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Traumatic Brain Injury

Dr Dita Aditianingsih, SpAn
 Pendahuluan

- 40 % total mortalititas
- Injuri primer : trauma tumpul, tajam
- Injuri sekunder :
. Hipoksia, hiperkarbia, hipotensi,
anemia, hiperglikemia
. Kejang, infeksi/sepsis, hipertermia,
gangguan elektrolit, koagulopati

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 Penilaian klinis

Tanda vital (TNSP, kesadaran)

- Reflek Cushing → herniasi
(hipertensi, bradikardia, bradipnea)
- Takiaritmia, VES
- Edema paru
- Apneic, Cheyne-Stokes, hiper-
hipoventilasi
- Hipertensi-hipotensi
- Hiper-hipotermi

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 Penilaian klinis

Inspeksi
- Hematoma periorbital (raccoon eye)
dan retroaurikuler (battle)
- Laserasi/luka kepala
Defisit neurologis
- Syaraf kranial, motorik, sensorik
GCS

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 Glasgow Coma Scale
- Eye : spontaneusly 4
to speech 3
to pain 2
none 1

- Verbal : oriented 5
confused 4
inappr. words 3
incompr. sounds 2
none 1
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 Glasgow Coma Scale

- Motor response :
obeys 6
localizes 5
withdraws 4
abnormal flexion 3
extensor response 2
none 1

Total GCS : E..V..M..

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 Evaluasi neurologis

Trauma kepala ringan

- GCS 14-15, pingsan <5 menit,
pengawasan, indikasi ICU (-)
Trauma kepala sedang
- GCS 9-13
Trauma kepala berat
- GCS 3-8, indikasi ICU (+)

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 A current model developed by the Department of
Defense and Department of Veterans Affairs uses all
three criteria

Severity of traumatic brain injury [13

  GCS PTA LOC

<1 0–30
Mild 13–15
day minutes
]

>1 to <7 >30 min to

Moderate 9–12
days <24 hours
>24
Severe 3–8 >7 days
hours

PTA : Post Traumatic Amnesia,

LOC : Loss Of Conciousness

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 Pemeriksaan penunjang

Klinis
CT SCAN
MR CT

SURGICAL, EARLY
NON TRAKEOSTOMI
SURGICAL (-/+)

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 Pemeriksaan Penunjang

CT SCAN
- Diffuse axonal injury, loss of gray-
white diff., kompersi ventrikel,
perdarahan (epidural, subdural,
subarahnoid, intraventrikel), kontusio
multifokal, edema, menghilangnya
cisterna basal, kompresi batang otak

MRCT
- Lebih baik DAI, lesi hiper-hipointens
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 The Marshall CT grading system

Tingkat Hasil CT TBI Mortalitas

injuri
I Normal 9,6%
II Cisterna intak : 13,5%
shift<5mm
III Cisterna kompresi/hilang 34%
:shift<5mm
IV Cisterna kompresi/hilang 56,2%
:shift>5mm

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 Prognosis

- Prognosis buruk :
GCS < 8, hipotensi (sistolik < 90
mmHg, hipoksia PaO2 60 mmHg
Mortalitas 75%

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 Autoregulasi Aliran Darah Otak

Respon CVR ↑, PCO2 ↓, ICP ↓

Iskemia/infark

CBF ↓ Metabolis Edema ICP ↑

me otak ↑ sitotoksik

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 Gangguan autoregulasi

Vasokonstriksi

Hipokapnia PCO2 ↓ Iskemia

regional/difus ↑

Hipoksia, anemia, hipotensi

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 ICP

JARINGAN OTAK

ICP
DARAH

LCS

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 Tanda Peningkatan ICP

- Sakit kepala
- Mual, muntah
- Papiledema
- Dilatasi pupil unilatral
- Gangguan saraf okulomotor, abdusen
- Penurunan kesadaran
- Pola nafas abnormal
- CT scan/MRI : midline shift 0,5cm
pembesaran otak ke dalam ventrikel
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 Penatalaksanaan

1 RESUSITASI INISIAL

a Survei Primer

b Survei Sekunder

2 PERAWATAN INTENSIF

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 SURVEI PRIMER

RESUSITASI
INISIAL SIRKULASI
BREATHING

DISABILITY SURVEI
PRIMER
AIRWAY

EKSPOSUR

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 Survei Primer

- Anamnesis (Allergic, Medication, Past

medical history, Last meal, Event)
- Airway
. Stabilisasi in-line
. Amankan jalan nafas (suction,
O/NPA, intubasi), NGT
. Hati2 perubahan hemodinamik, ICP,
PCO2, PaO2
. Rapid sequence induction, LMA,
fiberoptic intubation

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 Survei Primer

. Intubasi :
. Lidokain 1,5 mg/kg IV
. Propofol, pentotal, etomidat
. Relaksan short acting
. Konfirmasi : ET CO2, foto thorak

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 Survei Primer

- Breathing
. Oksigen high flow, cegah PaO2 <90
. Ventilasi tekanan positif, PEEP 5-10
cmH2O, PCO2 35-40 mmHg
. Sedasi (midazolam, propofol,
dexmedetomidine), analgesi
(fentanil, morfin)

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 Survei Primer

- Circulation
. Atasi syok/hipotensi, SBP >90
mmHg, jaga CPP, dengan cairan IV,
obat vasoaktif (dopamin,norepinefrin)
- Disability
. Nilai GCS, defisit neurologis, ↑ ICP, herniasi
transtentorial sebelum pemberian sedasi,
relaksan
- Exposure
. Nilai trauma tempat lain, cegah
hipo/hipertermia
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 Survei Sekunder

1 2 3
Pemeriksaan Tindakan Terapi
radiologis intervensi konservatif
(xray, CT scan) (operasi, (non/medikame
DPL pemasangan ntosa)
Hematologi monitor invasif)
Ur/Cr
GDS
Elektrolit

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 Perawatan Intensif

RESUSITASI
INISIAL Kontrol GD
Atasi demam

Nutrisi Monitoring

Terapi ↑ICP

Cegah kejang

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 Perawatan Intensif
Monitoring:
- Non-invasif : EKG, Sat O2, ETCO2,
NIBP, suhu, urin
- Invasif : ICP, CVP, IABP
Indikasi monitor ICP:
- CT scan abnormal, GCS 3-8, adekuat
resusitasi syok & hipoksia
- CT scan normal, GCS 3-8,
usia>40th,
SBP<90 mmHg

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 Monitoring ICP
Alat monitor ICP
- Kateter intraventrikel
- Pengukuran, terapi drainase LCS
Terapi :
Autoreg. rusak ICP/MAP slope>0,13
- ICP 20-25mmHg
- Target : CPP>60 mmHg (MAP-ICP)
Autoreg. intak ICP/MAP slope<0,13
- ICP 25-30mmHg
- Target : CPP>70mmHg

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 Terapi ICP

Cegah komplikasi :
- Hidrosefalus
- Herniasi
Penatalaksanaan :
- Non-medikamentosa
- Medikamentosa

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 Non-medikamentosa

1 Elevasi kepala 15-30

2 Ventilasi, PaCO2 35mmHg

3 PEEP < 10 mmHg

4 Suhu normal <38 C

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 Non-medikamentosa

5 Cegah obstruksi vena juguler

6 Drainase LCS

7 Normal homeostasis

8 Operasi dekompresi

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 Medikamentosa

1 Manitol, NaCL 3%, diuretik

2 Sedasi, analgesi, relaksan

3 Profilaksis kejang

4 Resusitasi cairan, vasoaktif

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 Medikamentosa

Manitol drip
- 0,25-1g/kgbb/6-8jam
NaCl 3%
- Hati2 kenaikan kadar Na>160 meq/dl
Diuretik
- Furosemide bolus/drip
Analgesi
- fentanil, morfin
Relaksan
- Vekuronium
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 Medikamentosa

Sedasi
- Midazolam, diazepam
- Koma barbiturat : tiopental bolus 10
mg / kgbb dalam 30 menit, 1-2mg /
kgbb/jam, propofol 1-2 mg/kgbb,
drip 50-150 mcg / kgbb /menit
Cairan koloid/kristaloid
Vasoaktif
- Dopamin, norepinefrin

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 Perawatan Intensif

Kontrol GD (80-110 mg/dl)

- Drip insulin, sliding scale
- Obat antidiabetik oral
- Diet
Atasi kejang
- 7 hari pertama, fenitoin bolus
15mg/kg IV 20 menit, 5-7mg/kg/hari
Atasi demam
- Selimut pendingin, antipiretik,
antibiotik

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 Perawatan Intensif

Nutrisi :
- Protein 15% kalori total hari ke 7
- Enteral
- Anti stress ulcer : H2 antagonis,
penghambat proton pump
Terapi lain :
- Profilaksis DVT
- Steroid (?)
- Progesteron (?)

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 Perawatan Intensif

Protokol (standarisasi terapi)

- Manajemen trauma kepala
- ICP/CPP, SjvO2
- Insulin
- Sedasi, analgesi
- Nutrisi (enteral, parenteral)
- Profilaksis stress ulcer
- Profilaksis DVT

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 Perawatan Intensif

Target terapi :
- SBP >90mmHg, MAP >60mmHg
- CVP >10cmH2O
- CPP >60mmHg
- ICP <20-25mmHg
- PaO2>60 atau SaO2>90%
- PaCO2 35-40 (ICP normal)
30-35 (ICP meningkat)
25-30 (ICP respon -)
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 Perawatan Intensif

Target terapi :
- Suhu <38 C
- INR <1,5
Trombosit >100.000
- GD 80-120 gr/dl

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 Indikasi operasi

- Trauma otak primer non-fatal

- Edema otak fokal/assimetrik
- Hipertensi intrakranial refrakter
- Gagal terapi medis, drainase LCS
- Usia < 55 tahun (relatif)

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