principle management in neuroemergency€¦ · cedera otak merusak mekanisme autoregulasi batas...
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Principle Management in
NeuroemergencyDR dr Rahadian Indarto Susilo SpBS (K)
17 Oktober 2020
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Outline
1. Problem utama Neuroemergency
2. Doktrin Monroe Kelly
3. Aplikasi doktrin Monroe Kellie pada tatalaksana neuroemergency
4. Cerebral Perfusion Pressure ( CPP)
5. AUTOREGULASI
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Problem utamaNeuroemergency
Tekanan intra kranial(TIK )
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Doktrin Monroe-Kelly
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“the TOTAL volume of the intracranial contents
MUST remain constant”
The MONROE KELLIE doctrine
Volume =Vdarah + Vcairan otak + Vjar. otak = konstan
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Mekanisme kompensasi peningkatan TIK
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Normal state → ICP normal
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Compensated state →ICP normal
1. Head up 30°
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Fase KOMPENSASI
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Uncompensated state → ICP Elevated
75 ml 75 ml
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Fase DEKOMPENSASI
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ROLE OF INTRACRANIAL PRESSURE
• 10 mmHg - Normal
• > 20mmHg - Abnormal
• > 40mmHg - Severe
ICP → deteriorates brain function → poor outcome
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Tekanan Intrakranial → Herniasi Otak
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Arterial Cerebral Blood Volume ( CBV )
2. Hiperventilasi → P CO2↓→ diameter ARTERI ↓
Jaga P CO2 tetap normal →monitor AIRWAY & BREATHING
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MENGURANGI VOLUME OTAK ???
EFEK MASSA + BRAIN EDEMA
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VOLUME otak
Edema otak
3.manitol
Hypertonic saline:
NaCl 3%totilac
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Tumor dan edema otak
4. Steroid :DEXAMETASON
manitol
Hypertonic saline:
NaCl 3%totilac
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ICP ► critical point ► Herniasi
Masuknya salah satukomponen intrakranial kedalam rongga intrakranialyang lain melalui locus minoris.
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Cerebral Perfusion pressure
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Cerebral Perfusion pressure
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CPP = MAP - ICP
Cedera otak membuat ICP naik
MAP tidak boleh turun
agar CPP tidak makin turun
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Intracranial Pressure
• Cerebral Perfusion Pressure (CPP) can be determined by the following formula:
CPP = MAP - ICP
• Normal CPP range is 60 - 150 for autoregulation to work well!
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AUTOREGULASI
26
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(ml /100 gram/ menit)
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Autoregulasi Aliran Darah Otak
Force – mediated dilatationIncrease flow Vasogenic edema
Impaired dilation Arterial collapse Ischemia
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Gangguan Autoregulasi
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Autoregulasi aliran darah otakpada Trauma kepala
Cedera otak merusak mekanisme autoregulasi
batas aman jadi lebih sempit
50 140
CBF
CPP (mmHg)
Waktu normalstabil disini
cedera
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Perubahan Autoregulasi
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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 ( Cushing respon ) :1. kesadaran menurun / muntah
2. 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 peningkatantekanan intra 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 membendungaliran vena leher
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CederaOtak
Sekunder
• Hipoksia
• Hipoperfusi (CPP )akibat shock MAP dan TIK
• Kejang
• Hipertermia (demam)
• Hipoglisemia
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Prinsip tatalaksana Neuroemergency
•Pahami doktrin monreo kellie, dan aplikasinya•Head up 30 derajad
•A dan B → cegah hypoksia dan hypercarbia
•C → cegah syok
•Cegah cedera otak sekunder
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Terima kasih