Penanganan Cedera Kepala

Cedera Kepala BeratApa yang seharusnya dilakukan di UGD?Dr.Agustinus Juhardi,Sp An.,MSc.Dept. Anesthesiology & ReanimationMardi Rahayu Hosp. Kudus

Penyebab utama kematian pada traumaUsia produktifLaki dan perempuan 2 : 1

Untuk menyelamatkan pasien ini, apa yang bisa dilakukan di UGD?55Traumatic Brain InjuryPrimary Brain InjurySecondary Brain InjuryResults from what has occurred to the brain at the time of the injury.Physiologic and bio-chemical events which follow the primary injury.Target terapi6Brain traumaBBB disruptiondiffuse axonal injuryedema formationEicosanoidsendocannabinoidsnecrosisenergy failurecytokinesSOME of the SECONDARY EVENTS IN TRAUMATIC BRAIN INJURYapoptosisinflammationROSpolyaminesCalciumAcetylCholineischemiaShohami, 2000Green pathophysiological processes; Yellow various mediators77Direct cell and vascular damage

Primary injuryInflammatory mediatorsIschemia Bleeding and haematomaIncreased CBFEdema formationIncreased intracranial pressureCell death8

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Monro-Kellie DoctrineVintracranial vault=Vbrain+Vblood +VcsfIdentifikasi dan EvaluasiIdentifikasiGCSCKRCKSCKBATLS trauma evaluation

Group A (minimal head injury GCS = 15Patient is awake, priented and without neurologic deficits and relates accidentNo loss of consciousnessNo vomitingAbsent or minimal subgaleal swellingThe patient is released into the care of family member with written instructions.

Group B (minor head injury GCS = 15)Patient is awake, oriented and without neurologic deficitsTransitory loss of consciousnessAmnesiaOne episode of vomitingSignificant subgaleal swellingThe patient who has at least one of these characteristic undergoes neurologic evaluation and CT scan which, if negative, shortens hospital observation. If CT scan is not available, the patient has skull X-rays and is held for an observation period of not less then 6 h. If the skull X-rays are negative and a subsequent neurologic control is normal, the patien can be released into the care of a family member with written instructions. If the X-rays reveal a fracture, the patient undergoes CT scan.

Group C (moderate head injury or mild head injury with complicating factors GCS = 9-15)Impaired consciousnessUncooperative for various reasonsRepeated vomitingNeurologic deficitsOtorrhagia/otorrhoeaRhinorrhoeaSign of basal fractureSeizuresPenetrating or perforating woundsPatients in anticoagulant therapy or affected by coagulopathyPatients who have undergone previous intracranial operationsEpileptic or alcoholic patients

The patient with at least one of these characteristics undergoes a neurologic evaluation and a CT scan. Hospitalization and repeated scan, if necessary, within 24 h or prior to discharge.Group D (severe head injury GCS = 3-8)

Patient is comaNecessary resuscitation manouvres followed by neurological evaluation and immediate CT scan (prior to surgical intervention). Coma management.

Intubasi EndotrakeaSemua pasien koma, GCS < 8Hilangnya reflek proteksi jalan nafasHipoksemia, hipercapnia (PaO2 < 60 mmHg; PaCO2 > 65 mmHg)Hipokapnia (PaCO2 < 25 mmHg)Respiratory aritmiaKejangTrauma jalan nafas dan thorakSemua pasien dianggap fraktur cervicalIn-line stabilization

VentilasiHipokapnia ringan (PaCO2 35-40)Hindari hiperventilasi pada 24 jam pertama (PaCO2 < 25 mmHg), bila tidak ada tanda kenaikan TIKAnalisa Gas DarahResusitasi CairanHipotensi post-trauma (secundary brain injury).Koreksi hipotensi (sistolik < 90 mmHg)MAP dipertahankan > 90

Resusitasi CairanKoloid atau kristaloid?Hipertonik atau isotonik?Pilihlah cairan hipertonik (NS 3%, 7,5%)Lebih umum dipakai NaCl 0.9%Hindari RL, NS 0.45%Hindari Dextrose.Apakah hipertensi perlu koreksi?Respon kompensasiYa. Jika MAP diatas limit autoregulasi.Idealnya alpa-blocker (pentolamine)Esmolol, propanolol, labetalol.Manajemen Kenaikan TIKCPP = MAP ICPTrias Cushing: bradikardi, hipertensi, bradipnea.

Manajemen Kenaikan TIKPosisi kepala head-up 30Hiperventilasi (kontroversi)Prinsip: normokapnia, jangan PaCO2 < 35 mmHg.Osmotik diuretik Manitol 20% 0.25-1 mg/kgBB 15-25 menit.Atasi hipovolemia sebelumnyaBolus lebih baik daripada infus kontinyuInfusnya harus ada filternyaLoop diuretikFurosemid 0.7 mg/kg iv 15 mnt setelah manitol

BarbituratKonsep Lund26Staircase ICP control algorithm7

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Barbiturate comaSurgical decompressionMild hypothermiaMannitol Ventricular drainageModerate head-upIntubation, normocapneic ventilation27Interstitial spaceCapillary PiPoipJv = Kf{(Pc-Pi) (p- i)}Physiological Basic of the Lund Management StrategyJv = transcapillary filtration of fluid; Kf = filtration coefficient; (Pc Pi) = hydrostatic pressure difference between plasma and interstitial fluid; (p- i) = oncotic pressure difference between plasma and interstitial fluid.Robertson, 2001The Lund strategy is based on knowledge of the forces that govern transcapillary filtration of fluid.Daisy 10 Months After Accident

28By December 2000, Daisy was back at school part time.Some residual cognitive problemsSome memory problems that limited her ability to take in new informationStill to have further cosmetic surgery for eye & forehead planned for later this year.Main interest was always art and has returned to drawing & paintingEmotionally stable, no recollection of accident, no sign of post traumatic stress