Cedera Kepala

Berat

Apa yang seharusnya dilakukan di UGD?

Dr.Agustinus Juhardi,Sp An.,MSc.

Dept. Anesthesiology & Reanimation
Mardi Rahayu Hosp. Kudus

Penyebab utama kematian pada trauma

Usia produktif
Laki dan perempuan 2 : 1

Untuk menyelamatkan pasien ini, apa yang bisa dilakukan di UGD?

Target terapi

Traumatic Brain Injury

Primary Brain
Injury
Results from what
has occurred to
the brain at the
time of the injury.

Secondary Brain
Injury
Physiologic and biochemical events
which follow the
primary injury.
5
5

SOME of the SECONDARY EVENTS IN TRAUMATIC BRAIN

INJURY

BBB
disruption

diffuse axonal
inflammation
injury

edema
formation

apoptosi
s
necrosis
Brain trauma

ischemia
energy failure

cytokine
s
Eicosanoids
endocannabinoids

Acetyl
Choline

RO
S

Green pathophysiological processes; Yellow various

polyamines Calcium

Shohami, 2000
6

Primary injury

Ischemia

Direct cell and

vascular damage

Bleeding
and
haematoma

Increase
d CBF

Inflammatory
mediators

Edema
formatio
n

Increased intracranial
pressure

Cell death
7
7

Monro-Kellie Doctrine
Vintracranial

=Vbrain+Vblood +Vcsf

vault

Identifikasi dan Evaluasi

Identifikasi
GCS
CKR
CKS
CKB

ATLS trauma evaluation

Group A (minimal head injury GCS = 15

Patient is awake, oriented and without neurologic
deficits and relates accident
No loss of consciousness
No vomiting
Absent or minimal subgaleal swelling
The patient is released into the care of family
member with written instructions.

Group B (minor head injury GCS = 15)

Patient is awake, oriented and without neurologic
deficits
Transitory loss of consciousness
Amnesia
One episode of vomiting
Significant subgaleal swelling
The patient who has at least one of these
characteristic undergoes neurologic evaluation
and CT scan which, if negative, shortens hospital
observation. If CT scan is not available, the
patient has skull X-rays and is held for an
observation period of not less then 6 h. If the
skull X-rays are negative and a subsequent
neurologic control is normal, the patien can be
released into the care of a family member with
written instructions. If the X-rays reveal a
fracture, the patient undergoes CT scan.

Group C (moderate head injury or mild head injury with complicating

factors GCS = 9-15)
Impaired consciousness
Uncooperative for various reasons
Repeated vomiting
Neurologic deficits
Otorrhagia/otorrhoea
Rhinorrhoea
Sign of basal fracture
Seizures
Penetrating or perforating wounds
Patients in anticoagulant therapy or affected by coagulopathy
Patients who have undergone previous intracranial operations
Epileptic or alcoholic patients
The patient with at least one of these characteristics undergoes a
neurologic evaluation and a CT scan. Hospitalization and repeated
scan, if necessary, within 24 h or prior to discharge.

Group D (severe head injury

GCS = 3-8)
Patient is coma

Necessary resuscitation manouvres followed by

neurological evaluation and immediate CT scan (prior
to surgical intervention). Coma management.

Intubasi Endotrakea
1. Semua pasien koma, GCS < 8
2. Hilangnya reflek proteksi jalan nafas
3. Hipoksemia, hipercapnia (PaO2 < 60
4.
5.
6.
7.

mmHg; PaCO2 > 65 mmHg)

Hipokapnia (PaCO2 < 25 mmHg)
Respiratory aritmia
Kejang
Trauma jalan nafas dan thorak

Semua pasien dianggap fraktur cervical

In-line stabilization

Ventilasi

Hipokapnia ringan (PaCO2 35-40)

Hindari hiperventilasi pada 24 jam

pertama (PaCO2 < 25 mmHg), bila tidak

ada tanda kenaikan TIK
Analisa Gas Darah

Resusitasi Cairan

Hipotensi post-trauma (secundary brain injury).

Koreksi hipotensi (sistolik < 90 mmHg)
MAP dipertahankan > 90

Resusitasi Cairan
Koloid atau kristaloid?
Hipertonik atau isotonik?
Pilihlah cairan hipertonik (NS 3%, 7,5%)
Lebih umum dipakai NaCl 0.9%
Hindari RL, NS 0.45%
Hindari Dextrose.

Apakah hipertensi perlu koreksi?

Respon kompensasi
Ya. Jika MAP diatas limit autoregulasi.
Idealnya alpa-blocker (pentolamine)
Esmolol, propanolol, labetalol.

Manajemen Kenaikan TIK

CPP = MAP ICP
Trias Cushing: bradikardi, hipertensi, bradipnea.

Manajemen Kenaikan TIK

Posisi kepala head-up 30
Hiperventilasi (kontroversi)

Prinsip: normokapnia, jangan PaCO2 < 35 mmHg.

Osmotik diuretik
Manitol 20% 0.25-1 mg/kgBB 15-25 menit.
Atasi hipovolemia sebelumnya
Bolus lebih baik daripada infus kontinyu
Infusnya harus ada filternya

Loop diuretik

Furosemid 0.7 mg/kg iv 15 mnt setelah manitol

Barbiturat
Konsep Lund

Staircase ICP control algorithm

7

Barbiturate
coma
Surgical decompression

6
5

Mild hypothermia
4
3
2
1

Mannitol
Ventricular drainage
Moderate head-up
Intubation, normocapneic ventilation
26

Physiological Basic of the

Lund Management Strategy
Jv = Kf{(Pc-Pi) (p- i)}
Pi

Interstitial
space

Po

Capillary

The Lund strategy is based on knowledge of the forces that

govern transcapillary filtration of fluid.
Jv = transcapillary filtration of fluid; Kf = filtration coefficient; (Pc Pi) =
hydrostatic pressure difference between plasma and interstitial fluid; ( pi) = oncotic pressure difference between plasma and interstitial fluid.
Robertson, 2001
27

Daisy 10 Months After Accident