EMERGENCY SURGICAL SERVICES

Sunday, June 10th 2018

Consultant On Site :
DR. dr Rendra Leonas, SpOT (K) Spine, Mhum kes
The Attending Doctor :
Chief : dr. Fredy F Carol
Chief OK : dr. Achmad Harri Kuncoro
OK : dr. KMS Ade Permana
dr. Abdur Rahman
P1 : dr. Rangga Kusuma
dr. Yogi Mahery
P2/P3 : dr. Ady Mulya
dr. Halbana Al Maududy
HCU : dr. Nurindah Dwi Utami
Ward : dr. M. Robby S
dr. Riama Noveria S
Traumatic patient : 3 patient

Non traumatic patient : 2 patient

Total : 5 patient
TRAUMA CASES (3)

1. Arif Arjun Prabowo/ ♂ /14 Years Old

Dx : Left flank stab wound at level of vertebra lumbal III + laceration of colon descendence

2. Erwin bin Yokor / ♂ /15 Years Old

Dx : Closed severe head injury of GCS 5T + Cerebral Edema

3. Suharsih Bt Harjo/ ♀ / 61 Years Old

Dx : Closed moderat head injury of GCS 9 + ICH + SAH + SDH on the left temporoparietal lobe

NON TRAUMA CASES (2)

1.Surtik bt Darjak / ♀ / 52 Years Old

Dx : Obstruktif jaundice due to CBD obstruction + multiple

cholelitiasis + Anemia + Hypoalbuminemia + Thrombositopenia + Hypokalemia

2. Cahya nindi / ♀/ 5 months old

Dx : Invaginasi ilocaecocolocolica
TRAUMA CASES

1. Arif Arjun Prabowo/ ♂ /14 Years Old

Admitted on Sunday, June 10th 2018 at AM 08.40

DIAGNOSIS

Left flank stab wound at level of Vertebra

Lumbal III + suspected laceration of viscous organ + injury of urinary tract

MANAGEMENT

 IVFD RL gtt xx/ minute

 Inj Ceftriaxon 1g /24 Hours IV

 Inj Metronidazole 500mg / 8 Hours IV

 Laparatomy Emergency

INTRA OPERATIF

 in abdominal cavity, we found hematom at the left zone 2 that is not pulsatil

 further identification we found laceration on colon descendence Ø 1 cm insize

 we do freshening and than we perform primer suture with PGA 3-0 R

 we performed ileostomi

 other identification  another organ intake

POST OPERATIF DIAGNOSIS

Left flank stab wound + laceration of colon

descendence

Patient was treated in the ward

2. Erwin bin Yokor / ♂ /15 Years Old

Admitted on Sunday, June 10th 2018 at PM 09.31

DIAGNOSIS

Closed severe head injury of GCS 5T + Cerebral Edema

MANAGEMENT
  O2 NRM 10L/minute

 Head Up 30º

 IVFD NaCl 0.9% gtt xx/ minute

 Inj Tramadol 100mg/12 hours IV

 Manitol 125mg/ 6 hours IV

Patient was treated in the ward

3. Suharsih Bt Harjo/ ♀ / 61 Years Old

Admitted on monday, June 11th 2018 at AM 01.30

DIAGNOSIS

Closed moderat head injury of GCS 12 + ICH of the left

temporal lobe + SAH temporoparietal lobe

THERAPY:

 O2 NRM 10L/minute

 Head Up 30º

 IVFD NaCl 0.9% gtt xx/ minute

 Inj Tramadol 100mg/12 hours IV

Follow up 11-6-2018

S : Decreassing of consciousness

O: A 02 NRM 10 L /minute

B. RR : 22 x/minute

C. BP : 140/80 mmHg

PR : 98 x/minute

D. GCS : E2M5V2: 9, Pupil Isochor, Light Reflex +/+

A : Closed moderat head injury of GCS 9 + ICH + SAH + SDH on the left temporoparietal lobe
P : plan to perform Craniotomy cito

INTRA OPERATIF

 We perform question mark incision on the left temporal lobe,

 We perform 2 borr hole, cranium opened by craniotome

 We found duramater looks tense and bluish

 Duramater open sharply  we found SAH & SDH

 We perform duroplasty with duragen , bone are planted in the abdomen

POST OPERATIF DIAGNOSIS

ICH + SAH + SDH of the left temporoparietal lobe

Patient was treated in the ICU

NON TRAUMA CASES

1. Surtik bt Darjak / ♀ / 52 Years Old

Admitted on Sunday, June 10th 2018 at AM 11.40

DIAGNOSIS

Obstruktif joundice due to CBD obstruction + multiple

cholelitiasis + Anemia + Hypoalbuminemia + Trombositopenia + Hypokalemia

THERAPY:

 O2 NRM 10L/minute

 IVFD RL gtt xx/ minute

 Inj Ceftriaxon 1gr /24 hours IV

 Inj Metronidazole 500mg / 8 hours IV

 Albumin 25% /24 hours

 TC 10 unit

 PRC 1x 200 cc

 Plan to MRCP june 27th 2018

 Drip KCL 54.5 meq/24 hours

Patient was treated in the ward

2. Cahya nindi / ♀/ 5 months old

Admitted on Sunday, June 10th 2018 at PM 22.55

DIAGNOSIS

Invaginasi

THERAPY:

 Rehidrasi RL 240ml

 IVFD D51/4 NS + KCL 7.46 % 5cc/500, 700 cc/24 hours

 Ceftazidime 175 mg/ 8 hours IV

 Metronidazole 100mg/8 hours IV

 NGT

 Plan to laparatomi explorasi

INTRA OPERATIF

 in the abdominal cavity we found ileocaecolocolica invagination

 We perform milking procedure, we found ileum, caecum and colon necrotik along 8 cm

 We perform resection and anastomosis ileum - colon ascendence with PGA 4.0 R

POST OPERATIF DIAGNOSIS

Invaginasi ileocaecocolocolica

Patient was treated in the ward

TRAUMA CASES

1. Arif Arjun Prabowo/ ♂ /14 Years Old

Admitted on Sunday, June 10th 2018 at AM 08.40

ANAMNESIS

Left flank stab wound

He got stabbed at the left flank by someone using a knife from behind

History of anal trauma (-).

(± 1 hours before admission)

PRIMARY SURVEY

A. Clear

B. RR : 24x/minute

C. BP : 110/80 mmHg

PR : 74 x/minute

VAS : 4

SECONDARY SURVEY

On the Thorax region

I : Simetris

P: Sonor in both hemithoraks

A: Vesicular in both hemithoraks

On Abdominal region

I : Flat, no bruish

P : Soft

P : Tympany

A : Bowel sound (+)

DRE : AST was good

HS : Feces (+), Blood (+)

SECONDARY SURVEY

On the flank region

I : There was stabbed wound about 3x1 cm in size at level of Vertebra Lumbal III on left axillary
posterior line

RADIOLOGY FINDING

FAST Emergency

Free fluid (-)

RADIOLOGY FINDING

Chest X-Ray at RSMH June 10th 2018

Hemopneumothorax (-)

LABORATORY FINDING:

Hb : 13.0 gr/dl (12-16 gr/dl)

Ht : 37 vol % ( 40-48vol%)

Leukosit : 14.400 /mm3 (5000-10000/mm3)

Trombosit : 297.000/mm3 (150.000-450.000/mm3)

Diff. Count : 0/5/69/22/4

Ureum : 21 mg/dL (16.6-48.5 mg/dL)

Kreatinin : 0.69 mg/dL (0.70-1.20 mg/dL)

BSS : 129 mg/dL (>200mg/dL)

Natrium : 146 mEq/L (135-155 mEq/L)

Kalium : 4.3 mEq/L (3.5-5.5 mEq/L)

URINALISA

Darah : Positif +++

Eritrosit sedimen (routine) : 14-16 (0-1)

DIAGNOSIS

Left flank stab wound at level of vertebra

Lumbal III + suspected laceration organ viscus + injury of urinary tract

MANAGEMENT

 IVFD RL gtt xx/ minute

 Inj Ceftriaxon 1g /24 Hours IV

  Inj Metronidazole 500mg / 8 Hours IV

 Laparatomy Emergency

INTRA OPERATIF

 in abdominal cavity, we found hematom at the left zone 2 that is not pulsatil

 further identification we found laceration on colon descendence Ø 1 cm insize

 we do freshening and than we perform primer suture with PGA 3-0 R,

 we performed ileostomi

 other identifikation  another organ intake

POST OPERATIF DIAGNOSIS

Left flank stab wound + laceration of colon

descendence

Patient was treated in the ward

2. Erwin bin Yokor / ♂ /15 Years Old

Admitted on Sunday, June 10th 2018 at PM 09.31

ANAMNESIS

Decreassing of consciousness after having a traffic accident

His motorcycle got hit by another motorcycle from the front side.

He fell with his head hit a hard thing.

(±1 day before admission)

(Reffered from Kayu agung Hospital)

PRIMARY SURVEY

A. ETT

B. RR : 20 x/minute

C. BP : 125/81 mmHg

PR : 98 x/minute

T : 36.5 ° C
D. GCS : E1M4VT: 5T, Pupil Isochor, Light Reflex +/+

SECONDARY SURVEY

On the left temporal region

I : hematom (+)

P : step of (-)

On the left orbita region

I : There was excoriated wound about 1 x 2 cm in size, subcutis based

P: Step of (-)

RADIOLOGY FINDING

CT – Scan Head RSMH June 10th 2018

Cerebral edema

LABORATORY FINDING

Hb : 12.0 gr/dl (12-16 gr/dl)

Ht : 37 vol % ( 40-48vol%)

DIAGNOSIS

Closed severe head injury of GCS 5T + Cerebral Edema

MANAGEMENT

 O2 NRM 10L/minute

 Head Up 30º

 IVFD NaCl 0.9% gtt xx/ minute

 Inj Tramadol 100mg/12 hours IV

 Manitol 125mg/ 6 hours IV

Patient was treated in the PICU

3. Suharsih Bt Harjo/ ♀ / 61 Years Old

Admitted on monday, June 11th 2018 at AM 01.30

ANAMNESIS
Decreassing of consciousness after having a traffic accident.

Her motorcycle got hit by another motorcycle from behind.

She fell with her head hit a hard thing.

(± 10 hours before addmission)

(Reffered from Kayu agung Hospital)

PRIMARY SURVEY

A. 02 NRM 10 L /minute

B. RR : 20 x/minute

C. BP : 110/70 mmHg

PR : 78 x/minute

T : 36.4 ° C

D. GCS : E3M5V4: 12, Pupil Isochor, Light Reflex +/+

PHYSICAL EXAMINATION

On the left temporo parietal Region

I : Hematom (+)

P: Step of (-)

RADIOLOGY FINDING

Head X-Ray AP/L at Kayu agung Hospital June 10th 2018

Fracture (-)

RADIOLOGY FINDING

CT- Scan Head at RSMH June 10th 2018

ICH of left temporal lobe + SAH temporoparietal lobe

LABORATORY FINDING

Hb : 12.1 gr/dl (12-16 gr/dl)

Ht : 36 vol % ( 40-48vol%)
Leukosit : 11.3 /mm3 (5000-10000/mm3)

Trombosit : 199 /mm3 (150.000-450.000/mm3)

Diff. Count : 0/0/90/7/3/1

BSS : 146 mg/dL (>200mg/dL)

Natrium : 147 mEq/L (135-155 mEq/L)

Kalium : 3.9 mEq/L (3.5-5.5 mEq/L)

DIAGNOSIS

Closed moderat head injury of GCS 12 + ICH of the left

temporal lobe + SAH temporoparietal lobe

THERAPY:

 O2 NRM 10L/minute

 Head Up 30º

 IVFD NaCl 0.9% gtt xx/ minute

 Inj Tramadol 100mg/12 hours IV

Patient treated in the ward

Follow up tgl 11-6-2018

S : Decreassing of consciousness

O: A 02 NRM 10 L /minute

B. RR : 22 x/minute

C. BP : 140/80 mmHg

PR : 98 x/minute

D. GCS : E2M5V2: 9, Pupil Isochor, Light Reflex +/+

Head CT scan

A : Closed moderat head injury of GCS 9 + ICH + SAH + SDH on the left temporoparietal lobe

P : Plan to perform Craniectomy cito

INTRA OPERATIF

 We perform question mark incision on the left temporal lobe,

 We perform 2 pcs borr holes, cranium opened by craniotome

 we found duramater looks tense and bluish

 Duramater open sharply  we found SAH + SDH

 We perform duroplasty with duragen , bone are planted in the abdomen

POST OPERATIF DIAGNOSIS

ICH + SAH + SDH of the left temporoparietal lobe

Patient was treated in the ICU

NON TRAUMA CASES

1. Surtik bt Darjak / ♀ / 52 Years Old

Admitted on Sunday, June 10th 2018 at AM 11.40

ANAMNESIS

Jaundice

± 7 days before admission she complained joundice, pale stool, nausea(+), vomite (+), dark urine (+),
pale stool (+), fever (-)

± 1 month before admission she complained pain on right upper abdomen (+)

History of previous jaundice (-)

(Reffered from BARI Hospital)

VITAL SIGN

Sens : CM

BP : 100/60 mmHg

PR : 74 x/minute
RR : 20x/minute

T : 36.8°C

PHYSICAL EXAMINATION

Right and left eyes

Sclera Icteric +/+

On the abdominal region

I : Flat

P : Soft, pain (+) on the right upper quadran

P : Tymphani

A : Bowel sound was Normal

RADIOLOGY FINDING

USG Abdomen June 8th 2018 dr. H. KMS Sani SpRad

Obstruction of the ductus biliaris extrahepatic

Colelithiasis multiple

Hidrops glablader

LABORATORY FINDING

Hb : 9.6 gr/dl (12-16 gr/dl)

Ht : 27 vol % ( 40-48vol%)

Leukosit : 6.100 /mm3 (5000-10000/mm3)

Trombosit : 3000 /mm3 (150.000-450.000/mm3)

Diff. Count : 0/0/89/6/5

Albumin : 1.8 pmg/dL (3,5-5,5 mg/dL)

Ureum : 184 mg/dL (16.6-48.5 mg/dL)

Kreatinin : 1.07 mg/dL (0.70-1.20 mg/dL)

BSS : 305 mg/dL (>200mg/dL)

Natrium : 135 mEq/L (135-155 mEq/L)

Kalium : 2.9 mEq/L (3.5-5.5 mEq/L)

Bilirubin total : 16.30 (0.1-1.0 mg/dl)

Bilirubun direct : 12.40 (0-0.2 mg/dl)

Bilirubin indirect: 3.90 ( <0.8 mg/dl)

SGOT : 21 mg/dL (0-38 mg/dL)

SGPT : 32 mg/dL (0-41mg/dL)

DIAGNOSIS

Obstruktif joundice due to CBD obstruction + multiple

cholelitiasis + Anemia + Hypoalbuminemia + Trombositopenia + Hypokalemia

THERAPY:

 O2 NRM 10L/minute

 IVFD RL gtt xx/ minute

 Inj Ceftriaxon 1gr /24 hours IV

 Inj Metronidazole 500mg / 8 hours IV

 Albumin 25% /24 hours

 TC 10 unit

 PRC 1x 200

 Plan to MRCP june 27th 2018

 Drip KCL 54.5 meq/24 hours

Patient was treated in the ward

2. Cahya nindi / ♀/ 5 months old

Admitted on Sunday, June 10th 2018 at PM 22.55

ANAMNESIS

Current jelly stool

Since 1 day before admission her mother complain

that her child was having current jelly stool, vomite (+), colicky

pain (+), fever (+), flatus (-)

Baby Weight : 7 kg

(Consult from Pediatrik dept)

VITAL SIGN

Sens : Hipoaktif

PR : 152 x/minute

RR : 40 x/minute

T : 38.2 °C

PHYSICAL EXAMINATION

On Abdominal region

I : Distended

P : Soft, palpable mass on

upper and lower left quadrant

P : Tympani

A : Bowel sound was increase

DRE : Pseudoportio, current jelly stool (+)

RADIOLOGY FINDING

USG Emergency

Pseudokidney (+)

LABORATORY FINDING Sobirin Hospital

Hb :12.4 gr/dl (12-16 gr/dl)

Ht : 37.8 vol % ( 40-48vol%)

Leukosit : 10.900/mm3 (5000-10000/mm3)

Trombosit : 581.000/mm3 (150.000-450.000/mm3)

Ureum : 20.43 mg/dL (16.6-48.5 mg/dL)

Kreatinin : 0.10 mg/dL (0.70-1.20 mg/dL)

BSS : 155 mg/dL (>200mg/dL)

Natrium : 141 mEq/L (135-155 mEq/L)

Kalium : 3.9 mEq/L (3.5-5.5 mEq/L)

CT : 1.30mnt (1-3 minute)

BT : 6.00mnt (4-10minute)

DIAGNOSIS

Invaginasi

THERAPY:

 Rehidrasi RL 240ml

 IVFD D51/4 NS + KCL 7.46 % 5cc/500, 700 cc/24 hours

 Ceftazidime 175 mg/ 8 hours IV

 Metronidazole 100mg/8 hours IV

 NGT

 Plan to laparatomi explorasi

INTRA OPERATIF

 in the abdominal cavity we found ileocaecocolocolica invagination

 We perform milking procedure, we found ileum, caecum and colon necrotik along 8 cm

 We perform resection and anastomosis ileum - colon ascendence with PGA 4.0 R

POST OPERATIF DIAGNOSIS

Invaginasi ilocaecocolocolica

Patient was treated in the ward

THANK YOU