EMERGENCY CASE REPORTS

Tuesday, January 4th , 2011

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
No. 1
Mr. ABD.
Name : Sex : Male
RAHMAN
No.
Age : 55 years old : 473079
Regof consciousness
Chief complaint : Decreased
History taking : Suffered since 10 hours before admitted to the hospital
due to traffic accident. There was history of vomiting and
unconcius.
Mechanism of : He was riding motorcycle with high speed, suddenly felt
injury down, and his head bump to the asphalt. Next
mechanism was unclear
Injury sustain : Head
Symptom & sign : Pain
Examination : Physical examination, laboratory examination, CT Scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 24x/minutes, spontaneous, symmetric,

Broncovesicular type

C: BP : 120/90 mmHg, HR :76 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil isokor 2,5 mm / 2,5 mm , LR

+/+
E: T (ax) : 36,8
Secondary Survey
Right Orbital Region:
I : Seen hematoma , stitch wound size 4 x 0,5 cm ,
active bleeding (-)
P : Tenderness difficult to evaluated, crepitating (-)
 Laboratory Result
WBC : 32,9 x 103 / L

RBC : 4,13 x 106 / L

HGB : 11,7 g/dL

HCT : 37,5%

PLT : 314x103/ L

CT / BT : 700 /3 00

Blood Sugar : 106 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 35/34 /L

Cervical x ray
Chest X - Ray
Head CT- Scan
WORKING DIAGNOSIS : Moderate head injury GCS 12 (E3M5V4)
Fracture depressed frontal bone
ICH at right frontobasal

MANAGEMENT : O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : Immediate trepanation

PROGNOSIS : Good

FOLLOW UP : Vital sign dan GCS

 Operating Procedure
1. Patient laid supine under GA
2. Asepsis and draping procedure
3. Perform bicoronal incision, deepend while
controlled bleeding.perform dura fascia flap seen
depressed fracture at frontal bone.
4. Perform 1 burr hole, continue craniectomy with
craniotom
5. Seen minimal EDH, evacuated hematom,
stitching brain dura and controlled bleeding
6. Place 1 suction drain
7. Stitch wound layer by layer
8. Operation finished
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
Lacerated wound at left parietal region

MANAGEMENT : Wound toilet

Stitch wound patient discharge

PROGNOSIS : Good

FOLLOW UP : Vital sign and wound healing