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GANGGUAN
BRAIN
Bagian Anestesiologi dan Reanimasi
FK Unsyiah RSUZA
Banda Aceh
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OTAK MANUSIA
OTAK MANUSIA
Sebesar sayur kol
Seberat + 1 kg
Bisa ditadah dgn sebelah
tangan
1/50 Berat Badan

HARTA KARUN YANG BESAR
RAKSASA TIDUR
ANUGERAH YG PALING BERHARGA DARI TUHAN
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Normal brain
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Normal Brain and Scalp
5 CEREBRAL VEINS
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NEUROPHYSILOGIS
C B F ( Cerebral blood Flow )
ICP ( Intra cerebral Pressure )
CMR O
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( Cerebral Metabolism Rate )
BBB ( Blood Brain Barrier )
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CEREBRAL BLOOD FLOW
Varies with metabolic activity
Regional CBF 10 300 ml / 100 g / min
Total CBF averages 50 ml / 100 g / min
< 20 25 ml/100 g/min cerebral impairment
< 10 ml/100 g/min I rreversible brain damage
Total CBF averages 750 ml / min
( 15 20 % CO )


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Physiology
Cerebral Blood Flow
Mean CBF~50 mL/100g/m
Coupled to CMRO
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{~3.5 mL/100g/m}
CBF = CPP/CVR
Autoregulated bet CPP 50-150 mmHg
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Gangguan Otak dapat disebabkan :

1. Trauma (paling sering)
2. Penyakit Sistemik
3. Stroke
4. Intoksikasi
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Kerusakan otak akibat cedera
kepala menyebabkan kematian
pada 34% dari seluruh kasus
trauma.
Limapuluh persen kasus trauma
kepala akibat kecelakaan
lalulintas.

Data dari
Amerika Serikat, 1992
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TRAUMA KEPALA
Kerusakan primer
hipoksia
hematoma
kontusi
DAI
Kerusakan sekunder:
kerusakan akibat
proses biokimiawi
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Pathophysiology
Primary Injury
- occurs during trauma
- damage already done
Secondary Injury
- occurs following trauma
due to hypoxia,
hypotension, hypertension,
free radicals etc
- preventable
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50
140
CBF
MAP (mmHg)
Autoregulation of cerebral blood flow
(CBF)
stable here
Brain injury destroy the autoregulation
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Efek sekunder pada trauma kepala
Sistemik Intrakranial
Suplai O
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Konsumsi O
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Asidosis
Hipoksemia
Hipotensi
Anemia
Hiperkarbia
Pireksia
Hiperglikemia
Hiperkarbia
ICP
Vasospasme
Autoregulasi (-)

Kejang
Cohadon,1995
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Head trauma
INJURIES
Scalp
Skull
Meningens
Brain

CSF
Blood supply
RESULT
Bleeding
Fracture & bleeding
Laceration
Contusion, bleeding,
edema, increase of ICP
Leakage (fr basis cranii)
Ischemia (due to shock and /
or ICP increase)

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Only severe trauma can break the skull
Assume equal damage to the brain tissue
Skull fracture
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Brain contusion, bleeding, edema ICP increase
Signs : GCS < 8 / Sluggish Pupil Reflex, possibly asymetrical
lateralisation of neurologic signs
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CPP = MAP - ICP

CPP = cerebral perfusion pressure
MAP = mean arterial pressure
ICP = intracranial pressure (TIK)

Brain injury results in increased ICP

MAP should not decrease
to prevent reduction of CPP
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Increased ICP
Danger
brain herniation:
medula oblongata to foramen magnum
trans-tentorial
damage to cortex cerebri & other structures
Signs:
decreased consciousness / vomit
increased BP (up to > 200 mmHg)
decreased pulse rate (bradikardia < 60)
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Secondary Injury
Hypoxia
Hypoperfusion due to shock
ICP MAP
Hypoglycemia
Hyperthermia
Convulsion
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Neurologic examination
main
Glasgow Coma Score
Pupil (size, symmetry, light reflex)
(cornea reflex)

Eyeball position
Occulocephalic Reflex
Occulovestibular Reflex
Fundus occuli
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Glasgow Coma Score
Eye opening (buka mata)
Open spontaneously 4
Open to command 3
Open to pain 2
None 1
Buka mata spontan
Buka mata diperintah
Buka mata karena nyeri
Tidak buka meski
dirangsang nyeri
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Glasgow Coma Score
Best verbal response (bicara)
Oriented 5
Confused 4
Inappropriate words 3
Inappropriate sounds 2
None 1
Orientasi baik
Bingung
Bicara tak tepat
Suara tak jelas
Diam
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Glasgow Coma Score
Best motor response (gerak ekstremitas)
Obeys command 6
Localises to pain 5
Withdraws to pain 4
Abnormal flexion 3
Extensor response 2
None 1
Menurut perintah
Menunjuk tempat nyeri
Menarik menjauhi nyeri
Fleksi abnormal thd nyeri
Ekstensi thd nyeri
Tak ada gerakan
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KLASIFIKASI CEDERA KEPALA
Cedera kepala ringan GCS 13 - 15
Cedera kepala sedang GCS 9 - 12
Cedera kepala berat GCS 8
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Sistem AVPU

A = Alert, sadar baik
V = Respon verbal
P = Respon terhadap nyeri
U = Unresponses
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Neurologic Examination
additional
Respiratory pattern
Scalp and skull
Membrana tympani
Muscle tonus
Tendon Reflex
Posture
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Pupil Response
Size
. mm
Light reflex
present / absent
normal / sluggish
Symmetry
isochoric / an-isochoric
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AIRWAY
BREATHING
CIRCULATION

Prevent ICP
Manangement of Head Trauma
Prevent Secondary Injury
Prevent hypoxia
Prevent hypoventilation
Prevent shock
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INDIKASI INTUBASI
Tidak mampu mempertahankan dan
melindungi jalan nafas
Ventilasi dan oksigenasi tidak memadai
untuk mencegah hipoksia otak
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FAKTOR YANG DIPERTIMBANGKAN
Fraktur tulang leher
Fraktur larynx
Fraktur maxilofacial
Stimulasi reflek simpatetik pada trachea
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Severe head injury
- Head-up 20
o
tilt to

prevent
increase of ICP
- Complete the secondary
survey
- Repeat examination
periodically
- Prevent Hyperthermia
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Hipoksia merupakan salah satu faktor yang
bertanggung jawab terhadap kerusakan otak.
Hipoksia mengawali terjadinya kerusakan
sekunder otak.
Hipotensi berkaitan dengan peningkatan
mortalitas dua kali lipat.
Hipotensi yang berlangsung singkat pada
awal resusitasi sudah dapat meningkatkan
mortalitas.
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?
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