CATATAN RES

Traumatic Brain Injury

Klasifikasi Cedera Otak

• Cedera otak berat : GCS <= 8
• Cedera otak sedang : GCS 9-13
• Cedera otak ringan : GCS 14 - 15

Doktrin Monro-Kellie
Rongga intrakranial memiliki total volume yang konstan  peningkatan volume
pada salah satu komponen akan menyebabkan volume pada dua komponen lain
akan berkurang  pada suatu saat : tidak terkompensasi  ICP meningkat

Cerebral Perfusion Pressure

• CPP = MAP - ICP
• CPP normal = 70-85 mmHg ICP normal = 5-10 mmHg
• Pada cedera kepala ICP akan meningkat  MAP perlu dijaga agar CPP
tetap optimal

Cerebral Autoregulation

Dalam situasi normal, otak mampu mempertahankan CBF konstan sekitar 50

ml/100 gr/menit pada rentang MAP yang lebar (sekitar 60-150 mmHg)
Pada kondisi cedera otak, autoregulasi akan terganggu atau akan hilang 
perubahan ini akan berbeda antar pasien satu dengan lainnya  jika terjadi
hipotensi, potensi akan terjadinya iskemia akan meningkat
 Principle management of Brain Trauma

Goal 1: Maintenance of cerebral perfusion pressure(CPP):

This is achieved by maintaining MAP above 90mmHg and preventing increases

in ICP,to be between
20-25mmHg.
CPP = MAP – ICP
Cerebral Perfusion Pressure
Cerebral Perfusion Pressure should be maintained at a minimum of 70 mm Hg.

How to maintaining MAP?

Treating hypovolaemia by 0.9% NaCl/ colloids/P- RBCs/FFP as indicated.
Avoid glucose containing fluids unless there is hypoglycaemia (blood sugar
should be between 4-7 mmols).
Start early enteral feeding as,TBI patients have induced hypermetabolic
and hypercatabolic state resulting in increased energy and protein.
Use inotropes (noradrenaline- dopamine), if other causes of hypotension are
treated.

Goal 2: Controlling ICP

Guideline of ICP monitoring

ICP monitoring is appropriate in severe head injury patients with an abnormal
CT, or a normal CT scan if 2 or more of the following are noted on admission:
SBP < 90 mm Hg
Age > 40 years
Uni-/Bilateral motor posturing
Risk of intracranial hypertension (with normal CT) increased to
60% if two or more of the following were noted:
 1) Age over 40 years
 2) SBP < 90 mm Hg
 3) motor posturing

ICP Treatment Threshold Guideline

ICP treatment should be initiated at an upper threshold of 20 - 25 mm Hg.
Raised ICP leads to secondary brain injury.
It is treated by;
Osmotherapy
Analgesia
Sedation
Optimal ventilation
Surgical
Positioning of patient.
Manitol
Mannitol induces changes in blood rheology and increases cardiac
output, leading to improved CPP and cerebral oxygenation.
Guideline: Mannitol is effective for control of raised ICP after severe
head injury
Option: Effective doses range from 0.25 - 1.0 gm/kg body weight.

Analgesia and Sedation

Morphine or fentanyl can be used for analgesia but with caution for their
respiratory depression in case patient is spontaneously breathing.
Remifentanyl can be used in ventilated patients.
Propofol is sedative of choice especially in first 48 hours. It causes
cerebral metabolic suppression and has neuroprotective effect
Using propofol in doses more than 5mg/Kg and for longer than
48hrs;
Midazolam should replace propofol for sedation. (for fear of propofol
infusion syndrome).

Obat Sedasi yang diberikan dan dosisnya

 Propofol loading dose diberikan 1-2 mg/kgBB dan diberi dosis rumatan 1-3
mg/kgBB/jam.
 Midazolam loading dose diberikan 0,03-0,3mg/kg diberikan dalam 20 menit;
dan dosis rumatan 0,03-0,2mg/kg/jam.
 Penthotal loading dose diberikan 5- 10mg/kg BB diberikan dalam 10 menit,
dan di beri dosis rumatan 2-4mg/kgBB/jam.
 Phenobarbital: Bolus 2-5 mg/kgBB atau Thiopenthal 2-10 mg/kg BB diikuti
infus siringe pump (0.3-7.5 mg/kgBB/jam) atau thiopental 1-6 mg/kg/hr.
 Dexmedetomidine diberikan dengan loading dose 0,5-1 mcg/KgBb selama 10
menit, diikuti dengan dosis maintanance 0,2-0,3 mcg/KgBb/jam.

Barb
iturate (Coma Barbiturate)

Guideline
 High-dose barbiturate therapy may be considered in hemodynamically
stable salvagable severe head injury patients with intracranial
hypertension refractory to maximal medical and surgical ICP lowering
therapy.
High-dose barbiturates are used to control intracranial hypertension in selected
patients. ICP is decreased due to decrease in CBV due to vasoconstriction caused
by increase in cerebrovascular resistance.

Indications:
1. Potentially survivable head injury
2. No surgically treatable lesion accounting for intracranial hypertension
(except when used for preparation for surgery)
3. Other conventional therapies of controlling ICP have failed (posture,
hyperventilation, osmotic and tubular diuretics, corticosteroids)
4. ICP > 20 to 25 mmHg for more than 20 min, or >40 mmHg at any time
5. Unilateral cerebral hemispheric edema with significant (>.7 mm) shift of
midline structures shown on CT
6. A low Glasgow Coma score
 Dosing Regimens

Dosing
Pentobarbital:
High dose: Loading:30-40 mg/Kg over 4 hours (~2500mg/70Kg) Maintenance:
1.8-3.3mg/Kg/hr (~175mg/70Kg)
Mid-level dose:
Loading: 10mg/Kg over 30min, 20-25mg/Kg over 4hr maintenance: 5mg/Kg/hr
for 3hrs,then 2-2.5mg/Kg/ with 5mg/Kg bolus prn if serum level < 3mg/dl
Low dose: Loading: 3-6mg/Kg over 30min Maintenance: .3- 3mg/Kg/hr
Therapeutic serum level: 2.5-4 mg/dl ( 6 mg/dl may be needed )
Thiopental:
Loading: 3mg/Kg bolus, followed by 10-20mg/Kg over 1 hr Maintenance: 3-5
mg/Kg/hr
Therapeutic serum level: 6-8.5 mg/dl
Weaning: dosage is halved q 12 hr.

Steroids
The use of steroids is not recommended for improving outcome or reducing
intracranial pressure in patients with severe head injury.

Mechanical Ventilation
In TBI patients, hypoxia, hypercarbia / hypocarbia should be prevented.
PaO2 should be above 100mmHg and SpO2 above 95%.
Mechanical ventilation should be started at GCS 8.
PaCO2 in first 24hrs should be 34-38mmHg and mild hyperventilation can be
started for PaCO2 to be 32-35mmHg in case of increased ICP.
Monitor end tidal CO2 and perform blood gases 15- 20 min. after any change in
ventilatory parameters.

NMBA
May be considersd to facilitate endotracheal intubation.
In cases of difficult ventilation inspite of adequate sedation/analgesia.
Use of neuromuscular blockade may mask seizure activity, increase risk
of pneumonia and cause critical illness neuropathy.

Patient positioning
Patient head should be in neutral position with head of bed elevated 15-30
degree.

Sutgical intervention
Whenever decided by neurosurgeon to decrease intracranial
hypertension.
Surgery can be performed on mass lesions or to eleminate objects that
penetrated the brain.
Mass lesions are like contusions or haematomas causing significant shift
of intracranial structures.

Maintenance of haematological parameters

Monitor HCT or haemoglobin level as CBF is influenced by blood viscosity which
increases by increase in HCT.
CBF is reduced by HCT levels above 50% and increased by HCT levels below
30%.
HTC of 30-34% is suggested to be best for optimal oxygen delivery to brain
tissue.

Antiseizure Prophylaxis
Standard
 Prophylactic use of phenytoin, carbamazepine, phenobarbital or
valproate is not recommended for preventing late post-traumatic
seizures.

Suurgical Intervention

Fever
Central fever is believed to be due to direct damage to the thermoregulatory
centers of the brain, which are found in the preoptic nucleus of the
hypothalamus and focal centers of the pons. Severe damage to these centers can
also result in profound hypothermia, which can result in coagulopathy, cardiac
arrhythmias, or depressed immune function.
Due to the deleterious effect of temperature on brain parenchyma, therapy
should be initiated when patient temperature exceeds 37˚ Celsius rather than
waiting until the traditional definition of fever has been reached.
Therapeutic Hypothermia
Data supporting its use following TBI has been less convincing.
Therapeutic hypothermia may have a role in the treatment of patients with
severe TBI and refractory ICP, but should only be used after consultation
between the attending intensivist and neurosurgeon.
When therapeutic hypothermia has been initiated, therapy should be continued
until ICP < 20 mmHg for 48 hrs at which time patients may be rewarmed at a
rate not to exceed 0.1˚ Celsius per hour with close monitoring for the
development of rebound intracranial hypertension.

Targeted Temperature Management

With the deleterious effects of fever and hypothermia established for TBI
patients, many modalities of achieving either normothermia or therapeutic
hypothermia have been described .
Conventional cooling methods include skin exposure, ice, cold packs, infused
cold fluid, peritoneal lavage, and antipyretics. There are also many commercially
available cooling devices available. The Blanketrol (Cincinnati Subzero,
Cincinnati, OH) is a water-circulating blanket system that utilizes two large
cooling blankets, one beneath and one on top of the patient, to maintain the
desired patient temperature.
The Arctic Sun (Medivance, Jugenheim, Germany) circulates water through
gel pads that are applied to the patient’s back, abdomen, and thighs,
automatically controlled by a rectal thermometer. Several intravascular cooling
systems are also commercially available. These systems infuse cold fluids via a
closed-loop central venous catheter to maintain the desired body temperature.
In a prospective study of ICU patients, Hoedemakers et al found superior
temperature control using water-circulating blankets, gel-pads, and
intravascular cooling as compared to conventional cooling techniques and air-
circulating blankets /

Shivering Management
When body temperature is lowered, the physiologic response is to prevent
further heat loss through vasoconstriction. When vasoconstriction is no longer
effective, shivering occurs to counterbalance heat loss.
In the context of induced hypothermia, shivering is undesirable because it
causes patient discomfort, increases body temperature, increases metabolic /
oxygen demand, and increases intraocular and intracranial pressures.
A step-wise approach to the prevention of shivering appears appropriate.
Pharmacologic options for the control of shivering include: meperidine,
morphine, fentanyl, propofol, magnesium, benzodiazepines, and neuromuscular
blockers .
It is important to consider that data on pharmacologic interventions for
shivering control are based upon experience with either health volunteers or in
the postoperative setting (20-23). Therefore, the effect of repetitive dosing and
prolonged use of these agents in therapeutic hypothermia is lacking (i.e. CNS
toxicity associated with merperidine).

Nutrition
Guideline
  Replacement of 140% of Resting Metabolic Expenditure in non-paralyzed
patients and 100% Resting Metabolic Expenditure in paralyzed patients
using enteral or parenteral formulas containing at least 15% of calories
as protein by the seventh day after injury.

Monitoring Renal Function

Urine output should be 0.5-1ml/Kg/min.
Diabetes insipidus should be suspected if urine output is more than 250ml/hr,
for more than 3hrs. and specific gravity less than 1005,confirmed by serum and
urine osmolalities.
If confirmed , start desmopressin

Tiers Of Therapy
Tier Zero
The following interventions should be implemented in all patients with
TBI:
 Maintain mean arterial pressure (MAP) > 80 mmHg if GCS < 8; otherwise
target MAP > 70 mmHg
 Administer supplemental oxygen to maintain SpO2 >92%
 Elevate head of bed to 30 degrees
 Maintain head in neutral position to avoid jugular vein constriction
 Correct hyponatremia (serum Na+ < 140 mEq/L) with isotonic
intravenous fluids (no dextrose)
 Correct coagulopathy with Prothrombin Complex Concentrate (PCC) in
life-threatening bleeds
 FEIBA NF 1000 units IV push over 5 minutes Transfuse platelets in
patients with known history of antiplatelet agent use
 Avoid hyperthermia (temperature > 37˚Celsius) Acetaminophen 650 mg
PO/PT q 4 hrs
 Avoid hyperglycemia (serum glucose > 180 mg/dL)
 Ensure early appropriate nutritional support
 Prevent deep venous thrombosis (DVT)
 Prevent gastrointestinal stress ulceration
 Prevent skin breakdown / decubitus ulcer formation through
appropriate bed surface

Tier One
The following interventions should be added in all patients with Glasgow
Coma Score (GCS) < 8:
Ensure all physiologic goals from Tier Zero are met
Airway / Breathing
 Intubate patient if GCS < 8 and as needed to protect the airway
 Maintain PaCO2 35-40 mmHg
 Maintain PaO2 80-120 mmHg
Systemic and Cerebral Perfusion
 Insert an arterial line (leveled at the phlebostatic axis)
 Insert a central venous catheter for central venous pressure (CVP)
monitoring
 Maintain euvolemia (fluid balance positive by 500-1000 mL in first 24
hrs, CVP > 8 mmHg)
 Maintain MAP > 80 mmHg if ICP is unavailable
 Maintain cerebral perfusion pressure (CPP=MAP-ICP) > 60 mmHg if ICP is
available
 If CPP < 60 mmHg, notify intensivist and: If CVP < 8 mmHg, give normal
saline 500-1000 mL bolus; If CVP > 8 mmHg, start norepinephrine 0-0.5
mcg/kg/min IV infusion to maintain CPP
Consider ICP monitoring
Indications:
 Salvageable patients with severe TBI (GCS 3-8 after resuscitation) and an
abnormal CT scan (hemorrhage, contusions, swelling, herniation or
 compressed basal cisterns) Patients with severe TBI and normal CT scan
if two of the following are noted at
 admission: age > 40 yrs, unilateral or bilateral posturing, systolic BP < 90
mmHg
 Patients with TBI who will not be examinable for a prolonged period of
time
Management
 Maintain ICP < 20 mmHg
 Consider Osmolar Therapy (see below)
 Consider short-term hyperventilation (PaCO2 30-34 mmHg) to acutely
reduce ICP
 Verify correct ICP waveform on extraventricular drain (EVD); notify
neurosurgery if ICP waveform is incorrect or there is no CSF drainage
 Level EVD at the external auditory meatus
 Close EVD and level at 0 mmHg upon insertion to monitor ICP
 If ICP > 20 mmHg for 10 minutes, open EVD at 0 mmHg for 15 minutes
 If EVD is opened more than 3 times within 90 minutes, leave EVD open at
0 mmHg continuously and notify neurosurgery
Osmolar Therapy
 First line therapy: 3% normal saline IV bolus 100-250 mL q 2 hrs prn ICP
> 20 mmHg for > 10 minutes
 Alternate therapy: Mannitol 0.25-1.0 gm/kg IV q 6 hrs prn ICP > 20 mmHg
Measure serum osmolality and electrolytes q 6 hrs
 Notify intensivist if serum Na changes by > 3 mEq/L from previous
measurement
 Hold hypertonic saline therapy for serum Na > 160 mEq/L
 Hold mannitol therapy for serum osmolality > 320 mOsm
Protect the Brain
 Initiate continuous EEG monitoring to rule non-convulsive status
epilepticus Provide judicious analgesia and sedation to control pain and
agitation Fentanyl 25-150 mcg/hr IV infusion
 Propofol 10-50 mcg/kg/hr IV infusion for Richmond Agitation Sedation
Score (RASS) >-2
 Exclude seizure activity
 Keppra 500 mg IV BID for first 7 days (discontinue after 7 days if no
seizure activity)
Avoid:
 Hypotension (MAP < 70 mmHg)
 Hypoxemia (SpO2 < 92%)
 Hypercarbia (PaCO2 > 45 mmHg)
 Hyponatremia (serum Na+ < 140 mEq/L)
 Hyperglycemia (glucose > 180 mg/dL) Hypovolemia
 Fever (maintain temperature at 36-37˚Celsius)
 Anemia (maintain hemoglobin > 9 gm during the patient’s critical illness)
Tier Two
The following interventions should be considered if ICP is persistently >
20 mmHg for more than 60 minutes after discussion with neurosurgery
and intensivist attendings:
 Ensure all physiologic goals from Tier One are met
 Consider head CT scan to rule out space-occupying lesion
 Consider continuous EEG monitoring to rule non-convulsive status
epilepticus
Paralysis
 Start rocuronium (50 mg/kg loading dose, then 8 mcg/kg/hr); adjust
dose according to Train of Four
Mild Hypothermia
 Induce hypothermia to 35˚ Celsius using the Arctic Sun™ cooling pads
Mild Hyperventilation
 Begin mild hyperventilation with goal PaCO2 30-34 mmHg

Tier Three
The following interventions should be considered if ICP
remains > 20 mmHg despite all Tier Two goals being met:
 Ensure that medical therapy with hypertonic saline is maximized
 Consider revised ICP threshold of 25 mmHg with strict adherence to CPP
goals
 Initiate continuous EEG (if not already present)
 Consider 23.4% hypertonic saline 30 mL IVP for refractory ICP
Surgical Decompression
 Consider decompressive craniectomy in consultation with neurosurgery
team
Hypothermia
 Consider hypothermia to 34˚ Celsius using the Arctic Sun cooling blanket
 Once ICP < 20 mmHg for 48 hrs, rewarm at rate no greater than 0.1˚
Celsius/hr
Barbiturate Coma
 If not a surgical candidate, and refractory to all above interventions,
consider pentobarbital coma
 Pentobarbital 10 mg/kg IV over 10 minutes, then 5 mg/kg IV q 1 hr x 3,
then 1 mg/kg/hr IV infusion
 Titrate pentobarbital to the minimal dose required to achieve EEG burst
suppression
 Discontinue all other sedative agents and paralytics Strongly consider
invasive hemodynamic monitoring (such as pulmonary artery catheter)
due to the negative inotropic effects of pentobarbital
 Once ICP < 20 mmHg for 48 hrs, taper pentobarbital dose over the next
48-72 hrs
Staircace Management of Increased ICP
Algoritma

B1 Bersihkan lendir, benda asing, jawthrust bila perlu, kepala tidak 
boleh
hiperextensi, hiperflexi atau rotasi, pasang orofaring atau nasofaring tube bila
perlu. Bila ada sumbatan jalan nafas akut dilakukan cricothyrotomi dan
persiapan intubasi atau tracheostomi 

Intubasi + Kontrol ventilasi (PCO2 35–40mmhg,,PaO2: 80–200 atau Spo2 >97
% ), pasang pipa lambung 

Pasang collar brace 

Lihat gerakan nafas, auskultasi, palpasi, perkusi dada. Cari tanda- 
tanda
pneumothorak, hematothorak, flail chest atau fraktur costa.. 


B2 Bila shock, berikan cairan isotonis (RL, NaCl, atau koloid atau 
darah). Cari
penyebab, atasi, pertahankan tensi > 90 mmHg. 

BilatelahstabilInfuscairanisotonis(NaCl0,9%) 
1,5 ml/kgBB/jam pertahankan
euvolume,pemasangan CVP atas 
indikasi.
.

B3 Adatanda-tandaTIKmeningkatdantidakadahipotensiataugagal ginjal dan atau

gagal jantung, manitol 20% 200 ml bolus dalam 20 menit atau 5
ml/kgBB, dilanjutkan 2 ml/ kgBB dalam 20 menit 
setiap 6 jam, jaga
osmolalitas darah < 320 mOsm. 

Bila kejang : Diazepam 10 mg iv pelan, dapat ditambah hingga kejang
berhenti. Awasi depresi nafas, dilanjutkan phenitoin bolus10-18 mg/kgBB
encerkan dengan aqua steril 20 ml iv pelan, 
dilanjutkan 8 mg/kgBB 

PasangICPmonitor,pertahankantekanan<15mmhg.atau<22cm 
H2O pada
pasien yang tidak ada indikasi operasi lesi intrakranial. Bila ada lesi
intrakranial indikasi operasi, ICP monitor dipasang bersamaan saat operasi
emergensi 

Analgetik  Guideline: Ketorolac dan acetaminophen dapat digunakan pada
pasien trauma kepala. Ketorolac hanya boleh diberikan maksimal 5 hari.

Sedasi dengan midazolam/propofol/pentobarbital/thiopental

Antibiotik profilaksis sesuai indikasi (pada penggunaan ventriculostomy)

B4 Pasangkateter,catatkeadaandanproduksiurine 


B5 Omeprazole
B6 Cari tanda fraktur tempat lain