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PREHOSPITAL CARE
PENANGANAN DI RUMAH SAKIT
Manajemen Cedera Kepala
Beberapa Kontroversi
Abdul Hafid Bajamal*
Mahyudanil **

*FK Unair /RSU Dr Sutomo,Surabaya

** RSUP Adam Malik , Medan
 Delayed ? hematom of EDH

23 y.o. man, GCS 15 to 12, and no lateralisation sign 4 hrs

after injury.
CT :EDH in R.parietooccipital.
2 hours after operation R.pupil dilated. CT : a new EDH on
R.frontotemporal Second surgery done.
A good outcome but he had a prolonged day care.
 Double site of EDH
(figure 1a) (figure 1d)

18 y.o.boy, cephalgia & vomiting , fall from motorcycle 1 hour, no

cushing respon, GCS 15.sign herniation (-),neurological deficit (-).
Later, complain persistent cephalgia and vomiting, GCS 13 with
bradicardy.
The next CT shows bilateral EDH, (figure 1a). Craniotomi and
evacuation done, the bleeding from fracture site.(figure 1d)
The GOS was 5 (good outcome) after 3 month post operation.
 Double site of EDH

6 y.o.boy, GCS: (1-1-1) after a motorcycle

accident 4 hrs before admission. After
resucitation the GCS increased 114 and anisocor
pupil ,R.hemiparesis. Bitemporal EDH with
multiple infarction show on CT . Patient died
after evacuation
Hematom Subdural ( Tipis )
 EDH with intradural lesion

53 y.o.women, 2 hrs after traffic accident. Never consciousness

(GCS 114) and Dilated R.pupil and contralateral hemiparesis.
Evacuation of EDH, SDH, ICH and decompression craniectomy
was performed.
Patient died 3 days after surgery.
 EDH associated with intradural lesion

43 y.o.man, the initial CT shows a Left

temporal EDH. After evacuation of EDH
contusional enlarge and evoluted to I C H
 EDH associated with intradural lesion

48 y.o.woman,EDH R- temporoparietal.
Contusional Haem. & ICH almost not seen
compare to post surgery CT.
 EDH with intradural associated lesion

27 y.o.man, an EDH at R- temporoparietal. GOS 5 after 3 month evaluation.

 Double Lesion

WHEN You do the surgery?

One or two step ?????

Mahyudanil, Bajamal : 2007, Comparation of The Prognosis on The One Step and Two Step Surgical Procedure on Moderate Head Injury
Patients with Supratentorial Bilateral Lesion on Extradural Hematoma as Evacuated Mass and Intra Cerebral Hematoma as Non Evacuated
Mass.Cohort Retrospective Analysis of 30 cases, Department of Neurosurgery Airlangga University, Dr Soetomo General Hospital, Surabaya
Indonesia Department of Neurosurgery Airlangga University Dr Soetomo Hospital, Surabaya, Indonesia
 Double lesi

One step vs two step Not significant :

Prognosis yang buruk akibat cedera
difus pada lesi bilateral hematom
epidural dan hematom intraserebral.

One step surgery : lower risk

Dekompresi cukup adekuat
TIK dan TPO cepat membaik
Mahyudanil, Bajamal : 2007, Comparation of The Prognosis on The One Step and Two Step Surgical Procedure on Moderate Head Injury
Patients with Supratentorial Bilateral Lesion on Extradural Hematoma as Evacuated Mass and Intra Cerebral Hematoma as Non Evacuated
Mass.Cohort Retrospective Analysis of 30 cases, Department of Neurosurgery Airlangga University, Dr Soetomo General Hospital, Surabaya
Indonesia Department of Neurosurgery Airlangga University Dr Soetomo Hospital, Surabaya, Indonesia
tSAH= traumatic Subarachnoid Hemmorhage

tSAH in initial CT Scan is correlated with a worse

outcome.
Mortality is increased twofold
tSAH occurs in between 26-53% of all severe TBI.
In our series the presence of tSAH is 23% in all of
case and aproximately 47% in severe head injury
PENETRATING BRAIN INJURY
Resuscitation and tracheostomy
 Resuscitation & Initial Assessment

AIRWAY :
Tracheostomy pada cedera
otak berat dengan perkiraan
perawatan lama perlukah
dilakukan sejak dini ?
Head injury & Pregnancy
Algorithm Severe head injury BRAIN DEATH

Evacuated Mass Non evacuated mass

craniotomy + SectioCaesaria
Non Viable baby
Viable baby

High value baby ?

termination

Continue support ?
termination
Viable baby

termination
 Decompressive Craniectomy
DECRA

Apakah efektif menurunkan TIK dan

memperbaiki prognosis penderita?
Kelas II (Standard)
DECRA dini direkomendasi untuk menurunkan TIK bila
terapi medikal tidak berhasil.
Dalam hal perbaikan prognosis hanya sampai level kelas
III (Optional).
TIK yang tetap tinggi pasca DECRA berkorelasi dengan
angka kematian yang tinggi.

Andrews 2005, Does Decompressive Craniectomy Really Improve Outcome After Head Injury ? in Neurotrauma : Evidence-based Answers to
Common Question : pp 163 - 165
 DECRA

Non Operative Lesion, kapan

dilakukan DECRA ?
Kelas II : Bila TIK tetap tinggi setelah
pengobatan hipertensi intrakranial, DECRA
dapat dikerjakan sebelum CPP terganggu.
Komplikasi DECRA ?
Kelas II dan III : Leakage CSF, kerusakan SCALP
pada pinggir tulang setelah TIK turun, infeksi luka
operasi, subdural hygroma pada sisi
DECRA,trephine syndrome

Andrews 2005, Does Decompressive Craniectomy Really Improve Outcome After Head Injury ? in Neurotrauma : Evidence-based Answers to
Common Question : pp 163 - 165
Fraktur Impresi
Kranioplasti?

Shunting ?
 Poly Trauma Patients :
Cervical, Thorax, Abdominal, and Extremity

Cedera kepala dan fraktur tulang panjang

Kelas III (Option) : Surgical fixation lebih aman dilakukan
pada fase lanjut beberapa hari kemudian untuk
memastikan resusitasi adekwat dan stabil.

Keterlambatan tidak menimbulkan pemburukan sistemik

dan prognosis ortopedik, bahkan dapat mencegah
potensial insult sekunder pada cedera kepala.

Valadka : 2005, When Should Head Injured Patients with Long-Bone Fractures Undergo Surgical Treatment of Their Fractures ?, In
Neurotrauma : Evidence-Base Answer to Common Question, Valadka-Andrews Ed, pp 8 - 13
 Operative Lesion

Hematom Epidural Temporalis atau MLS >

5 mm lebih agresif dilakukan
pembedahan
 Non Operative Lesion and or Post Op
Management
Chapter 13
The Role of Anti-Seizures BTF
 KESIMPULAN

1. Kontroversi manajemen prognosis

dijadikan sebagai wacana kearah perawatan
yang lebih baik.
2. Pemecahan masalah secara terstruktur
(protokol manajemen) mungkin lebih baik
dibanding individualistik
3. Protokol dikerjakan dalam periode waktu
yang panjang (misalnya 1 tahun) dengan
evaluasi database sampai tahap prognosis
dan komplikasi yang lengkap
Terima kasih
semoga
bermanfaat