EMERGENCY SURGICAL SERVICESWednesday, March 16th 2016

On Site Consultant :

Dr. Iqmal Perlianta SpBP-REDokter On Duty :

Chief : Dr. Dudi ACO-Chief : Dr. TobroniOK : Dr. Zeiky Y

Dr. Chandra BP1 : Dr. Sopyan H

Dr. Luthfy WP2/P3 : Dr. Fredy

Dr. Andri SWard : Dr. Gulraj S

Dr. DimasHCU : Dr. Ary Rachmanto

Out Patients : 9 Patients

TraumaCases : 3 Patients

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Non Trauma Cases : 2 Patients +

Total Patient : 14 Patients

TRAUMA CASES (3)

1. Asril / ♂ / 42 years old

Rupture of stensoni duct + Rupture of zygomaticus mayor an minor muscle + Rupture of bucinator muscle + Rupture of masster muscle + Rupture of risorius muscle + Rupture of mandibular branch of the right facial nerve

2. Mudayu / ♀ / 60 years old

Closed severe Head injury of GCS 4T + ICH on the left temporal lobe + SDH on the left temporal lobe

3.Fitri isneni / ♀ / 30 years old

Closed Severe Head injury of GCS 7T + ICH of the left temporoparietal lobe + EDH of the right temporoparietal lobe + SAH + Cerebral edema

NON TRAUMA CASES (2)

1. Bastari / ♂ / 36 years old

Incarserated Right Groin Hernia + Iatrogenic lasertion of smalbowel (K40.3)

2. Asep Pamin / ♂ / 59 years old

Intra abdominal mass due to caecal tumor + Anemic

TRAUMA CASE

1. Asril / ♂ / 42 years old

Admitted on Wednesday, March 16th 2016 at 11.00 AM

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Anamnesis

Lacerated wound on face region

His face was hited by grindstone when he was working.

(About 1 hours before admission)

PRIMARY SURVEY

A. Good

B. RR : 16 x/min

C. BP : 140/90 mmHg PR : 92 x/min

Pain score : 6

SECONDARY SURVEY

On the right face region

I : There was lacerated wound about ± 10 x 3 in size ireguler edge muscle based.

asimetry of face.

Lacerated wound about 1 cm insize of bucal mucosa.

P : Step off (-), hipoestesi of the right facial side,

SECONDARY SURVEY

On the right face region

SECONDARY SURVEY

RADIOLOGICAL FINDING

Head AP/Lateral X-Ray

Fracture (-)

LABORATORY FINDING

Hb : 14.1 gr/dl (14 – 18 g/dl)

Ht : 42 vol% (40 – 48 vol%)

DIAGNOSIS

Lacerated wound on the right face region + Susp. Rupture of the right facialis nerve.

MANAGEMENT

IVFD RL gtt xxx/m

Inj. ATS 1500 IU im (99.56)

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Inj. Ketorolac 30 mg / 8 hours iv (99.39)

Inj. Ceftriaxone 1 gram /12 hours iv (99.21)

Debridement

Wound Exploration + Repair in OR

IO

We found rupture of masseter muscle, bucinator muscle, zygomaticus mayor and minor muscle, and risorius muscle.

In the further exploration we found rupture of right facial nerve mandibular branch.

Rupture of right orifice stensoni duct.

We perform debridement and repair.

Muscle we repair with PGA 3.0 R interupted.

Nerve we repair with PPL 7.0 R interupted.

Stensoni duct we repair with PPL 7.0 R interupted, and we put NGT 3 Fr.

Post op Diagnose

Rupture of stensoni duct + Rupture of zygomaticus mayor an minor muscle + Rupture of bucinator muscle + Rupture of masster muscle + Rupture of risorius muscle + Rupture of mandibular branch of the right facial nerve

Patien was treated in the ER

2. Mudayu / ♀ / 60 years old

Admitted on Wednesday, March 16th 2016 at 11.20 AM

ALLOANAMESIS

Decreased of conciousness after traffic accident

The motorcycle which is she ride on was sliped,

she fell with her head hit the hard thing.

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(About 3 hours before admission)

PRIMARY SURVEY

A. Snoring ETT + O2 10 lt/m B. RR : 16 x/min

C. BP : 150/90 mmHg PR : 92 x/min D. GCS : E1M3VT = 4T, Pupil was anishokor left > right, LR -/-

SECONDARY SURVEY

On temporal region

I : Hematom (+)

RADIOLOGICAL FINDING

Head CT Scan

ICH on the left temporal lobe

SDH on the left temporal lobe

LABORATORY FINDING

Hb : 11.3 gr/dl (14 – 18 g/dl)

Ht : 34 vol% (40 – 48 vol%)

DIAGNOSIS

Closed severe Head injury of GCS 4T + ICH on the left temporal lobe

+ SDH on the left temporal lobe

MANAGEMENT

Head Up 30o IVFD NACL gtt xxx / m ( Fluid demands 2000 cc/day )

Inj Ceftriaxone 2 x 1 gr Inj tramadol 2 x 100 mg

Inj Manitol 20 % 4 x 60 g Plan to craniotomy if GCS Increased

Patient treated in the HCU

3. Fitri isneni / ♀ / 34 years old

Admitted on Wednesday, March 17th 2016 at 01.33 AM

ALLOANAMESIS

Decreased of conciousness after traffic accident

She fell from motorcycle after being snatched from behind, she fell with her head hit the hard thing.

(About 12 hours before admission)

Refered from Siti Aisyah General Hospital

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PRIMARY SURVEY

A. ETT + O2 10 lt/m

B. RR : 24 x/min

C. BP : 122/81 mmHg PR : 82 x/min

D. GCS : E2M5VT = 7T, Pupil was ishokor, LR +/+ Slow

SECONDARY SURVEY

On the right temporal region

I : Hematom (+)

On the right orbita region

I : Hematom (+)

RADIOLOGICAL FINDING

Head CT Scan

ICH of the left temporoparietal lobe

EDH of the right temporoparietal lobe

SAH

Cerebral Edema

LABORATORY FINDING

Hb : 12 gr/dl (14 – 18 g/dl)

Ht : 35 vol% (40 – 48 vol%)

DIAGNOSIS

Closed Severe Head injury of GCS 7T + ICH of the left temporoparietal lobe + EDH of the right temporoparietal lobe + SAH + Cerebral edema

MANAGEMENT

Head Up 30o

IVFD NACL gtt xxx / m ( Fluid demands 2000 cc/day )

Inj tramadol 2 x 100 mg

Inj Ceftriaxone 2 x 1 gr

Craniotomy and craniectomy

Patient treated in the ICU

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IO

We performed question mark incision at right temporal region, then We performed 4 burr hole

In the epidural space we found blood and blood clot 30 cc

We put 1 drain in the subgaleal space

We performed question mark incision at left temporal region than we performed 6 burr hole and craniectomy.

We found duramater was tense, in the subdural space we found 30 cc blood and blood clot.

We put duragen and duraplag in epidural space

Calvaria bone we put at abdominal subcutis

DIAGNOSE POST OP

Severe Head injury of GCS 7T + ICH of the left temporoparietal lobe

+ EDH of the right temporoparietal lobe + SAH + Cerebral edema

Patient treated in the ICU

NON TRAUMA CASES

1. Bastari / ♂ / 36 years old

Admitted on Wednesday, March 16th 2016 at 11.17 PM

ANAMESIS

Bulge on his right groin

About 3 days before admision, he complain bulge on his right groin that cannot be reduced into the abdominal cavity, pain (+), nausea (+), vomite (+), Flatus (-), defecate (-).

History of reducible bulge since 3 years ago

Refered from Kayu agung General Hospital

VITAL SIGN

RR : 22 x/min T : 36.1 o C

BP : 140/100 mmHg PR : 113 x/min

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VAS : 4

SECONDARY SURVEY

On the abdominal region

I : Distended

P : Soft, pain (±)

P : Timpani

A : Bowel sound (+) increase

DRE : Blood (-), feses (-)

NGT : Clear fluid

On Right Groin Region :

I : There was a bulge, colour same with around

P : The upper border of bulge was diffusely demarcated.

SECONDARY SURVEY

LABORATORY FINDING (Kayu agung general hospital)

Hb : 16.5 gr/dl (14 – 18 g/dl)

Ht : 46 vol% (40 – 48 vol%)

Leuko : 16.000 /mm3 (4.500-11.000 /mm3)

Trombo : 301.000 /uL (150.000 – 450.000 /uL)

DIAGNOSIS

Incasereted right groin hernia

MANAGEMENT

IVFD RL gtt XXX/minutes

Inj Ceftriaxone 2x1gr

NGT

Catheter urethra

Hernioraphy emergency

IO:

In the hernial sac we found omentum and colon transversum that still viable.

We perform to reposition and failed than we perform omentectomy.

We did reposition again than failed

We decided to perform reposition from laparatomy.

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When incisi we found distanded small bowel and iatrogenic laceration of ileum at 250 cm from treizt ligament.

We perform decompresion of small bowel which is distanded

The laceration we suture with PGA 3.0 R continous

We did reposition again and we succeed

We did omentectomy than herniotomy and Hernioraphy with mesh.

Abdominal cavity was clean with NaCl 0.9%

We put rectal tube.

Diagnosa post opreration:

Incarserated Right Groin Hernia + Iatrogenic lasertion of smalbowel (K40.3)

The Patient was treated in the

2. Asep Pamin / ♂ / 59 years old

Admitted on Wednesday, March 16th 2016 at 20.59 PM

ANAMESIS

Body weakness and bulge in the abdomen.

About ± 2 month ago patien was complained bulged in his abdomen. Defecate (+) nigrescent wich increasing frequent, flatus (+), nausea (-), vomite (-).

VITAL SIGN

RR : 18 x/min T : 36.0 o C

BP : 120/70 mmHg PR : 76 x/min

SECONDARY SURVEY

Conjuntiva : Anemic (+)

On the abdominal region

I : Flat

P : Soft, palpable mass on right lower quadrant

P : Timpani

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A : Bowel sound (+)

DRE :

TSA was good, ampula not colaps, mass (-), Blood (-), feses (+)

RT

LABORATORY FINDING

Hb : 7 gr/dl (14 – 18 g/dl)

Ht : 20 vol% (40 – 48 vol%)

Leuko : 5.400 /mm3 (4.500-11.000 /mm3)

Trombo : 186.000 /uL (150.000 – 450.000 /uL)

Na : 132 u/L (136-145 u/L)

K : 3.6 u/L (3,5-5,1 u/L)

BSS : 73 mg/dL (<200 mg/dL)

CEA : 0.97

DIAGNOSIS

Intra abdominal mass due to caecal tumor + Anemic

MANAGEMENT

IVFD RL/D5% gtt XXX/minutes

Blood Transfusion

Plan to Abdominal CT Scan

The Patient was treated in the ER

EMERGENCY OPERATION REPORT

1. Misgian / ♂ / 61 days

Admitted on : March 14th 2016 at 06.05 PM

Pre Op diagnose :

Diffuse peritonitis due to viceral organ perforation DD/ Gastric perforation

IO :

- In the abdominal cavity we found gas and bowel content about ± 1200 cc that came from perporation of gaster at the prepyloric site about 0.5 cm in size. And we found to adhesif from bowel with bowel and bowel with abdominal wall

- We performed freshning of the perforation site and we suture with silk 2.0 R interupted. the tissue was send to PA departement

- We clean abdominal cavity with warm normal saline

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- We put 3 drain intraperioneal tube

Post op diagnose :

Perforation of gaster at the prepyloric site

Patien treated in the ICU

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