EMERGENCY CASE REPORTS

Thursday, January 18th, 2010

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
No. 1
Name : Mrs.F Sex : Female
Age : 39 years old No. Reg : 454451

Chief complaint : Decreased of consciousness

History taking : Suffered since one hour before admitted to the hospital
due to traffic accident. There was history of vomiting .
Prior medical care at Lanto Dg Pasewang hospital and
Awal Bros hospital
Mechanism of : He was riding a motorcycle suddenly struck with car
injury from opposite direction. He fell down with his head
bumped asphalt
Injury sustain : Head
Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination, chest x-
ray, head CT scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: BP : 130/70 mmHg, HR : 80 x/minute, regular, adequate

D: GCS 11 ( E3M5V3), pupil equal 2,5/2,5mm , LR +/+

E: T (ax) : 37,5oC
Secondary Survey

Right temporo-occipital region :

I : stich lacerated wound, size 5 cm,
seen haematoma (+), edema (+)
 Laboratory Result??
WBC : 12,7 x 103 / L

RBC : 4,85 x 106 / L

HGB : 11,8 g/dL

HCT : 38,8 %

PLT : 277 x 103/ L

CT / BT : 00 / 00

Blood Sugar : 140 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,6 mg/dl

GOT / GPT : 61 / 18 /L
Head CT -Scan
Head CT-Scan
Thorax X-Ray
WORKING DIAGNOSIS : Moderate Head injury GCS 11 ( E3M5V3 )
region
region
region
MANAGEMENT : O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : craniotomy
 Operating Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform bicoronal incision , deepen until periosteum
Perform 1 burr holes, continue craniectomy with
craniotom
Perform hanging dura, seen EDH 30 cc, evacuated
hematome
Hanging duramater
Close the wound layer by layer and apply 1 vacuum
drain
Operation finished
POST OP DIAGNOSIS : Severe Head injury GCS 7 ( E2M4V1 )
EDH at right frontobasal region
ICH at right temporoparietal region
SDH at left temporal region

PROGNOSIS : Fair

FOLLOW UP : Vital sign and GCS