penangan ck di emg

8/20/2019 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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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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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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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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Disai!it4Disai!it4

Minineuro!ogic e=amMinineuro!ogic e=am

@n patient arri0 @n patient arri0

@[email protected].

@+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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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#$

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