Primary Survey

A: clear
B : RR: 22 times in a minute
C : Blood preasure : 130/70 mmHg , Pulse: 89
times/minute, reguler.
D : GCS E1V1M3, pupil ishokor, 3mm/3mm
E : vulnus laseratum regio frontalis dextra, supra
orbita dextra with bone expose, regio zygomaticum
dextra
Vulnus laseratum regio patela cruris dextra, vulnus
escoriatum cruris dextra
 Secondary Survey

Head : vulnus laseratum regio frontalis dextra with bone
expose, supra orbita dextra, regio zygomaticum dextra
Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Ear : blood clot at left ear, ottorea (-/-)
Nose : blood clot (-/-), rhinnorea (-/-)
Mouth : smell alcohol
 Thorax

Inspection : chest expansion bilateral simetric,
pattern of respiration is abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)
 Abdomen

Inspection : distended (-)
Auscultation : peristaltics (+) still normally
Palpation : tenderness pain (-), mass (-)
Percusion : timpany sound (+)
 Extremity

Look : normal
Feel : pain on the right leg (+), bruised (-)
Move
ROM : normal

 Laboratorium

CBC :
Hb 12,7 gr/dL
WBC 32,3 x 10^3/uL
Plt 295 x 10^3/uL
 Planning Diagnosis

Head CT Scan
 Assessment

Severe Head Injury
Vulnus laseratum regio frontalis dextra, supra orbita
dextra with bone expose, regio zygomaticum dextra
Vulnus laseratum regio patela cruris dextra, vulnus
escoriatum cruris dextra
 Planning therapy

O2 2-4 lpm
Wount Toilet
Hecting
IVFD NaCL 0,9% 20 tpm
KCT 2x30 mg
Ranitin 2x50 mg

Consul Sp. BS