Download - Cedera Kepala Presentasi
• SUDIHARTO
• NEUROSURGERY DIVISION• SURGERY DEPARTMENT
BRAIN INJURY
INTRUCTIONAL OBJECTIVE• Departement of Neurosurgery• Lecturer : DR. dr. P. Sudiharto• Topic of Lecture :I. Head injury
1. Mechanism of head injury2. Pathophysiology of head injury
a. Primary brain injury b. Secondary brain injury
3. Diagnosisa. History, physical and neurological examinationb. Laboratory tests c. Imaging studies
4. Principles of head injury managementa. Initial managementb. Early management of increased intracranial
pressurec. Surgical management
INTRUCTIONAL OBJECTIVE• Departement of Neurosurgery• Lecturer : DR. dr. P. Sudiharto• Topic of Lecture :I. Head injury
1. Mechanism of head injury2. Pathophysiology of head injury
a. Primary brain injury b. Secondary brain injury
3. Diagnosisa. History, physical and neurological examinationb. Laboratory tests c. Imaging studies
4. Principles of head injury managementa. Initial managementb. Early management of increased intracranial
pressurec. Surgical management
Head injury is defined an injury to any part of the head (e,g, face, skull)Brain injury denotes damage to the brain. That head and brain injuries can occur in combination (Ruff, R, 2005)Craniocerebral injury can involve scalp. Skull or brain in any combination (Pitts & Nockels, 1994)
DEFINITION
Mechanism of Head Injury• Skull molding occurs at site of impact
• A : pre injury contour
• B : subdural veins (bridging vein) torn as brain rotates forward
• C : contour after impact with inbending at point A and outbending at vertex
• D : direct trauma to inferior temporal and frontal lobes
• S : shearing strains throughout brain
MECHANISTIC CAUSES OF HEAD INJURIES
Head injuries are due to one of two basic mechanisms, contact or acceleration injuries
PROCESSES AND FACTORS LEADING TO SECONDARY BRAIN INJURY
• Mass lesion, brain shift and herniation- Intracranial hematoma (EDH, SDH,ICH)Focal brain Swelling, edema
• Cerebral ischemia- Reduced cerebral perfusion pressure- Hypotension- Intracranial hypertension- Cerebral vasospasm- Hypoxaemia- Seizures- Hyperthermia- Infection
PRIMARY HEAD INJURY(Gennarelli, TA, 1990)
Skull Fracture Focal Injuries Diffus Injuries- Linear - Contusions - Concussion- Depressed * Coup * mild- Basilar * Centre – coup * classic
* Intermediate - Diffus axonal injury- Hematomas * Mild
* Extradural/epidural * Moderate* Subdural * severe* Intracerebral
DIAGNOSIS OF BRAIN INJURY IS BASED UPON :
A. HISTORYB. PHYSICAL EXAMINATIONC. NEUROLOGIC EXAMINATIOND. LABORATORY TESTSE. IMAGING STUDIES
The clinical history is a most important factor in head injury and should include :
• The cause of the injury• Severity of the blow• The time, place and details of the accident• The presence of early neurologic abnormalities
(weakness, speech deorder, seizures, loss of consciousness)
• The past medical history (diabetes, hypertension)• A history of alcohol or any drugs consume
A. HISTORY
B. PHYSICAL EXAMINATION
• Initial examination should be rapid and systematic• Attention must be directed to assesment of other mayor
injuries (spinal, chest, abdominalm extremities)• Inspect and feel the entire scalp• Note any injuries to the aye• Inspect the face for evidence of maxillary and mandibular
fractures• Basal skull fractures maybe recognized by the presence of :
- fresh bleeding from an ear- cerebrospinal fluid otorrhea or rinorrhea- bilateral ecchymoses confined to the orbits
C. INITIAL NEUROLOGIC EXAMINATION
Glasgow Coma Score- eye opening- motor response- verbal responsePupillary size and response to light, and symmetryEye movementMotor power, symmetry of limb movementGross sensory examinationReflex activityCranial nerve deficit
D. LABORATORY TESTS
• Complete blood count• Blood urea nitrogen, creatinin• Blood sugar• Blood gas analysis• urinalysis
E. IMAGING STUDIES
• Skull X-rays• Computerized tomography scan
(CT Scan)• Magnetic Resonance Imaging
(MRI)
TATALAKSANA
AAIRWAY & C-SPINE CONTROL
BBREATHING
CCIRCULATION
PRIMARY
SURVEY
KONSEPNYARESPONSIBILITAS TERPENTING
MANAJEMEN ABC : CEGAHHIPOVENTILASI DAN HIPOVOLEMIA
POTENSIAL TERJADINYASECONDARY BRAIN DAMAGE
SCALP
SKULL
MENINGES
BRAIN
LCS
TENTORIUM
GCS
ICP
MENINGESTiga lapis : duramater, arachnoid, piamater
Arteri Meningea Media, potensial terlibat pada kasus EDH
CAIRAN SEREBROSPINAL
Diproduksi oleh pleksus koroideusRata-rata 30 ml per jamBersirkulasi
TENTORIUMMembagi 2 ruangan intrakranialSupratentorial dan Infratentorial
CEREBRAL PERFUSION PRESSURE ( CPP )
Merupakan PRIORITAS UTAMA
Rumus : CPP = Mean Arterial Pressure - ICP
CEREBRAL BLOOD FLOW ( CBF )
Normal : 50 ml/100 gram otak/ menitBila mencapai 5 ml/ menit :
cell death & irreversible damage
TEKANAN INTRAKRANIAL
Normal : 10 mmHg ( 136 mm air )Makin tinggi TIK makin jelek prognosis
HUKUM MONRO-KELLIE
Prinsip : total volume intrakranial bersifat TETAP,Oleh karena kranium merupakan NON EXPANSILE BOX
Vk = V darah + V likwor + V parenkim
60
50
40
30
20
10
0
Fatal
DisfungsiOtak
Obati
Normal
mmHg
Volume Intrakranial
100
50
TekananIntrakranial
Monro Kellie
KOMPONEN MATA
KOMPONEN MOTORIK
KOMPONEN VERBAL
Fraktur Impresi
CT scan Impresi Fraktur
TINDAKAN OPERATIF FRAKTUR DEPPRESI
BASILAR SKULL FRACTURES
Epidural
EPIDURALHEMATOM
PERJALANAN KLINIK EDH
ACUTE EPIDURAL HEMATOMA
Subdural hematom
Intraserebralhematom
Pre operasi Pasca Operasi
KorpusAlienum
FUNGSI OTAK• Sisi dominan untuk yang tidak kidal adl yg
sebelah kiri
• Orang kidal, 75 % sisi dominan adalah kiri
• Fungsi sisi dominan adalah untuk bahasa
dan memori yang berdasarkan bahasa
• Sisi kanan untuk memori visual
LOBUS FRONTALIS
1. PRE-SENTRAL GIRUS
Pusat motorik untuk muka, tangan, kaki, badan, dsb.
2. AREA BROCA
Pada sisi dominan adalah pusat bicara ekspresif motorik
3. AREA MOTOR TAMBAHAN
Untuk gerakan mata dan kepala sisi yang berlawanan
4. AREA PRE-FRONTAL
Untuk inisiatif dan personalitas
5. PARASENTRAL LOBUS
Pusat penahan BAK dan BAB