CASE REPORT (2 pm)

A 14 year old man, referred from dr. Loekmono Kudus Hospital

after trafic accident, already performed situational suturing and
craniocerebral MSCT, inserted 1 intravenous line

Chief complain: pain on his head

PRIMARY SURVEY
Airway and C-spine control
Speak clearly  air way patent
O2 3 liter /minutes
Breathing and Ventilation
RR: 20 times/minute, regular, adequate depth of breath,
no chest wall retraction
SpO2: 100%
trachea on mid line
JVP not increase
Chest: injury mark (-)
 Adequate breathing

Circulation and hemorrhage control

PR: 90 beats/min (regular, adequate tone and volume)
BP : 125/70 mmHg
External bleeding (-)
 stable circulation
Disability
GCS : E4M6V5 = 15
Eye : isocoric round pupil 3mm in diameters,
light reflex +/+, eye movement good

Exposure
Log roll  injury mark (-)
Secondary Survey
A 13 year old man, referred from dr. Loekmono Kudus Hospital after trafic
accident, already performed situational suturing and craniocerebral MSCT,
inserted 1 intravenous line

Chief complain :
Pain on his head

History of Illness :
6 hours before admission to Kariadi Hospital patient ‘s head was hit by iron rod which
caried by another vehicle that hit his motorcycle from behind. He didn’t wear helmet.
Patient was still conscious, vomit (+), seizure (-), by the helper he was brought to
Kudus general hospital, and performed situational suturing and craniocerebral MSCT
scan. From craniocerebral MSCT obtained there was a fracture on his skull. Because
there was no neurosurgeon , the patient then referred to Kariadi hospital

History of Past Illness :

Seizure (-), fever (-)
General condition : looks moderately ill
Vital sign :
RR : 16 times/min (reguler, enough depth of breath)
PR : 78 beats/min (reguler, adequate tone and volume)
BP : 120/86 mmHg
t : 36,5oC
Pain : 3 VAS
GCS : E4M6V5 = 15
Head (Parietal) : deformity (+) step off on left parietal bone, active
bleeding (-)
I : discontinuity of skin, active bleeding (-), inhibition (+)
Pa : size 2x1 cm, wound based is was bone, crepitation (+), tissue
bridging (-)
Eye : conjunctiva palpebra wasn’t pale, round and equal pupil 3 mm
in diameters, light reflex +/+
Ear : otoraghi (-), otorhea (-)
Nose : rhinoraghi (-), rhinorrhea (-)
Chest : injury mark (-)
Heart :
I : IC not seen,
Pa : IC palpated 5th ICS, 2 cm from medial mid clavicle line
Pc : Configuration wnl
A : Pure heart sound

Lung :
I : Static : right hemithorax = left hemithorax
Dynamic : right hemithorax = left hemithorax
Pa : stem fremitus simetric
Pc : sonor all around area
A : vesicular basic sound, additional sound (-)
Abdomen
I : Flat, no injury mark
Pa : Smooth, Muscle rigidity -
Pc : Tymphanic, LD +, FD +N, SD -
A : Bowel sound + N
Pelvic : stable

External genitalia : Male, within normal limit

Extremities : Upper Lower

Cyanosis -/- -/-
Cold acral -/- -/-
Deformities -/- -/-
CRT < 2 sec < 2 sec

Radiology
Plain MSCT scan craniocerebral
Working Diagnosis (2.30 am)

Open depressed fracture of left parietal bone , GCS E4M6V5 = 15

 Initial Plan
IP Dx : -
IP Tx :
• O2 10 L/min non rebreathing mask
• Head Elevation 30o
• IVFD Lactat ringer 20 drops/min intravenous
• Ceftriaxon inj. 2 gr / 24 hr intravenous
• Ketorolac inj. 30 mg / 8 hr intravenous
• Ranitidine inj. 50 mg / 12 hr intravenous
• Phenytoin inj. 200 mg / 24 hr intravenous
• Manitol inj. Loading 250 ml intravenous
• Manitol inj. Maintenance 100 ml / 4 hr intravenous
• Decompressive craniectomy + hematome evacuation + craniotomy elevation of depressed
fracture + debridement
IP Mx
• General condition, vital sign, GCS
• Laboratory study (blood count, ureum, creatinin, electrolit, coagulation study)
• AP Chest x-ray, AP/Lat cervical x-ray
IPEx
Informed consent, Management, and prognosis
Radiologic Study:
Cervical AP /Lateral x-ray
Thorax AP x-ray

Laboratory study (6.00 am)

Hb : 14,5 gr/dl (13,0-16,0)
Leuko : 19.300/mm3 (4000 – 10000 )
Tr : 296.000/mm3 (150.000-400.000)
Ht : 42,0 % (40% - 54%)
GDS : 140 mg/dL (80-140)
Ur : 16 mg/dl (15-39)
Cr : 0,8 mg/dl (0,5-1,5)
Na : 138 mmol/L (136-145)
K : 3,7 mmol/L (3,5-5,1)
Cl : 108 mmol/L (98-107)
PPT : 10.5 / 11.5 / dtk (10-15)
APTT : 33.8/42.1 / dtk (23.4-36.8)
Diagnosis (06.10 am)

Open depressed fracture of left parietal bone, GCS E4M6V5 = 15,

 Plan
Dx : -
Tx :
• O2 10 L/min non rebreathing mask
• Head Elevation 30o
• IVFD Lactat ringer 20 drops/min intravenous
• Ceftriaxon inj. 2 gr / 24 hr intravenous
• Ketorolac inj. 30 mg / 8 hr intravenous
• Ranitidine inj. 50 mg / 12 hr intravenous
• Phenytoin inj. 200 mg / 24 hr intravenous
• Manitol inj. Loading 250 ml intravenous
• Manitol inj. Maintenance 100 ml / 4 hr intravenous
• Decompressive craniectomy + hematome evacuation + craniotomy elevation of depressed
fracture + debridement
Mx
• General condition, vital sign, GCS
Ex
- Prognosis, operation finding
Operation Report (9-12 am)
• Patient lied supine under GA, head tilted to the right side
• Asepsis & antisepsis operation area, narrowed with sterile clothes
• Make incision on left parietal region, widen the wound to anterior and
caudal direction, deepened until periosteum
• Made flap to anterior
• Spoel with normal saline + betadine until clear
• Applied automatic reflector
• Identification : wound base depressed fracture os parietal > 1 tabula
• Burr hole on 1 sites at the edge of the fracture side
• Freed interlocking with bone carison and knabel tang
• Repotition depresed fracture
• Debridement, Spoel with H2O2 - normal saline until clear
• Control bleeding with spongostan
• Sutured fascia with PGA 2.0, sutured subcutis with PGA 2.0, sutured
cutis with silk 3.0
• Operation finished
Post op Dx (12 pm)
• Mild head injury GCS E4M6V5= 15
• Open depressed fracture of left parietal bone (>1 diploe)
P ost craniotomy elevation of depressed fracture
Post Operative Management
Dx: -
Tx:
•O2 10 L/min non rebreathing mask
•Head Elevation 30o
•IVFD Lactat ringer 20 drops/min intravenous
•Ceftriaxon inj. 2 gr / 24 hr intravenous
•Ketorolac inj. 30 mg / 8 hr intravenous
•Ranitidine inj. 50 mg / 12 hr intravenous
•Phenytoin inj. 200 mg / 24 hr intravenous
•Manitol inj. Maintenance 100 ml / 4 hr intravenous
Mx
General condition, vital sign, GCS, wound
Ex
•Op finding, post operation management, prognose
 Follow Up D+1
S : nausea (-), headache (-)
O : condition : looks moderate illness
level of cosciousness : GCS : E4M6V5 = 15
round and isocoric pupil ø 3mm, ight reflex +/+
RR : 20 x per minute (reguler, adequate depth)
PR : 100 bpm (reguler, adequate tone and volume)
BP : 140/100 mmHg
Head :
I : wound cover by gauze, leakage (-),
Pa : pain (+)
A : stable
P : O2 3 L/min nasal canula
•Head Elevation 30o
•IVFD Lactat ringer 20 drops/min intravenous
•Ceftriaxon inj. 2 gr / 24 hr intravenous
•Ketorolac inj. 30 mg / 8 hr intravenous
•Ranitidine inj. 50 mg / 12 hr intravenous
•Phenytoin inj. 200 mg / 24 hr intravenous
•Manitol inj. Maintenance 100 ml / 4 hr intravenous
Mobilization