CEDERA KEPALA

ATLS… ATLS… ATLS… ATLS… ATLS… ATLS…

Sherly tandililing, dr

Common problem High morbidity and

mortality

ANATOMI

MENINGEN

LCS

Intracranial Pressure (ICP) 10mm Hg = Normal >20 mm Hg = Abnormal >40 mm Hg = Severe Many pathologic processes affect

outcome ↑ICP →↓Brain function,↓outcome

MONRO-KELLIE

Cerebral Blood Flow

50 mL/100 g/min normal < 25mL/100 g/min ↓EEG

activity ≤ 5 mL/100 g/min Cell death

Classifications of Head injury BluntByMechanism

Penetrating

Mild

By ModerateSeverity

Severe

High velocity

Low velocity

GSW

Other

GCS = 14-15

GCS = 9-13

GCS = 3- 8

Classifications of Head Injury

By MorphologyFocal Injury: Epidural Subdural Subarachnoid Intracerebral

Diffuse Injury

Epidural Hematoma Associate with skull fracture Classic : Middle meningeal artery

tear Lenticular/biconvex due to dural adherence to skull Lucid interval

Subdural Hematoma

Venous tear /brain laceration Covers entire cerebral surface Morbidity /mortality due to

underlying brain injury Rpid surgical evacuation

recommended, especially if > 5 mm shift of midline

Diffuse Axonal Injury

Prolonged deep coma (not due to mass lesion)

Diffuse brain injury Normal CT

Management Brain injury

Airway / Breathing Airway protection Supplemental oxygen Assisted ventilation if

necessary (Paco₂ at 25-35mm Hg) Frequent reevaluation/ABGs

Circulation Hypotension not due to brain injury Hypotension causes secondary

brain injury • Correct hypotension quikly • Do not treat ↑BP, maintain CPP

Disability GCS

• Eye opening • Best motor response • Verbal response

Pupillary size equality, reaction to light

Symmetry of motor strength

Disability Minineurologic exam

• On patient arrival • After resusciation • Frequently

Document changes

Cause IIIrd Nerve

compression bilaterally Inadequate CNS

perfusion

IIIrd nerve compression

tentorial herniation

Optic nerve injury

Cause Drugs Pontine lesion

Injured sympathetic

pathway

Hermation

Deteriorating LOC (GCS score) Pupillary asymmetry Motor asymmetry Cardiopulmonary arrest Cushing’s triad

Medical Management Intravenous fluids

• Euvolemia • Isotonic

Hyperventilation, if necessary • Goal : PaCO₂ at 25-35 mm Hg

Mannitol • Use with signs of tentorial

herniation • Dose : 0.5 –1.0 g/kg IV bolus

Other • Anticonvulsants • Sedation • Paralytics

Surgical Management

Scalp injuries Possible site of major blood loss Direct pressure to control bleeding

Intracranial Mass Lesion May be life threatening if expanding

rapidly Immediate neurosurgical consult Hyperventilation / Mannitol ? Emergency burr holes ?