Dr Bambang Priyanto, SpBS

ABC’S on Brain Injury

1. Airway dengan kontrol servikal,
2. Breathing, menjaga pernafasan dan
ventilasi
3. Circulation, iv line dan kontrol
perdarahan
4. Disability, status neurologis cepat
(AVPU/GCS)
5. Exposure (buka baju, cegah
hipotermi)
Prinsip Penanganan
“ little can be done about the primary
brain injury, but that a lot can be
done to minimize secondary brain
injury “

 Close observation
 Prompt diagnosis and treatment
 MANAGEMENT
 Pre Hospital
 Hospital

 Rehabilitation/Prevention
 Management : Pre Hospital
 Manage ABCs
• Airway : if needed intubate
• Breathing : oxygenation, ventilation
• Circulation : iv acces, blood pressure
 Manage ICP
• Head position
• Antiepileptic, analgesia
• osmotic/hypertonic fluid
 Rapid Transportation
MANAGEMENT HOSPITAL
ABC
PRIMARY
SURVEY
D

CONSERVATIVE OPERATIVE
SECONDARY
SURVEY

OBSERVATION
1. GCS 7. Restlessness
2. Neurologic Sign 8. Seizures
3. Vital Sign : BP, Pulse 9. Urinary
4. Position 10. Skin Care
5. Fluid 11. ICP Monitoring
6. Temperature 12. Drug / Medicine
Langkah-langkah Tatalaksana Cedera Otak di Ruang
Gawat Darurat
1. General precaution
2. Primary Survey and Rescusitation :
1. Airway dengan kontrol servikal,
2. Breathing, menjaga pernafasan dan ventilasi
3. Circulation, iv line dan kontrol perdarahan
4. Disability, status neurologis cepat (AVPU/GCS)
5. Exposure (buka baju, cegah hipotermi)

Pemeriksaan Tambahan :
• MONITOR EKG
• PEMASANGAN NGT
• KATETER URIN
• MONITOR : RR, AGD, Pulse oxymetri
• Radiologi : Servikal Lat, Thorak AP, Pelvis AP

PERTIMBANGKAN RUJUKAN
Penatalaksanaan di Ruang Gawat Darurat
Penatalaksanaan Umum
Stabilisasi : Airway, Breathing, Circulation
(ABC)
 Bersihkan jalan nafas dari darah, cairan
muntah, gigi palsu, benda asing
 Pertahankan posisi leher, pasang collar brace
 Berikan oksigen masker 6-8 lpm
 Pasang iv line ( Fr.18; blood set; cairan NS/RL)
sekaligus ambil sampel darah (± 10 cc)
 Resusitasi cairan dengan target TD > 100
mmHg; N < 100
 Neurologis singkat : Kesadaran, besar dan
bentuk pupil, reflek cahaya, hemiparese
(tanda-tanda lateralisasi)
Prompt Diagnosis and
Treatment
Langkah-langkah Tatalaksana Cedera Otak di Ruang
Gawat Darurat
3. Secondary Survey (pemeriksaan
status general terdiri dari anamnesa dan
pemeriksaan fisik seluruh sistem organ)
1. Anamnesa : AMPLE
2. Pemeriksaan FISIK : head to toe
3. Pemeriksaan Tambahan : CT SCAN, FOTO
EKSTREMITAS, ARTERIOGRAFI, USG,
ENDOSKOPI

4. TERAPI DEFINITIP
Penatalaksanaan di Ruang Gawat Darurat
Penatalaksanaan Umum
Anamnesis dan Pemeriksaan Fisik
Anamnesis :
Identitas, mekanisme trauma, jam kejadian,
riwayat pingsan, kejang, muntah, nyeri kepala.
Penyakit sebelumnya : epilepsi, pernah operasi
bedah saraf, hipertensi, kencing manis.

Pemeriksaan Fisik : 6 B
Breath : pola nafas, frekuensi nafas, tanda-
tanda distress nafas, tanda hematothorak,
pneumothorak, fraktur costae
Blood : pertahankan TD > 100 mmHg, atasi
sumber perdarahan aktif
Penatalaksanaan di Ruang Gawat Darurat
Penatalaksanaan Umum
Anamnesis dan Pemeriksaan Fisik (Lanjutan)
Pemeriksaan Fisik : 6 B
Brain : luka dikepala, fraktur tulang kalvaria,
benda asing, tanda-tanda fraktur basis kranii

Bowel : jejas, bising usus, tanda-tanda

perdarahan intra abdomen, pasang NGT
sesuai indikasi

Bladder : jejas, trauma urogenital, pasang

kateter urin sesuai indikasi

Bone : luka, jejas, dislokasi, nyeri tekan pada

semua ekstremitas
 Pemeriksaan Neurologis, terdiri dari
• Tingkat kesadaran (GCS)
• Saraf kranial
 Pupil besar & bentuk, reflek cahaya 
bandingkan kanan-kiri
 Motoris & sensoris  bandingkan kanan dan

kiri, atas dan bawah

 Autonomis: bulbocavernous reflek, cremaster
reflek, spingter reflek.
 Pemeriksaan Radiologis, atas dasar indikasi
• Cervical lateral, bila :
 Jejas di leher
 Nyeri di leher
 Mekanisme trauma (jatuh dari ketinggian, flexi extensi
leher dsb)
 Gejala neurologis kelainan spinal
 Pasien tidak sadar
• Photo kepala AP / Lat, bila
 Jejas di kepala dengan diameter > 5 cm
 Luka tusuk, clurit,tombak atau korpus alienum lain
 Fraktur terbuka
 Deformitas kepala
• Indikasi CT-Scan
 Nyeri kepala, muntah menetap dengan
obat-obatan
 Kejang

 Luka tusuk atau tembak, korpus alienum

 GCS < 15

 Penurunan GCS > 1 point

 Lateralisasi (anisokor, hemiparese)

 Bradikardia dengan gejala lain diatas

 Cidera kepala GCS < 15 disertai cidera

multiple organ
 Indikasi sosial
 Observasi di Ruang Gawat Darurat

 Setidaknya selama 2 jam

 dicatat setiap 15 menit
 Keadaan vital ( T, N, R, t )
 Keluhan : nyeri kepala, muntah,
kejang
 Neurologis
 GCS
 Pupil
 Motorik
 Sensorik
 Kriteria MRS (Masuk Rumah Sakit)

 Pernah tidak sadar

 GCS < 15
 Terdapat gejala neurologis fokal
(lateralisasi, kejang)
 GCS < 15 progresif neurologis menurun
 Keluhan menetap setelah diberi obat-
obatan
 Fraktur basis kranii
 Tak ada yang mengawasi di rumah
 Tempat tinggal diluar kota
 Kriteria MRS (Masuk Rumah Sakit)

 Mabuk, epilepsi, pernah operasi

kepala
 Disertai penyakit lain yang berat
 Umur > 50 tahun
 Atas permintaan keluarga
 Kriteria Penderita Boleh Pulang

 Sadar dan orientasi baik, tidak

pernah pingsan
 Tidak ada gejala neurologis fokal
 Keluhan berkurang, muntah atau
nyeri kepala hilang
 Tak ada fraktur kepala atau basis
kranii
 Ada yang mengawasi di rumah
 Tempat tinggal dalam kota
 Peringatan di rumah, segera
dibawa ke Rumah Sakit bila :
(baca dalam lembar peringatan)

 Muntah makin sering

 Nyeri kepala atau vertigo memberat
 Gelisah atau kesadaran menurun
 Kejang
 INDIKASI OPERASI

 Cidera Otak Tertutup,

pertimbangan operasi adalah :
• Klinis
 Deteriorasi Neurologis Progresive
 Tanda-tanda herniasi

 Tanda-tanda penekanan batang otak

 Masih terdapat reflex batang otak

 INDIKASI OPERASI

• Radiologis, terdapat efek masa yang

berarti, yaitu :
 Deviasi garis tengah lebih dari 0,5 cm.
 Penekanan atau penyempitan sisterna
basalis
 Pembuntuan aliran liquor atau kompresi
batang otak pada lesi di fossa posterior
• Fraktur impresi yang menimbulkan
gejala neurologis.
 Trauma Kepala Terbuka
 Outcome, tergantung

 Quality of early management

 Severity of primary brain injury

 Adequate referral policy

 Prompt diagnosis and treatment

•

 Adequate prevent and treatment of

complication
 Proper Rehabilitation
31 pairs of spinal
nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
 Suspicion of
Neurologic Injury
 History
• Pain/paresthesias
• Transient or persistent motor or
sensory symptoms
 Physical Examination
• Abrasions/hematoma
• Tenderness
• Interspinous process widening
 ASIA (American Spinal Injury Association)
Impairment Scale
 Class A : Complete, no motor or sensory
preserved in sacral segment S4-5
 Class B : Incomplete, sensory but no motor
function preserved below lesion
 Class C : Incomplete, motor function preserved
below lesion (lebih dari separuh otot
mempunyai kekuatan motorik< 3)
 Class D : Incomplete, motor function preserved
below lesion (lebih dari separuh otot
mempunyai kekuatan motorik ≥3)
 Class E : Normal, Sensory and Motor function
Complete:
i) Loss of voluntary movement of
parts innervated by segment, this
is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:

i) Some function is present below

site of injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury,
although they are rarely pure and
variations occur
 Treatment of Spinal Injuries
 No Current Effective Treatment

 Prevention is Key
all current medical and surgical
treatments aimed to prevent further
injury to the spinal cord.
 Goals

• Stabilisation and Decompresion

 Immediate Management-
Goals:

 Resuscitation according to ATLS

guidelines
 Determination of neurological injury

 Prevention of neurological deterioration

 Ongoing ID & Tx of assoc injuries

 Prevention of complications

 Initiation of definitive management for

vertebral column injury or SCI
 ABC’S on Spine Injury
1. Airway : Intubate
2. Breathing : Assisted ventilation
3. Circulation : iv line dan medications
for neurogenic syok
4. Disability : ASIA Score
5. Exposure:another trauma
 Airway
 Risk Associated  Ventilatory Function
with Level of • C1 - C7 = accessory
Injury muscles
• C3 - C5 = diaphragm
 Decision to
“C3-4-5 keeps the
Intubate diaphragm alive!”
 Airway • T1 - T11 =
Intervention  intercostals
INTUBATE • T6 - L1 = abdominals
 Breathing
Cough Function Vital Capacity (acute phase)
 C1-C3 = 0 - 5% of
 C1-C3 = absent
normal
 C4 = non-
 C4 = 10-15% of normal
functional
 C5-T1 = 30-40% of
 C5-T1 = non-
functional normal
 T2-T4 = 40-50% of
 T2-T4 = weak
normal
 T5-T10 = poor
 T5-T10 = 75-100% of
 T11 & below =
normal
normal
 T11 and below = normal
 Breathing
 Intervention
•O2 therapy
•Assisted ventilation (PRN)
•Medications (bronchodilators)
•Positioning and mobilizing
•Chest physio
•Assisted Cough
 Circulatory
Spinal Shock Neurogenic Shock
 Temporary suppression  The body’s response to
of all reflex activity
below the level of the sudden loss of
injury sympathetic control
 Occurs immediately
after injury  Distributive shock
 Intensity & duration
vary with the level &
degree of injury
 Occurs in people who
 Once BCR returns, have SCI above T6 (>
spinal shock is over 50% loss of
sympathetic
innervation)
 SYOK TD <90
SYOK HIPOVOLEMIK SYOK NEUROGENIK
(PERDARAHAN)
NADI ↑ NADI ↓
KERINGAT ↑ TIDAK BERKERINGAT
AKRAL DINGIN BIASA
Hb ↓ Hb NORMAL
PCV ↓ PCV NORMAL

TERAPI : TERAPI :
CAIRAN  DARAH VASOPRESSOR
SULFAS ATROPIN
ANALGETIK
 GI System
 Risk of aspiration is high d/t:
• cervical immobilization
• local cervical soft tissue swelling
• delayed gastric emptying
 Parasympathetic reflex activity is altered,
resulting in:
• decreased gut motility and
• often prolonged paralytic ileus.
 GI Intervention

 Minimizing Risk for Aspiration:

•Nasogastric tube

 Minimizing Risk of Gastric Ulceration:

 GU System

 All ASCI patients initially managed with

indwelling urinary catheter
Skin Care: Common Sites of Pressure
Sores

Occiput
Sacrum

Trochanter

Ischium

Ankle

Heel
 Skin Intervention
 Remove spine board

 Turn or reposition individuals with

SCI initially every 2 hours in the
acute phase if the medical condition
allows.
 Pain Management
 Nociceptive: Musculoskeletal and Visceral
Responds well to opioids and NSAIDS
 Neuropathic: Above Injury/At Injury
Level/Below Injury Level
• Somewhat sensitive to Morphine
• More sensitive to anticonvulsants
(gabapentin) and tricyclics
(nortryptiline)

www.iasp-pain.org
 Pharmacologic Therapy
 Option:
Methylprednisolone

 Others:
• Antioxidants
• NSAIDs
• Antagonis Calcium, Nimodipine
• Analgetics
• Antibiotics
MethylPrednisolone :

• 30mg/kg IV loading dose + 5.4 mg/kg/hr

(during 23hrs)
• effective if administered within 8 hours of
injury
NASCIS II (1992)

• If initiated < 3hrs continue for 24 hrs, if 3-

8 hrs after injury, continue for 48hrs
(morbidity higher - increased sepsis and
pneumonia)
NASCIS III (1997)
 Transfer Checklist
 Spinal immobilisation  NG insitu
 Airway risk is identified
 Foley catheter
ETT if PaCO2 =  Skin is protected
50mmHg or  Level of SCI
greater documented
Supplemental O2

 X-rays, CT, MRI
 Assisted ventilation PRN accompany patient
 MPSS in progress if
appropriate  Family contacts
documented