CSS Trauma Kepala Luq

8/13/2019 CSS Trauma Kepala Luq

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Disusun oleh :M . L u q m a n H a s a n

Preseptor :

Dr. Arief Guntara, Sp. B

SMF BEDAH RSUD AL IHSAN BANDUNG

HEAD TRAUMA

ATLS(Advance Trauma Life Support)



Informasi penting yang harus didapat ketikaterdapat pasien dengan head injury

1.Usia dan mekanisme injury2. Status respirasi dan Cardiovaskular

3. Neurological examination (Level kesadaran, reaksipupil, dan kelemahan ekstremitas

4. Tipe non Cerebral injury5. Hasil dari studi diagnosis (Rontgen kepala, CT

scan)



ANATOMY DAN PHYSIOLOGY

A. SCALP

1. Skin

2. Connective Tissue

3. Aponeurotica

4. Loose Areolar Tissue

5. Periosteum



B. SkullTerdiri dari calvarium dan base

C. MeningensTersusun dari :

Duramater : lapisan luar fibrous yang kuat, tebalsubdural space

Arachnoidmater : lapisan tengah yang tipissubarachnoid space

Piamater : lapisan dalam yang tipis bervaskular

D. BrainE. Cerebrospinal Fluid

Diproduksi oleh choroid plexus, dikeluarkan ke dalam ventrikel otak, dan bersirkulasi melalui subarachnoid space



G. Consciousness

Alteration of consciousness is the hallmark of brain injury

H. Intracranial Pressure

Monroe-Kellie Hypothesis

K ICP ~ V CSF + V BI + V Br

K : ConstancyICP : Intracranial Pressure V : volumeCSF : Cerebrospinal fluidBl : Blood

Br : Brain



ASSESMENT OF HEAD INJURY

A. History

Mechanisme Injury (venticular crash or not)

Patient’s condition immediatly after inciden

B. Initial Assessment

Airway

Breathing

Circulary Control



C. Assessment of Vital Signs

1. Never presume brain injury is the cause ofhypotension

Although bleeding from scalp may cause ofhemorrhagic shock (especially child), intracranial

bleeding can’t cause shock. Hipotension occure dueto terminal process of brain damage, because of

medulary center failure.



2. Cushing response

Progressive hypertension associated with

bradycardia and diminished respiratory rate

3. Hypertension in combination with hyperthermia

Reflect central autonomic dysfunction caused brain injury



D. AVPU + Minineurologic Examination

Alert

Response to Vocal stimuliResponse to Pain stimuli

Unresponsive



1. Level of Consciousnessa) Glasgow Coma Scale



b) Patient Catagorization

1. Coma ( GSC <8 )

Define as : Having no eye opening (E=1)

No ability to follow comands (M=1 to 5)No word verbalization (V= 1 to 2)

2. Head injury severity

Severe = less than or equale to eightModerate = GCS 9 to 12

Minor = GCS 13 to 15



2. Assessment of pupillary function

A difference in pupil diameters more than 1 mm is abnormal

3. Lateralized extremity weaknessSuggest an intracranial mass lesion



Special Assessment

1. Skull rontgenograms

2. Computed tomography

3. Other testLumbar puncture, electroencephalogram



SPECIFIC TYPES OF HEAD INJURY

Head injury include (1) skull fracture, (2) diffuse brain injury, and (3) focal injury.

Pathophysiology, severity, need for urgenttreatment , and outcome are different in eachgroup.



A. Skull Fractures1. Linear, nondepressed fractures

Seen on roentgen as lucent line

2. Depressed skull fractures



3. Open skull fractures

4. Basal skull fractures



CSF leaking (otorrea,rhinorhea)

Battle’s Sign

(echimosis mastoidregion)

Raccon eyes (orbitalechimosis/cribriform

plate fracture)



B. Diffuse Brain Injury

Produced when rapid head motion (acceleration ordeceleration) cause widespread interuption of brain

function in most area of the brain.1. Concussion

Brain injury accompanied by loss neurologic function, maycause temporary confusion or amnesia or loss of consciousness

2. Diffuse axonal injuryBrain-stem injury, closed head injury

Characterized by prolong coma, last days to weeks.



C. Focal Injuries

1. Contusion

Patiens sustaining cerebral contusion should be admitted tothe hospital for observation, because delayed edema orswelling around contusion may cause neurologic deterioration



2. Intracranial Hemorrhages

Meningeal hemorrhagea) Acute epidural hemorrhage

bleeding from dural artery, usually middle meningeal artery

relative rare (0,5% in unselected head injury)

Sign and symptoms

1. Loss consciousness, followed by lucid interval (the lucidperiod may not be return to full consciousness)

2. Secondary depression of consciousness3. Development of hemiparesis on the opposite side



b) Acute subdural hematoma

Much more common than epidural hematomas(30% of severe head injuries).

Rupture of bridging veins between cerebral cortexand dura.



c) Subarachnoid hemorrhage

This type of hemorrhage results in bloody CSF andmeningeal irritation.

Patient usually complains : Headache

Photophobia



Brain Hemorrhages and laceration

1. Intracerebral hematomasNeurological deficits depend on these associated injuriesregion, and the size hemorrhage.

2. Impalement injuriesForeign bodies protuding from the skull, rontgen required todetermine the object’s single and depth of penetration

3. Bullet wounds



EMERGENCY MANAGEMENT

1. Maintenance of Cerebral Metabolic NeedsCerebral ischemia or hypoxia result insufficient substrat to

injured brain. The principal metabolic requirements of the brain are oxygen and glucose.

Delivery these substrate depends on their arterialconcentration and the blood flow to the brain.

Maintain arterial PO2 at greater than 80 mmHg.

2. Preventing / treating intracranial hypertension Fluid Control

Diuretics

Steroids (not recomended for treatment acute head injury)



Diuretics such manitol, cause diuresis by producingintravascular hyperosmolarity. Very effective inshrinking brain volume and lowering intracranialpressure.Doses : 1 g/kg , administred rapidly and intravenosly

Loop diuretics

Furosemide (40-80 mg IV for adults)

Urinary catheter is required



Other Manifestation of Head Injury

Seizures

10 mg of diazepam via an intravenous bolus, if has

another convulsion may be repeated once withcaution

Phenytoin 1 g IV at rate 50 mg/minute

Phenobarbital or anesthetic

Restlessness

Hyperthermia



Scalp Wounds

A. Blood LossCan be extensive, especially in children. General principles scalp

wound care include locating and stopping the bleeding.

B. Inspection of the Scalp Wound

Search for sign fracture or foreign material, also includes lookingfor CSF leaks.

C. Repairing the Scalp WoundIrrigate with saline, debris include hair, do not remove bone

fragment (because they may tamponading intracranial bleeding).

When possible , repair should be achived under sterile technique,as scalp wounds may become infected



Summary

A. Secure and maintain an open airwayB. Ventilate patient to maintain oxygenation

C. Treat shock, if present, and look for cause

D. Perform minineurologic examinationE. Establish an initial working diagnosis

F. Prevent secondary brain injury

G. Search for associated injuries

H. Obtain roentgenograms or CT scan, but only afterpatients stable

I. Consult neurosurgeon and consider transfer



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CSS Trauma Kepala Luq

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