Current Evaluation and Management of Head Injury - DR EB-East Park

dr. Endro Basuki, Sp.BS (K), M.
Kes
Cognita Manu Melia Cultu Neurosurgery Division

dr. ENDRO BASUKI, Sp.BS (K), M.Kes
 Jakarta, 8 Januari, 1953

 Dokter Umum – FK UGM, 1979
 Spesialis Bedah Saraf – FK UNPAD, 1989
 Vrije Universiteit Amsterdam, 1987 – 1988
 Magister Kesehatan – FK UGM, 2000
 Puskesmas Kec. Lamuru, Bone, 1979 – 1982
 Staf KSM Bedah Saraf RS Dr Sardjito
 As. WaDek bidang penelitian, kerjasama
dan pengabdian masyarakat FK-UGM 2013-
2017
 Pengurus Harian Komite Medik RSUP Dr
Sardjito/ Ketua Sub Komite Etik dan
Disiplin Profesi
 Ketua Perhimpunan Spesialis Bedah Saraf
Indonesia (PERSPEBSI), 2005-2009, 2013 –
2017
 Ketua Medical Advisory Board (Dewan
Pertimbangan Medik) BPJS kesehatan 2016-
2017

Introduction
 Head injuries are among the most common types of trauma

encountered in emergency departments (EDs).
 Many patients with severe brain injuries die before reaching a
hospital; in fact, nearly 90% of prehospital trauma-related deaths
involve brain injury.
 Approximately 75% of patients with brain injuries who receive
medical attention can be categorized as having mild injuries, 15% as
moderate, and 10% as severe.

Introduction
 Most recent United States data estimate 1,700,000 traumatic brain

injuries (TBIs) occur annually, including 275,000 hospitalizations
and 52,000 deaths.
 TBI survivors are often left with neuropsychological impairments
that result in disabilities affecting work and social activity.
 Every year, an estimated 80,000 to 90,000 people in the United
States experience long-term disability from brain injury

Anatomy and Physiology Review
SKIN
CONNECTIVE TISSUE
APONEUROSIS/GALEA
LOOSE AREOLAR TISSUE
PERICRANIUM
Because of the scalp’s generous blood supply, scalp lacerations can

result in major blood loss, potential to hemorrhagic shock

Skull
Meningen
Brain

TENTORIUM
- Supratentorial
- Infratentorial

CSF ( Cerebrospinal fluid)

Intracranial Pressure
Normal ICP = 10 mmHg ( 136 mmH2O)
Monro–Kellie Doctrine
Principle :
The total volume of the intracranial contents must
remain constant, because the cranium is a rigid
container incapable of expanding.
Monro–Kellie Doctrine
Vk = V darah + V likuor + V parenkim

mmHg
Tekanan Fatal 60
100
Intrakranial
50
Disfungsi
40
50
Otak
30
Obati
20
Volume Intrakranial Normal
10
0
CEREBRAL PERFUSION PRESSURE ( CPP )

CPP = MAP – ICP
CEREBRAL BLOOD FLOW ( CBF )

50 ml/100 gr / minute
If 5 ml/ minute :
cell death & irreversible damage

Glascow Coma Scale ( GCS )
E : Oye Opening : 1 – 4
M : Motoric Response : 1 – 6
V : Vocal Response: 1 – 5
Best possible score 15; worst possible score 3.
If an area cannot be assessed, no numerical score is given for that
region, and it is considered “non-testable”




Classifications of Traumatic
Brain Injury
SEVERITY :
- Mild : GCS Score 13-15
- Moderate : GCS Score 9-12
- Severe : GCS Score 3-8
Morphology
- Skull
- Intracranial Lesions
Brain Injury
Linear vs Stellate
Vault
Depressed/
Nondepressed
Skull Fracture
With/ without
CSF Leak
Basilar
With/Without
Seventh nerve
palsy
Brain Injury Epidural
Focal Subdural
Intracerebral
Intracranial
Lesions Concussion
Multiple
Contusions
Diffuse
Hypoxic/
Ischemic Injury
Axonal Injury

Normally Brain CT Scan

Depressed
Fracture

CT Scan of Depressed Fracture
BASILAR SKULL
FRACTURES

Epidural
Epidural
Hematome

Clinical Progress of EDH

EDH

Cerebral Contusions
Cerebral Laceration/ Multiple contusions
Intracerebral Hematoma
Intracerebral Hematoma

Intraventricular
Hematoma

Subdural Hematoma
Acute
Subdural Hematoma
Sub-acute
( 4 - 21 days after injury )
Chronic
( more than 21 days after injury)

Subdural Hematoma

Subarachnoid
Hemorrhage

Subarachnoid Hemorrhage

Management Overview of
Traumatic Brain Injury
All patients: Perform ABCDEs with

special attention to hypoxia and
hypotension

Management of Mild Brain Injury
(GCS Score 13–15)

(GCS Score 13–15)

(GCS Score 13–15)
Indications for CT
scanning in patients with mild
TBI
CT scanning is the preferred method of

imaging,
although obtaining CT scans should not delay
transfer of the patient who requires it.
(GCS Score 13–15)
Example of Mild TBI

Warning Discharge
Instructions
Management of Moderate Brain
Injury (GCS Score 9–12)

Management of Severe Brain
Injury (GCS Score 3–8)

Neurosurgical consultation for
patients with TBI

Goals of treatment of brain injury:
clinical, laboratory and monitoring
parameters

DON’T FORGET ...
Before transported:
1. ABC clear
2. Head Elevated 30º

Make a right and usefull
medical record

Medical Therapies for Brain
Injury
 Intravenous Fluids (Hypovolemia in patients with TBI is harmful)
 Correction of Anticoagulation
 Hyperventilation
 Prophylactic hyperventilation (pCO2 < 25 mm Hg) is not recommended (IIB).
 Use hyperventilation only in moderation and for as limited a period as possible
 Mannitol
 Use 0.25–1 g/kg to control elevated ICP ; arterial hypotension (systolic blood
pressure <90 mm Hg) should be avoided.
 Use with ICP monitor, unless evidence of herniation, keep Sosm <320 mOsm,
maintain euvolemia, and use bolus rather than continuous drip.
 Hypertonic Saline

Medical Therapies for Brain
Injury
 Barbiturates
 Anticonvulsants
 Anticonvulsants can inhibit brain recovery, so they
should be used only when absolutely necessary

Surgical Management
 Burr Hole
 Craniotomy hematom evacution
 Craniectomy decompressed hematom evacuation
 Depressed fracture correction

Burr Hole

 Craniotomy Hematom Evacuation

 Craniotomy Hematom Evacuation

Craniectomy decompressed hematom evacuation

Brain Death
Diagnosis of brain death requires meeting these criteria:

 Glasgow Coma Scale score = 3
 Nonreactive and midriatic pupils
 Absent brainstem reflexes (e.g., oculocephalic, corneal, and doll’s
eyes, and no gag reflex)
 No spontaneous ventilatory effort on formal apnea testing
 Absence of confounding factors such as alcohol or drug intoxication
or hypothermia


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dr. Endro Basuki, Sp.BS (K), M.

Cognita Manu Melia Cultu Neurosurgery Division

 Jakarta, 8 Januari, 1953

Cognita Manu Melia Cultu Neurosurgery Division

 Head injuries are among the most common types of trauma

Cognita Manu Melia Cultu Neurosurgery Division

 Most recent United States data estimate 1,700,000 traumatic brain

Cognita Manu Melia Cultu Neurosurgery Division

Because of the scalp’s generous blood supply, scalp lacerations can

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Vk = V darah + V likuor + V parenkim

CEREBRAL PERFUSION PRESSURE ( CPP )

CEREBRAL BLOOD FLOW ( CBF )

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

All patients: Perform ABCDEs with

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

CT scanning is the preferred method of

Example of Mild TBI

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Cognita Manu Melia Cultu Neurosurgery Division

Diagnosis of brain death requires meeting these criteria:

Cognita Manu Melia Cultu Neurosurgery Division

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