylactic interventionNever lower than 25 mm HgReduces ICP by vasoconstriction, may lead to cerebral ischemiaUsed as a last resort measureMaintain PaCO2 at 30-35 mm HgOptions for ImmobilizationAnatomical RegionsHeadNeckBodyGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseHead ImmobilizationManual - Hands, LegsSimple Assist Devices - Sandbags, Towels, Foam PadsAdditional Devices - StrapsHead/Neck immobilizerGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseHead ImmobilizationGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseCdang (Wikipedia)

Head ImmobilizationStudy compared 3 methods during simulated vehicle motion, (Spine 1999;24)SandbagsHeadbandStyrofoam wedgesWedges slightly betterKey is body immobilizationGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseNeck ImmobilizationCollarsPhiladelphiaStiffneckOther optionsGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseNeck ImmobilizationGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma Course

Emrgmgmtca (Wikipedia)

47Neck ImmobilizationAnn Emerg Med 1992; 21: 1185-1188Compared C collar with Ammerman Halo orthosis, with and without spine boardPhotographic comparison during transportConclusion:A rigid cervical collar and a spine board provide significantly better immobilization than the collar alone. Further immobilization is provided by an Ammerman halo orthosisGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseBody ImmobilizationBackboardsImportant for transporting patients and keeping them from possibly injuring themselves furtherGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseBack BoardsGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma CourseCdang (Wikipedia)

Ryan.mco (Wikipedia)

Canadian C Spine RuleGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma Course

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