head injury
Preliminary
Approximately 40% of patients will experience multiple cedara central nervous system injury. This group will experience a death rate twice as high (35% vs. 17%) compared with the group without CNS injury. Head injuries included 25% of all deaths from trauma and covers half of the death of a motorcycle accident where the other injuries, a thorough evaluation and penataalaksanaan and soon will provide a better possibility of recovery. To continue with the effective management of head injury, need to understand the basic anatomy and physiology is good about the head and brain. Head injuries that occur can be bruising of brain tissue followed by 'swelling' and increased intra-cranial pressure, injury to blood vessels accompanied by bleeding and increased intra-cranial pressure or penetrating injury that damage brain tissue. Selalau must be remembered that in severe head injury should always be assumed to also be accompanied by cedara cervical and spinal cord.
Anatomy of the head
Head (excluding face and facial structures) covers parts:
Scalp Ö
Bone Ö tenkorak
Ö membrane covering the brain (meningens)
Ö brain Network
Cerebrospinal fluid Ö
Ö Vascular Compartment
Scalp has vascularities rich and cause a lot of bleeding if injured, as many small blood vessels located in the matrix of elastic connective tissue.
Normal protective Vasospasme that should occur to reduce the bleeding does not function, causing bleeding continued and significant blood loss. Skull serves as a closed box, the only exit door where the pressure can continue is through foramen magnum is located at the base of the skull where there is a transition between the brainstem and spinal cord. The skull is rigid and narrow in several mechanisms contribute to head injuries.
Because the location of the brain in the head so that more movement at the peak of the brain basis of disbanding. This is an important determinant of the damage. Temporal bones thinner and prone to fracture. Membrane covering the whole brain, thinner layer of Pia arachnoid which lies below duramater and is home to the arteries and veins, the most thin layer piamater located directly below the arachnoid and the brain surface coating. Were found in the cerebrospinal fluid and arachnoid layer piamater.
The brain fills the entire cavity of the skull, which really does not have the adaptation of brain swelling. This has considerable importance in the pathophysiology of head injury.
Cerebrospinal fluid (CSF) is a liquid nutrition menyeliputi brain and spinal cord. This fluid is continuously produced in the ventricles of the brain with a speed of 1 / 3 ml / min. This fluid reabsorbed by the arachnoid membrane covering the brain and spinal cord. Anything that inhibits the flow of CSF will cause this fluid buildup in the brain and will cause increased intracranial pressure.
Pathophysiology of head injuries
Most brain injuries are not caused by direct injury to brain tissue, but occurred as a result of outside forces who hit the outer side of the skull or the brain itself from movements in the skull cavity. On deceleration injury, the head usually hit an object like a car windshield, resulting in deceleration that lasted skull suddenly. The brain keeps moving towards the front, hit the inside tengorak just below the point hit a bump and then turned toward the side opposite the point of initial bump. Therefore, the injury can occur in conflict areas (coup) or on the opposite side (contra coup).
Side of the skull is uneven surfaces. Friction tehadap this region of brain tissue can cause a variety of damage to brain tissue and blood vessels.
Initial response of the brain that have cedra is "swelling". Bruising on the brain caused vasoliditasi with increased blood flow to the area, causing the accumulation of blood and cause suppression of the surrounding brain tissue. Because there is no more space in the skull, the 'swelling' and the injured brain area will increase intracerebral pressure and reduce blood flow to the brain. Increased content of brain fluid (edema) does not occur immediately but began to flourish after 24 hours up to 48 hours. Early efforts to maintain brain perfusion is a life saving action.
CO2 concentration in the blood affect cerebral blood flow. Normal level of CO2 is 35-40 mmHg. Elevated levels of CO2 (hypoventilation) causes vasodilatation and swelling of the brain, while decreasing levels of CO2 (hyperventilation) causes vasokontruksi and cerebral ischemia. At the time of the past, it is estimated that by decreasing the concentration of CO2 (hyperventilation) in patients with head injuries will reduce brain swelling and improve brain blood flow. Recently demonstrated that hyperventilation gives only a small role against brain swelling, but a large effect in reducing cerebral blood flow due to vasoconstriction. This causes cerebral hypoxia. Brain injury are unable to tolerate hypoxia.
Hypoventilation or hypoxia increase the death rate by maintaining good ventilation at the breathing frequency range from 15 times a minute and adequate oxygen flow is very important. Prophylactic hyperventilation in head injury is not recommended.
Intracranial pressure
In the cavity of the skull and the membranes enveloping the brain are the brain tissue, cerebrospinal liquor. And blood volume increase in one component will be followed by a reduction or suppression of each volume of the other components because the adult skull (a rigid box) can not be expanded (enlarged). Although CSF provides tolerance, but the space given is not able to tolerate brain swelling occurs quickly. Blood flow must not be disturbed because the brain needs a constant blood supply (oxygen and glucose) to survive. None of the components that support the brain can mentoloransi this case, therefore, the brain swelling that occurs will quickly cause death. The pressure generated by the contents of the skull known as intracranial pressure (ICP). This pressure is usually very low. Intra-cranial pressure is considered dangerous when it increased to 15mmHg, and the herniation occurs at pressures above 25 mmHg. Blood pressure in the brain called the cerebral perfusion pressure (the CPP). CPP was obtained by subtracting the value of ICP MABP. Perfusion pressure must be maintained 70 mmHg or more. When the brain swells or bleeding within the skull, increased intracranial pressure and perfusion pressure decreases. The body has a protective reflex (response / Cushing reflex) are trying to maintain a constant perfusion pressure of circumstances. We increased intracerebral pressure, increased systemic blood pressure to try to maintain the blood flow of the brain. When conditions become more critical, decreased pulse rate (bradycardia) and even reduced the frequency of respiration. Intracranial pressure continued to increase until a certain critical point where all the head injury worsened and disrupted vital signs, and ended with the death of patients. If there was an increased intracranial hypotension will exacerbate the situation. Perfusion pressure must be maintained for at least 70 mmHg, which requires 100-110 mm Hg systolic pressure in patients with head injuries.
Herniation syndromes
When the brain swells, especially after the collision on the head, increased intracranial pressure can occur suddenly. This can encourage the brain towards the bottom, blocking the flow of CSF and cause great pressure on the brain stem. This is a life-threatening condition marked by decreased level of consciousness progressively into a coma, dilated pupils and eye deviation toward the bottom and lateral sides of the eye injury suffered head, leg and arm weakness on the opposite side of the injured side , and posture deserebrasi (explained below) then the patient will lose all movement, stopped breathing and died. This syndrome often occurs after an acute subdural hemorrhage. Herniation syndrome is the only state in which hyperventilation was still an indication.
Anoksia brain injury
Injury to the brain due to lack of oxygen (eg cardiac arrest, airway obstruction) seriously affects the brain. If the brain does not receive oxygen for four to six minutes, irreversible damage is almost always the case. After the episode anoksia, perfusion will be disrupted due to spasm of the cortex that occurs in small cerebral arteries. After anoksia 4 to 6 minutes, improved oxygenation and blood pressure will not improve cortical perfusion (no reflow phenomenon) and will continue anoksia injury in brain cells. Looks like hypothermia can protect the brain against the effects and there are case reports of patients who resuscitated after suffering hypothermia hypoxia for 1 hour.
Research is currently indicated for drug discovery that is able to overcome the persistent arterial spasm after anoksia situation or protect the cells against injury anoksia.
HEAD INJURY
Ä Scalp Injury
Vascularities Scalp has a rich and often bloody much after laceration, quickly generate a lot of blood loss. It is extremely important in children who have bleeding like adults but have different blood volume.
Unlike in adults who rarely went into shock because Scalp laceration, shock can occur in children after Scalp laceration, it must be sought other sources of bleeding (such as bleeding from the inside). However, do not underestimate the bleeding wounds of Scalp. Most of the Scalp hemorrhage can be stopped easily use the direct suppression.
Ä Skull Injury
The skull may have a non-displaced linear fracture, depressed fracture or open fracture should be suspected of skull fractures in adults if there is a large contusions or swelling and bruising on the Scalp. Very little that can be done against this injury in the field (the scene) but avoid direct pressure on the obvious depressed fracture or fracture open. Translucent objects left on the skull (not revoked) and the patient immediately elevated to the emergency room. If the patient suffered a gunshot wound to the head, without any obvious entrance wound and exit wound located strip, must be assumed that the bullet can be shifted and trapped in the neck near the spinal cord.
Suspect the existence of child abuse if the child suffered head injuries without adequate explanation for. Give attention to the scene where the child is helped and requested police assistance or social services from the scene if there is suspicion of child abuse.
BRAIN INJURY
Ä Concussion
Concussion showed no structural brain injury there is usually a history of head trauma with a period of fainting or disorientation different then back in normal consciousness. There is the possibility of amnesia due to injury. Amnesia typically include some time before the injury (retrograde amnesia is short) so that people usually forget when the incidence of injury. Short-term memory is often involved and the patient usually repeat-ngulang questions such as if patients do not notice you provide the answers. Can be accompanied by dizziness, headaches, ear buzzing and / or vomiting.
Ä cerebral contusions
Patients with cerebral contusions (bruises brain tissue) can have a longer history, or unconscious level of awareness of a serious disorder (such as the heavy orienta disorder, amnesia persistem, abnormal behavior). Swelling of the brain can be swift and severe. Patients may exhibit neurological signs or visible focal cerebrovascular attack (stroke). Depending upon the location of cerebral contusions, the patient may experience changes in personality such as rude behavior
Ä Intracranial Hemorrhage
Bleeding can occur between the skull and duramater (connective tissue membranes covering the brain) between dura and arachnoid, between the arachnoid and the brain, or directly into brain tissue.
Acute epidural hematoma th. (Acute EDH)
These injuries most often caused by a tear in an artery that runs along the media meningea surface of the skull at sisitem poral. Injury to the artery is often caused by a linear skull fracture in the temporal and parietal regions. Because the source of bleeding is of arterial (although sometimes it can be derived from one of the sinus dura), bleeding and pressure can develop rapidly, so that death occurs rapidly. Surgery to remove blood clots and ligation of the torn artery often gives a perfect repair if not lower section of brain tissue injury. Symptoms of acute epidural hematoma include a history of head injury accompanied by fainting during the event, followed by a state patients become aware of either orientation (Lucid interval). After 30 minutes to two hours later, the patient showed signs:
Ý increases in intracranial pressure (vomiting, headache, impaired mental status),
Ý weaknesses in the side opposite the side of the head injury
Ý often accompanied with a dilated pupil and terfiksir (no response to bright light) on the injured side of the head, usually it will soon be followed by death. Classic example is a boxer who collapsed from a stroke, then conscious and allowed to go home, and was found dead in bed the next day.
th acute subdural hematomas (SDH)
This is caused by bleeding between the arachnoid and durameter and connect with the surrounding brain tissue injury because perdarahn comes from a vein, pressures grow more slowly and often a new diagnosis ditegakan hours or days and after injury.
Symptoms and signs include:
Ý headache,
Ý fluctuations,
Ý level of consciousness and focal neurological signs (cth.kelemahan on one limb or one side of the body, tendon reflex changes in the talk pelo).
Because of the underlying brain injury, the prognosis is often unfavorable. Mortality is very high (60-90%) in patients with a comma when checked. Always suspect the existence of subdural in alcoholic patients with a mental status changes after a fall.
Bleeding th intraserebal (ICH)
This bleeding occurs in brain tissue. Traumatika intraserebal bleeding is always associated with penetrating injuries to the head and often associated with blunt impact to the head. Unfortunately, surgery is not always helpful. Symptoms and signs depend on the locations involved and the level of injury, with pattern resembling yamg stroke.
EVALUATION OF HEAD INJURY PATIENTS
Treatment of patients with head injury can be difficult because generally they are rarely cooperative and often under the influence of alcohol or drugs. As a helper, you must give more attention to detail matters and do not give up the patience for uncooperative patients. Remember always preliminary assessment of each patient following the sequence as follows:
th Perform comprehensive initial observations on the situation your patients as early pemerksaan
th Exempt airway in line with cervical spinal stabilization and do preliminary assessment of the level of awareness
Assessment of respiratory th
th Assessment of circulation and control major bleeding
Determine th patient transport decisions and critical intervention
th Perform secondary assessment
Ý vital signs
Ý SAMPLE History:
ü Symptoms (symptoms),
ü allergies,
ü Medications (drugs),
ü Past medical history (other diseases),
ü Last oral intake (time to eat or drink the last one),
ü Events preceding the accidents (events or circumstances prior to the accident)
Ý examination from head to toe
Ý dressing and further pembidaian
Monitor Ý further
Perform th re-examination
PRIMARY checks
Airway supervision must receive primary attention. Patients who received sedation lay, and was not aware of a tendency to airway obstruction due to tongue, blood, vomit or secret. Vomiting often occurs in the first hours after head injury. Airway should be protected by endotracheal intubation or by placing a protective oral or nasal breathing and positioning the patient on one side (in this case there is no suspicion of cervical fracture), and "suction" sustainable. Endoktrakheal intubation in patients with head injury should be done quickly and gently to avoid suffering from agitation, tense and hold your breath so that an increase in intracranial pressure. Before starting intubation, ventilation do (do not hyperventilate) with high oxygen. Avoid head injury from hypoxia. Even with a single episode of hypoxia can cause a significant effect on mortality.
In general, the evaluation of head injury begins with preliminary assessment of the level of consciousness of patients with neurological patients to speak with penderita.pemeriksaan more detail dilakuakn on secondary survey. Clearly patients with a history and examination results showed an epidural hematoma should be sent faster compared with conscious patients after undergoing brain gagar. It is important to note senua observation and examination results because treatment is often determined by changes in the stability of the clinical state of patients. The purpose of evaluation is to immediately determine whether the patient suffered a brain ceera, if so, if things deteriorate? Level of awareness is the most sensitive indicator of brain function.
It is important to know the overall history of injury if possible circumstances of head injuries is very important for the management of patients and represents an important prognostic factor in connection with the final result (out come), give special attention to patients who nearly drowned, electrical burns, lightning, abuse drugs, smoke inhalation, hypothermia, and seizures always ask about the behavior of patients with head injuries from the time of the incident until the moment you arrive.
All patients with head injuries and injuries to the face will cervical spine injury until proven not. Cervical spine stabilization must be accompanied by management of the airway and breathing. During the primary survey, neurological examination ranged only between levels of consciousness and motor weakness are obvious, change in level of consciousness, a sign of brain injury or increased intracranial pressure. Continue your evaluation and report results simply so that others can understand you.
AVPU method quite adequate:
Ä A: patient conscious
Ä V: patients react to sound stimuli
Ä P: patient reacted to pain stimuli
Ä U: patient did not react
SECONDARY EXAMINATION
After the primary inspection complete and on record, began with a Scalp and quickly and carefully, do the inspection for the presence of obvious injuries such as lacerations or fractures terbuka.ukuran depressed or injury estimates are often wrong because of injuries tetutup by dirty hair and blood. Feel Scalp carefully to find the existence of an unstable region of the skull. If you can not find a safe place swathe press or directly pressing the bandage to stop bleeding wounds.
Cranial base fracture can be characterized by bleeding from the ears or nose, the clear liquid out of the nose, swollen and / or discoloration behind the ear (Battle's sign), and / or swelling and discoloration around both eyes (raccoon eyes)
Pupil is controlled by some third nerve. This nerve has a long journey in the skull and brain prone to compression by the swollen, so this nerve can be affected by high intracranial pressure. After head injury, if both pupils are dilated and unresponsive to light, the patient may have suffered brain stem injuries and poor prognosis. If the pupil is dilated but still react to light, the injury is still reversible, so any attempt to make the sufferer soon arrive at a place that can treat a head injury, should be done immediately. Pupillary dilatation unilaterial which still reactive to light may be an early sign increased intracranial pressure. Unilateral pupillary dilatation that developed at the time of your observation is very emergency situation and requires immediate transportation.
Other causes of dilated pupils, whether that react to light or not, include:
Ý hypothermia,
Ý struck by lightning,
Ý anoksia,
Ý optic nerve injury,
Ý drug effects (such as atropine),
Y or direct injury to the eye.
Pupils are dilated and terfiksir have meaning in a head injury, only in patients with decreased levels of consciousness. If the patient has a normal level of consciousness, dilated pupils did not come from head injury.
Eyelid blink are often found on the hysterical. Slow eyelid closure is rarely found on the hysterical. If the brain stem is still good, the eye will remain synchronized (conjugate gaze) when the head rotated to the left and right. Eyes will be moving the opposite direction to head movements. Because the state is like the movement eyeball dolls when moved, this inspection is called reflex doll's eyes "(reflex okulosefalik) This test was never performed on patients with trauma who may suffer injury to the cervical, since turning his head from side to side can cause injury to the spinal cord is irreversible .
Inspection blink reflex (corneal reflex) with corneal touch and / or by examination of reaction to pain in patients with a technique that can not be trusted and are not essential for 'prehospital care'.
Limb, do the inspection and monorik sensory function in extremities. Can the patient felt the touch of the hands and feet? If patients are not aware, check the excitatory or leg pain sufferers indicate roughly still has sensory and motor function yanga good. This usually indicates cortical function was normal or slightly disturbed
Dekortikasi good posture (flexion of arm and leg extension) and deserebrasi (arm and leg extension) is a sign of disturbance or injury to the cerebral hemispheres of the brain stem top. Flaccid paralysis usually indicates spinal cord injury.
To be consistent with the 'revised trauma score' and the other scoring system used in the field, you should be familiar with the GCS (Glasgow Coma Scale), which is easy to use, simple, and has prognostic value when evaluating patients. In trauma patients, GSC 8 or less indicates severe head injury.
VITAL SIGNS, very important vital sign in patients with head injuries. Called very important because it may reflect changes in intracranial pressure. You must do the observation and recording vital signs obtained during the secondary survey and any time you do re-examination.
Ý blood pressure. pengkatan intracranial pressure causes increased blood pressure. Another cause of hypertension, including fear and pain. Hypotension associated with head injuries are usually caused by bleeding or spinal shock and must be addressed as where the bleeding. Head injury patients can not tolerate hypotension. One-time occurrence of hypotension (tek.Darah <90 mmHg) in adult mortality will increase by 150%. Give IV fluids to maintain systolic blood pressure of 100-110 in patients with head injury
Ý Nadi, causing increased intracranial pressure pulse decreases
Ý respiration, increased intracranial pressure caused breathing frequency increased, decreased, and / or become irregular. Irregular breathing pattern indicates the level of the brain or brain stem injury shortly before the death of the patient will menglami rapid respiration, is called central neurogenic hyperventilation. Because respiration is affected by many factors (such as fear, hysteria, thoracic injuries, spinal cord injuries, diabetes), its usefulness as an indicator is not as important as other vital signs in the supervision of head injury travel
shock head injury with increased intracranial pressure
Decreasing Blood Pressure Rising
Decreasing the pulse rise
respiration increased Varies but generally declining
Decreased level of consciousness decreased
Glascow Coma Scale (GCS)
To obtain uniformity of quantitative assessment of consciousness level (previously carried out a qualitative assessment of consciousness such as apathy, somnolen, coma and measurement results are not uniform between the examiner with one another) then was examined with a GCS scale, where there are three indkator who examined the eye reaction , verbal and motor.
1. 1. Eye-opening reaction:
1. Opens eyes spontaneously: 4
2. Opening eyes with excitatory vote: 3
3. Opens eyes with pain stimulation: 2
4. Not opening eyes with painful stimuli: a
2. 2. Verbal reactions:
1. Answered correctly: 5
2. Confusion, disorientation of time, place and space: 4
3. Get out the word with pain stimulation: 3
4. Exit the voice does not form words: 2
5. Not out words with any stimuli: 1
3. 3. Motor reactions:
1. Following orders: 6
2. Localizing pain stimuli: 5
3. Pulling the body when there is pain stimuli: 4
4. Abnormal flexion reaction to pain stimuli: 3
5. Abnormal extension reaction with painful stimuli: 2
6. No movement with pain stimulation: a
Based on scale of Glascow Coma Scale (GCS), then the head injury can be divided into three levels, namely:
1. Mild head injury: GCS: 13-15
2. Head injuries are: GCS: 9-12
3. Severe head injury: GCS: 3-8
In patients who can not be checking the valuation is labeled X. For example in cases where there is periorbital edema eyes given the reaction Ex nila, in patients with aphasia, the verbal reaction of VX was rated if the patient is tracheostomy performed intubation or the VT rated verbal reaction
ASSESSMENT REVIEW
Each time you do a reassessment, record the level of consciousness, pupil size and pupillary reaction to light. This is in line with the vital state of patients will provide sufficient information to initiate the condition of patients with head injury
The decision in the management of patients with head injury is made on the basis of changes in all parameters of physical and neurological examination. You make an initial assessment to be the basis for subsequent decision-making, record your observations
Management of HEAD INJURY PATIENTS
No special actions you can do to penderit head injuries at the scene. It is important to carry out checks quickly and send the patient to a center that has facilities capable of handling patients with head injuries before arriving at the hospital among others:
Exempt Ý airway and provide good oxygenation. The brain is not able to tolerate hypoxia, thus oxygenation are absolute requirements. If patients in a coma, intubation endotrakheal installation must be done. This prevents aspiration and allows oxygenation and ventilation is better because penderit head injuries tend to experience vomiting, preparation for immobilization 'log-roll "to the patient and suction the oropharynx lakuakn, particularly if it is not placed endotracheal tube.
Ý Stabilization patients with spine boards. The neck should diimmobilisasi with kollar rigid immobilization and equipment that a footstool head
Ý Perform initial recording observations. Record the blood pressure, respiration (frequency and pattern), pupils (size and reaction to light), sensation and spontaneous motor activity, also noted the value of GCS. If patients experienced hypotension, suspected the existence of bleeding or spinal injury
Ý often do repeated observations and record sequentially
Ý Put two iv infusion with a large catheter. There used to be thought to restrict liquids on penderit head injury. Already proved that the danger of more frequent occurrence of brain swelling caused by fluid administration of hypotension compared
POTENTIAL PROBLEMS
Always anticipate the existence of spinal injury in patients with head injury
Ý seizures. Head injuries, especially intracranial bleeding, may cause seizures. The patient became hypoxic seizures and hyperthermia, so seizures may exacerbate the ongoing situation. You can give intravenous medications to control seizures. Not infrequently that the seizures associated with bad breath, so must always be that oxygenation and ventilation is very important.
Ý Vomiting. Almost all patients will experience vomiting head injury. You must always be vigilant to prevent aspiration. If patients are not aware, should the intubation. Besides the mechanical suction ready and prepare patients for the log-roll to one side (keep immobilization of the cervical spine)
Ý rapidly worsening situation. Patients showed a rapid worsening of vital signs, or progressive worsening brain injury (eg dilated pupil, or deserebrasi dekortikasi posture) should be immediately sent to the trauma center. This is a situation where hyperventilation is still an indication of hyperventilation, although known to cause ischemia, can reduce brain swelling temporarily. although this is a futile effort but this can give the time to take the patient to the operating table as the act of saving lives. You can also give intravenous mannitol or furosemide. Make notification to the hospital intended to prepare neurosurgeons and operating room so that everything is ready when you arrive
Ý Shock. Think of bleeding or spinal shock
Ý metabolic disorders. Remember granting naloxon (narcan) in patients with mental status disorder, if suspected of using narcotic drugs. Recall of thiamine, and dextrose in diabetic patients with impaired consciousness, alcoholics, or patients who might be experiencing hypoglycemia.
CONCLUSION
Head injury is a serious complication of trauma. In order to provide the best for the patient to recover, you must be familiar with the anatomy important in the head and central nervous system, and understand how the main clinical presentation in different parts of the body. The most important thing in the management of head injury is a quick examination, the good management of the airway, prevention of hypotension, immediate referral to a trauma center, and the examination repeated. As well as recording the results of such examination is important for decision making in the management of patients. .
Article by:
Dr.M.Z.Arifin, sp.BS
Part / SMF.Bedah nerve FKUP perjan R.S. Hasan Sadikin
