Trauma Brain Injury, Kuliah Pakar

Head Trauma
Dr. Candy Lauwrenz SpS, MMKes, QIA
Head Trauma
Statistics :
In USA, 150-300 peoples dead due to head injury per
year.
Mortality rate of TBI is about 25 /100.000 pop ulation
annualy
Disability rate are three time
Main dead cause of young productive peoples
Cost : $ 400 billion per year
- Income loss - Medical fee
- Insurance cost - Indirect cost
(Narayan, 2005)
No data in Indonesia
Pathophysiology
Traumatic Brain Injury
Primary vs. Secondary

Injury
Primary
injury - direct
physical injury to neurons and
glial cells
Secondary injury physiological events after the
primary injury further damage.
Primary Injury
Impact
: epidural, subdural,
contusion, intracerebral hemorrhage,
skull fractures
Inertial
injury
: concussion, diffuse axonal
Hypoxic/Ischemic
Secondary Injury
Hypoxic-ischemic
injury
Release of excitatory amino acids
Excess NMDA receptor activity
Concurrent hypotension and
hypoxemia may be present
Inflammatory response
Jenis trauma
:
Ekstrakranial
Luka pada jaringan kulit bisa :
Luka tertutup oleh karena benda
tumpul berupa hematoma.
Luka terbuka akibat benda tajam /
runcing seperti luka sayat, luka
tusuk, terpotong.
11
12
Jenis trauma
:
Fraktur Tengkorak
Fraktur
pada batok kepala :
Linier
fraktur
Depresed fraktur
Comminuted fraktur
Fraktur
pada basis tengkorak
Longitudinal
fraktur
Transversal fraktur
Circular fraktur
13
Depressed Fraktur
14
15
16
Jenis trauma
:
Intrakranial
Trauma serebri :
Komotio serebri
(gegar otak)
Kontusio serebri
Laserasi serebri
17
Mekanisme trauma serebri :

Pergeseran,
otak dapat
bergesekan dengan tulang
tengkorak
Tergencet & terjepit oleh jaringan
keras disekitarnya
Mengalami pantulan (counter
coup)
18
Akibat trauma serebri berupa

oedema
serebri
perdarahan subaraknoid, subdural,
epidural
petechia / hematoma intraserebral
laserasi / memar
terpotong
19
Guidelines for the

Management
Initial :
Airway and Oxygenation
Breathing
Blood Pressure Control
Seizures Prevention
Fluid and Nutrition
Body Temperature
Exitation, vomitus, headache
(Fewel et al, 2003)
CONSIDER .
Cerebral
Blood Flow (CBF)

Mean Arterial Pressure (MAP)
Intracranial Pressure (ICP)
PENILAIAN GLASSGOW
COMA SCALE (GCS)
TAMPAKAN
SKALA
NILAI
EYE
OPENING
SPONTAN
DIPANGGIL
RANGSANG NYERI
TIDAK ADA RESPONSE

(DIAM)
22
23
PENILAIAN GLASSGOW
COMA SCALE (GCS)
TAMPAKAN
SKALA
NILAI
VERBAL
RESPONSE
ORIENTASI BAIK
JAWABAN KACAU
KATA-KATA TIDAK
PATUT
(INAPPROPRIATE)
BUNYI TAK BERARTI
INCOMPREHENSIBL
E
TIDAK BERSUARA
1
24
PENILAIAN GLASSGOW
COMA SCALE (GCS)
MOTOR
RESPONSE
SESUAI PERINTAH
LOKALISASI NYERI
REAKSI PADA NYERI
FLEKSI (DEKORTIKASI)
EKSTENSI
(DESEREBRASI)
TIDAK ADA RESPONSE
(DIAM)
2
1
25
26
27
MANAGEMENT OF
INCREASED ICP
Head elevation
Hyperventilation
Osmotic Therapy
Sedation
Cerebrospinal Fluid Drainage ( Ventricular, Subdural
Drainage )
beneficial in treating the hydrocephalus seen in
thalamic hemorrhage with ventricular extension
2003)
(Broderick et al, 1999; Fewel et al.,
ICP MONITORING
Placed in patient with GCS = 9

Cerebral Edema on CT, Multipel Intracranial Lesions
The duration not exceed of 5 days
Patient with suspected elevation ICP and
deteriorating level of conciousness are candidates
for invasive ICP Monitoring
Intraventricular ICP monitoring and
intraparenchymal fiber optic ICP device are two
commonly used methods of monitoring ICP
(Orlando Regional Health Care, 2003)
Pharmacological
Neuroprotection
1.
2.
3.
4.
Glutamate receptor antagonists,

Calcium antagonists
Free radical scavengers, and
Cyclosporin A
1. Glutamate receptor
antagonists
The
amino acid L-glutamate is an

extensively distributed, mostly
excitatory neurotransmitter in the
CNS.
Extracellular glutamate >>
deleterious effects to neurons.
Glutamate receptors : NMDA, AMPA
and Kainate receptors.
2. Calcium Antagonist
Nimodipine
Not
recommended for severely

head injured patients.
Treatment of the TBI patients
without signs of subarachnoid
bleeding is not indicated.
3. Free radical scavengers

TBI
may lead to an increase in intracellular

free radical activity.
Antioxidatives agents:
Tirilazad
No significant positive influence of treatment
with tirilazad on outcome of severely TBI
(phase III)
Polyethylene
glycol-conjugated
superoxide dismutase (PEG-SOD).
Trend towards better outcome
compared placebo (phase III)
4. Cyclosporin A
Cyclosporin
is a cyclic polypeptide,
consisting of 11 amino acids.
Transplantation medicine as an
immunosuppressant
Protective effect on mitochondrial
ultrastructure, and most likely
mitochondrial function, and on cytoskeletal
derangements after TBI (animals study).
No clinical phase II or III trials evaluating
the efficacy of cyclosporin A in the
treatment of human severe TBI
Citicholin
Mechanisms:
Preserving cardiolipin (an exclusive inner
mitochondrial membrane component) and
sphingomyelin;
Preserving the arachidonic acid content of
PtdCho and Ptd-ethanolamine;
Partially restoring PtdCho levels;
Stimulating glutathione synthesis and
glutathione reductase activity;
Attenuating lipid peroxidation; and
Restoring Na/K-ATPase activity.
Conclusions
Pathophysiological
cascades initiated by injury

of brain have many features in common, and
brain ischemia and mitochondria dysfunction
frequently are the common denominator.
The
effort of mitigating brain injury include:

Maintenance of brain perfusion.
Maintenance to adequate oxygen delivery.
Optimizing source of brain energy.
Neuroprotective strategy
Conclusions
Neuroprotective
Strategies:
Non
Pharmalogical (Hypothermia).
Pharmacological Neuroprotetion.
CDP-Choline
is one of
Pharmacological Neuroprotection can
used in the treatment of TBI
Outcome and Mortality depend

on :
Primary
Cerebral damages
Optimal initial care
Neurosurgery consultation procedure
Immediate and percise surgery
Post-operative ICU
Medical rehabilitation

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Head Trauma

Dr. Candy Lauwrenz SpS, MMKes, QIA

Primary vs. Secondary

: concussion, diffuse axonal

pada batok kepala :

pada basis tengkorak

Mekanisme trauma serebri :

Akibat trauma serebri berupa

Guidelines for the

Blood Flow (CBF)

TIDAK ADA RESPONSE

REAKSI PADA NYERI

(Broderick et al, 1999; Fewel et al.,

Placed in patient with GCS = 9

(Orlando Regional Health Care, 2003)

Glutamate receptor antagonists,

amino acid L-glutamate is an

recommended for severely

3. Free radical scavengers

may lead to an increase in intracellular

cascades initiated by injury

effort of mitigating brain injury include:

Outcome and Mortality depend

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