moderate head injury + sdh at the right temporo parietal zulfikar

8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR

1/22

Patient identity• Name : Zulfkar• Age : 17 years old• Sex : Male• Address : Matang Kumbang, Kec.

Gandaura

Kab. !"reuen• #$one : %&'()')(7'&'

• M* : 1 %1 + &%• -r""ng l"cense : /0• 2"me Arr"ed : 1:( AM


2/22

Chief complaint

• -ecrease o3 consc"ousness

Patient Illnes History

• 2$e at"ent re3erred 3rom !"reuen d"str"c$os"tal 5"t$ c$"e3 comla"n decrease o3

consc"ousness 3or 1' $our. 2$e comla"ntstarted 5$en $e r"de a motorcycle 5"t$out$elmet and strucked anot$er motorcycle t$atsuddenly came out 3rom t$e alley. 2$ere 5as$"story o3 nausea and om"t"ng /0. 2$ere5as no $"story o3 alert a3ter trauma.


3/22

Physical examination

• A : 6lear

• ! : Sontaneous, **: ' breat$s8 m"nute

• 6 : !# : 1(%8+% mm9g, #ulse: &% beats8m"nute

• - : G6S 1% /( M ;' < "soc$or"c u"l/(mm8(mm

l"g$t re=ex /080

• : >8S a.r 3ac"al"s

?er @ace / at t$e 3rontal

> : Symetr"c, ound /0 s"Be cm 5as sutured

•


4/22

M"d @ace :

> : Symetr"c, excor"ated 5ound /0, s5ell"ng /C

>o5er @ace :> : Asymetr"c, ound /C, s5ell"ng /0 de3orm"ty

/0,

$ematoma /C

Dntra Eral :• Malocclus"on /0• Mand"bular =oat"ng /0• Aleolar =oat"ng /C• Max"lla =oat"ng /C

>8S at t$e neck reg"on

D : 9aematoma /0, excor"ated 5ound /0

#: #a"n /C


5/22


6/22

Assessments:

1.Moderate 9ead DnFury

'.Mand"ble @racture


7/22

Management

• 9ead u (%

• Neck collar• D;@- Na6l %,+H '% dr"s8m"nutes

• E' & l8m"nutes "a 3acemask

• ?r"ne cat$eter

• DnF.6e3tr"axone 1 gr

• DnF. Ketorolac (% mg

• DnF. 2etagam '% D?

• >aboratory exam"nat"on• *ad"ology exam"nat"on


8/22

Laboratory result

• 9b : 11,& gr8dl

• $"te blood count : 17.1%%8ul• #latelet : 1)%.%%% 8ul

• 9t : () H

• 62 : 7 m"nute

• !2 : ' m"nute

• !lood Glucose ad random : 1' gr8>


9/22


10/22


11/22


12/22


13/22


14/22

Radiology examination

9ead 62CScan :

• Subgaleal $ematoma at le3t occ""tal reg"on

• >"near 3racture at t$e le3t 3rontal bone

• 2$ere 5as $"erdens abnormal area at t$er"g$t temoral reg"on surely S-9

• 2$ere 5as $"erdens abnormal area at t$e3alx cerebr" surely SA9

• ;entr"cle system 5as narro5

• Sulcus and gyrus narro5.

• M"d l"ne s$"3t to t$e le3t I %, cm


15/22

2$orax A# :

Dn normal l"m"t

Sc$edell A#8>at

Segmental 3racture o3 t$e mand"ble

6er"cal :

>oss o3 lordot"c aereance


16/22

Diagnose

1.Moderate $ead "nFury

'.>"n"er 3racture o3 t$e le3t 3rontal reg"on

(.S-9 at t$e r"g$t temoro ar"etal reg"on.Segmental 3racture o3 t$e mand"ble

Consult to eurosurgery Di!ision :

• 6ran"otomy S-9 eacuat"on emergency

Consult to Plastic "urgery Di!ision :

• 9os"tal"Be

• E*D@ elect"e


17/22

Intra #perati!e

• #at"ent "n su"ne os"t"on, extended to t$e le3ts"de, $ead u (% %, 5"t$ general anest$es"a.

• Aset"c and Ant"set"c rocedure, dra"ngrocedure

• *eerse Juest"on mark "nc"s"on at t$e r"g$t

temoro ar"etal reg"on, deeer layer by layerunt"l bone

• Made !urr $oles, t$e skull 5as sa5ed 5"t$g"gly and t$e 3ragment 5as ulled out.

• 2$e dura looked tens"on and blue"s$.• #er3ormed dura $"t st"c$es


18/22

• -uramater oened 5"t$ s$ar rocedure

• #er3orm S-9 eacuated 5"t$ olume about

) cc.• @ounded bleed"ng 3rom lacerated cortex at

seeral o"nt and er3ormed bleed"ng control

• #er3ormed dura 3ac"al gra3t

• !one =a 5as kee at subgaleal

• #er3ormed one tube dra"n

• ound oerat"on closed by r"mary sutured


19/22

#otoCoto "ntra oerat"3


20/22


21/22

Post #perati!e Diagnose

1.Moderate $ead "nFury

'.>"n"er 3racture o3 t$e le3t 3rontal reg"on(.S-9 at t$e r"g$t temoro ar"etal reg"on

.Segmental 3racture o3 t$e mand"ble


22/22

Date S O A P

22/9/2014POD I

VS/BP : 120/70 mmHg

HR : 90 x/mntRR : 22 x/mntGCS 12; E2M4 V3Is!"#$! %&%$'

(3mm/3mm

1. Moderate$ead "nFury

'. >"n"er 3ractureo3 t$e le3t3rontal reg"on

(. S-9 at t$er"g$t temoroar"etal reg"on

. Segmental3racture o3 t$emand"ble

IV)D *+C' 20,#$%s/m$n&t-s

H-+, &% 30O2 4'/m$n&t-.$+C-t#$+xn- 1 g/12 "s-t#'+! 3

In 1 +m%/ "s$5&$, ,$-t6x100 !!

moderate head injury + sdh at the right temporo parietal zulfikar

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