Iskandar Japardi Departemen Ilmu Bedah Saraf Fakultas Kedokteran Usu / Rs.h.adam Malik Medan

Iskandar Japardi Departemen Ilmu Bedah Saraf Fakultas Kedokteran USU / RS.H.Adam Malik MEDAN

ANATOMI KEPALA  KULIT

 TULANG TENGKORAK  DURAMATER  ARACHNOID

 PIAMATER

PEMERIKSAAN CEDERA KEPALA DI UGD 

PRIMARY SURVEY 

   

Airway Breathing Circulation Disability Exposure

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SECONDARY SURVEY

• • • •

KEPALA DAN LEHER THORAKS ABDOMEN EXTREMITAS

TERMINOLOGI YANG DAPAT DIPAKAI UNTUK MEMBAWA PENDERITA KE RUMAH SAKIT  Primary care: dilakukan pada tempat kejadian  Primary hospital : perawatan pertama pada

rumah sakit (rural)  Primary transport : pertama dipindahkan ke rumah sakit terdekat  Secondary transport : dipindahkan dari primary hospital ke secondary center untuk perawatan definitive  Tertiary transport : antara rumah sakit besar, penderita multiple trauma, pindah ke pusat dialisis

MANAJEMEN AWAL CEDERA KEPALA, HINDARI  HIPOKSIA

 HIPERKARBIA  HIPOTENSI  HIPOVOLEMIA

GELISAH  HYPOXIA

 RETENTION URINE  NYERI  PROSES INTRACRANIAL

 Intracranial contents,  Brain (including the neurological elements [70%] and interstitial fluid [10%] ) ; volume 1400 ml or 80%  Blood (arterial and venous) ; volume 150 ml or 10%  Cerebrospinal fluid (CSF) ; volume 150 ml or 10%

PEMERIKSAAN NEUROLOGIS       

TINGKAT KESADARAN PUPIL DAN GERAKAN BOLA MATA REAKSI TERHADAP RANGSANG DARI LUAR REAKSI MOTORIK POLA PERNAFASAN SINDROMA HERNIASI BRAIN DEATH

GLASGOW COMA SCALE • Eye Response. (4)  Motor Response. (6) 1. No eye opening 1. No motor response 2. Eye opening to pain 2. Extension to pain 3. Eye opening to verbal command 3. Flexion to pain 4. Eye open spontaneously 4. Withdrawal from pain 5. Localizing pain • Verbal Response. (5) 6. Obey Commands 1. No verbal response 2. Incomprehensible sounds Klasifikasi 3. Inappropriate words Mild 14 - 15 4. Confused Moderate 9 - 13 5. Orientated Severe 3-8

SYMPTOMS AND SIGNS  Headache, worse at night or recumbent position,

because of the increase in CO2 tension and increased venous pressure  Nausea and vomiting  Ataxia, papilledema, and cranial nerve paralysis  Irregular breathing patterns  Decorticate or decerebrate  Pupillary inequality

PEMERIKSAAN RADIOLOGIS  

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FOTO POLOS KEPALA FOTO CERVICAL FOTO THORAX FOTO LUMBAL CT SCAN / COMPUTED TOMOGRAPHY MRI / MAGNETIC RESONANCE IMAGING

Indikasi CT Scan     

 

Kesadaran menurun (GCS<15). Skull fracture. Tanda fraktur basis kranii. Sakit kepala menetap/ muntah. Cedera penetrasi. Kejang. Neurologic defisit (lateralization).

Indikasi rawat           

Kesadaran menurun Sakit kepala (sedang sampai berat). Riwayat kesadaran menurun > 15 minute. Fraktur tulang tengkorak. Rhinorea – otorhea. Cedera penetrasi. Alkohol/drugs intoxication. Significant multiple trauma. Abnormal CT Scan. Amnesia. No family at home.

CEREBRAL BLOOD FLOW    

Normal 55 to 60 ml/100 gr brain tissue/minute In the gray matter is 75 ml/100 gr brain tissue/minute In the white matter 45 ml/100 gr brain tissue/minute The most significant factor that determines CBF is the CPP which is the effective blood pressure gradient across the brain  MAP is the diastolic pressure plus one-third of the pulse pressure ; increased ICP is tendency for the CPP to decrease

MACAM MACAM FRAKTUR      

FRAKTUR LINEAR FRAKTUR DIASTASE FRAKTUR COMMUNITED FRAKTUR DEPRESSED FRAKTUR KONVEKSITAS / KUBAH FRAKTUR BASIS CRANII  ANTERIOR - ANOSMIA, RHINORRHOE  MEDIA - OTORRHEA, HEMATYMPANI, BATTLE’S SIGN  POSTERIOR - INFRA TENTORIAL

TANDA FRAKTUR BASIS KRANII  HAEMOTYMPANUM  OTORRHEA

 RHINORRHEA  RACOON EYES  BATTLE’S SIGN

CEREBRAL EDEMA  VASOGENIC EDEMA  Increased permiability of capillaries ; the tight junctions between the endothelial cell become incompetent, allowing plasma filtrate to escape into the intercellular space  Contrast enhancement because of the breakdown of the BBB  Edema is more marked in white matter than in gray matter  Edema is seen with trauma, tumor, and abscess

 CYTOTOXIC EDEMA  Hypoxia of the neural tissue and water intoxication  Hypoxia affects the ATP-dependent sodium pump mechanism in the cell membrane, promoting an accumulation of intracellular sodium and subsequent flow of water into cell to maintain osmotic equilibrium  Edema is intracellular and affects all cells : endothelial cells, astrocytes, and neurons (interstitial space is narrowed)  Subtle or no changes in CT scan, indicative in early phases of ischemic stroke

 INTERSTITIAL EDEMA  Transudation of CSF in obstructive hydrocephalus  Best observed on CT or MRI as periventricular low density areas because of the retrograde transependymal flow of CSF into the interstitial space of the white matter (mostly in frontal region) , indicates active hydrocephalus requiring surgical therapy

TYPES OF BRAIN HERNIATION  CINGULATE HERNIATION  Focal mass lesion in the supratentorial compartement pressure locally on the ipsilateral hemisphere  The mass lesion may displace the cingulate gyrus, which is next to the free edge of the falx cerebri, and cause it to herniate under the falx to the opposite side  Usually displacement of the ventricular system  Arterior cerebral artery, tight, sharp edge of the falx  No clinical signs and symptoms specific

 UNCAL HERNIATION  When lesions of the middle cranial fossa, such as acute epidural hematoma, subdural hematoma, temporal lobe contussions, or temporal lobe neoplasms  An expansile mass of the middle fossa cause the uncus, the inferomedial structure of the temporal lobe, to herniate between the rostral brainstem and tentorial edge into posterior fossa  The medial displacement of the brainstem may cause compression of the brainstem againts the opposite tentorial edge, producing a notch called Kernohan’s notch (ipsilateral hemiplegia)

 CENTRAL TRANSTENTORIAL HERNIATION  Mass lesions located to the tentorial hiatus  Bilateral mass lesions, such as bilateral subdural hematomas, can also cause herniation  Downward displacement of the diencephalon and midbrain centrally through the tentorial incisura  Clinical symptom,   

Bilaterally small, reactive pupils Cheyne-Stokes respirations Loss of vertical gaze

 TONSILLAR HERNIATION  The tonsil of the cerebellum herniates through the foramen magnum into the upper spinal canal, compressing the medulla  Manifestations of acute medullary compression are,        

Cardiorespiratory impairment Hypertension High pulse pressure Cheyne-Stokes respirations Neurogenic hyperventilation Impaired consciousness Stiff neck or opisthotonic position Decorticate or decerebrate posturing

INDIKASI OPERASI  Epidural Hematoma (EDH)

- EDH >30 ml - EDH,Koma,GCS <9, pupil anisokor - Bila EDH <30 ml dan ketebalan <15 mm serta midline shift <5 mm dan GCS >8 tanpa fokal defisit ------ tidak operasi

 Akut Subdural Hematoma (SDH)

- ketebalan >10 mm atau midline shift >5 mm pada CT Scan - koma (GCS<9), ketebalan <10 mm dan midline shift <5 mm,operasi bila GCS menurun 2 atau lebih (waktu antara kejadian dan masuk RS) atau ICP >20 mmHg - koma (GCS<9) ----- monitoring ICP

 Traumatic parenchymal lesions - GCS 6-8 dengan kontusi frontal atau temporal <20 ml, midline shift >5 mm dan kompresi sisterna pada CT Scan - lesi >50 ml  Lesi fossa posterior lesi dengan distorsi,dislokasi, atau obliterasi ventrikel IV, sisterna basalis, atau obstruksi hidrosefalus  Depressed skull fractures

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TREATMENT MANNITOL  It increases serum osmolality and to draw fluid from the

brain parenchyma into the vascular space  The osmotic effect of mannitol is  



Decrease CSF production Increases cerebral blood flow and cerebral oxygen consumption Decrease blood viscosity, thereby improving perfusion

INDIKASI EVAKUASI HEMATOMA  Tidak semua lesi intrakranial cedera kepala berat

tertutup dilakukan kraniotomi  Traumatic Coma Data Bank 37% penderita koma dilakukan operasi intrakranial hematoma  25% keadaan klinis menurun pada penderita dengan lesi intrakranial atau gambaran radiologi menunjukkan bertambahnya hematoma

Explorasi burrhole  Tidak dilakukan bila ada fasilitas CT Scan

 Life saving : rural area, jarak transfer ke lokasi CT Scan cukup jauh atau tidak memungkinkan

Lokasi burrhole     

frontal,parietal dan temporal dilatasi pupil ……… ipsilateral hemiparesis …….. kontralateral fraktur ……. ipsilateral bila tidak ada didaerah temporal, dilakukan burrhole didaerah frontal, dan parietal  bila ketiga tempat ini tidak ada, dilakukan pada sisi berlawanan

LOKASI BURR HOLE

INSIDENCE DEPRESSED FRACTURE  3% fraktur tulang tengkorak pada cedera kepala

ringan  65% fraktur tulang tengkorak pada cedera kepala berat, dengan atau tanpa kerusakan dura atau otak  >50% fraktur frontal dan memerlukan perbaikan kosmetik

fraktur depressed

fracture depressed

INSIDEN EPIDURAL HEMATOMA  2%-6% dari cedera kepala, dengan atau tanpa fraktur

tulang tengkorak  30% penderita, hematoma bertambah dalam 6 jam pertama setelah cedera  10%-50% berhubungan dengan hidrosefalus bila lokasi hematoma fossa posterior

SUBDURAL HEMATOMA  Simple atau intradural hematoma  Complicated atau mixed subdural hematoma

 Akut  Subakut  kronik

CHRONIC SUBDURAL HEMATOMA (CSDH)  Subdural hematoma is older than 3 weeks  Result of rupture of small bridging veins  Caused by minor head trauma or fall, often not

remembered by the patient or relatives  Bilateral clots about 20% of cases  Risk factor  

   

Old age Alkohol abuse seizures CSF shunts Anticoagulation Patients at risk for falls

DATA KEMATIAN AKIBAT TRAUMA (Meislin,Rogers,et.al.,1997)

 Very early deaths, 35%-50% dari total ; kerusakan CNS

permanen  Early deaths (dalam 4 jam), 18%-30% dari total; biasanya karena perdarahan atau problem jalan nafas  Hospital deaths dalam 24 jam, 20% dari total  Hospital deaths setelah beberapa hari atau minggu, 20% dari total; multiple system failure dengan sepsis

KESIMPULAN  Tidak ada obat atau miracle treatment untuk

memicu penyembuhan saraf paska trauma kepala  Penanganan konservatif dan operatif sesuai indikasi  Pengobatan terbaik mencegah cedera sekunder  Pengetahuan molekuler penting, menyusun kombinasi terapi penanganan cedera otak sekunder

TERIMA KASIH