MILD TRAUMATIC BRAIN INJURY

WITH SUBDURAL HEMATOMA

ICD X : S065
SKDI : 2
Oleh :
Aditya sadewa

SURGERY DEPARTMENT
MEDIACAL FACULTY RIAU UNIVERSITY
ARIFIN ACHMAD GENERAL HOSPITAL
IDENTITY
Name : Ms. H
Age : 15 years old
Date of examination : March-5-2019
Address : Pekanbaru

Chief Complaint ;
Headache after accident in past 3 days before admitted to
hospital
PRIMARY SURVEY
Airway and cervical control

a. Objective : (Look Listen Feel)

Look : - Patient spoke in full sentences.
-Not found maxilofacial trauma, not
found neck trauma
- Listen : - no stridor, no obstruction

b. Assessment:
• Impression : no obtruction in respiration tract.
• Airway paten

c. Action
- Give Oxygen via NRM 10 L/min
Breathing

a. Objective
- Look :Breathing spontaneously, Chest expansion
is symmetrical. Both sides take off at the
same time and to the same extent,
Respiration rate 24x/min
- Feel : there is not pain and tenderness on the
thoracic wall
b. Assessment
• Good lung ventilation and expansion.

c. Action
- Give Oxygen via NRM 10 L/min.
Circulation

a. Objective
• warm peripheries, capillary refill time (CRT) <2 s
• strong pulse volume, Heart rate 76 x/min
• Blood pressure 110/70 mmHg

b. Assessment
• Good circulation

c. Action
• IVFD Ringer Laktat 20 dpm
• Evaluation urine produce
Disability

a. Objective
Mini neurological examination
• (GCS) 14 (E4V5M5)
• Pupil isokor 2 mm, direct light reflex and
undirect (+/+)
• Motoric : 5 5
5 5

b. Assessment
• Impression good mini neurologic
Exposure

Objective :
• Temperature 36,2 ̊C (Axilla)

Assessment :
• good exposure

Action :
Cover the patient’s body with blanket
 SECONDARY SURVEY
Anamnesis
Chief Complaint
Left Headache after accident in past 3 days before admitted to
hospital
.
 TRAUMA MECHANISM
• Patient complain on her left headache 3 days before
she was taken to the Arifin Achmad hospital.
Previously, the patient rode a motocycle to her
house. The motocycle was driving by the patient
trampled a hole in the road, so that her motocycle
fell and the patient’s head hit the asphalt. The
patient at the time did not use a helmet. Then the
patient was unconscious. The patient was taken to
Syafira Hospital and given medical treatment.

• When the patient was conscious, the patient felt left

headache, nause (+), vomiting (+), blood out (-),
memory loss (-). Three days later the patient was
referred to Arifin Achmad Hospital
 AMPLE
A : The patient not allergy with food and medicine
M: The patient not use any medicine.
P : There is no past ilness
L : 1 hours before trauma (eating rice)
E : trauma mechanism
Past illness history
There is no relation between patient complain and past illness

Family history
There is no relation between patient complain and family history
 PHYSICAL EXAMINATION
Generally state
General appereance : Mild pain
: Composmentis
GCS : 14(E4 V5 M5)
Visual analog scale : 6
Vital Sign
BP : 110/70 mmhg
HR : 76 x/minute
Temperature : 36,2˚C
Respiration rate : 24 x/minute
VISUAL ANALOGIC SCALE
Head and neck : Localized state
Thorax : Normal limit
Abdomen : Normal limit
Extremity : Normal limit
Lymph nodes : Normal limit
Genitourinarius : Normal limit
LOCALIZED STATE
Head and neck
• Inspection : Laseration in nose, swealing (-), palpebra hematoma
(-), Raccon eyes (-), battle sign (-), rinorhea (-), otorhea (-)

•Palpation :
crepitation(-) pain (+) regio parietal sinistra
WORKING DIAGNOSIS
• Mild traumatic brain injury with GCS 14
 WORK UP PLAN
• Blood routine test
• Head CT-Scan
 WORK UP RESULT
• Hb : 10,6 g/dl MCV : 85,1 fl
• Ht : 32,9 % MCH : 27,9 pg
• RBC : 3.870x 103/uL MCHC : 32,8 g/dl
• WBC: 16.000 /uL
• Platelet : 247.000 /uL

• Neutrofil : 82,6 %
• Monosit : 8,4 %
BONE WINDOW
Bone Window
Not found discontinuity
in cranial bone
HEAD CT
SCAN
- Identity: An H, 15 years old
- Axial slice
- Distace between slide 5 mm
- soft tissue swelling (-)
- found image hiperdens in regio
temporoparietal
- Not found ventrikulomegali
- midline shift 4 mm
- Sulcus and gyrus not clear

Volume : P x L x T
2
: 5 X 0,4 X 4,5
2
= 4,5 cc
FINAL DIAGNOSE
• Mild traumatic brain injury with GCS 14 with sub acute Subdural
Hematoma in left temporoparietal lobe
TREATMENT
Elevation head 30 degress for decrease intracranial pressure
IVFD RL 20 tpm
Injection Ketorolac 1x30 mg  NSAID (analgetik)
Injection Ranitidin 2x50 mg Histamin H2 antagonis
Injection Cefriaxone 2x1 g
Inf Manitol 1x 125 cc
 LITERATURE

Head injury is defined as any trauma to the head, with

or without injury to the brain. The head injury can be
described as minimal, minor, moderate, or severe,
based on symptoms after the injury. Patients with
minimal head injury are those with trauma to the head
and no loss of consciousness, a normal Glasgow Coma
Scale (GCS) score, and no symptoms of head injury
 TBI

mechanism
Mechanism severity morfology
morfology

sharp blunt cranial brain

Focal Difus
 SUBDURAL HEMATOM
(SDH)
Definition
A subdural hematoma is a collection of blood between
the dural and arachnoid coverings of the brain. As the
volume of the hematoma increases, brain parenchyma is
compressed and displaced, and the intracranial pressure
may rise and cause herniation.
Etiology

• Head injury
• Aneurisma berry
Sign and symptom
• Deficit neurology
• Headache
• Nause and vomiting
• Decreased level of consciousness

Radiology Image

• CT-Scan: - Bleeding shaped crescent, hiperdens ( acute )

• Isodens ( subacute ), Hipodens ( chronic )
-often lie on temporoparietal
Diffrential diagnose
• Epidural hematoma

Treatment
Non Pharmachology :
- craniotomi

Pharmacology :
- Dexametason with initial dose 10 mg
-manitol 20 % ( 1-3mg/kg BB/hari)
MONRO KELIE
THANK YOU