Post on 23-Dec-2015
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HEAD INJURYHEAD INJURY
A N I N T R O D U C T I O NA N I N T R O D U C T I O N
AGUS BUDI SETIAWAN
NEUROSURGERY DEPARTMENT
AGUS BUDI SETIAWAN
NEUROSURGERY DEPARTMENT
HEAD INJURYHEAD INJURY
The Most Common Case
The Outcome is Still A Big Problem
The Most Common Case
The Outcome is Still A Big Problem
EVIDENCE BASED MEDICINE
GUIDELINES
HEAD INJURYHEAD INJURY
Declining mortality rate in severe head injury ( 50% to 36% between 1970 & 1980 )
The most probable cause is debatable
Declining mortality rate in severe head injury ( 50% to 36% between 1970 & 1980 )
The most probable cause is debatable
Quality Improvement in Emergency Medical Services
Better application of critical care methodologies
WHAT IS THE GOAL ?To Facilitate Healing
To Prevent Secondary Brain Damage
Maintain An Optimal Milieu
Uninjured Neuron
Injured Neuron
Fatally Damaged Neuron
Functioning Cell
Dead Cell
Optimal milieu
Suboptimal milieu
HOW TO MAINTAIN AN OPTIMAL MILLEU ?• Providing Good Oxygenation >< cerebral ischemia
• Preventing Hyponatremia >< seizure
• Preventing Hyperglycemia >< cerebral edema
• Providing Good Oxygenation >< cerebral ischemia
• Preventing Hyponatremia >< seizure
• Preventing Hyperglycemia >< cerebral edema
WHAT IS OUR ENEMYWHAT IS OUR ENEMY ?• High Intracranial Pressure
• Reduced Blood Pressure
• Hypoxia
• High Intracranial Pressure
• Reduced Blood Pressure
• Hypoxia
High Intracranial Pressure caused by :
• Hematoma
• Brain swelling / cerebral edema
• Pain
High Intracranial Pressure caused by :
• Hematoma
• Brain swelling / cerebral edema
• Pain
Reduced Blood Pressure caused by :
• Hypovolemic shock
• Severe Dehydration
Reduced Blood Pressure caused by :
• Hypovolemic shock
• Severe Dehydration
Hypoxia caused by :
• Pulmonary complication : hemato/pneumothorax
• aspiration pneumonia, lung contusion
Hypoxia caused by :
• Pulmonary complication : hemato/pneumothorax
• aspiration pneumonia, lung contusion
CLASSIFICATIONCLASSIFICATION
• Mechanism• Closed
• Penetrating
• Severity • Mild
• Moderate
• Severe
• Morphology • Skull Fracture
• Intracranial Lesion
• Mechanism• Closed
• Penetrating
• Severity • Mild
• Moderate
• Severe
• Morphology • Skull Fracture
• Intracranial Lesion
• Mechanism• Mechanism
CLOSED CLOSED
PENETRATINGPENETRATING
High Velocity High Velocity
Low Velocity Low Velocity
Gunshot Wound Gunshot Wound
Other open injuries Other open injuries
• Severity• Severity
GLASGOW
COMA SCALE
GLASGOW
COMA SCALE
MILD
GCS 13 - 15
MILD
GCS 13 - 15
MODERATE
GCS 9 - 12
MODERATE
GCS 9 - 12
SEVERE
GCS 3 - 8
SEVERE
GCS 3 - 8
TEASDALE AND JENNETT 1974
• Morphology• Morphology
SKULL
FRACTURES
SKULL
FRACTURES
VAULTVAULT
BASILARBASILAR
LINEAR OR STELLATE
DEPRESSED
LINEAR OR STELLATE
DEPRESSED
CSF LEAK
NERVE VII PALSY
CSF LEAK
NERVE VII PALSY
• Morphology• Morphology
INTRACRANIAL
LESION
INTRACRANIAL
LESION
FOCALFOCAL
DIFFUSEDIFFUSE
EPIDURAL
SUBDURAL
INTRACEREBRAL
EPIDURAL
SUBDURAL
INTRACEREBRAL
MILD CONCUSSION
CLASSIC CONCUSSION
DIFFUSE AXONAL INJURY
MILD CONCUSSION
CLASSIC CONCUSSION
DIFFUSE AXONAL INJURY
• EVALUATION
HISTORY OF ILLNESS HISTORY OF ILLNESS
Loss of consciousness
Loss of consciousness
Headache & vomitting Headache & vomitting
SeizureSeizure
Mechanism ? Mechanism ?
• EVALUATION
PHYSICALL
EXAMINATION
PHYSICALL
EXAMINATION
State of A B C State of A B C G C S, pupil, motoric G C S, pupil, motoric
Wound & Brain exposedWound & Brain exposed
Other injuries Other injuries
Sign of Skull Base FractureSign of Skull Base Fracture
• MANAGEMENT• MANAGEMENT
• A B C, & C Spine Stabilization
• Nasogastric Tube
• Pharmalogical Intervention
• Surgical Intervention
• A B C, & C Spine Stabilization
• Nasogastric Tube
• Pharmalogical Intervention
• Surgical Intervention
• MANAGEMENT• MANAGEMENT
A B C, & C Spine Stabilization
• Clear the airway
• Head extension with neck collar
• Oropharyngeal tube
• Oxygen supply 6 – 10 l/minute with face mask
• IV line
• Obtain Cervical X Ray and Head CT Scan
A B C, & C Spine Stabilization
• Clear the airway
• Head extension with neck collar
• Oropharyngeal tube
• Oxygen supply 6 – 10 l/minute with face mask
• IV line
• Obtain Cervical X Ray and Head CT Scan
• MANAGEMENT• MANAGEMENT
Nasogastric tube
• Preventing aspiration
• Beware of anterior skull base fracture
Pharmalogical Intervention
• Pain killer
• Mannitol 0,5 – 2 mg/ KgBW every 4 – 6 hour
• Anti convulsant agent
• Antibiotic
Nasogastric tube
• Preventing aspiration
• Beware of anterior skull base fracture
Pharmalogical Intervention
• Pain killer
• Mannitol 0,5 – 2 mg/ KgBW every 4 – 6 hour
• Anti convulsant agent
• Antibiotic
RADIOLOGICAL EXAMINATIONRADIOLOGICAL EXAMINATION
Skull X Ray
• Skull bone
• Lack of information especially for brain and soft tissue
Head CT Scan
• Gold standard
• Available for reconstruction
• Mandatory in patient with loss of consciousness
Skull X Ray
• Skull bone
• Lack of information especially for brain and soft tissue
Head CT Scan
• Gold standard
• Available for reconstruction
• Mandatory in patient with loss of consciousness
Surgical InterventionSurgical Intervention
• Indication
• When
• How
• Complication
• Indication
• When
• How
• Complication
Surgical InterventionSurgical Intervention
Indication
• Mass effect : midline shifting > 5 mm
• Depressed fracture > 1 diploe
• Penetrating head injury
• Headache
Indication
• Mass effect : midline shifting > 5 mm
• Depressed fracture > 1 diploe
• Penetrating head injury
• Headache