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Thursday, 19 April 2012

TRUE EMERGENCY : HEAD INJURY, WITH EPIDURAL HEMATOMA /cedera kepala, dengan epIidural hematom. (sign, symptoms, etiology, diagnosis, management)

Epidural hematoma is a type of intracranial bleeding most often occurs due to fracture of the skull. Olek cover the brain in the skull bones are rigid and hard. The brain is also surrounded by something that is useful as a wrapper which is called the dura. Its function is to protect the brain, blocking the venous sinuses, and form the periosteum tabula interna.

Epidural hematoma is a type of intracranial bleeding most often occurs due to fracture of the skull. By cover the brain in the skull bones are rigid and hard. The brain is also surrounded by something that is useful as a wrapper which is called the dura. Its function is to protect the brain, blocking the venous sinuses, and form the periosteum tabula interna .. When one gets a great impact on the head is likely to form a hole, the movement of the brain may cause abrasion or laceration of blood vessels surrounding the brain and dura, when a blood vessel had torn the blood will accumulate in the space between the dura and the skull, the state inlah are often known as an epidural hematoma.
Epidural hematoma as a state of emergency and the neurologist who is usually associated with a linear fracture that decides the larger arteries, causing bleeding. Venous epidural hematoma associated with vein laceration and progress gradually. Arterial hematoma occurred in the middle meningeal artery that lies beneath the temporal bone. Bleeding into the epidural space, so if there is bleeding artery hematoma will quickly occur.

In the United States, 2% of cases of head trauma resulting in epidural hematoma and about 10% resulting in a coma. Internationally frequency of occurrence of epidural hematoma is similar to the incidence in the United States who are at risk of edh . are parents who have problems walking and frequent falls.
60% of patients with epidural hematoma is under the age of 20 years, and rarely occurs in less than 2 years of age and over 60 years. The increased mortality in patients aged less than 5 years and more than 55 years. Occurs more frequently in males than in females with a ratio of 4:1.
1. Acute epidural hematoma (58%) of arterial bleeding
2. Subacute hematoma (31%)
3. Cronic hematoma (11%) bleeding from vena

III. Etiology
Epidural hematomas can happen to anyone and any age, some circumstances that can lead to epidural hematoma is such a collision on the head on motorcycle accident. Epidural hematoma caused by head trauma, which is usually associated with fracture of the skull and laceration of blood vessels.

The brain is protected from injury by the hair, skin and bones and wrap it, without this protection, the soft brain that makes us like it is, it would be easier to injury and damage. In addition, once a neuron is damaged, can not be repaired anymore. Head injuries can lead to big disaster for someone. Most of the problem is a direct result of head injuries. These effects should be avoided and immediately found from the medical team to avoid a series of events that lead to mental and physical disorders and even death.
Right at the top of the skull lies aponeurotika galea, a fibrous tissue, dense can move freely, which memebantu absorb the force of external trauma. In between the skin and galea there is a layer of fat and membrane layers in the vessel- large. If the tear is difficult to hold a vessel vasoconstriction and can cause significant blood loss in patients with lacerations on the scalp. Just below the galea are subaponeurotik space containing veins and diploika emisaria. These vessels can  infection of the scalp until deep into the skull, which clearly shows how important cleansing and debridement of the scalp galea carefully when torn.
In adults, the skull is a tough room that is not possible intracranial extension. Bone actually consists of two walls or a tabula separated by a hollow bone. Outer wall in  tabula externa, and the inner wall is called tabula interna. Structure and thus allows a force greater isolation, with a lighter weight. tabula interna contains grooves  anterior meningeal artery, the media, and p0osterior. If the fracture of the skull caused tear one of these artery-artery, which in  arterial bleeding, which accumulated in the epidural space, can  fatal consequences unless it is found and treated promptly.
Other protective lining of the brain are the meninges. The third layer of the meninges is the dura mater, arachnoid, and pia mater:
1. Cranial dura mater, the outer layer is thick and strong. Consists of two layers:
- Endosteal layer (periosteal) formed by the outer periosteum wrapped in calvari
- The inner meningeal layer is a strong fibrous membrane that goes on in the foramen magnum with the spinal dura mater that surrounds the spinal cord
2. Arachnoidea mater cranial, intermediate layer that resembles a spider's web
3. Cranial pia mater, the innermost layer of which contains many fine blood vessels.

Figure 1. Anatomy of the head

V. Pathophysiology
In the epidural hematoma, bleeding between the skull and the dura meter. Bleeding is more common in the temporal region when one branch of the middle meningeal artery torn media. These tears often occur when a skull fracture in the area concerned.
Hematoma may also occur in the frontal or occipital regions. Meningeal artery that goes on in the skull through the foramen spinosum and the road between durameter and bones on the surface and the os temporale. Bleeding that occurs causing an epidural hematoma, the hematoma will release the pressure by further durameter of the skull so that the hematoma increases. The enlarged hematoma in the temporal region causing pressure on the temporal lobes of the brain towards the bottom and inside. These pressures have led to the medial lobe herniation below the edge of the tentorium. This condition causes the onset of neurologic signs that can be recognized by the medical team. (1)
Pressure of arteria circulation pda unkus herniation who take care of the reticular formation in the medulla oblongata cause loss of consciousness. In this place there is the third cranial nerve nuclei (okulomotorius). This resulted in pressure on the nerves dilated pupils and eyelid ptosis. Pressure on the corticospinal path that runs up the area, causing weakness of the contralateral motor responses, hyperactive or very fast reflexes, and positive Babinski sign.
With the ever growing hematoma, the entire contents of the brain will be pushed in the opposite direction, causing a large intracranial pressure. Arise further signs of increased intracranial pressure such as stiffness deserebrasi and disruption of vital signs and respiratory function
Because the bleeding is coming from an artery, blood will continue pumping out up to increasingly large. When the head is smashed or hit the patient may be unconscious for a while and soon regained consciousness. Within a few hours, the patient will feel pain progersif head become heavy, then gradually decreased consciousness. The period between the two decreased patient consciousness during conscious after the accident called lucid interval. The phenomenon of lucid interval occurs because the primary injury is minor epidural hematoma. If the subdural hematoma is almost always severe primary injury or epidural hematoma with severe primary trauma lucid interval does not occur because of direct patient is unconscious and never had a conscious phase.
Source of bleeding:
• meningeal artery (lucid interval: 2-3 hours)
• Sinus duramatis
• Diploe (mengisis Kalvaria cranial hole) that contains a. diploica and venous diploica
Epidural hematoma is the most emergency cases in neurosurgery because of the rapid progresifitasnya because durameter firmly attached to the suture so that the direct cause of brain parenchyma urged to easily trans herniation and infra tentorial. that every patient with head trauma who complain of persistent headache, especially progressively become heavy, should be hospitalized and carefully examined.
A very prominent symptom is progressively decreased consciousness. Patients with this condition often appear bruised around the eyes and behind the ears. Are also looking liquid that comes out on the nose or ears. Such patients should be observed carefully.
Every person has a collection of symptoms that result from a variety of head injury. Along many of the symptoms that arise in the event of injury that often seem . sign :
• Decreased consciousness, can be up to coma
• Confused
• Blurred vision
• It's hard to talk
• a severe headache
• Discharge of blood from the nose or ears
• It appears that adalam wounds or scratches on the scalp.
• Nausea
• Dizziness
• Sweating
• Pale
• Pupils anisokor, the ipsilateral pupil became dilated.

Figure 2. Epidural Hematoma
At this stage of consciousness before the stupor or coma, can be found hemiparese or focal epileptic seizures. On his journey, will achieve maximum pupil dilation and reaction to light in the beginning is still positive to negative. This is a sign of tentorial herniation has occurred. There were also increases blood pressure and bradycardia. In the final stage, decreased consciousness to deep coma, the contralateral pupil dilation are also experiencing until both pupils showed no reaction to light again which is a sign of death. Respiratory symptoms that could occur next, reflecting the rostrocaudal brainstem dysfunction.
Epidural hematoma in if accompanied by a brain injury such as bruising of the brain, free interval will not be visible, while other signs and symptoms become blurred.
With CT-scan and MRI, intracranial hemorrhage due to head trauma is more easily recognized.
Photos Plain Head
On a plain head, we can not definitely diagnose as epidural hematoma. Antero-posterior projection with (AP), lateral sides of the traumatized by the movie to find a bone fracture that cuts off the middle meningeal artery sulcus media.

Computed Tomography (CT Scan)
CT-Scan examination can show the location, volume, effects, and other intracranial cedara potential. In the epidural is usually on one side only (single) but can also occur on both sides (bilateral), shaped bikonfeks, most often in the temporoparietal region. Homogeneous density of blood (hiperdens), demarcated, pushed to the side contralateral midline. There is also a fracture line in the area of ​​epidural hematoma, a high density in the acute stage (60-90 HU), characterized by the stretching of blood vessels.

Figure 3. CT scan picture of epidural hematoma

Magnetic Resonance Imaging (MRI)
MRI will depict a shifting mass of hiperintens bikonveks dural position, in between the bones of the skull and the dura mater. MRI also can depict the boundary fracture occurs. MRI is one of the selected type of examination for diagnosis.
1.Hematoma subdural
Subdural hematoma caused by the collection of blood between the dura mater and arachnoid. Clinically difficult to distinguish acute subdural hematoma with epidural hematoma that developed slowly. Can be caused by severe trauma to the head that causes the shifting of whole brain parenchyma and damage on a bone. kortikalis. Usually accompanied by bleeding in the brain tissue. CT-Scan image subdural hematoma, visible buildup of fluid that hiperdens ekstraaksial crescent-shaped.
Figure 4. Subdural hematoma
Figure 5. CT scan picture of subdural hematoma

2.Hematoma subarachnoid
Subarachnoid hemorrhage due to rupture of blood vessels in it.

Figure 6. Bleeding Head

Emergency management:
• Decompression with simple trepanation
• craniotomy to evacuate the hematoma

Medical treatment
- Elevation of the head 300 of bed after making sure there is no spinal injury, or use reverse Trendelenburg position to abate intracranial pressure and improved its venous drainage.
- Treatment is commonly given to the head injury is dexametason group (with an initial dose of 10 mg followed 4 mg every 6 hours), mannitol 20% (dose of 1-3 mg / kg / day) which aims to overcome the edema cerebri occurring but the it is still controversy in choosing which one is best. It is advisable to give prophylaxis with phenytoin therapy as early as possible (24 hours of the first) to prevent the onset of epileptogenic focus and to long-term use can be continued with carbamazepine.
- Tri-hydroxymethyl-amino-methane (Tham) is a buffer that can enter the central nervous system and are theoretically superior to sodium bicarbonate, in this case to reduce intracranial pressure.
- Barbiturates may be used for pushing handle the pressure of rising inrakranial and have a protective effect against ischemic brain from anoxia and the usual dose is applied beginning with the 10 mg / kg in 30 minutes and then continued with 5 mg / kg every 3 hours and drip 1 mg / kg / hour for pushing to achieve serum levels of 3-4mg%. (8)
Operative therapy
Operation is done when there is:
• Volume hamatom> 30 ml (other literature> 44 ml)
• The state of the patient deteriorated
• encouragement of the center line of> 3 mm
Indications of surgery in the field of neurosurgery is to life saving and saving for the functional. If for the second goal then becomes operative emergenci operations. Usually the condition is caused by emergenci lesions persisted space.
Indications for life saving is if the lesion persisted space volume:
•> 25 cc = pressed supra tentorial space
•> 10 cc = pressed infratentorial space
•> 5 cc = pressed the space thalamus

While the indications are life saving evacuation of the significant effects:
• Decrease in clinical
• Mass effect with volume> 20 cc with a midline shift> 5 mm with a progressive clinical decline.
• Thickness of epidural hematoma> 1 cm with a midline shift> 5 mm with a progressive clinical decline.
X. Prognosis
Prognosis depends on:
• The location (infratentorial worse)
• The amount of
• Awareness of when entering the operating room.

If treated quickly, the prognosis of epidural hematoma is usually good, because the overall brain damage can be limited. The mortality rate ranges from 7-15% and 5-10% of cases of disability on. Very poor prognosis in patients with coma before surgery.


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3. Doherty GM. Current Surgical Diagnosis and Treatment. USA : McGraw Hill. 2006. Hal: 207-215
4. Listiono Djoko. Ilmu Bedah Saraf Satyanegara. Edisi Ketiga. Penerbit  PT Gramedia Pustaka Utama. Jakarta. 1998. Hal: 153-158
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6. http://www.angelfire.com/nc/neurosurgery/Kepalateks.html.

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