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7/27/2019 Case Subdural Hematom Asep
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Subdural Hematom
Asep Aminudin AzizPembimbing : DR.dr. M.Z. Arifin . SpBS(K)
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Tn. Romlan/73 thn// 13060729/Trauma/MZKU : Penurunan kesadaran
AK:
2 jam SMRS ketika pasien sedang berjalan didaerah Husein Bandung tiba-tiba
pasien tertabrak motor dari arah belakang, sehingga pasien terjatuh dengan kepala
membentur aspal. Riwayat pingsan (+), muntah (-), perdarahan telinga, hidung dan mulut (-).
Pasien langsung dibawa ke emergensi RSHS
Survei Primer
A : Clear + C-spine control
B : Bentuk dan gerak simetris, VBS kanan = kiri , RR : 20x/menit
C : HR : 82x/menit , TD 120/80 mmHg
D : GCS : E3M5V2 = 10 Pupil bulat anisokor ODS 3/5mm, RC +/+
Motorik : parese -/-
Survei Sekunder
At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasar subcutis
At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasar subcutis
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Rontgen Kepala
tidak ada garis fraktur
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Head CT Scan (Hasan Sadikin ,14-6-2013)
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Head CT Scan :
Soft tissue swelling ar left
parietooccipital et left frontal
Bone discontinuity (-)
Sylfian fissure compressed
Sulcy and gyri compressed
Hyperdense mass crescent shape at
right frontotemporoparietal
Ventricle and cysterns are
compressed
Midline shift > 5 mm to the left
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Thorax x-ray:normal
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Lab :
WD/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome
frontotemporoparietal dextra (S06.5)+ vulnus laceratum at parietooccipital
sinistra (S01.0)
Th/ Craniotomy Evacuation
ICU Ward
Hb 14.4
HMT 42
Leko 13800
Trombo 193.000
GDS 137
Na 138
K 3.4
ur 30cr 1.05
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WD/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subdural hematome
temporoparietooocipital dextra (S06.5)+ vulnus laceratum at parietooccipital
sinistra (S01.0)
DO : a/r ltemporoparietooccipital dextra:
- Duramater intact, bluish, tensed
- SDH clot 30 cc, lysis 5 cc, from Bridging vein
- GCS pre op : E3M5V2 = 10
- Interval op : 10 hours
Intra Operative Finding :
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Permasalahan
Bagaimana mekanisme truma pada pasien ini
karena pada pemeriksaan fisik ditemukan jejas
sebelah kiri sementara pada pemeriksaan CT
Scan kesan SDH sebelah kanan ?
Apakah indikasi opersi pada pasien ini ?
Bagaimana prosedur tindakan yang dilakukan
bila ditempat pelayanan tidak terdapat CT-
Scan
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PEMBAHASAN
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ResumeAnamnesis
/73tahun
2 jam SMRS mengalami kecelakaan lalu lintas, terjatuh,
kepala membentur aspal.
Pingsan (+)
Langsung ke RSHS
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Pemeriksaan fisik
GCS : E3M5V2 = 10 Pupil bulat an isokor ODS 3/5mm, RC+/+ , Motorik : parese -/-
At l parietal sin: hematome (+), VL ukuran 3x1x1 cm dasarsubcutis
At occipital sin: vulvus laceratum (+) ukuran 5x1x1 cm dasarsubcutis
CT scan kepala : SDH frontotemporoparietal dextra LAB: Hb: 14,4, L;13.800
Dx/ Cedera Kepala Sedang (GCS 10) (S06.0) + Subduralhematome frontotemporoparietal dextra (S06.5)+ vulnuslaceratum at parietooccipital sinistra (S01.0)
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Mechanism of injury in head trauma
Direct trauma by compression or crushing
Acceleration-Deceleration Injuries Brain has inertia. For example, when a person falls backwards onto a hard floor, the
back of the persons head hits the floor and stops. The brain, however, is stillmoving until it strikes the inside of the skull. If the brain gets bruised, there isbleeding, also called a hemorrhage. This bleeding causes further damage to the
brain. The skull does not need to strike an object in order for the brain to get injured.
There are many situations in motor vehicle crashes where the forces aretransmitted through the brain without the skull hitting the dashboard, windshield,steering wheel or window.
Coup/Contrer-CoupInjuries:Related to acceleration-deceleration injuries(e.g injury totemporal lobe in contralateral temporal trauma)
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Subdural Hematoma
A subdural hematoma (SDH)is a form of traumatic braininjury in which blood gathersbetween the dura and the
arachnoid.
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Subdural Hematoma
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Subdural hematomas
Occur between the dura and the arachnoid mater.
Typically, low-pressure venous bleeding of bridging
veins (superior cerebral veins) (between the cortex andvenous sinuses) dissects the arachnoid away from thedura and layers out along the cerebral convexity
Can be acute, subacute or chronic
CT Scan shows a crescent shaped clot. It conforms tothe shape of the brain and the cranial vault, exhibitingconcave inner margins and convex outer margins
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a) Acute subdural hematomas
most common types of intracranial hematomas.
often occur in head trauma from falls and motor vehicle
accidents,assults. Associated with compression of the brain and cerebral edema and
which increase intracranial pressure
Mortality and morbidity are high
b) Subacute subdural hematomas Take a week for symptoms to develop.
c) Chronic subdural hematomas
develop over weeks or months.
occur mostly in old patients esp those taking antiplatelet andanticoagulant drugs and with brain atrophy.
common in alcoholics (susceptible to falls)
Increased intracranial pressure and cerabral edema are unusual.
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Acute Subdural Hematoma
Crescent shaped;Hyperdense, may contain hypodense foci due
to serum, CSF or active bleeding
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Diagnosis Radiographic findings
hyperdense crescent-shaped
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Diagnostic Imaging
Noncontrast head CT scan (imaging study ofchoice for acute SDH) The SDH appears as a hyperdense (white) crescentic
mass along the inner table of the skull, mostcommonly over the cerebral convexity in the parietalregion. The second most common area is above thetentorium cerebellum
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History
Usually involves moderately severe to severe blunthead trauma
Acute deceleration injury from a fall or motor vehicleaccident, but rarely associated with skull fracture
Generally loss of consciousness
Any degree or type of coagulopathy should heightensuspicion of SDH
Commonly seen in alcoholics because theyre proneto thrombocytopenia, prolonged bleeding times, and
blunt head trauma Patients on anticoagulants can develop SDH with
minimal trauma and warrant a lowered threshold forobtaining a head CT scan
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Epidemiology
Trauma
- Frequency is related directly to the incidence of
blunt head trauma
-Its the most common type of intracranial mass
lesion, occurring in about a third of those withsevere head injuries
Acquire coagulopathies
Anticoagulation therapy Congenital bleeding disorders
Arteriovenous malformations
Aneurysm rupture
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Mortality/Age
Mortality Simple SDH (no parenchymal injury) is associated
with a mortality rate of about 20% Complicated SDH (parenchymal injury) is
associated with a mortality rate of about 50% Age Its associated with age factors related to the risk
of blunt head trauma
More common in people older than 60 years(bridging veins are more easily damaged/falls aremore common)
Bilateral SDHs are more common in infants sinceadhesions existing in the subdural space are
absent at birth
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Diagnosis Clinical manifestations
Headache
Nausea Vomiting Alteration of consciousness orneurological status Pupillary dilatation Focal neurological deficit Intracranial shift or herniation
Note:
For people taking anticoagulants e.g aspirin, the possibility of developing
intracranial hematomas from minor head injuries is increased.
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Treatment
Subdural hematomas
Symptoms: persistent headache, fluctuating drowsiness, confusion,memory changes, paralysis on the side of the body opposite thehematoma, and speech or language impairment.
Small ones require no treatment because the blood is absorbed onits own.
Large ones removed by surgery, (a drain is usually inserted and leftin place for several days).
monitored closely for recurrences.
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Treatment Surgical evacuation
Indications
Significant mass effect
Thickness of hematoma > 10 mm
Midline shift > 5 mm
Decrease in GCS score by 2 or more
Loss of pupillary reactivity or pupillary dilatation
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Outcomes Degree ofmass effect is more importantthan
Extracerebral mass lesions
Associated factor
age, time to evacuation, admission GCS score,
hypoxia or hypotention, extent of primary brain
injury, duration of coma, mechanism of injury,
present of coagulopathy
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Thank you
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NP 1. Mr Romlan/73 yo// 13060729/Trauma/MZ
CC : decreased of conciousnessHistory :
2 hours prior to admission, when he was walking at Husein area, suddenly he wasstrucked by motorcycle from behind. he fell down and him head hit the ground.History of unconscious (+), vomiting (-), bleeding from ear (-), nose (+) and mouth (-).he was brought direcly to Emergency Hasan Sadikin Hospital.
Primary Survey :
A : Clear + C-Spine control
B : Shape and movement simmetrycal ; Rh -/- ; RR = 20x/m
C : BP : 120/90 mmHg PR : 82 x/m
D : GCS E3M5V2 = 10
Pupil round unequal ODS 3/5 mm LR +/+Motoric : no paresis
Secondary Survey :
At left parietal : hematome (+), VL size 3x1x1 based on subcutis
At Left occipital : vulvus laceratum (+) size 5x1x1 cm based on subcutis
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Head CT Scan (Hasan Sadikin ,14-6-2013)
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Head CT Scan :
Soft tissue swelling ar left
parietooccipital et left frontal
Bone discontinuity (-)
Sylfian fissure compressed
Sulcy and gyri compressed
Hyperdense mass crescent shape at
right frontotemporoparietal
Ventricle and cysterns are
compressed
Midline shift > 5 mm to the left
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Thorax x-ray: within normal limit
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Lab :
WD/ moderate Head Injury (GCS 10) (S06.0) + Subdural hematome at left
temporoparietooocipital (S06.5)+ vulnus laceratum at left parietooccipital
(S01.0)
Th/ Craniotomy Evacuation
ICU Ward
GCS this morning E3M6V5 = 14
Hb 14.4
HMT 42
Leko 13800
Trombo 193.000
GDS 137
Na 138
K 3.4
ur 30cr 1.05
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WD/ moderate Head Injury (GCS 10) (S06.0) + Subdural hematome at left
temporoparietooocipital (S06.5)+ vulnus laceratum at left parietooccipital (S01.0)
Th/ Craniotomy Evacuation
DO : a/r left temporoparietooccipital :
- Duramater intact, bluish, tensed- SDH clot 30 cc, lysis 5 cc, from Bridging vein
- GCS pre op : E3M5V2 = 10
- Interval op : 10 hours
Intra Operative Finding :
Recommended