Dr. Ida Ratna Nurhidayati, Sp.S
Bagian Ilmu Penyakit Saraf Fakultas Kedokteran Universitas YARSI
Trauma Kepala
Pendahuluan
Di AS jutaan org dirawt krn cedera kepala
45% krn kll, 26% jatuh dari ketinggian, 17% sbb lain
>
Biaya tinggi dlm perawatan
Indonesia?
Trauma Kepala
Sinonim
Trauma kapitis = cedera kepala = head injury = trauma kranioserebral = traumatic brain injury
Definisi
Trauma mekanik thp kepala, langsung/tdk lgs, yg menyebabkan gg fs neurologis fisik, kognitif, psikososial (temporer/permanen)
Klasifikasi
Patologi
1. Komosio serebri
2. Kontusio serebri
3. Laserasio serebri
Klasifikasi
Lokasi lesi 1. Lesi difus
2. Lesi kerusakan vaskuler otak
3. Lesi fokal 1. Kontusio & laserasi serebri
2. Hematoma intrakranial 1. Hematoma ekstradural (hematoma epidural)
2. Hematoma subdural
3. Hematoma intraparenkhimal
1. Hematoma subarakhnoid
2. Hematoma intraserebral
3. Hematoma intraserebelar
Klasifikasi Kategori SKG Gambaran Klinik CT scan otak
Minimal 15 Pingsan (-), defisit neurologi (-) Normal
Ringan 13-15 Pingsan < 10 menit, defisit neurologi (-) Normal
Sedang 9-12 Pingsan > 10 menit s/d 6 jam, defisit neurologi (+)
Abnormal
Berat 3-8 Pingsan > 6 jam, defisit neurologi (+) Abnormal
1. Tujuan klasifikasi ini u/ pedoman triase di gawat darurat 2. Jika abnormalitas CT scan berupa perdarahan intrakranial, penderita dimasukkan
klasifikasi trauma kapitis berat
Diagnosis
Anamnesis Trauma kapitis + gg kesadaran + interval lucid Perdarahan (otore/rinore) Amnesia traumatika (retrograd/antegrad)
Pemeriksaan Fisik Status Neurologis Radiologi fraktur
(linier/impresi/terbuka/tertutup) Foto kepala : AP/lat/tangensial Foto servikal
CT scan kepala + bone window
Tanda-tanda Suspek Fraktur Basis Kranii
Brill hematoma / Racoons eye / Hematoma periorbita 1
Battles sign / Hematoma retroaurikular 2
Otorrhea / Rhinnorhea 3
Fraktur Linear
Fraktur Impresi
Epidural Hematoma
Subdural Hematoma
Subarachnoid Hematoma
Manajemen
Survei Primer ABCD
Survei Sekunder EF
Manajemen
Manajemen TTIK
Elevasi kepala 300
Manitol 20% (awal 1 gr/kgBB dlm -1 jam drip cepat lanjut 0.5 mg/kgBB)
Analgetika
Manajemen
Manajemen komplikasi
Kejang
Infeksi
Gastrointestinal
Demam
DIC
Manajemen
Manajemen cairan & nutrisi adekuat
Roboransia, neuroprotektan sesuai indikasi
Indikasi Operasi
EDH > 40 cc dg midline shift (temporal/frontal/parietal) dg fs batang otak
baik > 30 cc pd fossa posterior dg tanda2 penekanan batang
otak/hidrosefalus dg fs batang otak baik EDH progresif
SDH SDH luas (> 40 cc) dg GCS > 6, fs batang otak baik SDH dg edema serebri/kontusio + midline shift dg fs batang otak baik
ICH Penurunan kesadaran progresif Cushing reflex Perburukan defisit neurologi fokal
Indikasi Operasi
Fraktur impresi > 1 diploe
Fraktur kranii dg laserasi serebri
Fraktur kranii terbuka (pencegahan infeksi intrakranial)
Edema serebri berat dg TTIK (dekompresi)
Trauma Medulla Spinalis
Pendahuluan
Trauma medulla spinalis/spinal cord injury (SCI) defisit neurologis & hendaya permanen
Tujuan menegakkan diagnosis & memulai terapi secepatnya mencegah defisit lanjut (primer & sekunder)
Epidemiologi
AS, 2006 Insidens + 50 / 1 jt populasi, 14.000 ps/th (AS,
2006)
Pria : wanita = 2,5 - 3 : 1
80% pria dg SCI (spinal cord injury) berusia 18-25 th
Australia, 2006 Insidens 12 / 1 jt populasi / th
Indonesia ??
Etiologi Acute Spinal Cord Injury (ACSI)
Kecelakaan bermotor 50 Mobil Motor Sepeda Jatuh 15-20 Kekerasan individual 15-20 Luka tembak Kekerasan lain Olahraga dan rekreasi 10-15 Menyelam (2/3 kasus dalam kategori ini) Football dan rugby Hoki Senam Gulat
Etiologi Perkiraan Persentase Dari Keseluruhan SCI
Neurotrauma. Narayan RK, Wilberger JE, Povlishock JT. 1996.
Anatomi & Patofisiologi
Segmen servikal MS paling rentan
Thoracolumbar junction rentan (15%)
Komplit VS Inkomplit SCI
Komplit : sensoris & motorik di bawah level (-)
Inkomplit : sensoris & motorik di bawah level (+) prognosis >>
Anatomi & Patofisiologi
Trauma MS Primer
Deformasi lokal & transformasi energi dr kompresi akut, laserasi, distracting, atau regangan
Sekunder Kaskade biokimia & proses selular kerusakan /
kematian sel
Perubahan vaskular, perubahan kadar ion, akumulasi neurotransmiter, produksi radikal bebas & lipid peroksidase, efek opioid endogen, edema, inflamasi, ATP
Critical Care and Resuscitation 2006;8:56-63
Neurosurgery 1999;44:1027-40
Grade A Complete No motor/sensory function is preserved in the sacral segments S4-S5 Grade B Incomplete Sensory but not motor function is preserved below the neurological level and extends through the sacral segments S4-S5 Grade C Incomplete Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade less than 3 Grade D Incomplete Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3 Grade E Normal Motor and sensory function are normal
ASIA (American Spinal Injury Association)/ IMSOP (the International Medical Society of Paraplegia)
Impairment Scale
Neurotrauma. Narayan RK, Wilberger JE, Povlishock JT. 1996.
Terapi
Methylprednisolone / MP (corticosteroid)
Tirilazad mesylate (corticosteroid)
Naloxone
GM-1 ganglioside
Indian Journal of Neurotrauma (IJNT) vol 4, No. 1, 2007
Methylprednisolone
Efek neuroprotektif MPSS (MP-sodium succinate)
Menghambat lipid peroksidase
Menghambat influks kalsium
Menghambat iskemia
Efek anti inflamasi
MP in ACSI. Guidelines Department Of Surgical
Education, Orlando Regional Medical Center. 2004.
Methylprednisolone
MP (30 mg/kg IV loading dose followed by 5.4 mg/kg/h for the next 23 h NASCIS 2 regimen) may be considered in pts w/ blunt ASCI presenting less than 3 h after injury after considering the potential risks & benefits to the pt
MP (30 mg/kg IV loading dose followed by 5.4 mg/kg/h for the next 47 h NASCIS 3 regimen) may be considered in pts w/ blunt ASCI presenting between 3 and 8 h after injury after considering the potential risks & benefits to the pt
Steroids should not be administered to pts w/ blunt ASCI presenting greater than 8 h after injury
Methylprednisolone
NASCIS II (1990, Class II) Prospective, randomized, double-blind multi-center trial in 487 pts w/ ASCI 3 arms :
MPSS 30 mg/kg bolus given within 15 min, followed by 5.4 mg/kg/h infusion for 23 h
Naloxone 5.4 mg/kg bolus given within 15 min, followed by 4.5 mg/kg/h infusion for 23 h
Placebo infusion
Naloxone improved systemic hypotension, spinal cord blood flow, neurologic recovery in animal lab
Given within 12 h injury Conclusion :
All primary outcome measures, including neurologic outcome & mortality, didnt differ between the 3 groups
Post hoc subgroup analysis of fewer than 50% of those enrolled identified improved neurologic fx in pts treated w/ MPSS within 8 h of injury.
Pts who received MPSS more than 8 h after injury demonstrated worse neurologic fx than did the placebo group
Increased wound infection, GI bleeding, & pulmonary embolus in pts who received MPSS although these differences were not statistically significant
Methylprednisolone
NASCIS III (1997, Class II) Prospective, randomized, double blind multi-center trial in 499 pts w/ ASCI All pts were administered MPSS 30 mg/kg & then randomized to 1 of 3 arms
MPSS 5.4 mg/kg/h infusion for 23 h MPSS 5.4 mg/kg/h infusion for 47 h Tirilizad mesylate (enhance spinal cord recovery) 2.5 mg/kg bolus q 6 h for 48 h
Treatment was initiated within 8 h in all pts Conclusion :
Randomization didnt result in equal pt groups as 25% of Group 1 pts had normal motor fx while only 14% of Group 2 pts had normal motor fx
Pts who received tirilizad demonstrated significantly worse motor fx than did patients who received MPSS
Among the MPSS groups, all primary outcome measures werent different Post hoc subgroup analysis identified that pts who received their MPSS bolus more than 3 h
post injury demostrated significantly greater motor fx if they received 48 h of MPSS rather than 24 h
This excludes almost 70% of the study pts from further analysis Although improved motor & sensory scores were seen in the MPSS groups at 6 weeks & 6
months post-injury, no differences in motor or sensory fx were detectable at 1 year There was 2x increase in severe pneumonia, 6x increase in mortality due to respiratory
complications in the 48 h MPSS pts when compared to 24 h MPSS pts
Methylprednisolone
Merola et al., 2002 perubahan jaringan scr mikroskopik thd pemberian MP dosis tinggi dilanjutkan 23 jam berikutnya pd tikus
Edema & struktur yang berkaitan dg lokasi injuri dipertahankan
Tdk mengubah perkembangan proses nekrosis / response sel astrosit pada lokasi injuri MS
Prognosis
Ps hidup > 18 bl angka harapan hidup 70% (tetraplegia) & 84% (paraplegia)
5 tahun setelah SCI, mortalitas : Septicemia 40x
Pneumonia 13x
Emboli paru 8x
Penyakit jantung 3x
Gg. berkemih 9x
Bunuh diri 2x
Prognosis
SCI segmen servikal, torakal, & torakolumbal prognosis perbaikan neurologis incomplete > complete
Complete (prognosis perbaikan klinis dlm 1 th) servikal > torakal > torakolumbal (T11-T12, L1-L2)
Incomplete (prognosis perbaikan klinis dlm 1 th) servikal = torakal > torakolumbal
Ps dg komplit SCI < 5% perbaikan
Jk komplit SCI menetap dlm 72 jam perbaikan 0
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