Curiculum Vitae DR. Rahadian Indarto Susilo, dr SpBS(K)€¦ · Curiculum Vitae DR. Rahadian...
Transcript of Curiculum Vitae DR. Rahadian Indarto Susilo, dr SpBS(K)€¦ · Curiculum Vitae DR. Rahadian...
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Curiculum Vitae
DR. Rahadian Indarto Susilo, dr SpBS(K)
• Fak Kedokteran Universitas Airlnggga 1996-2002
• PPDS Bedah Saraf Universitas Airlangga Surabaya 2003-2009
• Skull Base Fellow Program Keio University Tokyo Japan, 2009
• WFNS Grade A: Skull Base Fellowship Program Osaka City University, Japan. 2011
• Program paska sarjana (S3), FK UNAIR SURABAYA , 2019
• Neurooncology Division, Neurosurgery Department Airlangga University-Dr. Sutomo General Hospital, Surabaya, 2009 – now
HP : 081 3260 79197 Email : [email protected] / appointment : 0822-6000-6070
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TRAUMATIC
BRAIN INJURYRahadian Indarto Susilo,
Divion Of Neuro-0ncology & Skull Base Neurosurgery
Dept. of Neurosurgery, Airlangga Univ. Faculty Of Medicine / Dr. Sutomo General Hospital
SURABAYA INDONESIA
WEBINAR RS PREMIER 2020
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Traumatic brain injury OUTLINE
1. PATOFISIOLOGI TRAUMA KEPALA
2. KONSEP TEKANAN INTRA KRANIAL & APLIKASI PADA TERAPI
3. Cegah SYOK
1. CEREBRAL PERFUSION PRESSURE
2. AUTOREGULASI
4. Pemeriksaan imaging
5. Tatalaksana cedera otak
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Emergency Neurological Life Support
Traumatic Brain Injury Version: 2.0
Last Updated: 19-Mar-2016
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Emergency Neurological Life Support
Traumatic Brain Injury Version: 2.0
Last Updated: 19-Mar-2016
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TRAUMA KEPALA
• CEDERA
• Kulit kepala
• Tulang kepala
• Otak
• CSF (cairan otak)
• Suplai aliran darah
• AKIBATNYA
• Perdarahan
• Fraktur & perdarahan
• Kontusio, perdarahan,
edema, TIK naik
• Kebocoran (fr basis cranii)
• Ischemia (karena shock
atau TIK naik)
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Perdarahan kulit kepala
Cardiac output 5000 cc/min
Cerebral Bloof Flow 15% CO
Aliran darah ke otak =
2 art carotis interna
= 750 cc/min
Aliran darah ke kulit kepala
sama banyaknya
= 750 cc/min
Kulit kepala robek satu sisi
= 375 cc/min
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The goal of Emergency Department management of TBI
1.definitive care of the primary brain injury
2. Preventing secondary brain injury
Rahadian I Susilo, dr.SpBS 11
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INTRACRANIALSECONDARY INSULT
SYSTEMICSECONDARY INSULT
CEDERA OTAK
SEKUNDER
• ICP, CPP•ISKEMIK-HIPOKSIK
•Kerusakan sel
•MORTALITAS•MORBIDITAS
CEDERA OTAK
PRIMER
Patofisiologi Cedera Otak
Normal
Tx adequad
AIRWAYBREATHING
CIRCULATION
TRAUMA KEPALA
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ON GOING PROCESS
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Harus dianggap ada contusio cerebri dan edema otak
Fraktura tulang tengkorak = pasti trauma berat
ON GOING PROCESS
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ON GOING PROCESS
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KONSEP TEKANAN INTRA KRANIAL DAN APLIKASI PADA TERAPI
DOKTRIN MONRO-KELLIE
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Ventricles
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Intracranial Volume
• 80%Brain Matter
• 10%Blood ( artery & vein )
• 10%CSF
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Normal state → ICP normal
“the total volume of the intracranial contents
MUST remain constant”
DOKTRIN MONRO-KELLIE
Volume = Vdarah + Vcairan otak + Vjaringan otak
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Compensated state → ICP normal
Head up 30°
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HERNIASI
TITIK MULAI
DEKOMPENSASI
T I K
FINISH
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75 ml 75 ml
Uncompensated state → ICP Elevated
• 10 mmHg : Normal
• 20 mmhG : Abnormal
• 40 mmHg : Severe
ICP → deteriorates brain
function → poor outcome
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Cerebral Blood Volume ( CBV )
P CO2 → diameter arteriJaga P CO2 tetap normal →monitor AIRWAY & BREATHING
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REDUCE BRAIN VOLUME ???
BRAIN EDEMA
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edema otak
Edema otakmanitol
Hypertonic saline:
NaCl 3%totilac
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Tumor dan edema otak
Steroid :DEXAMETASON
manitol
Hypertonic saline:
NaCl 3%totilac
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Tekanan Intrakranial → Herniasi Otak
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Tekanan Intra Kranial meningkat
• Bahaya:– herniasi otak:
• medula oblongata ke foramen magnum
• bagian otak lain ke trans-tentorial
– kerusakan cortex cerebri
Tanda:1. kesadaran menurun / muntah2. tekanan darah meningkat (bisa > 200
mmHg)3. nadi menurun (bradikardia < 60)
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Penyebab naiknya ICP / TIK
• Trauma kepala / CEDERA OTAK PRIMER →edema otak → ICP / TIK naik
• CEDERA OTAK SEKUNDER:
– Batuk, mengejan, semua peningkatan tekananintra thorax atau intra abdomen
– Obat anestesia halothan, ketamin, morfin
– Hipoksia, hiperkarbia
– Baring kepala lebih rendah (Trendelenburg)
– Muntah ICP tinggi
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Posisi miring menjepit vena jugularis
dan meningkatkan ICP
Cervical collar /
Collar brace yang
tight-fit (pas benar)
justru membendung
aliran vena leher
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Penyebab Cedera
sekunder
• Hipoksia
• Hipoperfusi (CPP )
akibat shock MAP dan TIK
• Kejang
• Hipertermia (demam)
• Hipoglisemia
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HINDARI SYOK
1. Cerebral Perfusion pressure
2. Autoregulasi tekanan darah otak
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CPP = MAP - ICP
CPP = cerebral perfusion pressure
MAP = mean arterial pressure
ICP = intracranial pressure (TIK)
Cedera otak membuat ICP naik
MAP tidak boleh turun
agar CPP tidak makin turun
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Autoregulation
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PEMERIKSAAN IMAGING
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BRAIN IMAGING
CT scan
CT scan 64 slices → 128 slices
GOOD brain imaging → GREAT brain imaging
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CT Scan
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EpiDural Hematoma (EDH) SubDural Hematoma ( SDH )
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TAKE HOME MESSAGES
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AIRWAY
BREATHING
CIRCULATION
BRAIN / Disability
Penanganan AWAL Trauma Kepala
CEGAH CEDERA SEKUNDER !!
• Atasi hipoksia
• Atasi hipoventilasi
• Atasi shock
• Cegah TIK naik
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LAMPIRAN
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CT Scan
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TATALAKSANA PEMBEDAHAN PADAKASUS BEDAH SARAF
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Bedah saraf
OPERASI
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Apakah AMAN ???
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Terapi Tumor Otak
OPERASI
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OPERASI BEDAH SARAF
Prioritas Utama
KUALITAS HIDUP PASIEN
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Prioritas UTAMA
Keamanan Proses Pembedahan
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Microneurosurgerymembedakan jaringan otak dan PATOLOGIS
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Alat KhususPenghancurABNORMAL
cavitron ultrasonic surgical aspirator (CUSA)
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Keamanan Proses PembedahanIntraoperative monitoring
• Evaluasi fungsi saraf
• Area fungsi bicara
• Saraf wajah
• Saraf perasa
• Saraf penggerak
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Minimal invasifEndoscopic
Neurosurgery
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Kraniotomi
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MINIMAL INVASIF
Endoskopi
Endonasalneurosurgery
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Endoskopi neurosurgery
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Penekanan Saraf
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KEUNGGULANTEHNIK MINIMAL INVASIVE
• Rasa sakit lebih sedikit
• Tidak ada / meminimalisir bekas luka padawajah dan kulit kepala
– Kosmetik
– Scar minimal
• Masa pemulihan lebih cepat
–WAKTU DI RUMAH SAKIT LEBIH SINGKAT
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ICP monitoring
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ICP monitor : Intraventricle
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Indikasi Pembedahan EDH
• Pasien EDH tanpa melihat GCS dengan volume > 30 cc, atau ketebalan > 15 mm, ataupergeseran midline > 5 mm, atau
• Pasien EDH akut (GCS <9) dan pupil anisokor
Waktu :
Pasien EDH akut dengan koma (GCS < 9) dan pupil anisokor dilakukan cito pembedahan atauevakuasi
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l
• S
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Indikasi Pembedahan SDH
• Pasien SDH tanpa melihat GCS :
– Dengan ketebalan > 10 mm
– Atau midline shift (MLS) > 5 mm pada CT Scan
• Semua pasien SDH dengan GCS < 9 harus dilakukan monitoring TIK
• Pasien SDH dengan GCS < 9 :
– Ketebalan SDH < 10 mm dan pergeseran struktur midline, jika mengalami penurunan GCS lebih dari 2 poin atau lebih antara saat kejadian dengan saat masuk ke rumah sakit
– Dan atau jika didapatkan pupil yang dilatasi asimetri atau fixed
– Dan/atau TIK > 20 mmHg
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Indikasi pembedahan ICH
• Pasien dengan GCS 6-8 dengan perdarahan parenkimotak pada daerah frontal atau temporal dengan volume perdarahan > 20 cc, dengan pergeseran struktur midline ≥ 5 mm dan atau kompresi pada sisterna.
• Perdarahan parenkim otak dengan volume perdarahan> 50 cc
• Pasien dengan perdarahan parenkim otak dan tanda-tanda deteriorasi neurologis yang progresif sesuaidengan lesi, hipertensi intrakranial yang refrakterdengan medikamentosa, atau didapatkan tanda-tandaefek massa pada CT scan.
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Penilaian Kesadaran
102
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menilai kesadaran dengan cepat
• A = Awake
– sadar penuh
• V = responds to Verbal command
– ada reaksi terhadap perintah
• P = responds to Pain
– ada reaksi terhadap nyeri
• U = Unresponsive
– tak ada reaksi terhadap nyeri
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Glasgow Coma Score
E - Eye opening (buka mata)
V - Best verbal response (bicara)
M - Best motor response (gerak ekstremitas)
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105
Glasgow Coma Score
• Menilai derajat cedera kepala
• Evaluasi GCS berkala sangat bermanfaat untuk meramal prognosis
• Score total maksimal 15 – Eye (4), Verbal (5), Motoric Responses (6)
– Mata bengkak E = x
– Intubasi V = x
– Paraplegia M = x (coba sisi terkuat)
– * Dapat bervariasi antar pemeriksa
• Lengkapi dengan respons pasien
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Glasgow Coma Score
Eye opening (buka mata)
Open spontaneously 4
Open to command 3
Open to pain 2
None 1
• Buka mata spontan
• Buka mata diperintah
• Buka mata karena nyeri
• Tidak buka meski
dirangsang nyeri
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Glasgow Coma Score
Best verbal response (bicara)
Oriented 5
Confused 4
Inappropriate words 3
Inappropriate sounds 2
None 1
• Orientasi baik
• Bingung
• Bicara tak tepat
• Suara tak jelas
• Diam
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Glasgow Coma Score
Best motor response (gerak ekstremitas)
Obeys command 6
Localises to pain 5
Withdraws to pain 4
Abnormal flexion 3
Extensor response 2
None 1
• Menurut perintah
• Menunjuk tempat nyeri
• Menarik menjauhi nyeri
• Fleksi abnormal thd nyeri
• Ekstensi thd nyeri
• Tak ada gerakan
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Jika pemeriksa ragu,GCS = 3 atau 4 atau 5 ?
• Jika akan memutuskan suatu tindakan, tetapkan harga yang jika salah, tetap tidak merugikan pasien
– Kalau GCS rendah berakibat kita harus melakukan tindakan invasif, berikan nilai rendah
– kalau GCS tinggi membuat harapan yang lebih baik, berikan nilai tinggi agar upaya medik jadi maksimal dn bersemangat
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E = …... V = …… M = ……..
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Respons pupil
• Ukuran
– …. Mm
• Respons cahaya
– ada / tidak
– cepat / lambat
• Simetri
– isocor / an-isocor (lebih besar satu sisi)
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EARLY EVALUATION
Pupil abnormality• The development of pupillary abnormalities
is a sensitive indicator for pressure on the
midbrain (tentorial herniation)
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Glasgow Coma Score
menilai derajat cedera kepala
Severe GCS < 8
Moderate GCS 9-12
Minor GCS 13-15
Respons pupil
• Ukuran
• Refleks cahaya
• Simetri
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Contoh Kasus
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Waspadalah menghitung GCS pada kasus sulit
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117
|
setelah
30 menit berlalu
|
GCS 2 - 3 - 4
Saat tiba di RS sadar
GCS 4 - 4 - 5(lucid interval?)
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Perdarahan akut
Epidural dan Subdural
(perlu pembedahan)
• Sangat membahayakan jiwa
• Segera diagnosis
• Segera dekompresi
(burr-hole)
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Perdarahan akut epidural tanda klasik
• Pada kejadian trauma tidak sadar sebentar
→ lalu sadar baik (interval bebas, lucid interval)
→ lalu kesadaran cepat memburuk
• Perubahan pupil pada sisi perdarahan
– asimetris, lebih besar
– refleks cahaya turun / (-)
• Lumpuh tangan + kaki pada sisi yang lain
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Raccoon eyes / bril hematoom = fraktura basis cranii
Hati-hati memasang pipa lewat hidung
Pipa oro-gastrik
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Pasien TIK tinggi
sering muntah
Posisi baring miring
perhatikan cedera leher
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Cedera kepala berat
- Baringkan head-up 20o
u/ mengurangi TIK
- Selesaikan survei sekunder
- Lakukan pemeriksaan
berulang-ulang
- Cegah hipertermia
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Ganjal pasir di kiri kanan leher membantu fiksasi
tanpa risiko naiknya ICP
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KLASIFIKASI CEDERA OTAK
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Klasifikasi (Head – Brain Injury)
Berdasar:
1. Mekanisme
2. Severity
3. Morphologi
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Mekanisme
Luka penetrasi
Luka tembak
Motorbike accident
Penetrasi
Tumpul(Blunt)
Blunt assault
Falls
Automobile collision
Depends on the presence ofdural penetration
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Severity
Severe (GCS: 3-8)
Mild (GCS: 14-15)
Moderate (GCS: 9-13)
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Morfologi
Diffuse
Focal
Vault
Intracraniallesions
SkullFracture
Basilair
Linier/ satellite
Depressed/ non depressed
Open/ Close
With or w/o CSF leakage
With or w/o N VII palsy
-Vascular injury→ EDH,SDH,ICH
-Axonal injury-Contusion-Laceration
Diffuse axonal injury→Mild, classic concussion & diffuse axonal injury
Diffuse vascular injury→Multiple small hemorrhage
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SPORTS RELATED CONCUSSION
• Concussion = cedera otak ringan
• Sport related event → 10%
• GCS → insensitive
• Concussion grading system
1. CANTU
2. AAN ( American Academy of Neurology)
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Concussion grading system
GRADE CANTU SYSTEM AAN SYSTEM
1 ( MILD) 1. Post TraumaticAmnesia < 30 menit
2. No Loss of consciousness
1. Transient confusion2. No LOC3. Symptoms resolve in
< 15 min
2 ( MODERATE) 1. Post TraumaticAmnesia > 30 menit
2. Loss of consciousness < 5 min
As above, but sysptomslast > 15 mins ( still no LOC) ( PTA is common)
3 ( SEVERE) 1. Post TraumaticAmnesia > 24 jam
2. Loss of consciousness > 5 min
Any LOC
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