Download - Penangan Ck Di Emg
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Dr. Dasa Sariadi Sp.BS., M.KesDr. Dasa Sariadi Sp.BS., M.Kes
Departement of Neurosurgery Departement of Neurosurgery Gunung Jati HospitalGunung Jati Hospital
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HEAD INJURY HEAD INJURY
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AnatomiAnatomi
Tulang tengkorak Tulang tengkorak
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AnatomiAnatomi
Meningen :Meningen :
duramater,duramater,
arachnoid,arachnoid,
piamaterpiamater..
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AnatomiAnatomi Otak : serebrum,Otak : serebrum,
serebellum danserebellum dan
batang otak.batang otak.
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AnatomiAnatomi
CairanCairan
sererospina!is :sererospina!is :
produ"si p!e"susprodu"si p!e"sus
"horoideus #$"horoideus #$m!%&am.m!%&am.
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AnatomiAnatomi 'entorium'entorium
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CEDERA (E)A*ACEDERA (E)A*A
Masalah utama.Masalah utama.
Morbiditas & mortalitas tinggi.Morbiditas & mortalitas tinggi.
Cedera otak sekunderCedera otak sekunder
•Hasil akhir buruk.•Hasil akhir buruk.
•Dapat dicegah.•Dapat dicegah.
Rujuk & konsul ahli bedah sarafRujuk & konsul ahli bedah saraf
sedini mungkin.sedini mungkin.
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)ADA RUJU(AN )ER*U)ADA RUJU(AN )ER*U
DIIN+RMA-I(ANDIIN+RMA-I(AN
Umur penderita, a"tu / me"anismeUmur penderita, a"tu / me"anisme
cedera.cedera.
-tatus respiratori" / "ardio0as"u!er-tatus respiratori" / "ardio0as"u!er1terutama te"anan darah 2.1terutama te"anan darah 2.
)emeri"saan minineuro!ogis : 3C-)emeri"saan minineuro!ogis : 3C-
terutama motori" / pupi!.terutama motori" / pupi!.
Cedera pen4erta / &enis cedera pen4ertCedera pen4erta / &enis cedera pen4ert Hasi! pemeri"saan radio!ogis :Hasi! pemeri"saan radio!ogis : 5oto5oto
"epa!a / Ct6scan "epa!a"epa!a / Ct6scan "epa!a..
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'E(ANAN'E(ANAN
IN'RA(RANIA*1'I( IN'RA(RANIA*1'I( 22
10 mmHg !ormal.10 mmHg !ormal.
"#0 mmHg $bnormal."#0 mmHg $bnormal.
"%0 mmHg erat."%0 mmHg erat.
erbagai proses patologis pada otakerbagai proses patologis pada otak
dapat berakibat pada hasil akhir.dapat berakibat pada hasil akhir.
''() men*ebabkan fungsi otak''() men*ebabkan fungsi otak
terganggu+ hasil akhirterganggu+ hasil akhir uru".uru".
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D('RIN MNR6D('RIN MNR6
(E**IE(E**IE ,olume,olume
intrakranial selaluintrakranial selalu
konstan.konstan. , otak - , darah, otak - , darah
- , lcs konstan- , lcs konstan..
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'E(ANAN 'IN33I IN'RA'E(ANAN 'IN33I IN'RA
(RANIA*(RANIA*
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'E(ANAN )ER+U-I'E(ANAN )ER+U-I
'A( 1')2'A( 1')2 '$R '() '/.'$R '() '/.
!ormal 20 10 30!ormal 20 10 30 Respon Cushing 100 #0 30Respon Cushing 100 #0 30
Hipotensi 40 #0 50Hipotensi 40 #0 50
'/ tidak sama dengan $D'/ tidak sama dengan $D )uncin*a adalah $D.)uncin*a adalah $D.
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AU'RE3U*A-IAU'RE3U*A-I
Mempertahankan $D dgn tekananMempertahankan $D dgn tekanan
darah ratarata 40 160 mmHg.darah ratarata 40 160 mmHg.
Cedera kepala sedang atau berat seringCedera kepala sedang atau berat sering
men*ebabkan autoregulasi terganggu.men*ebabkan autoregulasi terganggu.
tak sangat rentan terhadaptak sangat rentan terhadap cedera otakcedera otak
sekundersekunder karena iskhemia sebagai akibatkarena iskhemia sebagai akibat
hipotensi *ang tibatiba.hipotensi *ang tibatiba.
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A*IRAN DARAH (EA*IRAN DARAH (E
'A( 1AD'A( 1AD22 40 m78100 g8min !ormal.40 m78100 g8min !ormal.
9 #4 m78100 g8min akti:itas9 #4 m78100 g8min akti:itas;;< menurun8hilang.;;< menurun8hilang.
9 4 m78100 g8min selsel otak9 4 m78100 g8min selsel otak
mati.mati.
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(*A-I+I(A-I CEDERA(*A-I+I(A-I CEDERA
(E)A*A(E)A*A
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FRAKTUR DASARFRAKTUR DASAR
T!"KORAK T!"KORAK
Rhinorrhea =D'Rhinorrhea =D'
anterior.anterior.
torrhea =D' medial.torrhea =D' medial.
Hemot*mpanum.Hemot*mpanum.
;kimosis periorbital.;kimosis periorbital.
;kinosis retroaurikuler.;kinosis retroaurikuler.
Cedera !.=asialis.Cedera !.=asialis. Hilang pengdengaran.Hilang pengdengaran.
/neumosefalus./neumosefalus.
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(*A-I+I(A-I CEDERA(*A-I+I(A-I CEDERA
(E)A*A(E)A*A
*E-I IN'RA (RANIA**E-I IN'RA (RANIA*
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)EMERI(-AAN 3C-)EMERI(-AAN 3C-
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E)IDURA* HEMA'MAE)IDURA* HEMA'MA
$ssociated >ith skull$ssociated >ith skull
fracture.fracture.
Classic MiddleClassic Middlemeningeal arter* tear.meningeal arter* tear.
7enticular8bicon:e?7enticular8bicon:e?
due to duraldue to dural
adherence to skull.adherence to skull.
7ucid inter:al.7ucid inter:al.
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E)IDURA* HEMA'MAE)IDURA* HEMA'MA
Can be rapidl* fatal.Can be rapidl* fatal.
;arl* e:acuation;arl* e:acuation
good prognosis.good prognosis. ,enous epidurals+,enous epidurals+
/ossible nonsurgical/ossible nonsurgical
managementmanagement..
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-U7DURA* HEMA'MA-U7DURA* HEMA'MA
,enous tear8brain,enous tear8brain
laceration.laceration.
Co:ers entire cerebralCo:ers entire cerebral
surface.surface.
Morbidit*8mortalit* due toMorbidit*8mortalit* due to
underl*ing brain injur*.underl*ing brain injur*.
Rapid surgical e:acuationRapid surgical e:acuation
recommended especiall* ifrecommended especiall* if" 4mm shift of midline." 4mm shift of midline.
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CN'U-IN%HEMA'MACN'U-IN%HEMA'MA
Coup8contrecoupCoup8contrecoup
injuries.injuries.
Most common Most common
frontal8temporal lobes.frontal8temporal lobes.
@@Aalt & pepperBAalt & pepperB
appearance on C'.appearance on C'.
C' changes usuall*C' changes usuall*
progressi:e.progressi:e.
Most conscious patients Most conscious patients
no operation.no operation.
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CNCU--INCNCU--IN
'ransient loss of consciousness.'ransient loss of consciousness.
!ormal head C'.!ormal head C'.
!ausea+ :omiting.!ausea+ :omiting.
Headache (f se:ere+ repeat C'.Headache (f se:ere+ repeat C'.
A*mptoms ma* >orsen beforeA*mptoms ma* >orsen before
impro:ement.impro:ement.
Aeuelae common.Aeuelae common.
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DI++U-E A8NA*DI++U-E A8NA*
INJURY INJURY /rolonged deep coma not due to/rolonged deep coma not due to
mass lesion E.mass lesion E. Diffuse rain injur*.Diffuse rain injur*.
Motor posturing.Motor posturing.
=reuent autonomic disfunction=reuent autonomic disfunction
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MI*D 7RAIN INJURY MI*D 7RAIN INJURY
3C- -core 9 ; 6 ndings.
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MDERA'E 7RAINMDERA'E 7RAIN
INJURY INJURY 3C- -core 9 ? 6 #.3C- -core 9 ? 6 #.
Initia! e0a!uation same as 5or mi!dInitia! e0a!uation same as 5or mi!d
in&ur4.in&ur4. C' scan 5or a!!.C' scan 5or a!!.
Admit / oser0e :Admit / oser0e :
@+reuent neuro!ogic e=ams.@+reuent neuro!ogic e=ams.
@Repeat C' scan. @Repeat C' scan. Deterioration : Manage as se0ereDeterioration : Manage as se0ere
head in&ur4.head in&ur4.
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-EBERE 7RAIN INJURY -EBERE 7RAIN INJURY
3C- -core 9 # 6 .3C- -core 9 # 6 .
E0a!uate%resuscitate.E0a!uate%resuscitate.
Intuate 5or aira4 protection.Intuate 5or aira4 protection.
+ocused neuro!ogic e=am.+ocused neuro!ogic e=am.
+reuentree0a!uation.+reuentree0a!uation. Identi54 associated in&uries.Identi54 associated in&uries.
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-EBERE 7RAIN INJURY -EBERE 7RAIN INJURY
Aira4%7reathingAira4%7reathing
Aira4 protection.Aira4 protection.
-upp!ementa! o=4gen.-upp!ementa! o=4gen.
Assisted 0enti!ation.Assisted 0enti!ation.
ModestModest
h4per0enti!ation, i5 necessar4h4per0enti!ation, i5 necessar4
)aC < 6 #< mmHg2.)aC < 6 #< mmHg2.
+reuent ree0a!uation%A73s.+reuent ree0a!uation%A73s.
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-EBERE 7RAIN INJURY -EBERE 7RAIN INJURY
CIRCU*A'INCIRCU*A'IN
H4potension not due to rainH4potension not due to rain
in&ur4.in&ur4.
H4potension causes secondar4H4potension causes secondar4
rain in&ur4.rain in&ur4. @Correct@Correct
h4potension uic"!4.h4potension uic"!4.@Do not treat high 7),@Do not treat high 7),
maintain C)).maintain C)).
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-EBERE 7RAIN INJURY -EBERE 7RAIN INJURY
Disai!it4Disai!it4
3C-3C-
@E4e opening.@E4e opening.
@7est moto @7est motorresponse.response.
@Bera! response.@Bera! response.
)upi!!ar4 sie, eua!it4, reactio)upi!!ar4 sie, eua!it4, reactioto !ight.to !ight.
-4mmetr4 o5 motor strength.-4mmetr4 o5 motor strength.
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-EBERE 7RAIN INJURY -EBERE 7RAIN INJURY
Disai!it4Disai!it4
Minineuro!ogic e=amMinineuro!ogic e=am
@n patient arri0 @n patient arri0
@+reuent!4.@+reuent!4.
Document changes.Document changes. Consu!t neurosurgeon ear!4.Consu!t neurosurgeon ear!4.
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pada penderita Cederapada penderita Cedera
(epa!a(epa!a
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-EBERE 7RAIN INJURY -EBERE 7RAIN INJURY
HerniationHerniation
Deteriorating !oss o5Deteriorating !oss o5
consciousness 1 3C-consciousness 1 3C-
-core 2.-core 2. )upi!!ar4 as4mmetr4.)upi!!ar4 as4mmetr4.
Motor as4mmetr4.Motor as4mmetr4.
Cardiopu!monar4 arrest.Cardiopu!monar4 arrest.
CushingFs triad.CushingFs triad.
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Indications 5or C'Indications 5or C'
-can-can
A!! patients ithA!! patients ithsuspicion o5 rain in&ur4suspicion o5 rain in&ur4
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Medica! ManagementMedica! Management
Intra 0enous GuidsIntra 0enous Guids
@Eu0o!emia.@Eu0o!emia.@Isotonic. @Isotonic.
H4per0enti!ation, i5H4per0enti!ation, i5
necessar4necessar4@3oa! : )aC at < 6 #
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Medica! ManagementMedica! Management
Mannito!Mannito!
@Use ith signs o5@Use ith signs o5
tentoria! herniation. @Dose :tentoria! herniation. @Dose :$,< 6 ,$ g%"g IB o!us.$,< 6 ,$ g%"g IB o!us.
therther
@Anticon0u!sants.@Anticon0u!sants.@-edation.@-edation.
@)ara!4tics @)ara!4tics
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ManagementManagement
-ca!p in&uries-ca!p in&uries
)ossi!e site o5 ma&or !ood)ossi!e site o5 ma&or !ood!oss.!oss.
Direct pressure to contro!Direct pressure to contro!
!eeding.!eeding.ccasiona! temporar4ccasiona! temporar4
c!osure.c!osure.
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Intracrania! MassIntracrania! Mass
*esion*esion
Ma4 e !i5e6threatening i5Ma4 e !i5e6threatening i5
e=panding rapid!4.e=panding rapid!4. Immediate neurosurgica!Immediate neurosurgica!
consu!t.consu!t.
H4per0enti!ation%Mannito!.H4per0enti!ation%Mannito!. Emergenc4 urr ho!es Emergenc4 urr ho!es
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-UMMARY -UMMARY
)rescription 1 Do 2)rescription 1 Do 2
Maintain mean 7) ?$ mmHg.Maintain mean 7) ?$ mmHg.
Maintain )aC eteen < / #
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-UMMARY -UMMARY
)rescription 1 DonFt 2)rescription 1 DonFt 2
A!!o patient to ecomeA!!o patient to ecome
h4potensi0e.h4potensi0e.
0er aggressi0e!4 h4per0enti!ate.0er aggressi0e!4 h4per0enti!ate. Use h4potonic IB Guids.Use h4potonic IB Guids.
Use !ong6acting para!4tics.Use !ong6acting para!4tics.
)ara!4e e5ore per5orming)ara!4e e5ore per5ormingcomp!ete e=am.comp!ete e=am.
Depend on c!inica! e=am a!one.Depend on c!inica! e=am a!one.
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TR#MA KAS#$ TR#MA KAS#$