Modul Trauma Edit.id.en (1)

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TRAUMA P rogram P Education DOK T ER S P NERVES OF SURGICAL SCIENCE ESIALIS UNI V ERSI T US

AIRLANGGA 201 6

Mild Brain Injury ICD-10: S06.0

1. Definition (Definition) Mild Brain Injury is a brain injury that is classified based on the level of awareness were measured using a scale GCS (Glasgow Coma Scale) 13-15 were measured 30 minutes after trauma (1,2,5)

2. History The identity of the patient: Name, Age, JenisKelamin, Ethnicity, Religion, Occupation, Address - Main complaint - mechanism of trauma - Time and travel trauma - Never passed out or unconscious after trauma - Retrograde or antegrade amnesia - Complaints: how severe headache, loss of consciousness, seizures, vertigo - History drunk, alcohol, narcotics, postoperative head - Morbidities: epilepsy, heart disease, asthma, chief operating history, hypertension and diabetes mellitus, and impaired blood clotting physiology

3. PemeriksaanFisik Primary Examination Survey Evaluation Note, record, and fix the obstruction? A. Airway Patency of the airway? Additional sound? B. Breathing Is Effective Rate and depth of chest movement oxygenation .... ? Water entry cyanosis Pulse rate and volume returns skin color Capilarry Bleeding Blood Pressure Levels or C. Circulation Is Adequate AVPU kesadaranmenggunakan perfusion ... ..? GCS system. Pupil (large, shape, light reflex, compare kanankiri) lesion, deformity, and limb movement. Evaluation of response D. Disability (neurological Is there a neurological to commands or painful stimuli status) disability ...?

E. Exposure (open the whole Another organ injury ...? outfit)

Secondary Examination Survey generalist Status Examination by inspection, palpation, percussion and auscultation, as well as a special inspection to determine the pathology, the method: - From the head to the toe or,

- Per organ B1 - B6 (Breath, Blood, Brain, Bowel, Bladder, Bone)

Physical examination is closely related to brain injury are:

1. Examination of the head for the mark:

a. The lesion in the head covering; sub-cutaneous hematoma, sub galeal, open wounds, penetrating wounds and foreign bodies.

b. Signs fracture of the skull base, include; periorbital ecchymosis (brill hematoma), ecchymosis post auricular (Battle sign), rhinorhoe, and otorhoe and bleeding in the tympanic membrane or leserasi auditory canal.

c. Signs include facial bone fractures; maxilla fractures (Lefort), rhyme orbital fracture and fracture of the mandible

d. Signs of trauma to the eye include; conjunctival hemorrhage, bleeding anterior chamber, pupil damage and other eye injury.

e. Auscultation of the carotid artery to determine the presence of a bruit related to carotid

dissection

2. Examination of the neck and spine. Looking for signs of injury to the cervical spine and the spine and spinal cord injury. Checking involves injury, deformity, the status of motor, sensory and autonomic.

Status Examination Neurological Examination Neurological status consists of:

a. The level of awareness: based on a scale of Glasgow Coma Scale (GCS). Head injury is based GCS, which was assessed after the stabilization of the ABC classified as mild brain injury GCS 13-15

b. Cranial nerve, especially:

Nerves II-III, ie pupils examination: large and shape, light reflex, reflex konsensuil compare the right and left signs of peripheral nerve lesions VII.

c. Fundoskopi look for signs of edema pupils, pre-retinal hemorrhage, retinal detachment.

d. Motor and sensory, compare the right and left, up and down looking for signs of lateralization.

• Autonomis: bulbocavernous reflex, cremaster reflex, reflex spingter, tendon reflexes, pathological reflexes and tone spingter ani.

4. Criteria for Diagnosis 1. History according above 2. Clinical examination in accordance Issuer 3. Imaging studies

5. DiagnosisKerja Mild brain injury (concussion) S06.0 6. Diagnosis - alcohol intoxication

- Stroke 7. Investigations

Grad

e

No. Examination Recommendation Reko Ref

mend care

CT scan is recommended in patients

by COR. CT Scan selected for evaluation in

ER. In some of the literature mentioned

CT scan abnormalities found in 5% of patients

with GCS 15 and 30% in patients with

GCS 13. The incidence of abnormalities CT Scan

require surgical approaches 1%.

CT scans performed on patients with a COR

one of the following disorders:

1 CT Scan - GCS <15 2 h after injury 1B 2,4,9,10

- suspected fractures open head or

impression

- FBC marks: hemotimpanum, racoon eyes,

Battle's sign, or leakage of CSF

- two or more episodes of vomiting

- age 65 years or older

- dementia before the incident 30 minutes

or more

- mechanism of injury

MRI is more sensitive to indicate the area

kontusional small or minor bleeding,

2 MRI

axonal injury and minor bleeding extras 1B 4.8

axial. In patients COR, obtained

15% of the MRI abnormality on CT

Scan is normal.

Whole Body CT ( WBCT) used in cases

3

multitrauma to reduce the time 2A 13

diagnosis, can be used in patients

CT Scan Whole body

hemodynamically unstable

8. Therapy

Grad

e

No. Therapy Procedures (ICD 9 CM) Reko Ref

mend

care

if the indications obtained intracranial lesions

1 Operations to do surgery (bleeding

3,7,12

1B

epidural, subdural hematoma, bleeding

intracerebral)

patients admitted to the hospital in patients with:

- GCS <15

- Abnormal CT Scan: intracranial bleeding,

cerebral edema

- seizures

- kelaianan parameters of bleeding

causes the background as

use of oral anticoagulation.

- Head Up 30 o ( 2B)

- Give enough fluids (normal

saline) to resuscitate the victim to remain

normovolemia, overcome hypotension

happened and give blood transfusions when

Hb less than 10 g / dl. (1B)

- Check vital signs, injury

2 Conservative systemic in other body parts, 1B 3,7,12

GCS and examination of the brain stem

periodically.

- Give analgesic drugs (eg:

acetaminophen, ibuprofen for pain

Mild and moderate) when obtained

complaints of pain in patients (2B)

- Give anti-vomiting drugs (eg:

metoclopramide, or ondansetron)

and anti-ulcer gastritis H2 blockers (eg:

ranitidine or omeprazole) if the patient

vomiting (2B)

- Give hypertonic fluid (mannitol

20%), when looked edema or injury

not operable on CT Scan. mannitol

can be administered as a bolus of 0.5 to 1

g / kg. BB in certain circumstances, or

repeated small doses, for example, (4-6) x 100

cc mannitol 20% in 24 hours.

Gradual discontinuation. (1B)

- Give Phenytoin (PHT) prophylaxis

patients with high risk of seizures

at a dose of 300 mg / day or 5-10 mg kg bw / day for 10 days. when you have

seizures, IPM is given as therapy. (1B)

9. Education Explanations to patients and families:

• Course of the disease and complications that may occur • Therapy and actions that will be given along with the advantages and disadvantages • The procedure for the treatment and the treating physician

10. Prognosis Ad Vitam (Live) : Ad Dubia bonam Ad Sanationam (cured) : Ad Dubia bonam Ad Fungsionam (function) : Ad Dubia bonam Prognosis is affected: - Age - Neurological status early - The distance between trauma and surgery - cerebral edema - Other intracranial abnormalities such as kontusional, subarachnoid hematoma and epidural hematoma

- factors extracranial 11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS

2. Dr. Agus Turchan, dr., Sp.BS 3. Dr. M. Arifin Parenrengi, dr., Sp.BS 4. Dr. Joni Wahyuhadi, dr., Sp.BS 5. Dr. Eko Agus Subagyo, dr., Sp.BS 6. Dr. Asra Al Fauzi, dr., Sp.BS 7. Wihasto Suyaningtyas, dr., Sp.BS 8. Rahadian Indarto, dr., Sp.BS 9. Muhammad Faris, dr., Sp.BS 10. Fahmi Achmad, dr., Sp.BS 11. Nur Setiawan Suroto, dr., Sp.BS 12. Irwan Barlian Immadoel Haq, dr, Sp.BS 13. Tedy Apriawan, dr., Sp.BS 14. Heri Subianto, dr., Sp.BS

12. Medical Indicators Improvement of neurological status. 13. Bibliography 1. Practice parameter: the management of concussion in sports (summary statement). Report of the Quality

Standards Subcommittee. Neurology 1997; 48: 581 2. Stein SC, Ross SE. The value of computed tomographic scans in Patients with lowrisk head injuries.Neurosurgery 1990; 26: 638 3. Servadei F, Teasdale G, Merry G, Neurotraumatology Committee of the World Federation of Neurosurgical Societies. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma 2001; 18: 657

4. Uchino Y, Okimura Y, Tanaka M, et al. Computed tomography and magnetic resonance

imaging of mild head injury is it Appropriate to classify Patients with Glasgow Coma Scale score of 13 to 15 as "mild injury"? Acta Neurochir (Wien) 2001; 143: 1031

5. Culotta VP, Sementilli ME, Gerold K, Watts CC. Clinicopathological heterogeneity in the classification of mild head injury. Neurosurgery 1996; 38: 245

6. Dacey RG Jr, Alves WM, Rimel RW, et al. Neurosurgical complications after apparently minor head injury. Assessment of risk in a series of 610 Patients. J Neurosurg 1986; 65: 203.

7. The management of minor closed head injury in children. Committee on Quality Improvement, the American Academy of Pediatrics. Commission on Clinical Policies and Research, American Academy of Family Physicians. Pediatrics 1999; 104: 1407

8. Hughes DG, Jackson A, Mason DL, et al. Abnormalities on magnetic resonance imaging seen

acutely following mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery. Neuroradiology 2004; 46: 550.

9. Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain injury: results of the WHO

Collaborating Center Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004;: 61.

10. Atzema C, Mower WR, Hoffman JR, et al. Defining "therapeutically inconsequential" head computed tomographic findings in Patients with blunt head trauma. Ann Emerg Med 2004; 44:47.

11. Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial

hemorrhage in Patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012; 59: 460.

12. Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in Patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 2012; 59: 451.

13. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed tomography versus selective radiological imaging on outcomes Patients in major trauma: a meta-analysis. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:54.

No Specific Brain Injury (Traumatic Brain Injury Brain Medium & Heavy) ICD-10: S06.9

1. Definition No Specific Brain Injury (Traumatic Brain Injury Brain Medium and Heavy) is a brain injury that are classified (Definition) based on the level of consciousness as measured using a scale GCS (Glasgow Coma Scale), GCS 9-12 for

Brain Injury Medium, and GCS <8 for Brain Injury Serious , (1,2,3,4)

2. History - The identity of the patient: Name, Age, Gender, Ethnicity, Religion, Occupation, Address - Main complaint - mechanism of trauma - Time and travel trauma - Never passed out or unconscious after trauma - Retrograde or antegrade amnesia - Complaints: how severe headache, loss of consciousness, seizures, vertigo - History drunk, alcohol, narcotics, postoperative head - Morbidities: epilepsy, heart disease, asthma, chief operating history, hypertension and diabetes mellitus, and impaired blood clotting physiology

3. PemeriksaanFisik Primary Survey (1,2,3,4,9) Examination Evaluation Note, record, and fix

A. Airway Patency of the airway? Obstruction? Additional sound? B. Breathing Is Effective Rate and depth of chest oxygenation .... ? movement Water entry cyanosis

C. Circulation Is Adequate Pulse rate and volume perfusion ... ..? returns skin color Capilarry Bleeding Blood Pressure

D. Disability (neurological Is there a neurological Kesadaranmenggunakan level status) disability ...? or AVPU GCS system. Pupil (large, shape, light reflex, compare kanankiri)

E. Exposure (open the whole Another organ injury ...? Injury, deformity, and limb outfit) movement. Evaluation of response to commands or painful stimuli



Physical examination is closely related to brain injury are: 1. Examination of the head for the mark: a.The lesion in the head covering; sub-cutaneous hematoma, sub galeal, open wounds, penetrating wounds and foreign bodies.




e. Auscultation of the carotid artery to determine the presence of a bruit related to carotid dissection


Status Examination Neurological Examination Neurological status consists of: a. The level of awareness: based on a scale of Glasgow Coma Scale (GCS). Head injury is based GCS, which was assessed after the stabilization of the ABC classified: GCS 14-15: mild brain injury (COR) GCS 9-13: moderate brain injury (COS) GCS 3-8: severe traumatic brain injury (COB)

b. Cranial nerve, especially: Nerves II-III, ie pupils examination: large and shape, light reflex, reflex konsensuil compare the right and left signs of peripheral nerve lesions VII.



Autonomis: bulbocavernous reflex, cremaster reflex, reflex spingter, tendon reflexes, pathological reflexes and tone spingter ani.

4. Criteria for Diagnosis 1. History according above 2. Clinical examination in accordance Issuer 3. Imaging studies From a physical examination, GCS assessment can be used to classify the type of brain injury by keparahanya level. GCS with a total value of 13-15 can be categorized as Brain Injury Light (COR), GCS by the number of 9-12 is categorized as CederaOtak Medium (COS), and GCS with a total value of less than or equal to 8 dekategorikan as Traumatic Brain Weight (COB)

For Brain Injury Brain Injury Medium and Heavy, according to ICD 10 can be grouped into Head Injury Not Be Specific. In patients with COS & COB, after physical inspection, installation of drip hose and blood sampling for laboratory preparation and the possibility of operation, can be done in the form of diagnostic X-ray and CT scan

5. Work Diagnosis No Specific Brain Injury (Traumatic Brain Injury Brain Medium & Heavy) ICD-10: S06.9

6. Diagnosis - alcohol intoxication

- Stroke

- AVM

7. Investigations

Recommendation grade

No. Examination RecommendationsRef

endasi

Cervical X-Foto done in patients COS

1

Cervical X-Foto

or COB to exclude 1C

14,15,1

the possibility of cervical injury. sensitivity x- 6

Cervical photo 70% -80%

X-Thoracic photos done in trauma patients

which does not require CT scans. X-Photo

2

done by the mechanism of injury 1C 17,18

X-Thoracic Photo and clinical findings. X-thoracic photos done

in patients with penetrating trauma to the chest, back,

or stomach which does not require CT Scan

CT Scan is a modality selected on

acute phase of head trauma and should

done as soon as possible. CT Scan head 19,20,2

3 CT scan Recommended done at all 1B

1,22,23

brain injury patients with a GCS of 14 or

less. CT scan evaluation can be done

when obtained deteriorisasi neurological.


4



CT Scan Whole body


8. Therapy

Procedures (ICD 9 CM) grade

No. Therapy Recommen Dations. Ref

indication for immediate surgery on

Operation COS or COB based neurological status,

24,25,2

1

(ICD 9 CM: 1C

usually GCS and CT scan findings were 6

1:24)

according to criteria such as the volume of bleeding

large or the thickness and evidence

mass effect included midline shift.

- surgery is recommended for

evacuation EDH with a volume> 30ml

GCS any patient. Also on

EDH acute with GCS <8 with

pupil anisokor

- surgery is recommended for

> 5mm any patient GCS. Action

Surgical is also recommended in

patients with GCS <8 or GCS down 2

points from the moment he came, or

patients with asymmetric pupils and

scaling, or ICT> 20mmHg.

- indication for surgery in ICH yet

too obvious. some sources

said evacuation of ICH in volume

> 50ml, or GCS 6-8 in patients with ICH

The temporal or frontal volume> 20ml

MLS> 5mm or compression

cisterns on CT Scan

- Installation is done in the ICP Monitor

COB patients (GCS 3-8 after the process

resuscitation) by CT scan head

abnormal (hematoma, contusio, edema

cerebral or narrowing cisterns

basal). ICP monitors are also installed on the

COB patients with CT-Scan head

normal if obtained two or more of

the following:

- Age> 40 years

- TDS <90 mmHg

- Bilateral or unilateral postural

Management COS (GCS 9-12) (2B)

2 Conservative - Hospitalized for observation, IB 3,27,28,

neurological examination periodically. 29,30,3

- When conditions improve, the patient is discharged 1,32,33,

and control back, if conditions 34,35

deteriorating done the CT scan Scan

and appropriate treatment protocol

severe head injury.

Management COB (GCS <= 8)

- Make sure the patient's airway clear, give

oxygenation 100% and do a lot

manipulate the movement of the neck before

cervical injury can be ruled out, if

need intubation. (1B)








systemic in other body parts,


periodically.






metoclopramide, or ondansetron) and

anti-ulcer gastritis H2 blockers (eg:


vomiting (2B)

- Give hypertonic fluid (mannitol


not operable on CT Scan. mannitol

can be administered as a bolus of 0.5 to 1







at a dose of 300 mg / day or 5-10 mg

kg bw / day for 10 days. when you have


- Cito operation on progress towards Operating indication.

9. Education Explanations to patients and families: • Course of the disease and complications that may occur • Therapy and actions that will be given along with the advantages and disadvantages • The procedure for the treatment and the treating physician

10. Prognosis Ad Vitam (Live) : Ad Dubia bonam Ad Sanationam (cured) : Ad Dubia bonam Ad Fungsionam (function) : Ad Dubia bonam Prognosis is affected: - Age - Neurological status early - The distance between trauma and surgery - cerebral edema - Other intracranial abnormalities such as kontusional, subarachnoid hematoma and epidural hematoma


2. Dr. Agus Turchan, dr., Sp.BS 3. Dr. M. Arifin Parenrengi, dr., Sp.BS 4. Dr. Joni Wahyuhadi, dr., Sp.BS 5. Dr. Eko Agus Subagyo, dr., Sp.BS 6. Dr. Asra Al Fauzi, dr., Sp.BS 7. Wihasto Suyaningtyas, dr., Sp.BS 8. Rahadian Indarto, dr., Sp.BS 9. Muhammad Faris, dr., Sp.BS 10. Fahmi Achmad, dr., Sp.BS 11. Nur Setiawan Suroto, dr., Sp.BS 12. Irwan Barlian Immadoel Haq, dr, Sp.BS 13. Tedy Apriawan, dr., Sp.BS 14. Heri Subianto, dr., Sp.BS

12. Medical Indicators Improvement of neurological status.

13. Bibliography 1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;

2:81 2. Rosenfeld JV, Maas AI, Bragge P, et al. Early management of severe traumatic brain injury. Lancet 2012; 380: 1088 3. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. Introduction. J Neurotrauma 2007; 24 Suppl 1: S14. 4. Maas AI, Dearden M, Teasdale GM, et al. EBIC guidelines for management of severe head injury in adults. European Brain Injury Consortium. Acta Neurochir (Wien) 1997; 139: 286

5. Newcombe R, Merry G. The management of acute Neurotrauma in rural and remote locations: A set of guidelines for the care of head and spinal injuries. J Clin Neurosci 1999; 6:85.

6. Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 1: Introduction. Pediatr Crit Care Med 2003; 4: S2 7. Patel HC, Bouamra O, Woodford M, et al. Trends in head injury outcomes from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2005; 366: 1538

8. PN Varelas, Conti MM, Spanaki MV, et al. The impact of a neurointensivist-led team on a semiclosed Neurosciences intensive care unit. Crit Care Med 2004; 32: 2191 9. Visca A, Faccani G, Massaro M, et al. Clinical and neuroimaging features of severely Brain Injured Patients treated in a neurosurgical unit Compared with Patients treated in peripheral non neurosurgical hospitals. Br J Neurosurg 2006; 20:82 10. JA Pineda, Leonard JR, Mazotas IG, et al. Effect of implementation of a Pediatric neurocritical care program on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol 2013; 12:45. 11. Marmarou, A, Anderson, L, Ward, J, et al. Impact of ICP instability and hypotension on outcome in Patients with severe head trauma. J Neurosurg 1991; 75: 159 12. Schreiber MA, Aoki N, Scott BG, Beck JR. Determinants of mortality in Patients with severe blunt head injury. Arch Surg 2002; 137: 285 13. Badri S, Chen J, Barber J, et al. Mortality and longterm functional outcomes associated with intracranial pressure after traumatic brain injury. Intensive Care Med 2012; 38: 1800

14. MacDonald RL, Schwartz ML, Mirich D, et al. The diagnosis of cervical spine injury in motor vehicle crashes Victims: Xrays how many are enough? J Trauma 1990; 30: 392. 15. Zabel DD, Tinkoff G, Wittenborn W, et al. Adequacy and efficacy of lateral cervical spine radiography in alert, highrisk blunt trauma patient. J Trauma 1997; 43: 952. 16. Fisher A, Young WF. Is the lateral cervical spine xray obsolete during the Initial Evaluation of Patients with acute trauma? Surg Neurol 2008; 70:53. 17. Wisbach GG, Sise MJ, Sack DI, et al. What is the role of chest X-ray in the initial assessment of stable trauma Patients? J Trauma 2007; 62:74. 18. Duane TM, Dechert T, Wolfe LG, et al. Clinical examination is superior to plain films to diagnose pelvic fractures Compared to CT. Am Surg 2008; 74: 476. 19. Servadei F, Murray GD, Penny K, et al. The value of the "worst" computed tomographic scans in clinical studies of moderate and severe head injury. European Brain Injury Consortium. Neurosurgery 2000; 46:70.

20. Chang EF, Meeker M, Holland MC. Acute traumatic intraparenchymal hemorrhage: risk factors for progression in the early postinjury period. Neurosurgery 2006; 58: 647. 21. Oertel M, Kelly DF, McArthur D, et al. Progressive hemorrhage after head trauma: Predictors and consequences of the evolving injury. J Neurosurg 2002; 96: 109. 22. RK Narayan, Maas AI, Servadei F, et al. Progression of traumatic intracerebral hemorrhage: a prospective observational study. J Neurotrauma 2008; 25: 629. 23. Thomas BW, Mejia VA, Maxwell RA, et al. Scheduled repeat CT scanning for traumatic brain injury remains important in assessing head injury progression. J Am Coll Surg 2010; 210: 824.

24. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas. Neurosurgery 2006; 58: S7.

25. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery 2006; 58: S16.

26. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of traumatic parenchymal lesions. Neurosurgery 2006; 58: S25.

27. HE Hinson, Stein D, KN Sheth. Hypertonic saline and mannitol therapy in critical care neurology. J Intensive Care Med 2013; 28: 3.

28. James HE. Methodology for the control of intracranial pressure with hypertonic mannitol. Acta Neurochir (Wien) 1980; 51: 161.

29. McGraw CP, Howard G. Effect of mannitol on Increased intracranial pressure. Neurosurgery 1983; 13: 269.

30. Sakowitz OW, JF Stover, Sarrafzadeh AS, et al. Effects of bolus administration of mannitol on intracranial pressure, cerebral extracellular metabolites, and tissue oxygenation in severely head Injured Patients. J Trauma 2007; 62: 292.

31. Vandromme MJ, Melton BC, Griffin R, et al. Intubation patterns and outcomes in computed tomography verified Patients with traumatic brain injury. J Trauma 2011; 71: 1615.

32. Diringer MN, Yundt K, Videen TO, et al. No reduction in cerebral metabolism as a result of early moderate

hyperventilation following severe traumatic brain injury. J Neurosurg 2000; 92: 7.

33. Temkin NR. Risk factors for posttraumatic seizures in adults. Epilepsia 2003; 44 Suppl 10:18.

34. Frey LC. Epidemiology of posttraumatic epilepsy: a critical review. Epilepsia 2003; 44 Suppl 10:11.

35. Vespa PM, Nuwer MR, Nenov V, et al. Increased incidence and impact of nonconvulsive and convulsive seizures

after traumatic brain injury as detected by continuous electroencephalographic monitoring. J Neurosurg 1999; 91: 750.


Skull base fracture ICD-10: S02.1

1. Definition Fracture Head covering one of the basic bone head: cribiformis lamina of the ethmoid Os, Pars orbit of (Definition) Os Frontal, pars petrous and squamous temporal bone, sphenoid and Os Os occipital

2. History • Be a history of trauma

• A history of blood or fluid discharge from the nose and / or ears • Nausea • Gag • disruption Viewed • wry face • Hearing Impaired

3. PemeriksaanFisik General Physical Examination (Examination by inspection, palpation) Physical examination was first priority in the evaluation of A ( airways), B ( breathing), and C ( circulation) • May be accompanied by other injuries and loss of consciousness

Typical localist examination Overview:

• Retro aurikular / mastoid ecchymosis (Battle sign) • Periorbital ecchymosis (Raccoon eyes) • Clear Rhinorea • Clear Otorhea • Hemotimpanum

Neurological examination (if available)

• The level of awareness Glasgow Coma Scale ( GCS)

• Lesions N III, IV, VI

• Lesions N VII

• Lesions N VIII

4. Criteria for Diagnosis 1. History according above 2. Clinical examination in accordance Issuer 3. Examination of appropriate clinical imaging

5. DiagnosisKerja Skull base fracture (ICD 10: S02.1) 6. Diagnosis - trauma maksilofacial 7. Investigations

No. Examination Recommendation GR Ref

• CT-Scan Bone Window to see

calvaria bone images and CT-Scan Brain

Window to look at the brain parenchymal lesions 2, 3, 4, 5,

or a brain hemorrhage.

6, 7, 8,

1 CT Scan Head

• Fracture of the base of the skull can

1A

11, 12,

use thinly sliced pieces of axial

13, 14

the base of the skull bone window

• Rhinorrhea and ottorhea an indication

for action CT Scan

• If the lesion is large enough; find the fracture line,

aerokel, blood in the paranasal sinuses,

shift pinealis gland, bone fragments

2 X head photo and corpus alienum 1C 3, 4, 15,

• Not to mencarifraktur base

Patients who require a CT-scan

head does not need to be made X-head photo

• Looking for concomitant injuries, especially when

X-vertebral photo lesion was also found in the shoulders, neck, and

3 cervical suspected neck injury from 1C 2, 3, 4, 5,

clinical examination

15

4 X chest x-ray

• Looking for concomitant injuries 1C 2, 3, 4, 5

5

Lab beta 2 • Looking for evidence of leakage LCS 1C 2, 3, 21,

transferrin

22, 23

• Whole Body CT ( WBCT) used in

6 CT Scan Whole

multitrauma case to reduce 2A 32

the time of diagnosis, it can be used in

body

patients with hemodynamically unstable

8. Therapy

No. Therapy Procedures (ICD 9 CM) GR Ref

indications Surgery

• Post-traumatic CSF leaks are accompanied by

operation meningitis 1C 3,8,12

• Transverse fracture Os petrous involving

optic capsule

• Temporal bone fracture resulting in total lesion

of the facial muscles

• Temoral ballistic trauma resulting in vascular damage

• The defects are spacious with brain herniation into the paranasal sinuses, pneumocephalus, or leakage of CSF over five days

• Surgery:

• craniotomy ( ICD 9: 1:24) • Duraplasty ( ICD 9: 2:12) • cranioplasty ( ICD 9: 2:04)

Non-operative treatment in the room include • Observation GCS, pupil, lateralization, vital danfaal

• Optimization of stabilization vital physiology, maintaining optimal

supply of O 2 to the brain • Airway: suck secret / blood / vomit when

needed, tracheostomy. COB patients with lesions that do not require the evacuation and patients with impaired blood gas analysis treated in respirator

• Maintain cerebral perfusion, head-up position

the head about 30 degrees to avoid neck

flexion

• Bladder catheter is required to record the

production of urine, prevent urinary retention,

preventing the bed was wet (thus reducing the 2, 3, 4, 6,

risk of pressure sores)

8, 12,

- Head Up 30 o ( 2B) 24, 25,

- Give enough fluids (normal saline) to resuscitate

2 Conservative the victim to remain normovolemia, overcome 26, 27,

hypotension occurs and give blood transfusion if 1C

28, 29,


30, 31,

- Check vital signs, the presence of systemic injuries 33, 34,

in other body parts, GCS and periodic examination

of the brain stem. 35

- Give analgesic medications (eg,

acetaminophen, ibuprofen for mild and

moderate pain) when obtained complaints of

pain in patients (2B)

- Give anti-vomiting drugs (eg, metoclopramide,

or ondansetron) anti-ulcer and gastritis H2

blockers (eg, ranitidine or omeprazole) if the

patient vomiting (2B)

- Give hypertonic fluid (mannitol 20%), when looked

edema or injury that is not operable on CT Scan.

Mannitol can be administered as a bolus of 0.5 to 1 g /

kg. BB in certain circumstances, or repeated small

doses, for example, (4-6) x 100 cc of mannitol 20% in

24 hours.

Gradual discontinuation. (1B) • Give Phenytoin (PHT) prophylaxis in patients with a high risk of seizures at a dose of 300 mg / day or 5-10 mg kg / day for 10 days. When you have seizures, IPM is given as therapy. (1B)

• antibiotic prophylaxis

9. Education Explanations to patients and families: • Gejaladarifraktur skull base • Complications bisaterjadi (intra-cranial hemorrhage, cerebral edema, infection, swelling) • Therapy and actions that will be given along with the advantages and disadvantages • The procedure for the treatment and the treating physician

10. Prognosis Ad Vitam (Live) : Ad Dubia bonam Ad Sanationam (cured) : Ad Dubia bonam Ad Fungsionam (function) : Ad Dubia bonam Prognosis is affected: - Age - Status Neurologisawal - Jarakantara trauma dantindakanbedah - cerebral edema - Other intracranial abnormalities such as kontusional, subarachnoid hematoma and epidural hematoma

- Faktorekstrakranial 11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS

2. Dr. Agus Turchan, dr., Sp.BS 3. Dr. M. Arifin Parenrengi, dr., Sp.BS 4. Dr. Joni Wahyuhadi, dr., Sp.BS 5. Dr. Eko Agus Subagyo, dr., Sp.BS 6. Dr. Asra Al Fauzi, dr., Sp.BS 7. Wihasto Suyaningtyas, dr., Sp.BS 8. Muhammad Faris, dr., Sp.BS 9. Rahadian Indarto, dr., Sp.BS 10. Fahmi Achmad, dr., Sp.BS 11. Nur Setiawan Suroto, dr., Sp.BS 12. IrwanBarlianImmadoelHaq, dr, Sp.BS 13. TedyApriawan, dr., Sp.BS 14. HeriSubianto, dr., Sp.BS

12. Medical Indicators Improvement of neurological status. 13. Bibliography 1. Cooper PR, (ed), 1993, Head Injury, 3 rd Ed, William & Wilkins Baltimore,

Maryland, USA. 2. Wilkins RH and Rengachary SS (eds), Neurosurgery, Vol. II, 2 nd ed. MC Graw Hill Co. New York. 3. Narayan RK, Wilberger JE Jr, Povlishock JT (eds) 1996. Neurotrauma, MC Graw Hill Co. New York.

4. PG Patil, Radtke RA, Friedman AH 2002 Contemp. Neurosurgery 24 (22): 1-6. 5. Mayer S, Rowland L. Head injury. In: Merritt's Neurology, Rowland L. (Ed), Lippincott Williams & Wilkins, Philadelphia, 2000. p.401. 6. Golfinos JG Cooper PR. Skull fracture and post-traumatic cerebrospinal fluid fistula. In: Head Injury, 4th, Cooper PR, Golfinos JG. (Eds), McGraw-Hill, New York 2000. p.155 7. Chan KH, KS Mann, Yue CP, et al. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J Neurosurg 1990; 72: 189.

8. Hung CC, Chiu WT, Lee LS, et al. Risk factors predicting significant surgically

Intracranial hematomas in Patients with head injuries. Formos Med Assoc J 1996; 95: 294.

9. Macpherson BC, MacPherson P, Jennett B. CT evidence of intracranial contusion and hematoma

in relation to the presence, site and type of skull fracture. ClinRadiol 1990; 42: 321.

10. R Dahiya, Keller JD, Litofsky NS, et al. Temporal bone fractures: the otic capsule-sparing versus violating

the otic capsule clinical and radiographic considerations. J Trauma 1999; 47: 1079.

11. Nosan DK, Benecke JE Jr, Murr AH. Current perspective on the temporal bone trauma.

Otolaryngol Head Neck Surg 1997; 117: 67. 12. Yilmazlar S, Arslan E, Kocaeli H, et al. Cerebrospinal fluid leakage complicating skull base

fractures: analysis of 81 cases. Neurosurg Rev 2006; 29:64. 13. Hasso AN, Ledington JA. Traumatic injuries of the temporal bone. Otolaryngol Clin North Am 1988;

21: 295. 14. Flores Pretto L, De Almeida CS, Casulari LA. Positive predictive values of selected clinical signs

associated with skull base fractures. J Neurosurg Sci 2000; 44:77. 15. Savastio G, Golfieri R, Pastore Trossello M, Venturoli L. [Cranial trauma: the predictability of

the presentation symptoms as a screening for radiologic study]. Radiol Med 1991; 82: 769.

16. Liang W, Y Xiaofeng, Weiguo L, et al. Accompanying traumatic carotid cavernous fistula basilar skull

fracture: a study on the incidence of traumatic carotid cavernous fistula in the Patients with basilar skull fracture and the prognostic analysis about traumatic carotid cavernous fistula. J Trauma 2007; 63: 1014.

17. York G, Barboriak D, Petrella J, et al. Association of internal carotid artery injury with fractures of the carotid canal in Patients with head trauma. AJR Am J Roentgenol 2005; 184: 1672.

18. Resnick DK, Subach BR, Marion DW. The significance of the carotid canal involvement in basilar cranial

fracture. Neurosurgery 1997; 40: 1177. 19. Kim YI, Cheong JW, Yoon SH. Clinical comparison of the predictive value of the simple skull x-ray and

3-dimensional computed tomography for skull fractures of children. J Korean Neurosurg Soc 2012; 52: 528.

20. Mulroy MH, Loyd AM, Frush DP, et al. Evaluation of pediatric skull fracture imaging techniques. Forensic Sci Int 2012; 214: 167.

21. Kaptigau WM, Ke L, Rosenfeld JV. Open depressed skull fractures and penetrating in the Port Moresby General Hospital from 2003 to 2005. PNG Med J 2007; 50:58.

22. Tubbs, RS, Shoja, MM, Loukas, M. William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture. J Neurosurg 2009; :.

23. Flores Pretto L, De Almeida CS, Casulari LA. Positive predictive values of selected clinical signs associated with skull base fractures. J Neurosurg Sci 2000; 44:77.

24. Macpherson BC, MacPherson P, Jennett B. CT evidence of intracranial contusion and hematoma in relation to the presence, site and type of skull fracture. Clin Radiol 1990; 42: 321.

25. Michel O, Bamborschke S, Nekic M, Bachmann G. Beta-trace protein (prostaglandin D synthase) -

a stable and reliable protein in perilymph. Ger Med Sci 2005; 3: Doc04.

26. Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly, anticoagulated,

minor head injury patient who presents without evidence of neurologic abnormality. J Trauma 2003; 54: 492.

27. Mina AA, Knipfer JF, Park DY, et al. Intracranial complications of anticoagulation preinjury in Patients with head trauma injury. J Trauma 2002; 53: 668.

28. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in Patients anticoagulated. J Trauma 2006; 60: 553.

29. Karni A, Holtzman R, Bass T, et al. Traumatic head injury in the elderly anticoagulated patient: a lethal combination. Am Surg 2001; 67: 1098.

30. Franko J, Kish KJ, O'Connell BG, et al. Advanced age and preinjury warfarin anticoagulation increase of the risk of mortality after head trauma. J Trauma 2006;

61: 107. 31. Alrajhi KN, JJ Perry, Forster AJ. Intracranial bleeds after minor and minimal head injury in Patients

on warfarin. J Emerg Med 2015; 48: 137. 32. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed tomography

versus selective radiological imaging on outcomes Patients in major trauma: a meta-analysis. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014, 22:54.

33. Servadei F, Teasdale G, Merry G, Neurotraumatology Committee of the World Federation of Neurosurgical Societies. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma 2001; 18: 657

34. The management of minor closed head injury in children. Committee on Quality Improvement, the

American Academy of Pediatrics. Commission on Clinical Policies and Research, American Academy of Family Physicians. Pediatrics 1999; 104: 140

35. Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in Patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 2012; 59: 451.

SKULL BONE FRACTURE

ICD-10: S02.0

1. Understanding Fractures of the skull can be categorized as linear fractures, depression.

(Definition) Linear fracture: a single fracture that affects the entire thickness of the calvarium with

alignment is still good.

Fractures depress / impressions: fracture in which the fracture segments below the segment level

adjacent fractures. Fractures impression can be either open or closed fracture


• Obtained neurological disorders (amnesia, loss of consciousness, seizures, etc.)

• Kinds of trauma: occupational accidents, traffic accidents, assault, fell from

altitude and others

3. PemeriksaanFisik General Physical Examination

(Examination by inspection, palpation, percussion and auscultation)

• Physical examination was first priority in the evaluation of A ( airways), B

(Breathing), and C ( circulation)

examination of the head

• Looking for signs of injury, skull base fractures, facial fractures, trauma

on the eye, to determine their carotid auscultation bruit

Examination of the neck and spine

• Looking for signs of injury to the spine (especially cervical injury)

and injury to the spinal cord

other tests

• Another injury of cranial searched carefully kekaudal

• All findings noted signs of trauma. Bumps, abrasions, open wounds, false

movement, flail chest, abdominal wall, tenderness and others, bleeding

which seemed immediately terminated

PemeriksaanNeurologis


• Nerves II-III, VII lesisaraf peripheral

• Fundoskopi look for signs of edema pupil, retinal detachment

• Motor and sensory, compare the right and left, up and down

• Autonomis

4. Criteria for Diagnosis 1. History according above

2. Clinical examination in accordance Issuer

3. Examination of appropriate clinical imaging

5. DiagnosisKerja Linear fracture or fracture Kalvaria Kalvaria Impressions ( ICD-10: S02.0)

6. Diagnosis • Pediatric congenital abnormalities

• Metabolic Bone Disease of Prematurity

7. Examination

Support


• CT-Scan Bone Window to see

calvaria bone images and CT-Scan Brain

Window to look at the brain parenchymal lesions

or a brain hemorrhage. if necessary

do CT-Scan 3D

• Linear fracture line drawings or 2, 3, 4, 6,

1 CT Scan Head

bone fragments that enter exceeds 1A

18, 19,

bone fragments nearby

28, 29,

• Usually accompanied by scalp hematoma in 30

point of fracture

• Skull fractures usually with lesions

intraparenkim.

• Depressed fracture of the skull

requires a CT scan.

• MRI is more sensitive for the show

2 MRI

small area kontusional or bleeding 2A 2,4,6,8,

small, axonal injury, and bleeding

31,32,33

extra small axial. ,

• If the lesion is large enough; find the fracture line,

aerokel, blood in the paranasal sinuses,

shift pinealis gland, bone fragments

3 X-head photo and corpus alienum 1C 3, 4, 6,

• Not to mencarifraktur base

17, 18

Patients who require a CT-scan

head does not need to be made X-fotokepala

X-vertebral photo • Looking for concomitant injuries, especially when 2,3,4,5,6

4 cervical lesion was also found in the shoulders, neck, and 1C ,17,18,

22, 23

suspected neck injury from

clinical examination

• Looking for concomitant injuries 1C 2,3,4,5,6

5 X chest x-ray

• In infants and children with bone

6 ultrasound head

thin has a sensitivity and 1C 6,24,25

specificity of x-ray photo

,26,27

head

• Whole Body CT ( WBCT) used in

7 CT-Scan Whole


body the time of diagnosis, it can be used in


8. Therapy No. Therapy Procedures (ICD 9 CM) GR Ref

• Skull fractures with open wounds

• Frontal sinus fractures with

injuries open or obtain an

overview pneumatocephalus

• Impression with a skull fracture

exceeds bone fragments of bone fragments in

found nearby and neurological deficits. 1 Operations 1C 3,6,8 • Operating procedures, among others:

craniotomy ( ICD 9: 1:24) Frontal sinus debridement + decortication +

decompression ( ICD 9: 2:02)

cranioplasty ( ICD 9: 2:04) Sewing dura mater ( ICD 9: 2:11)

• Closed fractures, fractures

impressions closed without deficit 2, 3, 4, 6,

neurologic 8, 34,

• Non-operative treatment room 35, 36,

2 Conservative include: 1B 37, 38,

• Observation GCS, pupil, lateralization, 39, 40,

and physiology vital. (1B) 41, 43,

• Optimization of stabilization vital physiology, 44, 45

maintain optimal supply of O 2

keotak. (1B)

• Airway: suck secretions / blood /

vomit when necessary,

tracheostomy. patient

COB

with lesions that do not require

evacuation and patients with

disorders treated blood gas analysis

the respirator. (1B)

• Maintaining perfusion brain,

head head-up position

approximately 30 to avoid

neck flexion. (1B)

• Bladder catheter is required to

record production of urine, prevent

urinary retention, preventing place

tidurbasah (with thus

reduce the risk of pressure sores). (1C)

• Head Up 30 o ( 2B)

• Give enough fluids (normal saline)

to resuscitate the victim to fixed


happened and give transfusions

blood if Hb less than 10 g / dl.

(1B)

• Check vital signs, injury

systemic in parts of the body

Another, GCS and rod

inspection periodically brain.

• Give drugs analgesic

(Eg acetaminophen, ibuprofen

for mild and moderate pain) when

obtained complaints of pain in

patients (2B)

• Give anti-vomiting drugs

(example:

metoclopramide

or

ondansetron) and anti

ulcer

gastritis H2 blockers (eg ranitidine

or omeprazole) if the patient

vomiting (2B)

• Give hypertonic fluid (mannitol

20%), when looked edema or

injuries that are not operable on CT

Scan. mannitol can be given

as a bolus of 0.5 to 1 g / kg. BB on

particular circumstances, or small doses

repeatedly, for example, (4-6) x 100 cc

mannitol 20% in 24 hour.


• Give Phenytoin (PHT) prophylaxis

in patients with high risk

seizures at a dose of 300 mg / day

or 5-10 mg kg / day for 10

day. When you have seizures, PHT

given as therapy. (1B)


• Course of the disease and complications that may occur

• Therapy and actions that will be given along with the advantages and disadvantages

• The procedure for the treatment and the treating physician

• Type of hemorrhage that gives most excellent postoperative results between types

other bleeding if immediate evacuation

• Require adjuvant treatment for recovery of neurological functions disturbed, through the program rehabilitasimedik

10. Prognosis Ad Vitam (Live) : Ad Dubia bonam

Ad Sanationam (cured) : Ad Dubia bonam Ad Fungsionam (function) : Ad Dubia bonam

Prognosis is affected:

- Age

- Status Neurologisawal

- The distance between trauma and surgery

- cerebral edema

- Other intracranial abnormalities such as kontusional, subarachnoid hematoma and hematoma

epidural

- Faktorekstrakranial

11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS

2. Dr. Agus Turchan, dr., Sp.BS

3. Dr. M. Arifin Parenrengi, dr., Sp.BS

4. Dr. Joni Wahyuhadi, dr., Sp.BS

5. Dr. Eko Agus Subagyo, dr., Sp.BS

6. Dr. Asra Al Fauzi, dr., Sp.BS

7. Wihasto Suyaningtyas, dr., Sp.BS

8. Muhammad Faris, dr., Sp.BS

9. Rahadian Indarto, dr., Sp.BS

10. Fahmi Achmad, dr., Sp.BS

11. Nur Setiawan Suroto, dr., Sp.BS

12. Irwan Barlian ImmadoelHaq, dr, Sp.BS

13. Tedy Apriawan, dr., Sp.BS

14. Heri Subianto, dr., Sp.BS


13. Bibliography 1. Cooper PR, (ed), 1993, Head Injury, 3 rd Ed, William & Wilkins Baltimore,

Maryland, USA.

2. Wilkins RH and Rengachary SS (eds), Neurosurgery, Vol. II, 2 nd ed. MC Graw Hill

Co. New York.

3. Narayan RK, Wilberger JE Jr, Povlishock JT (eds) 1996. Neurotrauma, MC Graw Hill

Co. New York.

4. PG Patil, Radtke RA, Friedman AH 2002 Contemp. Neurosurgery 24 (22): 1-6.

5. Mayer S, Rowland L. Head injury. In: Merritt's Neurology, Rowland L. (Ed),

Lippincott Williams & Wilkins, Philadelphia, 2000. p.401.

6. Team Neurotrauma Hospital Dr. Soetomo. 2014 Guidelines for Management of Brain Injury

Second edition. Hospital Dr. Soetomo: Surabaya

7. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural

hematomas. Neurosurgery 2006; 58: S7.

8. Besenski N. Traumatic injuries: imaging of head injuries. EurRadiol 2002; 12: 1237.

9. Matsumoto K, Akagi K, Abekura M, Tasaki O. Vertex epidural hematoma

associated with traumatic arteriovenous fistula of the middle meningeal artery: a

case report. SurgNeurol 2001; 55: 302.

10. JI McIver, Scheithauer BW, Rydberg CH, Atkinson JL. metastatic hepatocellular

carcinoma presenting as epidural hematoma: case report. Neurosurgery 2001;

49: 447.

11. Ng WH, Yeo TT, Seow WT. Non-traumatic acute spontaneous epidural

hematoma - report of two cases and review of the literature. J ClinNeurosci

2004; 11: 791.

12. Moonis G, Granados A, Simon SL. Epidural hematoma as a complication of

sphenoid sinusitis and epidural abscess: a case report and literature review. Clin

Imaging 2002; 26: 382.

13. Szkup P, Stoneham G. Case report: spontaneous spinal epidural hematoma

during pregnancy: case report and review of the literature. Br J Radiol 2004;

77: 881.

14. Jea A, Moza K, Levi AD, Vanni S. Spontaneous spinal epidural hematoma during

pregnancy: case report and literature review. Neurosurgery 2005; 56: E1156;

E1156 discussion.

15. Takahashi K, Koiwa F, Tayama H, et al. A case of acute spontaneous epidural

hematoma in a patient of chronic renal failure undergoing hemodialysis:

successful outcomes with surgical management. Nephrol Dial Transplant 1999;

14: 2499.

16. Naran AD, Fontana L. Sickle cell disease with orbital infarction and

epidural hematoma. PediatrRadiol 2001; 31: 257.

17. Shahlaie K, Fox A, Butani L, Boggan JE. Spontaneous epidural hemorrhage

in chronic renal failure. A case report and review. PediatrNephrol 2004; 19: 1168.

18. JN Awad, Kebaish KM, Donigan J, et al. Analysis of the risk factors for the

development of post-operative spinal epidural hematoma. J Bone Joint Surg Br

2005; 87: 1248.

19. Sokolowski MJ, Garvey TA, Perl 2nd J, et al. Prospective study of postoperative

lumbar epidural hematoma: incidence and risk factors. Spine (Phila Pa 1976)

2008; 33: 108.

20. Radulovic D, Tasic G, Jokovic M. [Epidural hematomas of the posterior fossa].

Vojnosanit Pregl 2004; 61: 133.

Owler 21. BK, Besser M. extradural hematoma causing sinus venous obstruction and

pseudotumorcerebri syndrome. Childs NervSyst 2005; 21: 262.

22. Kim YI, Cheong JW, Yoon SH. Clinical comparison of the predictive value of

the simple skull x-ray and 3-dimensional computed tomography for skull fractures

of children. J Korean Neurosurg Soc 2012; 52: 528.

23. Mulroy MH, Loyd AM, Frush DP, et al. Evaluation of pediatric skull

fracture imaging techniques. Forensic Sci Int 2012; 214: 167.

Rabiner 24. JE, Friedman LM, Khine H, et al. Accuracy of point-of-care ultrasound for

diagnosis of skull fractures in children. Pediatrics 2013; 131: e1757.

25. Weinberg ER, tunic MG, Tsung JW. Accuracy of clinician-performed point-of-care

ultrasound for the diagnosis of fractures in children and young adults. Injury

2010; 41: 862.

26. Riera A, Chen L. Ultrasound evaluation of skull fractures in children: a feasibility

study. Pediatr Emerg Care 2012; 28: 420.

27. Parri N, BJ Crosby, Glass C, et al. Ability of emergency ultrasonography to

detect pediatric skull fractures: a prospective, observational study. J Emerg

Med 2013;

44: 135.

28. R. Braakman Depressed skull fracture: data, treatment, and follow-up in 225

Consecutive cases. J Neurol Neurosurg Psychiatry 1972; 35: 395.

29. JH Harris Jr. High yield criteria and skull radiography. JACEP 1979; 8: 438.

30. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of depressed

cranial fractures. Neurosurgery 2006; 58: S56.

31. Liang W, Y Xiaofeng, Weiguo L, et al. Traumatic carotid cavernous fistula

Accompanying basilar skull fracture: a study on the incidence of traumatic carotid

cavernous fistula in the Patients with basilar skull fracture and the prognostic

analysis about traumatic carotid cavernous fistula. J Trauma 2007; 63: 1014.

32. York G, Barboriak D, Petrella J, et al. Association of internal carotid artery injury

with carotid canal fractures in Patients with head trauma. AJR Am J Roentgenol

2005; 184: 1672.

33. Resnick DK, Subach BR, Marion DW. The significance of the carotid canal involvement

in basilar cranial fracture. Neurosurgery 1997; 40: 1177.

34. Macpherson BC, MacPherson P, Jennett B. CT evidence of intracranial contusion and

hematoma in relation to the presence, site and type of skull fracture. Clin

Radiol 1990; 42: 321.

35. Michel O, Bamborschke S, Nekic M, Bachmann G. Beta-trace protein

(Prostaglandin D synthase) - a stable and reliable protein in perilymph. Ger Med

Sci 2005; 3: Doc04.

36. Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the

elderly, anticoagulated, minor head injury patient who presents without evidence

of neurologic abnormality. J Trauma 2003; 54: 492.

37. Mina AA, Knipfer JF, Park DY, et al. Intracranial complications of preinjury

anticoagulation in Patients with head trauma injury. J Trauma 2002; 53: 668.

38. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in

anticoagulated Patients. J Trauma 2006; 60: 553.

39. Karni A, Holtzman R, Bass T, et al. Traumatic head injury in the

anticoagulated elderly patient: a lethal combination. Am Surg 2001; 67: 1098.

40. Franko J, Kish KJ, O'Connell BG, et al. Advanced age and preinjury warfarin

anticoagulation increase of the risk of mortality after head trauma. J Trauma 2006;

61: 107.

41. Alrajhi KN, JJ Perry, Forster AJ. Intracranial bleeds after minor and minimal head

injury in Patients on warfarin. J Emerg Med 2015; 48: 137.

42. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body

computed tomography vs. selective radiological imaging on outcomes in major

Patients trauma: a meta-analysis. Scandinavian Journal of Trauma, Resuscitation

and Emergency Medicine, 2014, 22:54.

43. Servadei F, Teasdale G, Merry G, Neurotraumatology Committee of the World

Federation of Neurosurgical Societies. Defining acute mild head injury in adults: a

proposal based on prognostic factors, diagnosis, and management. J

Neurotrauma 2001; 18: 657

44. The management of minor closed head injury in children. Committee on Quality

Improvement, American Academy of Pediatrics. Commission on Clinical Policies and

Research, American Academy of Family Physicians. Pediatrics 1999; 104: 140

45. Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in

Patients receiving oral anticoagulant therapy: a prospective study of a 24-hour

observation protocol. Ann Emerg Med 2012; 59: 451.

Traumatic intracerebral hematoma ICD-10: S06.3

1. Definition Collection of blood in the brain parenchyma. It can be a little bleeding bleeding-fused, or blood vessel (Definition) injury is quite large.

2. History • Be a history of trauma • Obtained neurological disorders (amnesia, loss of consciousness, seizures, etc.) • Kinds of trauma: occupational accidents, traffic accidents, assault, falls from height, etc.

3. PemeriksaanFisik General Physical Examination (Examination by inspection, palpation, percussion and auscultation) • Physical examination was first priority in the evaluation of A ( airways), B (Breathing), and C ( circulation)

examination of the head • Looking for signs of injury, skull base fractures, facial fractures, trauma to the eye, to

determine their carotid auscultation bruit

• Looking for signs of injury to the spine (especially cervical injuries) and injuries to the spinal cord

other tests • Another injury searched carefully from cranial to caudal • All findings noted signs of trauma. Bumps, abrasions, open wounds, false movement, flail

chest, abdominal wall, tenderness and others, who looked immediately stopped bleeding

Neurological examination


• Nerves II-III, VII peripheral nerve lesions • Fundoskopi look for signs of edema pupil, retinal detachment • Motor and sensory, compare the right and left, up and down • Autonomis



3. Examination of appropriate clinical imaging

5. DiagnosisKerja Intracerebral hematoma (ICD 10: S06.3)

6. Diagnosis - Cerebro vascular accident

- epileptic fits

- drug intoxication

- metabolic diseases

7. Investigations


Lab. DL (Blood

Lab. DL (CBC) and crossmatch 9,10,11

recommended in patients with ICH

,12,13,

1

Complete),

1B

eligible operative to smooth

14,15,1

crossmatch

6,17,18

operation process.

2 X- Head Photos

F-recommended head vertebra Photo 2A 3,4,19,

if the lesion is large enough; then seek

the fracture line, aerokel, blood in the sinuses 20,21

paranasalis, shift pinealis glands, fragments bone and alienum corpus. Not for

search fracture base. patients

require a CT-scan of the head is not necessary

made X-photograph of the head.

3 X Vertebra photo

Exclusion of cervical injury 1B 22,23,2

cervical 4,25,26

4 X-Thorax photo

Thorax X-photos used to find 1C 2,3,4,5

concomitant injury

CT scan is recommended in patients with ICH 2,3,4

with a picture shaped hiperdens

27,28,2

5 CT Scan Head crescent (kresens). It also can be

1B

9,30,31

accompanied by a picture of scalp hematoma

,32.33

and calvaria in the contralateral fracture.

MRI is more sensitive to indicate the area 6,8,47,

kontusional small or minor bleeding,

6 MRI

2B 48,49,5

axonal injury and minor bleeding extras

0

axial.


7 CT-Scan Whole



body


8. Therapy No. Therapy Procedures (ICD 9 CM) GR Ref

When there is:

operative

- The volume of bleeding in the frontal or

temporal> 20ml.

craniotomy +

- Midline shift> 5mm

evacuation ICH - And or compression on cisterns

+ decompression

- Mass effect with neurological deterioration

1,2,28,2

1 ( ICD 9: 1B

in accordance with less lesions

9.30

01:24),

- Bleeding volume of more than 50ml

osteoplasty

- Hematome intracerebral in the posterior fossa

( ICD 9:

with mass effect (distortion, dislocation,

2:04)

obliteration ventricular four, compression

basal cisterns, or obstructive hydrocephalus)

2 Operative Improved Intra Cranial Pressure 1B 33,34,35

installation associated with increased ,36,37,3

ICP monitor mortality and worsening of the patient's condition. 8.39

( ICD 9: 01.1) Indications on the monitor ICP installation brain injury is GCS 3-8 and CT scan

Abnormal show an effect mass such as hematoma and contusions. When

found patients with COB (GCS 3-8

after resuscitation process) with CT Scan

no indication of abnormal head to

evacuation hematome

Management COS (GCS 9-12) (2B)

- Hospitalized for observation,

neurological examination periodically.

- When conditions improve, the patient is discharged

and control back, if conditions

deteriorating done the CT scan Scan

and appropriate treatment protocol

severe head injury.

Management COB (GCS <= 8)


oxygenation 100% and do a lot 5,6,8,40,

manipulate the movement of the neck before ,41,42,4

3. conservative cervical injury can be ruled out, if

1B

need intubation. (1B)

3,44,45,

46, 52,


53, 54









periodically.








ranitidine or omeprazole) if the patient vomiting (2B)

- Give hypertonic fluid (mannitol 20%),

when looked edema or injury

not operable on CT Scan. mannitol can be administered as a bolus of 0.5 to 1

g / kg. BB in certain circumstances, or repeated small doses, for example, (4-6) x 100








Cito operation on progress towards operating indication





• Memerlukanperawatanpascaoperasiuntukpemulihanfungsineurologis that disturbed, through the program rehabilitasimedik

10. Prognosis Ad Vitam (Live) : Dubia

Ad Sanationam (cured) : Dubia

Ad Fungsionam (function) : Dubia


- Age


- Jarakantara trauma dantindakanbedah

- cerebral edema


epidural













12. IrwanBarlianImmadoelHaq, dr, Sp.BS

13. TedyApriawan, dr., Sp.BS

14. HeriSubianto, dr., Sp.BS

12. Medical Indicators Improvement of neurological status. 13. Bibliography 1. Bullock MR, Chesnut R, Ghajar J, Gordon D, et al. 2006. Surgical Management of

Traumatic parenchymal lesions. Neurosurgery. 2006; 58 (3 Suppl): S25.

2. Cooper PR (ed), 1993, Head Injury, 3 rd ed, William & Wilkins Baltimore, Maryland,

USA.

Subdural 2015. 3. W. McBride Hematome In Adults: etiology, Clinical Features, and

Diagnosis. Wolters Kluwe: UpToDate

4. McBride W. Subdural Hematome 2015. In Adults: Prognosis and Management.

Wolters Kluwe: UpToDate

5. RK Narayan, WilbergerJr, Povlishock JT (Eds). 1996.Neurotrauma, MC Graw Hill

Comp, New York.

6. PG Patil, Radtke RA, Friedman AH. 2002. Contemp. Neurosurgery 24 (22): 1-6.

7. Palmer JD (ed) (1997) Head Trauma in the Manual of Neurosurgery Churchill

Livingstone, New York, pp 499-580.

8. Wilkins RH and Rengachary SS (eds), Neurosurgery, Vol. II, 2 nd ed. MC Graw Hill Co.

New York.

9. Harhangi BS, Kompanje EJ, Leebeek FW, Maas AI. Coagulation disorders after

traumatic brain injury. Acta Neurochir (Wien) 2008; 150: 165.

10. CB Allard, Scarpelini S, Rhind SG, et al. Abnormal coagulation tests are associated

with progression of traumatic intracranial hemorrhage. J Trauma 2009; 67: 959.

11. Wafaisade A, Lefering R, Tjardes T, et al. Acute coagulopathy in isolated blunt

traumatic brain injury. Neurocrit Care 2010; 12: 211.

12. Stein SC, Young GS, Talucci RC, et al. Delayed brain injury after head

trauma: significance of coagulopathy. Neurosurgery 1992; 30: 160.

13. Murray GD, Butcher I, McHugh GS, et al. Multivariable prognostic analysis in traumatic

brain injury: results from the IMPACT study. J Neurotrauma 2007; 24: 329.

14. Zehtabchi S, Soghoian S, Liu Y, et al. The association of coagulopathy and traumatic

brain injury in Patients with isolated head injury. Resuscitation 2008; 76:52.

15. Nishijima DK, Zehtabchi S, Berrong J, Legome E. Utility of platelet transfusion in

Adult Patients with traumatic intracranial hemorrhage and preinjury antiplatelet

use: a systematic review. Acute Care Trauma Surg J 2012; 72: 1658.

16. Perel P, Roberts I, Shakur H, et al. Haemostatic drugs for traumatic brain injury.

Cochrane Database Syst Rev 2010; : CD007877.

17. RK Narayan, Maas AI, Marshall LF, et al. Recombinant factor VIIa in traumatic

intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery

2008; 62: 776.

18. Winter JP, Plummer D, Bottini A, et al. Early prophylaxis of fresh frozen plasma

abnormal coagulation parameters in the severely head-Injured patient is not

effective. Ann Emerg Med 1989; 18: 553.

19. Kim YI, Cheong JW, Yoon SH. Clinical comparison of the predictive value of the

simple skull x-ray and 3-dimensional computed tomography for skull fractures of

children. J Korean Neurosurg Soc 2012; 52: 528.

20. Mulroy MH, Loyd AM, Frush DP, et al. Evaluation of pediatric skull fracture imaging

techniques. Forensic Sci Int 2012; 214: 167.

21. Frush DP, O'Hara SM, Kliewer MA. Pediatric imaging perspective: acute head

trauma - Is useful skull radiography? J Pediatr 1998; 132: 553.

22. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule

out injury to the cervical spine in Patients with blunt trauma. National Emergency X-

Radiography Utilization Study Group. N Engl J Med 2000; 343: 94.

23. Gonzalez RP, GR Cummings, Phelan HA, et al. Clinical examination in Ballsbridge

with computed tomography scans: an effective method for identification of cervical

spine injury. J Trauma 2009; 67: 1297.

24. Halpern CH, AH Milby, Guo W, et al. Clearance of the cervical spine in clinically

Patients unevaluable trauma. Spine (Phila Pa 1976) 2010; 35: 1721.

25. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical

spine injuries. J Trauma 1993; 34: 342.

26. JD Berne, Velmahos GC, El-Tawil Q, et al. Value of complete cervical helical

Computed tomographic scanning in identifying cervical spine injury in the

unevaluable blunt trauma patient with multiple injuries: a prospective study. J

Trauma 1999; 47: 896.

27. Servadei F, Murray GD, Penny K, et al. The value of the "worst" computed

tomographic scans in clinical studies of moderate and severe head injury. European

Brain Injury Consortium. Neurosurgery 2000; 46:70.

28. Chang EF, Meeker M, Holland MC. Acute traumatic intraparenchymal hemorrhage:

Risk factors for progression in the early post-injury period. Neurosurgery 2006;

58: 647.

29. Oertel M, Kelly DF, McArthur D, et al. Progressive hemorrhage after head trauma:

Predictors and consequences of the evolving injury. J Neurosurg 2002; 96: 109.

30. RK Narayan, Maas AI, Servadei F, et al. Progression of traumatic intracerebral

hemorrhage: a prospective observational study. J Neurotrauma 2008; 25: 629.

31. FF Connon, Namdarian B, Ee JL, et al. Do routinely repeated computed tomography

scans in traumatic brain injury management influence? A prospective observational

study in a level 1 trauma center. Ann Surg 2011; 254: 1028.

32. Kaups KL, Davis JW, Parks SN. Routinely repeated computed tomography after blunt

head trauma: Patients does it benefit? J Trauma 2004; 56: 475.

33. Huang AP, Lee CW, Hsieh HJ, et al. Early parenchymal contrast extravasation

Predicts subsequent hemorrhage progression, clinical deterioration, and need for

Surgery in Patients with traumatic cerebral contusion. J Trauma 2011; 71: 1593.

34. Marmarou, A, Anderson, L, Ward, J, et al. Impact of ICP instability and hypotension

on Outcome in Patients with severe head trauma. J Neurosurg 1991; 75: 159.

35. Schreiber MA, Aoki N, Scott BG, Beck JR. Determinants of mortality in Patients with

severe blunt head injury. Arch Surg 2002; 137: 285.

36. Badri S, Chen J, Barber J, et al. Mortality and long-term functional outcome

associated with intracranial pressure after traumatic brain injury. Intensive Care

Med 2012; 38: 1800.

37. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress

of Neurological Surgeons, et al. Guidelines for the management of severe traumatic

brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma

2007; 24 Suppl 1: S37.

38. HA Biersteker, Andriessen TM, Horn J, et al. Factors Influencing the intracranial pressure

guideline compliance monitoring and outcome after severe traumatic brain injury.

Crit Care Med 2012; 40: 1914.

39. Chesnut RM, Temkin N, N Carney, et al. A trial of intracranial-pressure monitoring in

traumatic brain injury. N Engl J Med 2012; 367: 2471.

40. Macpherson BC, MacPherson P, Jennett B. CT evidence of intracranial contusion and

hematoma in relation to the presence, site and type of skull fracture. Clin Radiol

1990; 42: 321.

41. Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly,

anticoagulated, minor head injury patient who presents without evidence of

neurologic abnormality. J Trauma 2003; 54: 492.

42. Mina AA, Knipfer JF, Park DY, et al. Intracranial complications of preinjury

anticoagulation in Patients with head trauma injury. J Trauma 2002; 53: 668.

43. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in Patients anticoagulated.

J Trauma 2006; 60: 553.

44. Karni A, Holtzman R, Bass T, et al. Traumatic head injury in the anticoagulated

elderly patient: a lethal combination. Am Surg 2001; 67: 1098.

45. Franko J, Kish KJ, O'Connell BG, et al. Advanced age and preinjury warfarin

anticoagulation increase of the risk of mortality after head trauma. J Trauma 2006; 61:

107.

46. Alrajhi KN, JJ Perry, Forster AJ. Intracranial bleeds after minor and minimal head

injury in Patients on warfarin. J Emerg Med 2015; 48: 137.

N. Besenski 47. Traumatic injuries: imaging of head injuries. EurRadiol 2002; 12: 1237.

48. Liang W, Y Xiaofeng, Weiguo L, et al. Traumatic carotid cavernous fistula

Accompanying basilar skull fracture: a study on the incidence of traumatic carotid

cavernous fistula in the Patients with basilar skull fracture and the prognostic

analysis about traumatic carotid cavernous fistula. J Trauma 2007; 63: 1014.

49. York G, Barboriak D, Petrella J, et al. Association of internal carotid artery injury with

carotid canal fractures in Patients with head trauma. AJR Am J Roentgenol 2005; 184:

1672.

50. Resnick DK, Subach BR, Marion DW. The significance of the carotid canal involvement in

basilar cranial fracture. Neurosurgery 1997; 40: 1177.

51. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body

computed tomography vs. selective radiological imaging on outcomes in major

Patients trauma: a meta-analysis. Scandinavian Journal of Trauma, Resuscitation and

Emergency Medicine 2014, 22:54.

52. Servadei F, Teasdale G, Merry G, Neurotraumatology Committee of the World

Federation of Neurosurgical Societies. Defining acute mild head injury in adults: a

proposal based on prognostic factors, diagnosis, and management. J Neurotrauma

2001; 18: 657

53. The management of minor closed head injury in children. Committee on Quality

Improvement, American Academy of Pediatrics. Commission on Clinical Policies and

Research, American Academy of Family Physicians. Pediatrics 1999; 104: 140

54. Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in

Patients receiving oral anticoagulant therapy: a prospective study of a 24-hour

observation protocol. Ann Emerg Med 2012; 59: 451.

Diffuse Axonal Injury (DAI, ICD 10: S06.2) 1. Definition Extensive injury in brain axons caused shearing mechanism which looks at pathologic examination and CT

(Definition) scan of the head as multiple small lesions seen in the area white matters brain. 1,2,3 2. History - The identity of the patient: Name, Age, Gender, Ethnicity, Religion, Occupation, Address

- Main complaint - mechanism of trauma - Time and travel trauma - Never passed out or unconscious after trauma - Retrograde or antegrade amnesia - Complaints: how severe headache, loss of consciousness, seizures, vertigo - History drunk, alcohol, narcotics, postoperative head - Morbidities: epilepsy, heart disease, asthma, chief operating history, hypertension and diabetes mellitus, and impaired blood clotting physiology 3. Primary Physical Examination Survey (1,2,3,4,9)

Examination Evaluation Note, record, and fix

A. Airway Patency of the airway? Obstruction? Additional sound?

B. Breathing Is Effective Rate and depth of chest oxygenation .... ? movement Water entry cyanosis


D. Disability (neurological Is there a neurological Kesadaranmenggunakan level status) disability ...? or AVPU GCS system. Pupil

(large, shape, light reflex, compare kanankiri)

E. Exposure (open the whole Another organ injury ...? Injury, deformity, and limb outfit) movement. Evaluation of response

to commands or painful stimuli



Physical examination is closely related to brain injury are:

1. Examination of the head for the mark:

a. The lesion in the head covering; sub-cutaneous hematoma, sub galeal, open wounds, penetrating wounds and

foreign bodies.

b. Signs fracture of the skull base, include; periorbital ecchymosis (brill hematoma), ecchymosis post

auricular (Battle sign), rhinorhoe, and otorhoe and bleeding in the tympanic membrane or leserasi auditory canal.




dissection



a. The level of awareness: based on a scale of Glasgow Coma Scale (GCS). Head injury is based GCS, which was assessed after the stabilization of the ABC classified: GCS 14-15: mild brain injury (COR) GCS 9-13: moderate brain injury (COS) GCS 3-8: severe traumatic brain injury (COB)





Autonomis: bulbocavernous reflex, cremaster reflex, reflex spingter, tendon reflexes, pathological reflexes and tone spingter ani.

4. Criteria for Diagnosis 1. History according above 2. Clinical examination in accordance Issuer 3. Imaging studies

5. Work Diagnosis Diffuse Axonal Injury (DAI, ICD 10: S06.2) 6. Diagnosis • Diffuse vascular injury

• Hypoxic / ischaemei damage • Brain edema

7. Investigations


No. Examination RecommendationsRef

endasi

Most patients with DAI (50-

80%) showed abnormal CT Scan

There may be bleeding spots

1 CT scan the gray-white matter junction, corpus 2B 7

callosum and brainstem

For the initial diagnostic DAI in patients post

Episodic early trauma

MRI performed if the CT scan is not

looked a picture of abnormalities (CT Scan

normal) but based on clinical gejalan

patients showed a picture of DAI

At a certain sequence, for example

gradient-echo sequence, usually

2 MRI

show paramagnetic effect of 2B

8, 9,10,

ptekie form of black spots. sequence

11

T2-weighted images can be also be seen

picture hyperintense spots.

In the MR-DTI, looked picture

fractional decrease Anisotropy (FA)

especially on the part of the brain

suffered axonal injury

Whole Body CT ( WBCT) used in

3 CT-Scan Whole



body


8. Therapy

No. Therapy Procedures (ICD 9 CM) grade Ref

Recomm endations

endasi

1 Conservative - Observation GCS, pupil, lateralization, and 1B 4,5,6

vital physiology.

- Optimization of stabilization vital physiology,

maintain adequate supply of O 2 to the brain.

- Circulation: intravenous fluids impartial

NaCl-glucose, prevent the occurrence of

overhydration, when it is stable

gradually replace fluid / nutrition

enteral / pipe stomach.

- Airway: suck secretions / blood /

vomit when needed,

tracheostomi. COB patients with

lesions that do not require evacuation

and patients with impaired treated

blood gas analysis in respirator

- Maintain cerebral perfusion,

head head-up position around

30 •• to avoid neck flexion.

- Bladder catheter is required to


urinary retention, prevent bed wet

(thus reducing

the risk of pressure sores).



GCS and examination of the brainstem

periodically.





- Give anti-vomiting drugs (Eg,

metoclopramide or ondansetron)

anti-ulcer and gastritis H2 blockers

(eg ranitidine or omeprazole) if the

patient vomiting

(2B)


in patients with high risk seizures at

a dose of 300 mg / day or

5-10 mg kg / day for 10 days.

When you have a seizure, given PHT

as therapy. (1B)

- Mild hypothermia

9. Education Explanations to patients and families: • Course of the disease and complications that may occur • Therapy and actions that will be given along with the advantages and disadvantages • The procedure for the treatment and the treating physician • Require adjuvant treatment for recovery of impaired neurological function, through medical rehabilitation program

10. Prognosis Ad Vitam (Live) : Dubia Ad Sanationam (cured) : Dubia Ad Fungsionam (function) : Dubia Prognosis depends on: 1. Age 2. The patient's neurologic status when it comes to hospital 3. DAI grading. 4. The accompanying diseases and complications arising

11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS 2. Dr. Agus Turchan, dr., Sp.BS 3. Dr. M. Arifin Parenrengi, dr., Sp.BS 4. Dr. Joni Wahyuhadi, dr., Sp.BS 5. Dr. Eko Agus Subagyo, dr., Sp.BS 6. Dr. Asra Al Fauzi, dr., Sp.BS 7. Wihasto Suyaningtyas, dr., Sp.BS 8. Rahadian Indarto, dr., Sp.BS 9. Muhammad Faris, dr., Sp.BS 10. Fahmi Achmad, dr., Sp.BS 11. Nur Setiawan Suroto, dr., Sp.BS 12. Irwan Barlian Immadoel Haq, dr, Sp.BS 13. Tedy Apriawan, dr., Sp.BS 14. Heri Subianto, dr., Sp.BS

12. Medical Indicators Improvement of neurological status. 13. Bibliography 1. DH Smith. Axonal Damage in Traumatic Brain Injury. The Neuroscientist. 2000; 6 (6): 483-95

2. Park CO, Ha YS, Clinical Analysis of 34 Diffuse Axonal Injured (DAI) Patients Below GCS

8. Yonsel Medical Journal. 1992; 33 (4): 326-36

3. Meythaler JM. Current Concepts: Diffuse Axonal Injury-Associated Traumatic Brain Injury. Arcyh Phys Med Rehabil 2001; 82: 1461-71

4. Blumbergs PC. Diffuse Axonal Injury in Head Trauma. Od Journal of Neurology, Neurosurgery, and Psychiatry. 1989; 52: 838-41

5. Simth DH, Diffuse Axonal Injury in Head Trauma. J Head Trauma Rahabil. 2003; 18 (4): 307-16

6. DH Smith. Development Therapy for Diffuse Axonal Injury. , 2013; 30: 307-23 7. JH Adams, Doyle D, Ford I, et al. Diffuse axonal injury in head injury: definition, diagnosis, and

grading. Histopathol. 1989; 15: 49-59 8. Paterakis K, Karantanas AH. Outcome of Patients with Diffuse Axonal Injury: The Significance and

prognostic Value of MRI in the Acute Phase. J Trauma. 2000; 49: 10715

9. Wang H, Duan G, Zhang J, et al. Clinical studies on diffuse axonal injury in Patients with severe closed head injury. Chin Med J (Engl). Jan. 1998 111 (1): 59-62

10. Ljungqvist J, Nilsson D, F Ljungberg, Sorbo A, Esbjörnsson E, Eriksson-Ritzen C, et al. Longitudinal study of the diffusion tensor imaging properties of the corpus callosum in acute and chronic diffuse axonal injury. Brain Inj. 2011. 25 (4): 370-8

11. Skandsen T, KA Kvistad, Solheim O, et al. Prevalence and impact of diffuse axonal

injury in Patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and the 1-year outcome. J Neurosurg. 2009

12. de la Plata CM, Ardelean A, Koovakkattu D, et al. Magnetic resonance imaging of diffuse axonal injury: quantitative assessment of white matter lesion volume. J Neurotrauma. April, 2007. 24 (4): 591-8

13. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed tomography versus

selective radiological imaging on outcomes Patients in major trauma: a meta-analysis. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014, 22:54.

epidural hematoma ICD-10: S06.4

1. Definition Bleeding in the epidural space due to trauma. (1,9) (Definition)

2. History - The identity of the patient: Name, Age, Gender, Ethnicity, Religion, Occupation, Address - Main complaint - mechanism of trauma - Time and travel trauma - Never passed out or unconscious after trauma - Retrograde or antegrade amnesia - Complaints: how severe headache, loss of consciousness, seizures, vertigo - History drunk, alcohol, narcotics, postoperative head - Morbidities: epilepsy, heart disease, asthma, chief operating history, hypertension and diabetes mellitus, and impaired blood clotting physiology

3. PemeriksaanFisik Primary Survey (1.9) Examination Evaluation Note, record, and fix

A. Airway Patency of the airway? Obstruction? Additional sound? B. Breathing Is Effective Rate and depth of chest oxygenation .... ? movement Water entry cyanosis


D. Disability (neurological Is there a neurological Kesadaranmenggunakan level status) disability ...? or AVPU GCS system. Pupil (large, shape, light reflex, compare kanankiri)

E. Exposure (open the whole Another organ injury ...? Injury, deformity, and limb outfit) movement. Evaluation of response to commands or painful stimuli



Physical examination is closely related to brain injury are: 1. Examination of the head

Looking for a sign: a. The lesion in the head covering; sub-cutaneous hematoma, sub galeal, open wounds, penetrating wounds and foreign bodies.





dissection



a. The level of awareness: based on a scale of Glasgow Coma Scale (GCS). Head injury is based GCS, which was assessed after the stabilization of the ABC classified: GCS 14-15: mild brain injury (COR) GCS 9-13: moderate brain injury (COS) GCS 3-8: severe traumatic brain injury (COB)





Autonomis: bulbocavernous reflex, cremaster reflex, reflex spingter, tendon reflexes, pathological reflexes

and tone spingter ani.



6. Examination of imaging

5. DiagnosisKerja Epidural HematomTraumatika (ICD-10: S06.4)


- drug intoxication


7. Investigations


Examination

Recomm endations

No. endasi

Ref

1 Cervical X-Foto

Cervical X-Foto done in patients COS 1C 4,5,6

or COB to exclude

the possibility of cervical injury. sensitivity x-

Cervical photo 70% -80%

Thoracic X-Foto performed on patients

trauma that does not require CT scans.

X-Foto done based mechanism

2 X Thorax Photo injury and clinical findings. X-thoracic Photo 1C 7.8

performed in patients with penetrating trauma

chest, back, or stomach are not

require CT Scan

Overview hiperdens shaped biconvex

because the blood is collected is limited to

attachment of the dura mater in the cranial sutures

Can be accompanied by a picture of scalp

hematomas and fractures calvaria

EDH volume calculated by the formula:

3

CT scan

A x B x C x 0:52 1B 1,2,3,9

Where A = thick EDH on slice CT-Scan

The thickest

B = length of EDH on slice

equal to A

C = height of the EDH (calculated from

the number of slice CT-Scan)

MRI is more sensitive than CT Scan

4 MRI

for the detection of intracranial hemorrhage. 2C 19,20

MRI is particularly useful for diagnosis

EDH at the vertices.

Whole Body CT ( WBCT) used in

5 CT-Scan Whole



body


8. Therapy

Procedures (ICD 9 CM) grade

No. Therapy Recommen dationsRef

endasi

EDH surgery indications:

• Volume> 30 cc, or

• The thickness of> 15 mm, or

• friction midline> 5 mm, or

1 Operations

• EDH acute patients (GCS <9) and 1C 1,3,9

anisokor in the evacuation as quickly

maybe

surgery include:

Craniotomy + Evacuation EDH ( ICD 9cm:

01:24), osteoplasty ( ICD 9cm: 02:04).

• Volume <30 cc, a thickness of <15 mm,

friction midline < 5 mm

• Non-operative treatment in the room

include:

• Observation GCS, pupil, lateralization, and

vital physiology. (1C)

• Circulation: balanced intravenous fluids NaCl-

glucose, prevented the occurrence of overhydration,

when it stabilized gradually in

replace fluid / EN / pipe

hull. (1C)


vomit when needed, 10,11,12,

2 Non Operating tracheostomi. COB patients with 1B / 1C 13,14,15,

lesions that do not require evacuation 16,17,18

and patients with disorders of analysis

Blood gas was treated in a respirator.

(1B)

• Maintain cerebral perfusion,

head head-up position around

30 •• to avoid neck flexion.

(1C)

• Bladder catheter is required to


urinary retention, prevent bed

wet (thus reducing

the risk of pressure sores). (1B)

• Give analgesic drugs (eg:




• Give anti-vomiting drugs (Eg,

metoclopramide or ondansetron) anti-

ulcer and gastritis H2 blockers (eg


vomiting (2B)



are not operable on CT Scan.

Mannitol can be given as a bolus

0.5 to 1 g / kg. BB in certain circumstances,

or repeated small doses, for example, (4-6)

100cc mannitol 20% in 24 hours.



in patients with a high risk of seizures


kg bw / day for 10 days. when you have seizures, IPM is given as

therapy. (1B)

9. Education Explanations to patients and families: • Course of the disease and complications that may occur • Therapy and actions that will be given along with the advantages and disadvantages • The procedure for the treatment and the treating physician

10. Prognosis Ad Vitam (Live) : Ad Dubia bonam Ad Sanationam (cured) : Ad Dubia bonam Ad Fungsionam (function) : Ad Dubia bonam Prognosis is affected: - Age - Status Neurologisawal - The distance between trauma and surgery - cerebral edema - Other intracranial abnormalities such as kontusional, subarachnoid hematoma and epidural hematoma


2. Dr. Agus Turchan, dr., Sp.BS 3. Dr. M. Arifin Parenrengi, dr., Sp.BS 4. Dr. Joni Wahyuhadi, dr., Sp.BS 5. Dr. Eko Agus Subagyo, dr., Sp.BS

6. Dr. Asra Al Fauzi, dr., Sp.BS 7. Wihasto Suyaningtyas, dr., Sp.BS 8. Muhammad Faris, dr., Sp.BS 9. Rahadian Indarto, dr., Sp.BS 10. Fahmi Achmad, dr., Sp.BS 11. Nur Setiawan Suroto, dr., Sp.BS 12. IrwanBarlianImmadoelHaq, dr, Sp.BS 13. TedyApriawan, dr., Sp.BS 14. HeriSubianto, dr., Sp.BS

12. Medical Indicators Improvement of neurological status. 13. Bibliography 1. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas.

Neurosurgery 2006; 58: S7. 2. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol 2002; 12: 1237. 3. Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996; 27: 1304. 4. MacDonald RL, Schwartz ML, Mirich D, et al. The diagnosis of cervical spine injury in motor vehicle crashes Victims: Xrays how many are enough? J Trauma 1990; 30: 392. 5. Zabel DD, Tinkoff G, Wittenborn W, et al. Adequacy and efficacy of lateral cervical spine radiography in alert, highrisk blunt trauma patient. J Trauma 1997; 43: 952. 6. Fisher A, Young WF. Is the lateral cervical spine xray obsolete during the Initial Evaluation of Patients with acute trauma? Surg Neurol 2008; 70:53. 7. Wisbach GG, Sise MJ, Sack DI, et al. What is the role of chest X-ray in the initial assessment of stable trauma Patients? J Trauma 2007; 62:74. 8. Duane TM, Dechert T, Wolfe LG, et al. Clinical examination is superior to plain films to diagnose pelvic fractures Compared to CT. Am Surg 2008; 74: 476. 9. Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. Introduction. J Neurotrauma 2007; 24 Suppl 1: S14. 10. HE Hinson, Stein D, KN Sheth. Hypertonic saline and mannitol therapy in critical care neurology. J Intensive Care Med 2013; 28: 3. 11. James HE. Methodology for the control of intracranial pressure with hypertonic mannitol. Acta Neurochir (Wien) 1980; 51: 161. 12. McGraw CP, Howard G. Effect of mannitol on Increased intracranial pressure. Neurosurgery 1983; 13: 269. 13. Sakowitz OW, JF Stover, Sarrafzadeh AS, et al. Effects of bolus administration of mannitol on intracranial pressure, cerebral extracellular metabolites, and tissue oxygenation in severely head Injured Patients. J Trauma 2007; 62: 292. 14. Vandromme MJ, Melton BC, Griffin R, et al. Intubation patterns and outcomes in computed tomography verified Patients with traumatic brain injury. J Trauma 2011; 71: 1615.

15. Diringer MN, Yundt K, Videen TO, et al. No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury. J Neurosurg 2000; 92: 7.

16. Temkin NR. Risk factors for posttraumatic seizures in adults. Epilepsia 2003; 44 Suppl 10:18.

17. Frey LC. Epidemiology of posttraumatic epilepsy: a critical review. Epilepsia 2003; 44 Suppl 10:11.

18. Vespa PM, Nuwer MR, Nenov V, et al. Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring. J Neurosurg 1999; 91: 750. 19. Gentry LR, Godersky JC, Thompson B, Dunn VD. Prospective comparative study of intermediatefield MR and CT in the evaluation of closed head trauma. AJR Am J Roentgenol 1988; 150: 673.

20. Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical versus conservative management: two case reports and review of the literature. Neurosurgery 1999; 45: 621.


Traumatic Subarachnoid Hemorrhage (SAH) ICD-10: S06.6

1. Definition Bleeding in the subarachnoid space, which lies between the arachnoid mater and the pia mater after a head (Definition) injury. The mechanism of bleeding in these cases are often not identified. (1, 2, 6, 7, 8)

2. History • Trauma history

• Severe headache • Loss of consciousness • Nausea and Vomiting • convulsions • blurred vision

3. PemeriksaanFisik General Physical Examination (Examination by inspection, palpation, percussion and auscultation) • Physical examination was first priority in the evaluation of A ( airways), B ( breathing), and C ( circulation)

examination of the head • Looking for a sign - a sign of injury, skull base fractures, facial fractures, trauma to the eye, to

determine their carotid auscultation bruit Examination of the neck and spine

• Looking for a sign - a sign of injury to the spine (especially cervical injuries) and injuries to the spinal cord

other tests • Another injury searched carefully from cranial to caudal • All findings noted signs of trauma. Bumps, abrasions, open wounds, false movement, flail chest, abdominal

wall, tenderness and others, who looked immediately stopped bleeding


• The level of awareness Glasgow Coma Scale ( GCS) • Fundoskopi, look for signs of edema pupil, retinal detachment • Motor and sensory, compare the right and left, up and down

4. Criteria for Diagnosis • Anamnesis according above

• Clinical examination according above

• Clinically appropriate imaging examination

5. Work Diagnosis Traumatic Subarachnoid Hemorrhage (ICD-10: S06.6)

6. Diagnosis - SAH due to aneurysm rupture

7. Investigations

Recommendation Grad

e

No. Examination Reko Ref

mend

care

1 CT scan

CT scan without contrast is 1C 2,3,4

a safe and sensitive examination for

showed bleeding

subarachnoid

Non-invasive angiography is the modality

2 CT / MR advanced to acute cases perimesencephalic 2B 2, 3, 4, 9

angiography

LEGITIMATE

MRI is more sensitive than CT head scan

head to detect bleeding

3 MRI

Intracranial. MRI of the head dikpakai on 2B 2, 3.4

some cases where suspected SAH

or other bleeding that does not appear on

CT scans of the head.

5 DSA

DSA is the best modality for 2B 9, 12,13

perimesencephalic SAH


6 CT-Scan Whole



body


8. Therapy

Procedures (ICD 9 CM) Grad

e

No. Therapy Reko Ref

mend

care

EVD (ICD 9 CM: 02:21) when obtained

1 Operative hydrocephalus

2B 6, 7, 11,

16

ICP Monitor (ICD 9 CM: 01.1)

when GCS <9

Management of the patient in the room:


oxygenation 100% and do a lot

2 Non-Operative manipulate the movement of the neck before

2B 6,7, 8,

cervical injury can be ruled out, if 14, 16

need intubation. (IIB)









GCS and examination of the brain stem periodically.









vomiting (2B)




g / kg. BB in certain circumstances, or repeated small doses, for example, (4-6) x 100








9. Education Given an explanation from the examination needs to be done, the patient's diagnosis that there is bleeding

in the membrane lining the brain, where it can worsen the condition of patients with brain injury output and an explanation of a given therapeutic treatment Possible long

Complications that can occur, ranging from worsening, rebleeding, infection due to a long treatment, hydrocephalus


Ad Sanationam (cured) : Ad Dubia bonam Ad Fungsionam (function) : Ad Dubia bonam Prognosis is affected: - Age - Status Neurologisawal - Jarakantara trauma dantindakanbedah - cerebral edema - Other intracranial abnormalities such as kontusional, subarachnoid hematoma and epidural hematoma

- Faktorekstrakranial 11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS

2. Dr. Agus Turchan, dr., Sp.BS 3. Dr. M. Arifin Parenrengi, dr., Sp.BS 4. Dr. Joni Wahyuhadi, dr., Sp.BS 5. Dr. Eko Agus Subagyo, dr., Sp.BS 6. Dr. Asra Al Fauzi, dr., Sp.BS 7. Wihasto Suyaningtyas, dr., Sp.BS 8. Muhammad Faris, dr., Sp.BS 9. Rahadian Indarto, dr., Sp.BS 10. Fahmi Achmad, dr., Sp.BS 11. Nur Setiawan Suroto, dr., Sp.BS 12. IrwanBarlianImmadoelHaq, dr, Sp.BS 13. TedyApriawan, dr., Sp.BS 14. HeriSubianto, dr., Sp.BS

12. Medical Indicators Improvement of clinical condition of the patient, improving the quality of life of patients 13. Bibliography 1. Z. Wu et al. Evaluation of traumatic subarachnoid hemorrhage using susceptibility-

weighted imaging. AJNR Am J Neuroradiol 31: 1302-10. 2010. p1302-1310

2. Vermeulen M, van Gijn J. The diagnosis of subarachnoid haemorrhage. J Neurol

Neurosurg Psychiatry 1990; 53: 365.

3. Grossman RI. Head Trauma. In: neuroradiology: The requisites, 2nd ed, Mosby,

Philadelphia, 2003. p.243.

4. Gentry LR, Godersky JC, Thompson B, Dunn VD. Prospective comparative study

of intermediatefield MR and CT in the evaluation of closed head trauma. AJR Am J

Roentgenol 1988; 150: 673.

5. MikiT, IkedaY, UtsugiO, etal.Evaluationoftraumaticsubarachnoidhaem- orrhage on

computed tomography. J ClinNeurosci 1998; 5: 49 -57

6. Rinkel GJ, van Gijn J, Wijdicks EF (1 September 1993). "Subarachnoid hemorrhage

without detectable aneurysm. A review of the causes "(PDF). stroke 24 (9): 1403-9.

7. Rinkel GJ, van Gijn J, Wijdicks EF. Subarachnoid hemorrhage without detectable

aneurysm. A review of the causes. Stroke 1993; 24: 1403.

8. vanGijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and

management. Brain 2001; 124: 249.

9. JJ Perry, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed

within six hours of onset of headache for the diagnosis of subarachnoid haemorrhage:

prospective cohort study. BMJ 2011; 343: d4277.

10. D Backes, Rinkel GJ, Kemperman H, et al. Timedependent test characteristics of

head computed tomography in Patients suspected of nontraumatic subarachnoid

hemorrhage. Stroke 2012; 43: 2115.

11. Canovas D, Gil A, Jato M, et al. Clinical outcome of spontaneous nonaneurysmal

Subarachnoid hemorrhage in 108 Patients. Eur J Neurol 2012; 19: 457.

12. Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in Patients with

Subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a

metaanalysis. Stroke 1999; 30: 317.

13. Li MH, YS Cheng, Li YD, et al. Largecohort comparison between three-dimensional

timeofflight magnetic resonance and rotational digital subtraction angiographies in

intracranial aneurysm detection. Stroke 2009; 40: 3127.

14. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of

aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the

American Heart Association / American Stroke Association. Stroke 2012; 43: 1711.

15. Barker FG 2nd, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic

deficit after subarachnoid hemorrhage: a metaanalysis. J Neurosurg 1996; 84: 405.

16. Traumatic subarachnoid haemorrhage.Gale Encyclopedia of Medicine. 2008. The Gale

Group, Inc. Feb. 20 2016 http://medical-dictionary.thefreedictionary.com/

+ + Traumatic subarachnoid haemorrhage

17. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed

vs. selective radiological tomography imaging on outcomes Patients in major trauma: a

meta-analysis. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

2014, 22:54.

Traumatic subdural hematoma

ICD-10: S06.5

1. Understanding A collection of blood in the brain subdural space (between the dura and arachnoid membrane).

(Definition) Usually due to rupture bridging veins that drain blood from the brain surface

to dural sinues. Causes SDH else is tearing of the artery, approximately 20-30% of cases SDH.

Or can be derived from the superficial brain contusions. (1,2,3,4,5)



• Kinds of trauma: occupational accidents, traffic accidents, assault, fell from

altitude and others

3. Physical Examination General Physical Examination


• Physical examination was first priority in the evaluation of A ( airways), B ( breathing),

and C ( circulation)


• Looking for a sign - a sign of injury, skull base fractures, facial fractures, trauma

padamata, auscultation of the carotid to determine their bruit


• Looking for a sign - a sign of injury to the spine (especially cervical injuries) and

injury to the spinal cord

other tests

• Another injury searched carefully from cranial to caudal

• All findings noted signs of trauma. Bumps, lukalecet, open wounds, false


seemed to be stopped



• Nerves II-III, VII peripheral nerve lesions

• Fundoskopi look for signs of edema pupil, retinal detachment


• Autonomis



9. Imaging studies corresponding above

5. Work Diagnosis Subdural hematoma (ICD 10: S06.5)


- epileptic fits

- drug intoxication


7. Examination

Support

Recommendation Grad

e


mend

care

1 Laboratory DL, cross match 1B 22

2

X-vertebral photo • Exclusion of cervical injury 1B 6,7,8

cervical

3 X-chest x-ray • Looking for concomitant injuries 1C 9.10

• CT Scan head is most often used

for imaging patients with trauma

acute head with a quick excuse, relative

simple, and widely available. appear

4 CT scan of the head

as a moon-shaped lesions hiperdens 1B 11,12

Sickle (crescentic shape) at the convexity

hemispheres

• Approximately 91% of SDH ≥5 mm thick dg already

identified on CT scan

head

MRI is more sensitive than CT head scan

head to detect bleeding

5 MRI of the head

Intracranial. MRI of the head dikpakai on 1B 12

some cases where suspected SDH

or other bleeding that does not appear on

CT scans of the head.

Indicated for the evaluation of SDH, when 13,14

6 angiography do not be a history of trauma and do not 1C

obvious cause.


7 CT Scan Whole



body


8. Therapy Grad

e

No. Therapy Procedures (ICD 9 CM) Reko Ref

mend

care

1. Craniotomi evacuation of hematoma (ICD 9

CM: 01:24) when

• hematoma subdural with

thickness> 10mm or midline shift

> 5mm without notice GCS 1C 15,16

• ≤8 or when GCS GCS down ≥2 points

1 Operation

from the first moment to come to the hospital, and

or when a pupil obtained asymmetric

or the pupil dilated and fixed, and

or the measurement of ICT> 20mmHg.

2. ICP Monitor (ICD 9 CM: 01.1)

• GCS <9 1B

18,19,

• Subdural hematoma with thick 20, 21

<10mm or midline shift <5mm

• Small hematoma and

effect period ( midline shift <

0.5 cm), also does not provide symptom

clinic.

• Treatment in the room

Non-operative: • Observation GCS, pupil, lateralization, and physiology 1B 15,17,18

vital. 19

• Optimization of stabilization vital physiology, keeping

solid supply of O 2 to the brain.

• Circulation: balanced intravenous fluids NaCl-

glucose, prevented the occurrence of overhydration,

when it stabilized gradually replaced

liquid / EN / pipe stomach.


vomit when needed,

61racheostomy. COB patients

with lesions require evacuation

and patient with impaired blood

gas analysis treated in a

respirator.

• catheter jar requires for


urinary retention, prevent bed

wet (thus reducing

the risk of pressure sores).

• Head Up 30 o ( 2B)

• Give enough fluids (normal





• Check vital signs, injury



periodically.

• Give analgesic drugs (eg:




• Give anti-vomiting drugs (eg:




vomiting (2B)



are not operable on CT Scan.

Mannitol can be administered as a bolus of 0.5

- 1 g / kg. BB in certain circumstances, or







kg bw / day for 10 days. When you have



• Course of the disease and complications that may occur • Therapy and actions that will be given along with the advantages and disadvantages



Ad Sanationam (cured) : Ad Dubia bonam

Ad Fungsionam (function) : Ad Dubia bonam


1. Age 2. The initial Neurological Status

3.Jarakantara trauma and surgery

4. edema cerebri 5. The other intracranial abnormalities such as kontusional, subarachnoid hematoma and hematoma

epidural

6. The extracranial
















13. Bibliography 1. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol.2002; 12: 1237.

2. Victor M, Ropper A. craniocerebral trauma. In: Adams and Victor’s Principles of

Neurology, 7th ed, Victor M, Ropper A. (Eds), McGraw- Hill, New York, 2001. P.925.

3. Gennarelli TA, Thibault LE. Biomechanics of acute subdural hematoma. J Trauma 1982;

22: 680.

4. Haselsberger K, Pucher R, Auer LM. The prognosis after acute subdural or epidural

haemorrhage. Acta Neurochir (Wien) 1988; 90: 111.

5. Maxeiner H, Wolff M. Pure subdural hematomas: a postmortem analysis of Reviews their form

and bleeding points. Neurosurgery 2002; 50: 503.

6. Macdonald RL, Schwartz ML, Mirich D, et al. The diagnosis of cervical spine injury in motor

vehicle crash Victims: Xrays how many are enough? J Trauma 1990; 30: 392

7. Zabel DD, Tinkoff G, Wittenborn W, et al. Adequacy and efficacy of lateral cervical spine

inalert radiography, highriskblunt trauma patient. J Trauma 1997; 43: 952.

8. Fisher A, Young WF. Is the lateral cervical spine during the initial evaluation xrayobsolete

of patientswith acute trauma? Surg Neurol 2008; 70:53.

9. Wisbach GG, Sise MJ, Sack DI, et al. What is the role of the initial chest Xrayin

assessment of stabletrauma Patients? J Trauma 2007; 62:74.

10. TM Duane, Dechert T, Wolfe LG, et al. Clinical examination is superior to plain films to

pelvicfractures diagnosis Compared to CT. Am Surg 2008; 74: 476.

11. Grossman RI. Head Trauma. In: neuroradiology: The requisites, 2nd ed, Mosby,

Philadelphia, 2003. P.243.

12. Gentry LR, Godersky JC, Thompson B, Dunn VD. Prospective comparative study of

intermediatefield MR and CT in the evaluation of closed head trauma. AJR Am J

Roentgenol 1988; 150: 673.

13. Koerbel A, Ernemann U, D. Freudenstein Acute subdural hematoma without

subarachnoid haemorrhage the caused by the rupture of an internal carotid artery bifurcation

aneurysm: case report and review of literature. Br J Radiol 2005; 78: 646.

14. Nonaka Y, Kusumoto M, Mori K, Maeda M. Pure acute subdural hematoma without

subarachnoid haemorrhage the caused by rupture of internal carotid artery aneurysm. Acta

Neurochir (Wien) 2000; 142: 941.

15. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural

hematomas. Neurosurgery 2006; 58: S16.

16. Hatashita S, Koga N, Hosaka Y, Takagi S. Acute subdural hematoma: severity of injury,

surgical intervention, and mortality. Neurol Med Chir (Tokyo) 1993; 33:13.

17. Servadei F, Rice MT, Cremonini AM, et al. Importance of a reliable admission Glasgow

Coma Scale score for Determining the need for evacuation of posttraumatic subdural

hematomas: a prospective study of 65 Patients. J Trauma 1998; 44: 868.

18. Mathew P, OluochOlunya DL, Condon BR, R. Bullock Acute subdural hematoma in the

Conscious patient: initial outcomes with nonoperative management. Acta Neurochir

(Wien) 1993; 121: 100.

19. Wong CW. Criteria for conservative treatment of supratentorial acute subdural

haematomas. Acta Neurochir (Wien) 1995; 135: 38.

20. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management

protocol and clinical results. J Neurosurg 1995; 83: 949.

21. Lane PL, Skoretz TG, Doig G, Girotti MJ. Intracranial pressure monitoring and

outcomes after traumatic brain injury. Can J Surg 2000; 43: 442.

22. Harhangi BS, Kompanje EJ, Leebeek FW, Maas AI. Coagulation disorders after

traumatic brain injury. ActaNeurochir (Wien) 2008; 150: 165.

23. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed



2014, 22:54.

Penetrating Traumatic Brain

ICD-10: S01.9

1. Understanding Penetrating trauma of the cranium are lesions in which a foreign object penetrates the skull and not come out

(Definition) again. Impact missile to the head followed by primary and secondary pathophysiology. When the projectile into the

brain, neural tissue damage will occur that causes a permanent cavity. The patient’s clinical condition is highly

dependent on the mechanism (speed, kinetic energy), anatomical location of the lesion, and related injuries.

Penetrating trauma can cause intracranial hematoma, epidural hematoma,

intracerebral hematoma,

serdbri contusions and subdural hematoma.

Lacerations directly affecting blood vessels can cause bleeding. The pressure caused by projectile

motion induces teregangnya brain and vascular tissue.

Pathophysiology of secondary can be disturbances caused by a disruption stems cardiopulmoner

brain.

2. History • Be a history of trauma due to a foreign body projectiles, including a history of incidents of witness


• Kinds of trauma: pierced by a sharp object, hit, work accidents, traffic accidents

cross, persecution, falls from height, etc.

3. Physical Examination General Physical Examination


• Physical examination was first priority in the evaluation of A ( airways), B ( breathing),

and C ( circulation)


• Looking for a sign – a sign of injury, skull base fractures, facial fractures, trauma

padamata, auscultation of the carotid to determine their bruit


• Looking for a sign – a sign of injury to the spine (especially cervical injuries) and

injury to the spinal cord

other tests

• Another injury searched carefully from cranial to caudal

• All findings noted signs of trauma. Bumps, lukalecet, open wounds, false


seemed to be stopped



• Nerves II-III, VII peripheral nerve lesions • Fundoskopi look for signs of edema pupil, retinal detachment


• Autonomis

4. Criteria for Diagnosis 10. Issuer in accordance History


12. Imaging studies corresponding clinical

5. Work Diagnosis Penetrating Traumatic Brain (ICD-10: S01.9)


7. Examination

Support

Recommendation Grad

e


mend

care

1 DL Laboratories, cross match 1B 6

• to find cuts, foreign objects and the location of

2 X-head photo

bone fragments also air intracranial 1C 1.2

• This examination is not routinely performed if

there is a CT-Scan

• The main modalities in penetrating trauma

• to look for bone fragments, objects

4 CT scan of the head alien, projection pathway, hematoma

1B 1.2

and intracranial mass effect

• No recommended on

Acute management for time-consuming and

5 MRI of the head

dangerous objects such as metal cool. 2B 1,2,3

• However, MRI is useful for modalities

neuroradiologik if foreign matter such as wood.

6 angiography 2C 1,2,3


7 CT Scan Whole



body


8. Therapy No. Therapy Procedures (ICD 9 CM) Grad Ref

e

Reko

mend care

Procedures start is to perform resuscitation patient, then do operative measures for evacuation of hematoma, repair damaged tissues and take a foreign object that still exists in the brain tissue. The drugs can be given pre and intraoperative to reduce intracranial pressure. Indication of operation:

1 Operations (1) to eliminate such mass 1B 1,2,3,5 epidural hematoma, subdural, or

intracerebral; (2) to clean the necrotic tissue

and prevent brain swelling and further ischemia, (3) to control active bleeding (4) to remove necrotic tissue,

metal, bone fragments, or other foreign objects to prevent infection.

- Debridement and wound care when just get small cuts and no intracranial lesions

- Broad-spectrum antibiotics to reduce

the incidence of infection - Head Up 30 o ( 2B)






2. Non-operative - Check vital signs, injury

1B 1,2,3,4,5



periodically.






metoclopramide, or ondansetron)

and anti-ulcer gastritis H2 blockers (eg:


vomiting (2B)








Give Phenytoin (PHT) prophylaxis in patients with a high risk of seizures at a dose of 300 mg / day or 5-10 mg kg / day for 10 days. When you have seizures, IPM is given as therapy. (1B)






Ad Sanationam (cured) : Ad Dubia bonam

Ad Fungsionam (function) : Ad Dubia bonam


- Age


- The distance between trauma and surgery

- cerebral edema


epidural

















13. Bibliography 1. Sundstrom T, Wester K. Surgical management of Penetrating Brain Injuries. 2012.

19; 101-3

2. Esposito DP, JP Walker. Contemporary management of penetrating brain injury.

Q. Neurosurg 2009; 19: 249-54.

3. Miner ME, Ewing-Cobbs L, Kopaniky DR, Cabrera J, Kaufmann P. The results of treatment

of gunshot wounds to the brain in children. Neurosurgery. 1990; 26: 20-5.

4. Gonul E, Baysefer A, Kahraman S, Ciklatekerlioðlu O, Gezen F, Yayla O, et al. Causes of

infections and management results in penetrating craniocerebral injuries. Neurosurg

Rev. 1997; 20: 177-81

5. Eckstein M. The pre-hospital and emergency department management of penetrating

wound injuries. Neurosurg Clin North Am. 1995; 6: 741-51.

6. Harhangi BS, Kompanje EJ, Leebeek FW, Maas AI. Coagulation disorders after traumatic

brain injury. ActaNeurochir (Wien) 2008; 150: 165.

7.Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed



2014, 22:54.

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