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