Primary Survey

 A : clear
 B : RR 24x/m adecuate, simetris D/S
 C : HR 88x/m reguler, adecuate
 D : Verbal respons
 E : Head
History Taking
 A man, 41 years old, admitted to hospital with a chief complaint:
unconsciousness after an accident.
 4 hours before admission, the patient was riding a motorcycle and
he was not wearing a helmet. The rider rode the motorcycle with
high-speed and loses control and the patient fell down, head
bumped asphalt road, he was found unconscious on the side of the
road.
 He looks sleepy. Unresponse when his family called him
 There were vomiting 1 times of the patient, not projectile, contain
food and yellow fluid.
 Blood from nose (-), blood from ears(-),
 Seizure (-),Fever(-), Slurred Speech(-), Weakness of one side of
the body(-), alcohol (-)
 After that, he was taken to Kandou Hospital for the first aid and
treatment
History of Past Illness
Hypertension (-)
Cholesterol (-)
Heart Disease (-)
DM (-)
Kidney (-)
 Physical Examination
 General examination:
 General condition: Moderate, Consciousness : Somnolen
 BP: 110/70 mmHg, MABP: 83, HR: 88 times per minute reg, RR: 24
times per minute , T: 36,4°C, SaO2 : 98%
 Conjunctiva: pale (-/-), sclera ikteric (-/-)
 JVP : normal
 Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
 Abdomen : Flat, normal turgor, peristaltic normal
 Extremities : warm acral
 Neurological Examination
 GCS E3M5V2. Pupil round ø 2/2 mm. Direct light Reflex +/+
Indirect Light Reflex +/+
 Meningeal Sign: nuchal rigidity not evaluated. Lasegue (>70/>70)
Kernig (>135/>135)
 Cranial Nerves: impression of paresis (-).
 Motoric examination : hemiparesis impression (-).
MT : N N PhyR : ++/++/++ ++/++/++ PathR : - -
N N ++/++ ++/++ - -
 Sensoric exam : can’t be evaluated
 Autonomic state : urination via catheter
Localized Examination
 Otorrhea - / -
 Rhinorrhea - / -
 Racoon eye - / -
 Battle sign - / -
 Hematome r/ temporoparietal dekstra 4x5 cm
 Hematome r/ temporoparietal sinistra 4x4 cm
WDx
Moderate head injury
 Planning
 Bed rest + C Spine control
 Family CIE
 Pro NGT+catheter ( family approval)
 O2 nasal canule 2-4 lpm
 IVFD NaCl 0,9% 500 cc 20gtt /m
 Paracetamol 3x500mg NGT
 Vitamin C 2x200mg NGT
 Zink 2x20mg NGT
 Observe GCS/Pupil/O2 per hour.
Diagnostic Planning
 Blood exam: hematology, blood sugar, electrolyte, renal
function, liver function.
 Brain CtScan + BW
 Cervical X-ray AP/lat.
Laboratory Examination 8 September 2017
 Hb : 13.8
 Ht : 42.3%
 WBC : 21.420
 PLT : 280.000
 RBC : 5.18 x 10^6
 SGOT : 30
 SGPT : 38
 Ureum : 23
 Creatinine : 1.0
 Random Blood sugar : 165
 Na : 137
 K : 3.60
 Cl : 106.0
 OSM : 293 mOsm/L
Cervical X-ray AP/ Lat
Brain CT
Brain CT Scan (zoomed)
Bone
Window
WDx
ICH r/ temporoparietal dekstra vol 33 cc
SAH traumatical
Fracture linear r/ temporoparietal dekstra
Pneumoencephal
Additional Therapy
 Tranexamat acid 4x1gr IV
 Nimodipin 4x60 mg via NGT if BP>130/80
 Manitol loading dose 300cc, next 4x 150 cc 6
hours after loading if BP> 110/80
 Ceftriaxone 2x2 gr IV
THANK YOU