Cidera Kepala berat

Cidera Kepala beratCedera Kepala Berat (CKB) GCS lebih kecil atau sama dengan 8, kehilangan kesadaran dan atau terjadi amnesia lebih dari 24 jam. Dapat mengalami kontusio cerebral, laserasi atau hematoma intracranial.

Tata LaksanaPrimary survey dan resusitasiAirway and BreathingPada pasien CKB risiko obstruksi jalan napas >> & henti napas >> pasang ETPasien dengan tanda-tanda TIK hiperventilasi PaCO2 vasokostriksi TIK SirkulasiHipotensi perdarahan resusitasi cairan RL/NS 1-2 L bolus, cek penyebab hipotensi DPL /FASTPemeriksaan NeurologisPupil : refleks pupil, ukuran pupilDolls eye phenomenon

Secondary surveyPx GCS serialTanda lateralisasiRefleks pupilIndikasi Imaging CT scanGCS 13 tanpa adanya intoksikasi alcohol atau fraktur tulang tengkorak.GCS 14 dengan adanya fraktur tulang tengkorakPupil yang berdilatasi unilateral pada keadaan AMSdepressed skull fractureDefisit neurologik fokalpasien cedera kepala yang membutuhkan ventilasipasien cedera kepala yang membutuhkan anestesi general untuk operasi lainnya.

Penatalaksanaan Cedera Kepala BEratIndikasi penggunaan Mannitol pada cedera kepala :pasien koma yang awalnya memiliki pupil yang normal dan reaktif namun kemudian berkembang menjadi dilatasi disertai atau tanpa adanya hemiparesis.Dilatasi pupil bilateral dan nonreaktif tetapi tidak hipotensive.Dosis Mannitol : 1g/kgBB, cth [5x BB (kg)] ml larutan mannitol 20% dalam infus cepat selama 5 menit.Perhatian sebelum menggunakan mannitol :Pasang kateter urinaryPastikan px tidak hipotensiPastikan px tidak menderita gagal ginjal kronis

Indikasi Intubasi pada cedera kepalaKoma (GCS 30x/menit , pola napas abnormal, hipoxia tidak terkoreksi.cedera penyerta pada maxillofacialkejang berulangconcurrent edema pulmonal berat, cedera jantung atau abdominal bagian atas.

Direct Brain Injury CategoriesFocalOccur at a specific location in brainDifferentialsCerebral ContusionIntracranial HemorrhageEpidural hematomaSubdural hematomaSubarachnoid hemorrhageIntracerebral HemorrhageDiffuseConcussionModerate Diffuse Axonal InjurySevere Diffuse Axonal Injury

Cerebral Contusion

Blunt trauma to local brain tissueCapillary bleeding into brain tissueCommon with blunt head traumaConfusionNeurologic deficitPersonality changesVision changesSpeech changesResults fromCoup-contrecoup injury

Epidural HematomaBleeding between dura mater and skullInvolves arteries: Middle meningeal artery most commonRapid bleeding & reduction of oxygen to tissuesHerniates brain toward foramen magnumLevel of consciousnessInitial loss of consciousnessLucid interval followsAssociated symptomsIpsilateral dilated fixed pupil, signs of increasing ICP, unconsciousness, contralateral paralysis, death

Management of EDHEDH > 30 cm3 should be evacuated.

EDH < 30 cm3 and 8 may be managed nonoperatively with serial CTSubdural HemorrhageBleeding within meningesBeneath dura mater & within subarachnoid spaceAbove pia materOrigin: Superior sagital sinusOnset bleeding: hours to daysSigns progress over several daysSlow deterioration of mentationLevel of consciousnessFluctuations Associated symptomsHeadacheFocal neurologic signs

MANAGEMENT OF SDHAcute SDH with thickness > 10 mm or midline shift > 5mm should be evacuatedPatient in coma with a decrease in GCS by >2 points with a SDH should undergo surgical evacuation.

Sub Arachnoid HemorrhageBleeding into the subarachnoid spaceDefects in the media of the arteries Clinical PresentationHeadachesudden onset & severesmall leak may cause minor headache & may be warning sign of ruptureReduced consciousnessMeningism : vomiting, necck stiffness, photophobiaSeizures

Intra Cerebral HemorrhageRupture blood vessel within the brainPresentation similar to stroke symptoms:Alteration of consciousness, headache, vomiting, paresisSigns and symptoms worsen over time

Diffuse Brain InjuryDue to stretching forces placed on individual nerve cellsPathology distributed throughout brainTypesConcussionModerate Diffuse Axonal InjurySevere Diffuse Axonal Injury

ConcussionMild to moderate form of Diffuse Axonal Injury (DAI)Nerve dysfunction without anatomic damageTransient episode ofConfusion, Disorientation, retrograde short term amnesia, dizziness, headache, tinnitusSuspect if patient has a momentary loss of consciousnessManagementFrequent reassessment of mentationABCs

Moderate Diffuse Axonal InjuryClassic ConcussionGeneralized edema without structural lesionMay exist with a basilar skull fractureSigns & SymptomsUnconsciousness or Persistent confusionLoss of concentration, disorientationRetrograde & Antegrade amnesiaVisual and sensory disturbancesMood or Personality changes

Severe Diffuse Axonal InjuryBrainstem InjurySignificant mechanical disruption of nerve cellsCerebral hemispheres and brainstemHigh mortality rateSigns & SymptomsProlonged unconsciousnessCushings reflexHypertensionBradycardiIrregular breathing

Decorticate or Decerebrate posturing

Cranial Injury

Trauma must be extreme to fractureLinearDepressedOpenImpaled Object

Basal Skull FractureBattles SignsRetroauricular EcchymosisAssociated with fracture of auditory canal and lower areas of skullRaccoon EyesBilateral Periorbital EcchymosisAssociated with orbital fractures