20 Trauma Kapitis

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    Trauma kapitisProf.DR.Dr.Hasan Sjahrir SpS(K)

    Departemen Neurologi FK USU

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    definisi

    Trauma kapitis : adalah trauma mekanikterhadap kepala baik secara langsungataupun tidak langsung yangmenyebabkan gangguan fungsi neurologis

    yaitu gangguan fisik, kognitif, fungsipsikososial baik temporer maupunpermanen.

    Sinonim: cedera kepala= head injury=trauma kranioserebral=traumatic braininjury

    75% KLL

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    epidemiology

    Incidence head trauma

    350 per 100.000 in Europe, 200 per

    100.000 in North America,

    US hospitalization rates due to traumaticbrain injury (TBI) are on the rise,

    85% mild head injury,

    15% moderate - severe Head injury

    Severe head injury intracranialhaemorrhagic lesion 10-27%

    Less than 2% require neurosurgery

    1.Baandrup L & Jensen R. Cephalalgia 2005; 25:132138.

    2.National Institute of Health Traumatic Coma Data Bank

    3.Ropper AH, Gorson KC. N Engl J Med 2007;356:166-724.Thomas & Kegler. Morb Mortal Wkly Rep. 2007;56:167-170

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    Berat ringan cedera otak tgt:

    Besar & kekuatan benturan

    Arah & tempat

    Posisi/keadaan kepala

    Lesi yang terjadi:

    Lesi bentur(coup) Lesi media/antara

    Lesi kontra(counter coup)

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    Akibat lesi bentur thd otak

    Blockade ARAS

    Retensi cairan & elektrolit

    TIK meninggi Perdarahan

    Kerusakan otak primer

    Kerusakan otak sekunder

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    Pemeriksaan neurologis

    Monitor batang otak Besar & reaksi pupil, refleks kornea

    Dolls eye phenomen

    Monitor pernafasan Cheyne stokes lesi hemisfer

    Centr neuro hyperventilation lesi mesensefalon-pons

    Apneustic breathing : lesi pons

    Ataxic breathing lesi medula oblongata

    Monitor fungsi motorik

    Brills hematon, likuorrhea,battles sign Funduskopi

    Radiologi

    EEG

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    TBI (Traumatic Brain Injury)

    Closed head injury

    Primary injury Concussion

    Contusion Hematoma epidural, subdural, intraventricular,

    subarachnoid

    Secondary

    Hypotension, hypoxia, acidosis, edema, ischaemia orother subsequent factors that can secondary damage

    brain tissue

    Penetrating head injury

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    Eye Opening

    Score 1 Year 0-1 Year

    4 Spontaneously Spontaneously

    3 To verbal command To shout

    2 To pain To pain

    1 No response No response

    Best Motor Response

    Score 1 Year 0-1 Year

    6 Obeys command

    5 Localizes pain Localizes pain

    4 Flexion withdrawal Flexion withdrawal

    3 Flexion abnormal (decorticate)Flexion abnormal

    (decorticate)

    2 Extension (decerebrate) Extension (decerebrate)

    1 No response No response

    Best Verbal Response

    Score >5 Years 2-5 Years 0-2 Years

    5 Oriented and converses Appropriate words Cries appropriately

    4Disoriented and

    conversesInappropriate words Cries

    3Inappropriate words;

    criesScreams

    Inappropriate

    crying/screaming

    2Incomprehensible

    soundsGrunts Grunts

    1 No response No response No response

    Normal Skor

    pada anak:

    < 6 bulan : 126-12 bulan : 12

    1-2 thn : 13

    2-5 thn : 14

    > 5 thn : 14

    Normal skor

    Dewasa

    4+5+6=15

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    klasifikasi TK non Operatif

    Komosio cerebri

    Kontusio c

    Impresio fraktur non neurologik (< 1 cm)

    Fraktur basis kranii

    Fraktur kranii tertutup

    TK operatif

    Hematoma intrakranial > 75 cc Epidural, subdural, intraserebral/serebellar

    Fraktur kranii terbuka ( + laserasio)

    Impresi frk dengan kelainan neurologik (> 1 cm)

    Likuorrhoe yang tidak berhenti

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    Klasifikasi trauma kapitis

    berdasarkan WHO: (......ICD) Patologi:

    Komosio serebri Kontusio serebri

    Laserasio serebri Lokasi lesi

    Lesi diffus Lesi kerusakan vaskuler otak Lesi fokal

    Kontusio dan laserasi serebri Hematoma intrakranial

    hematoma ekstradural(hematoma epidural) hematoma subdural hematoma intraparenkhimal

    hematoma subarakhnoid hematoma intraserebral hematoma intraserebellar

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    Kategori SKG Gambaran Klinik CT Sken otak

    minimal 15 Pingsan (-),defisit

    neurologi(-)

    Normal

    Ringan 13-15 Pingsan < 10 men,defisit neurologik (-) Normal

    Sedang 9-12 Pingsan >10 men s/d 6

    jamDefisit neurologik (+)

    Abnormal

    Berat 3-8 Pingsan>6 jam, defisit

    neurologik (+)

    abnormal

    Catatan: Jika abnormalitas CT Sken berupa perdarahan intrakranial,

    penderita dimasukkan klasifikasi trauma kapitis berat

    Klasifikasi berdasarkan SKG di triase

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    Diagnostik : Trauma kapitis ringan(TKR) Mild Head injury:

    SKG 13-15,

    CT Sken normal,

    pingsan < 30 menit,

    tidak ada lesi operatif,

    rawat Rumah sakit < 48 jam,

    amnesia pasca trauma (APT) < 1 jam

    TKS=Moderate Head Injury SKG 9-12 dan dirawat > 48 jam,

    atau SKG > 12 akan tetapi ada lesi operatif intrakranial

    atau abnormal CT Sken, pingsan >30 menit- 24 jam, APT 1-24 jam

    TKB=Severe Head injury: SKG < 9 yang menetap dalam 48 jam sesudah trauma,

    pingsan > 24 jam, APT > 7 hari.

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    Komosio serebri (80%)

    Definisi: disfungsi neuron otak sementara,

    makroskopis normal

    Gejala:

    Pening/sakit kepala Tidak sadar < 30 menit

    Amnesia retrograde (AR) ,Amnesia anterograde (PTA)

    Mual muntah

    Pasien harus opname minimal 48 jam

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    Kontusio serebri (15-19%)

    Definisi: perdarahan interstitiil parenchymotak,tanpa putusnya kontinuinitas jaringan.

    =/= laserasio serebri Gejala gangguan neurologi fokal (+/-) Gejala

    Tidak sadar > 30 menit FASE I :Fase shock FASE II : FAse hiperaktif sentral FASE III : serebral oedem FASE IV: fase regenerasi/rekovalesens

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    Kontusi serebri pada anak2

    Fase latent

    Fase akut serebral (II)

    Fase regenerasi

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    Epidural hematom

    Def : antara tabula interna- duramater

    Lucid interval pendek

    Jarang pada anak2

    Hematom massif:

    Arteri meningea media

    Sinus venosus

    Dx: Brain ct scan

    X foto polos

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    Gejala epidural H

    Lucid interval (+) pendek : yaitu periode sadar diantara 2 fase penurunan

    kesadaran Kesadaran makin menurun Hemiparese terlambat Pupil anisokor Babinsky (+) Fraktur menyilang di temporal Kejang bradikardi

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    Gejala EDH fossa posterior

    Lucid interval tidak jelas

    Fraktur krainii oksipital

    Kehilangan kesadaran cepat

    Gangguan serebellum, batang otak,pernafasan

    Pupil isokor

    Prognosa jelek

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    Subdural hematom

    Def : duramater arakhnoid

    =/= hygroma subdural

    Hematom:

    Bridging vein robek Kausa: Tr.Kapitis, keheksi, ggan darah

    Lokasi frontal ,parietal, temporal

    Gejala/klasifikasi Akut : Lucid interval 0-5 hari Subakut : 5-15 hari

    Kronik : 15 hari - tahun

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    Intraserebral hematom

    Dwf: pecahnya arteri

    intraserebral/serebellar

    Mono- multiple

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    Fraktur basis kranii

    Anterior

    Media

    Posterior Diagnosa tgt gejala ,sebab x

    foto hanya 50%(+)

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    X foto

    X foto tengkorak 30% , fraktur

    (+)

    3-5% kelainan intrakranial

    kepentingan:

    Kematian 80% fraktur (+)

    Medikolegal

    kepentingan pengawasan klinik

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    Penanggulangan traumakapitis akut Atasi shock

    Air way

    Evaluasi kesadaran

    Amati jejas kepala & tubuh Awas fraktur servikalis

    Klinik neurologi & X ray

    Atasi oedema serebri

    Keseimbangan cairan & elektrolit, kalori

    Monitor tek intra kranial

    Pengobatan konservatif

    Refer bedah satraf atas dasar indikasi

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    Oedema serebri Def: peninggian cairan intra/ekstra sel

    otak o.k. proses lokal atau umum

    Jenis Vasogenik

    Sitotoksik

    Osmotik

    hidrostatik

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    VASO SITO OSMO HIDRO

    pato BBB sod pump osmotik gga LCS

    lokalisasi subs alba alb+grisea alb+grisea alba

    permeable meninggi normal normal normal

    histologis ekstrasel intra eks+intra ekstrasel

    unsur plasma plasma air air