Bagian ilmu anestesi dan reanimasi

Fakultas kedokteran
Universitas pattimura

Manajemen TIK
pada Trauma Brain Injury

Konsulen : dr. Ony W. Angkejaya, Sp.An

dr. Fahmy Maruapey, Sp.An
 pendahuluan
Weight ± 2%
from body

brain
Jrngn yg mmpnyai metablism tnggi Kebutuhan
In emergency &
Memerlukan : critical situation bahan – bahan
metabolik
• 15% Cardiac output
• 20% Oxygen
• 25% glucose

Dikarenakan peningkatan kebuthan metabolic,

sehingga metabolism u/ otak terggu akan
menyebabkan kerusakan jaringan otak yang berakibat
kematian dan kerusakan permanen
meninges duramater

Arachnoid mater
Subarachnoid space
Houses of Cerebrospinal Fluid (CSF) piamater
The cerebrospinal fluid (CSF) is
produced from arterial blood by the
choroid plexuses of the lateral and
fourth ventricles by a combined
process of diffusion, pinocytosis and

Otak dilindungi
active transfer

• Clear watery liquid

around brain and oleh lapisan
•
spinal cord
Cushion impact
meninges
• Bathes them in Meninges have 3 Layers
nutrient
 Intracranial pressure
Volume of brain
+
CSF Fluid “About the same”
+
Intracranial
venous &
arterial blood

Increase in one  decrease in other two( compensate)

If they cannot compensate, intracranical pressure increase
“Normal ICP = 8 to 10/15 mmHg  Higher than 20 mmHg interpretate Intracranial Hypertension”
 The monro-kellie doctrine

In zone I, compensatory mechanisms are optimal. In zone

II, compensatory mechanisms fail. There is a slow increase
(period of spatial compensation). In zone III, virtually
irreversible increased intracranial pressure and herniations
occur. There is a rapid increase (period of spatial
decompensation).

Pressure-Volume Curve
Adapted from Wijdicks EFM. The clinical practice of critical care neurology. 2nd ed. Oxford [UK]: Oxford University
Press; c2003. Chapter 9, Intracranial pressure; p. 107–25. Used with permissionof Mayo Foundation for Medical
Education and Research
CONTINUE…..

When ICP is suspected to be increased, it must be measured by direct or indirect means.

Once ICP is measured, it can be used to calculate CPP, according to the equation

Cpp = map - icp

CPP = CEREBRAL PERFUSION PRESSURE
MAP = MEAN ARTERIAL PRESSURE
Pulse pressure = systolic pressure – diastolic pressure
ICP = INTRACRANIAL PRESSURE
map = 1/3 pulse pressure + diastolic pressure

CPP merupakan tekanan yang membuat aliran darah otak (CBF) bergerak atau mengalir. CPP
bergantung pada tekanan darah pasien, entah itu normal maupun hipertensi.
Pada Tekanan Darah Normal 120/80 mmHg (MAP = 93 mmHg dan ICP = 10 mmHg), CPP = 83 mmHg
Kebanyakan kasus untuk Traumatic Brain Injury atau Stroke, CPP biasanya tetap pada angka
minimum 65 mmHg atau lebih. Untuk Kasus Hipertensi Kronik, “Normal CPP” bergeser ke kanan
tergantung MAP kronis.
Normal range cpp is 60-80/100 mmHg
“When ICP is more than 20 mmHg, CPP becomes compromised
and decreases to less than 50 mmHg and ischemia can occur.
When CPP global brain ischemia, infarction, and
brain death can occur unless immediately reversed”
In normal states, CBF is held constant across a range of
CPP values termed cerebral autoregulation, which is due
to varying cerebrovascular resistance (CVR) (CBF =
CPP/CVR). In stroke and brain injury, CVR becomes
constant (k) and CBF varies linearly with CPP.
The ischemic threshold is less than 20 mL/100g per
minute CBF, and gray matter typically has higher
requirements (about 80–100 mL/100g per minute) than
white matter (about 50 mL/100g per minute). Normal CBF
is typically between 50 and 100mL/100g per minute.
 Cerebral autoregulation
When ICP is suspected to be increased, it must be measured by direct or indirect means.
Once ICP is measured, it can be used to calculate CPP, according to the equation

Cpp = map - icp

CPP = CEREBRAL PERFUSION PRESSURE
MAP = MEAN ARTERIAL PRESSURE
ICP = INTRACRANIAL PRESSURE

In normal states, cerebral blood flow (CBF) is held constant

over a range of cerebral perfusion pressure (CPP) values
due to varying cerebrovascular resistance (CVR). In stroke
and brain injury, CVR becomes constant (k), and thus CBF
varies linearly with CPP values (linear relationship).

CBF = CPP/CVR
Adapted from Rose JC, Mayer SA. Optimizing blood pressure in neurological
emergencies. Neurocrit Care 2004;1[3] :287–99.
increased intracranial pressure
“When Two Component in Intracranial Pressure cannot Compensate because of improvement of the other components”

CPP = CEREBRAL PERFUSION PRESSURE

Cpp = map - icp

MAP = MEAN ARTERIAL PRESSURE
ICP = INTRACRANIAL PRESSURE

map = 1/3 pulse pressure + diastolic pressure

CCP has to be certain range to give neurons and cells 2 factors that made intracranial pressure increase
in brain enough of oxygen and nutrients to survive.
So when CCP is getting low, brain not going working
very well and theres gonna be problems. 1. Non – Pathological Causes
Remember!! “The monro-kellie doctrine” a) Coughing / Sneezing
b) Lifting
 Intracranial Preassure will be increase, if it components, like Brain c) Stress
Volume or CSF Fluid or Intracranial Venous / Arterial Blood is
d) Blood Pressure Changes, etc
getting increased before without any compensate or the compensate
mechanism is fail ( zone II and III)
2. Pathological Causes
Brain Volume If : Tumour, Abscess, Edema, Bleeding a) Traumatic Brain Injury (Concussion,
CSF Fluid If : Tumour in choroid plexuses, there in Contusion)
some blockage in CSF drainage b) Space Occupying Lessions (Subdural
Intracranial Blood If : Heart Failure, High in CO2
brain
Hematoma, Epidural Hematoma,
(Hypercapnia) Subarachnoid Hemorrhage,
Hydrocephalus, Tumour, Edema,
Absces or Infections.
increased intracranial pressure
“When Two Component in Intracranial Pressure cannot Compensate because of improvement of the other components”
 increased intracranial pressure
1. Headache
2. Hypertension
(The Cushing Triad  Hypertension, Bradicardia, Abnormal Breathing)

3. Change in Mental Status

4. Vomiting
5. Hiccups
6. Diplopia & Pupillary changes
 Traumatic BRAIN INJURY
“Traumatic brain Injury is defined as brain function impairment that results from external force.”
“Clinical manifestations represent a broad constellation of symptoms from brief confusion to coma, severe disability, and/or death.”

TBI is classified as mild, moderate, and severe based on the GCS score.
Mild GCS 14-15* and is often call “concussion” (Over 80% case TBI)
Moderate GCS 9-13, over 40% case and have an abnormal CT Finding
& Will Require neurosurgical intervention
Severe GCS 3-8, mortality rate approaches 40%, with most death
Ocurring in the first 48 hours aftr injury

“Prevelance TBI of man : women (2:1)”

“Motor vehicle collisions are the primary cause of blunt head injury in young adults and children, and falls are more common in the elderly”

TBI has been called a "signature injury" of modern-day warfare

*15 which indicates a fully awake patient
 Traumatic BRAIN INJURY
“Traumatic brain Injury is defined as brain function impairment that results from external force.”
“Clinical manifestations represent a broad constellation of symptoms from brief confusion to coma, severe disability, and/or death.”

Cpp = map - icp

CPP = CEREBRAL PERFUSION PRESSURE
MAP = MEAN ARTERIAL PRESSURE
Pulse pressure = systolic pressure – diastolic pressure
ICP = INTRACRANIAL PRESSURE
map = 1/3 pulse pressure + diastolic pressure
Under normal situations, autoregulation can adjust to accommodate CPPs form 50 to 150mmHg in order to maintain local cellular oxygen demand and
regional cerebral blood flow.

“In brain injury, auto-regulation is often impaired, so even modest drops in blood
pressure can decrease brain perfusion and result in cellular hypoxia A CPP <60 mmHg is
considered the lower limit of autoregulation in humans, below which local control of
cerebral blood flow cannot be adjusted to maintain flow adequate for function.”

Elevations in ICP are lifethreatening and may lead to a phenomenon

known as the Cushing reflex (hypertension, bradycardia, and respiratory
irregularity). Hypertension is an attempt to maintain cerebral perfusion.
CONTINUE…..

Normal cerebral blood flow (CBF)

autoregulation curve and the abnormal curve
with traumatic brain injury (TBI). Normal
autoregulatory control (blue line) maintains a
relatively constant CBF over a broad range of
mean arterial pressure (MAP).9

Loss of autoregulation results in a more linear

relationship between CBF and MAP. Elevated
intracranial pressure (ICP) can dramatically
decrease CBF when autoregulation is impaired
(inflection point of chocolate line). Increases in
ICP may result in a net loss in CBF.

Cpp = map - icp

Pressure–volume relationship in brain injury.
 Traumatic BRAIN INJURY

OPEN SKULL FRACTURE WITH UNDERLYING CEREBRAL CONTUSIUON

Traumatic BRAIN INJURY

EPIDURAL HEMATOMA AND SMALL SUBDURAL HEMATOMA

Traumatic BRAIN INJURY

DIFFUSE SUBARACHNOID HEMORHAGE

Traumatic BRAIN INJURY
 increased intracranial pressure
“The goals of medical management of increased ICP are to maintain brain perfusion
and prevent hypotension without considerable contribution to an increase in ICP.”

MONITORING ICP
“A more invasive means of measuring ICP is by way of an
intraventricular catheter. It is considered the standard
for monitoring ICP. In addition to its use for quantitative
measurement, an intraventricular catheter can be
therapeutic. It can be used to drain CSF and thus provide
a means of decreasing ICP. With all invasive techniques,
there are risks, including hemorrhage and infection.”

Non-Invasif = Clinical Symptomp and Imaging Without Contras

increased intracranial pressure
increased intracranial pressure
increased intracranial pressure
increased intracranial pressure
increased intracranial pressure
increased intracranial pressure
Thank you