Multitrauma Case

Agus/ Male/ 40 years old

Identity/ Accident Data
 Name : Agus
 Sex/ Age : Male / 40 Years Old
 No.Medical Rec. : 10546976
 Address : Paras Gunung IC/3 Sby
 Time of Accident : Nov 28th 2005 (09.15 PM)
 Time of Admission : Nov 28th 2005 (09.30 PM)
 Mode of Injury : Fall from steplladder.
 RTS : 7,84 (Probability of survival 99 %)
Primary Survey

 A : Clear, C-spine stable

 B : Respiration rate 24/ min with symetrical
movement, ronchi(-).
 C : BP 130/80 mmHg, Pulse 84/ min. with warm
extremity
 D : GCS 456 equal pupil 3/3 mm light reflect +/+,
lat(-)
 E : Slight bruise at left ICS V anterior axillair
line
Problems
 Chest pain
Evaluation
 RR 20-24 x/i
 Vesicular and sonor both
Planning

 Chest X’ray
 Secondary Survey

History:
 Fall from alluminium stepladder about 3 mtrs
 Still conscious since the accident
 Feld pain at left chest
Secondary Survey
Physical Examination
 Head and Neck :
 Pupil equal, light Reflex +/+
 Cervical: pain(-), normal limit
 Thorax:
 I : Slight bruise on left 5thICS anterior axillair line,
symmetrical chest movement
 A: Normal heart sound, normal breath sound,
Vesicular both, Ronchi/Wheezing -/-
 P : Sonor percussion on both side, crepitation(-)
Secondary Survey
Physical Examination
 Abdomen and Pelvis:
 I : Bruise (-), flat
 A: Normal bowel sound
 P: Muscular Guarding (-), pelvis stable
 P: Free fluid sign (-), Liver Dullness (+)
DRE: normal
 Extremity:
 Normal limit movement, pain(-)
Laboratory Finding

Blood Examination
 Hb : 14,8 g%
 Lekocyte : 11,5 x 109/ L
 Thrombocyte : 213 x 109/ L
Assessment

 Blunt chest trauma

 Observation blunt abdominal trauma
Planning

 Closed observation at F5
 Circumferential abd tape, NGT
 Repeated chest X’ray
 Evaluation respiratory distress, vital sign,
GCS
Evaluation at F5
 28-11-2005
14.00 : BP 120/80 PR 80x/i RR 20x/i, defans(-)
21.00 : BP 120/70 PR 96x/i RR 20x/i, defans(-)
 29-11-2005

05.30 : BP 120/80 PR 86x/i RR 22x/i T36.8C, distended(-),

defans (-)
16.00 : BP 120/70 PR 88x/i RR 20x/i defans(-), pain (-)
19.00 : BP 120/70 PR 120x/i RR 32x/i T 38.0.C, anemia (-)
decreased bowel sound, defans (+), liver dumping (+)----
D/ generalized peritonitis ec s. hollow organ perforation
 Consult Anesthesi dept; consult Senior dr SWB by dr VIC : BOF,
LLD, exp.lap.
Control chest X’ray
Operation Result (Sonny VIC,Farolan
LHF)
Nov 30th2005,02.00am
 Ceilotomy:
 Found: Browny blood about 1500cc
Spleen rupture grade 3, active
bleeding from pedicle
Hematome subserosa desendens colon
and sigmoid
 Done: Splenectomy with spleen implantation
Thank You