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4_ Gangguan_Brain.ppt
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GANGGUAN BRAINBagian Anestesiologi dan ReanimasiFK Unsyiah RSUZABanda Aceh
OTAK MANUSIAOTAK MANUSIASebesar sayur kolSeberat + 1 kgBisa ditadah dgn sebelah tangan 1/50 Berat Badan
HARTA KARUN YANG BESAR RAKSASA TIDUR ANUGERAH YG PALING BERHARGA DARI TUHAN
Normal brain
Normal Brain and Scalp
CEREBRAL VEINS
NEUROPHYSILOGISC B F ( Cerebral blood Flow )ICP ( Intra cerebral Pressure )CMR O2 ( Cerebral Metabolism Rate )BBB ( Blood Brain Barrier )
CEREBRAL BLOOD FLOW Varies with metabolic activityRegional CBF 10 300 ml / 100 g / minTotal CBF averages 50 ml / 100 g / min < 20 25 ml/100 g/min cerebral impairment< 10 ml/100 g/min Irreversible brain damage Total CBF averages 750 ml / min ( 15 20 % CO )
PhysiologyCerebral Blood FlowMean CBF~50 mL/100g/mCoupled to CMRO2{~3.5 mL/100g/m}CBF = CPP/CVRAutoregulated bet CPP 50-150 mmHg
Gangguan Otak dapat disebabkan :
Trauma (paling sering) Penyakit Sistemik3. Stroke4. Intoksikasi
Kerusakan otak akibat cedera kepala menyebabkan kematian pada 34% dari seluruh kasus trauma. Limapuluh persen kasus trauma kepala akibat kecelakaan lalulintas.
Data dari Amerika Serikat, 1992
TRAUMA KEPALAKerusakan primer hipoksia hematoma kontusi DAI Kerusakan sekunder: kerusakan akibat proses biokimiawi
PathophysiologyPrimary Injury - occurs during trauma- damage already doneSecondary Injury- occurs following traumadue to hypoxia, hypotension, hypertension,free radicals etc- preventable
50140CBF MAP (mmHg)Autoregulation of cerebral blood flow(CBF)stable hereBrain injury destroy the autoregulation
Efek sekunder pada trauma kepalaCohadon,1995
Head trauma INJURIESScalpSkullMeningensBrain
CSFBlood supplyRESULTBleedingFracture & bleedingLacerationContusion, bleeding, edema, increase of ICPLeakage (fr basis cranii)Ischemia (due to shock and / or ICP increase)
Only severe trauma can break the skullAssume equal damage to the brain tissueSkull fracture
Brain contusion, bleeding, edema ICP increaseSigns : GCS < 8 / Sluggish Pupil Reflex, possibly asymetrical lateralisation of neurologic signs
CPP = MAP - ICP
CPP = cerebral perfusion pressureMAP = mean arterial pressureICP = intracranial pressure (TIK)
Brain injury results in increased ICP
MAP should not decreaseto prevent reduction of CPP
Increased ICPDangerbrain herniation:medula oblongata to foramen magnumtrans-tentorialdamage to cortex cerebri & other structuresSigns:decreased consciousness / vomitincreased BP (up to > 200 mmHg)decreased pulse rate (bradikardia < 60)
Secondary InjuryHypoxiaHypoperfusion due to shockICP MAP HypoglycemiaHyperthermia Convulsion
Neurologic examinationmainGlasgow Coma ScorePupil (size, symmetry, light reflex)(cornea reflex)
Eyeball position Occulocephalic ReflexOcculovestibular ReflexFundus occuli
Glasgow Coma Score Eye opening (buka mata)Open spontaneously4Open to command3Open to pain2None1Buka mata spontanBuka mata diperintahBuka mata karena nyeriTidak buka meski dirangsang nyeri
Glasgow Coma Score Best verbal response (bicara)Oriented5Confused4Inappropriate words3Inappropriate sounds2None1Orientasi baikBingungBicara tak tepatSuara tak jelasDiam
Glasgow Coma ScoreBest motor response (gerak ekstremitas)Obeys command6Localises to pain5Withdraws to pain4Abnormal flexion3Extensor response2None1Menurut perintahMenunjuk tempat nyeriMenarik menjauhi nyeriFleksi abnormal thd nyeriEkstensi thd nyeriTak ada gerakan
KLASIFIKASI CEDERA KEPALACedera kepala ringan GCS 13 - 15 Cedera kepala sedang GCS 9 - 12 Cedera kepala berat GCS 8
Sistem AVPU
A = Alert, sadar baikV = Respon verbalP = Respon terhadap nyeriU = Unresponses
Neurologic ExaminationadditionalRespiratory patternScalp and skull Membrana tympaniMuscle tonusTendon Reflex Posture
Pupil ResponseSize. mmLight reflexpresent / absentnormal / sluggishSymmetryisochoric / an-isochoric
Manangement of Head TraumaAIRWAYBREATHINGCIRCULATION
Prevent ICP Prevent hypoxiaPrevent hypoventilationPrevent shockPrevent Secondary Injury
INDIKASI INTUBASI Tidak mampu mempertahankan dan melindungi jalan nafas Ventilasi dan oksigenasi tidak memadai untuk mencegah hipoksia otak
FAKTOR YANG DIPERTIMBANGKAN Fraktur tulang leher Fraktur larynx Fraktur maxilofacial Stimulasi reflek simpatetik pada trachea
Severe head injury- Head-up 20o tilt to prevent increase of ICP- Complete the secondary survey - Repeat examination periodically - Prevent Hyperthermia
Hipoksia merupakan salah satu faktor yang bertanggung jawab terhadap kerusakan otak. Hipoksia mengawali terjadinya kerusakan sekunder otak. Hipotensi berkaitan dengan peningkatan mortalitas dua kali lipat. Hipotensi yang berlangsung singkat pada awal resusitasi sudah dapat meningkatkan mortalitas.
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