HEAD INJURIES
Yunus Elon, [Link]., Ns., MSN
Faculty of Nursing
Adventist University of Indonesia
Organization of the
Nervous System
2 big initial divisions:
1. Central Nervous System
The brain + the brainstem + the spinal cord
The CNS receives and transmit information
via nerves or special tracts of nerve tissue
that extend through the CNS and extend
out into the PNS.
2. Peripheral Nervous System
The nervous system outside of the brain
and spinal cord
Consists of:
31 Spinal nerves
Carry info to and from the spinal cord
12 Cranial nerves
Carry info to and from the brain
Peripheral Nervous System
Responsible for communication btwn the CNS
and the rest of the body.
Can be divided into:
Sensory Division
Afferent division
Conducts impulses from receptors to the CNS
Informs the CNS of the state of the body interior and exterior
Sensory nerve fibers can be somatic (from skin, skeletal
muscles or joints) or visceral (from organs w/i the ventral body
cavity)
Motor Division
Efferent division
Conducts impulses from CNS to effectors (muscles/glands)
Motor nerve fibers
Motor Efferent Division
Can be divided further:
Somatic nervous system
VOLUNTARY (generally)
Somatic nerve fibers that conduct impulses from
the CNS to skeletal muscles
Autonomic nervous system
INVOLUNTARY (generally)
Control vital body functions, including: Heart rate,
constriction and dilatation of blood vessels,
digestion, heat regulation.
Autonomic Nervous System
Can be divided into:
Sympathetic Nervous
System
Fight or Flight
Parasympathetic
Nervous System
Rest and Digest
These 2 systems are antagonistic. Ex. PNS: Slow HR, Where SNS:
Speed Up.
Typically, we balance these 2 to keep ourselves in a state of
dynamic balance.
The Nervous Systems Dependence on
Oxygen and Glucose
If some oxygen is not delivered to the
brain within about 3-6 minutes, irreversible
brain damage occurs.
Other condition such Hypoxia and
hypotension, which result in an inadequate
supply of O2 to the brain, can cause
varying degrees of cell damage.
Pt who are hypoxic have altered brain
function. Changes in ability to reason,
judgment and level of consciousness will
occur.
Altered mental status is the most sensitive
indication of inadequate oxygen.
Protection of The Brain and Spinal
Cord
Because the brain and spinal cord are
of such central importance and so
sensitive to pressure, they are
protected and encased within strong
bones that make up the skull and
vertebral column.
The scalp, the thickest layer of body
covering, provides a spongy
protection for the skull.
Membranes which cover the brain tissue,
consist of three layers
Durameter
Arachnoid
Is tough, thick, inelastic. The meningeal arteries are
located between the internal surface of the skull and
dura called epidural space
White in color because it has no blood supply. The
arachnoid layer contains the choroid plexus, which
absorb CSF. Also has unique fingerlike projections
called arachnoid villi, which absorb CSF. When blood
enter the system (Fr trauma, a ruptured aneurysm,
stroke and so forth) they become obstructed. When
arachnoid villi become obstructed, Hydrocephalus can
result.
Piameter
Piameter means soft mother in latin. The meningeal
vein are located in the subarachnoid space. Bleeding
due to break out of menigeal veins in this space is
called subdural hematoma.
Cerebrospinal Fluid
Fills the space btwn the
arachnoid and pia mater, as
well as the internal cavities of
the brain (ventricles) and spinal
cord.
Functions:
Shock absorption
Support
Nourishment
A choroid plexus consists of a
combination of specialized
ependymal cells and permeable
capillaries for the production of
CSF.
Ependymal cells selectively secrete capillary filtrate into the
ventricles. They also remove waste products from the CSF and adjust
its composition over time. CSF differs markedly from blood in its
[soluble protein] and cellular content.
About 500mL of CSF is produced per day. but 150mL absorbed by
the villi.
CSF circulates from the choroid plexus thru the ventricles and the
central canal of the spinal cord. As it circulates.
CSF reaches the subarachnoid space thru 2 lateral apertures and a single
median aperture in the roof of the 4th ventricle. CSF then flows thru the
subarachnoid space surrounding the brain, spinal cord, and cauda equina
Along the axis of the superior sagittal sinus, fingerlike extensions of the
arachnoid membrane, called arachnoid villi, penetrate the dura. In adults,
clusters of villi form arachnoid granulations.
CSF is
absorbed into
the general
circulation at
the arachnoid
granulations
Injuries to Brain and Skull
Blood Supply
Most of the blood supply to the brain (80%) is
provided by the carotid arteries. That is why
you never palpate both carotid pulses at one
time. The rest of the brains blood flow comes
from 2 vertebral arteries.
Structural and Metabolic Injuries
Injuries to the nervous system can occur in 2
ways:
Structural injuries: Injuries to the brain that cause
disruption of specific sections of the brain tissue or
nerves results in loss of specific functions. This
injuries may be traumatic or non traumatic. Ex,
penetrating wound to the left brain may not have use
of the right side of the body, but the left side remain
function.
Metabolic Injuries: Ex, Lack of oxygen after a
cardiac arrest. All the brain cells are affected.
Penurunan kesadaran
Penurunan kesadaran dapat disebabkan
karena cedera pada cerebral cortical
bilateral atau injury pada daerah system
yang mengendalikan aras/ ascending
reticularis system.
Penurunan kesadaran dalam bentuk
penurunan point GCS lebih dari 1 atau 2
lebih menandakan perlunya konsultasi
bedah syaraf.
Tanda Lateralisasi
Disebabkan karena adanya suatu proses pada
satu sisi otak, seperti misalnya perdarahan
intrakranial.
Pupil: cheek kedua pupil. Diameter sama normal
disebut isokor, or unisokor.
Motorik: lakukan rangsangan pada kedua tungkai
apabila salah satu lengan atau tungkai tidak bereaksi
disebut tanda lateralisasi. Biasanya tanda lateralisasi
antara pupil yang melebar dan hemiparese pada
motorik berlawanan.
Peningkatan TIK
TIK adalah tekanan yang dikeluarkan oleh
kombinasi volume dari 3 komponen
intrakranial yaitu: Jaringan otak, CSF dan
darah.
Peningkatan TIK dihasilkan dari
peningkatan volume intrakranial seperti
Massa (hematoma/edema),
Membengkaknya otak (edema serebri atau
karena terjadi perdarahan dalam otak
(intrakranial Bleeding)
ICP dapat mengakibatkan
komplikasi serius yaitu turunnya
batang otak (herniasi batang otak)
yg berakibat gagal pernafasan dan
gagal jantung serta kematian.
Tanda2 ICP
Pusing dan muntah
Tekanan darah sistolik meninggi
Nadi melambat (Bradikardia)
Kerusakan Otak akibat Trauma
Otak dapat mengalami pembengkakan
(edema) baik karena trauma langsung
(Primer) ataupun setelah trauma (sekunder)
pembengkakan otak ini dikenal dengan
edema serebri.
Karena Cranial merupakan ruang yg
tertutup rapat maka edema dapat
mengakibatkan ICP .
Cedera Langsung (Primer)
Otak menumbuk bagian dalam tengkorak,
maka kemungkinan terjadi Perdarahan
dalam jaringan (kontusio serebri), robekan
jaringan otak (laserasi serebri) atau
perdarahan karena terputusnya pembuluh
darah.
Cedera otak (Sekunder)
Berupa: edema serebri, Ischemia jaringan otak dan Infark
jaringan otak.
Disebabkan oleh:
Hypovolemia: perdarahan yang menyebabkan terjadinya
syok. Hypovolemia bila ringan akan dikompensasi oleh
tubuh. Namun bila hypovolemia berat akan mengakibatkan
perfusi darah ke otak berkurang. (Iskemia atau infark)
Hypoksia: O2 dalam darah akan mengakibatkan kekurangan
O2 pada otak. Iskemia atau Infark.
Hypercarbia: Pngaruh CO2 dalam darah sangat penting pada
trauma kapitis. CO2 meyebabkan vasodilatasi yang
kemudian megakibatkan edema serebri. CO2
(hipocarbia) meyebabkan vasokonstriksi pembuluh
darah sehingga terjadi iskemia yang berlanjut ke
Infark.
Jenis Trauma kepala
Berdasarkan Penyebabnya
Fx Cranial: bila tidak terbuka tidak
memerlukan perhatian segera. Bila fx
terbuka/berhubungan dengan lingkungan
maka diperlukan operasi segera.
Fx Basis kranial: fx yg cukup serius, bila
terjadi fx basis kranial maka keluar
darah/csf dari hidung atau telinga. Sehingga
harus berhati2 dalam pemasangan NGT atau
Suction.
Pendarahan Intra Kranial (PIS)
Dapat berupa perdarahan
epidural, subdural atau
intrakranial.
Cedera kepala dibagi menjadi 3
Golongan
CKR = GCS 14-15 (didefinisikan sebagai trauma kepala dengan
mental status dan neurologis normal dan tidak terdapat fx pada
skull. Pada keaadaan ini dapat disertai kehilangan kesadaran < 1
mnt. Kejang singkat stelah trauma, muntah, sakit kepala dan
lesuh.)
CKS = GCS 9-13 ( Kehilangan atau penurunan kesadaran untuk
beberapa waktu disertai lupa mengenai kejadian tersebut. Cedera
kepala terjadi dengan luka terbuka atau tertutup.)
CKB = GCS 8 (kehilangan kesadaran dalam waktu 5-10 mnt.
Lalu ada luka atau memar, pendarahan dari hidung atau keluar
cairan dari telinga, kejang dan Muntah. Pada CKB Pendarahan
sampai ke otak atau di tulang cranial. Dianggap berat bila muncul
kejang atau kelumpuhan.
