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 ?