EMERGENCY CASE REPORTS

Friday, January 7 th, 2011

SURGERY DEPARTMENT
RS. Wahidin Sudirohusodo

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
No. 5
Name : Mr. Syarifuddin Sex : Male
Age : 20 years old No. Reg : 44 28 50

Chief complaint : Decreased of consciousness

History taking : Suffered since 4 hours before admitted to the hospital
due to traffic accident. There was history of vomiting .
Prior medical care at Pangkep Hospital
Mechanism of : He was riding a motorcycle , he riding with high speed,
injury suddenly he felt down with his head bumped to the
asphalt.
Injury sustain : Head
Symptom & sign : Wound and pain
Examination : Physical examination, laboratory examination, x ray,
Head CT Scan
PHYSICAL EXAMINATION
Primary Survey
A: Partial obstruction apply orofaring tube suction

B: RR : 20 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/70 mmHg, HR : 72x/minute, regular, adequate

D: GCS 7(E1M4V2), pupil unequal 3mm/2mm , LR +/+

apply ETT
E: T (ax) : 36,7 oC
Secondary Survey
Temporoparietal region :
I : Seen lacerated wound 10x0,5 cm,
edema(+), hematoma(-)
P : Tenderness (+), Crepitating (-)
Frontal region :
I : Seen excoriated wound size 5x0,5 cm,
3x 0,5 cm, edema(-), hematoma(-),
Active bleeding (-)
P : Tenderness (+), Crepitating (-)
Left Zygoma region :
I : Seen excoriated wound,edema(+),
hematoma(-)
P : Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 21,2 x 103 / L

RBC : 4,01 x 106 / L

HGB : 14,6 g/dL

HCT : 36,1%

PLT : 250x103/ L

CT / BT : 630 / 3 00

Blood Sugar : 116 mg/dl

Ureum : 27 mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 23 /15 /L

Head CT
Scan
Skull X Ray
WORKING : Severe Head Injury GCS 7 (E1M4V1)
DIAGNOSIS Open depressed Fracture at left temporoparietal
bone
EDH at left basaltemporoparietal region
MANAGEMENT : Apply ETT
IVFD
Medicaments
Report to senior neurosurgeon
advice : immediately trepanation
 Operating Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform , deepen until periosteum
Perform musculus flap, seen depressed fracture of os
temporal
Perform 1 burr hole, continue with craniectomy , seen
EDH about 30cc, evacuated hematoma and Bleeding
control
Perform dura fascia flap + hanging dura
Close the wound layer by layer and apply 1 vacuum drain
Operation finished
POST OP DIAGNOSIS : Moderate Head Injury GCS 11 (E3M5V3)
Open depressed Fracture at left
temporoparietal bone
EDH at left basaltemporoparietal region
PROGNOSIS : Good
FOLLOW UP : Vital sign and GCS