Mr X II / L / 17 thn / 18028891

T Arr 05.00 T acc 03.00

Keluhan Utama: Tidak Sadar

Riwayat Penyakit Sekarang : Pasien datang tidak sadar setelah kecelakaan lalu lintas 3
jam SMRS. Riwayat tidak sadar (+) muntah (-) kejang (-)
Pasien di ditemukan tim BPPD sudah tergeletak tidak sadar di jalan.

MOI : Pasien pengendara motor tidak memakai helm ditemukan tergeletak di jalan.
Pemeriksaan Fisik
Primary Survey
A : Clear
B : Spontan, Resp 26 bpm, SpO2 97 x/min
C : Unstable, BP 70/50 mmhg, CRT <2’
D : Pain response
Secondary Survey
GCS : E2V2M5
Kepala : Cephalhematome (+) regio frontal, krepitasi (+)
Mata : Refleks pupil (+/+), isokor 3mm/3mm, refleks cahaya +/+
THT : Normal, Othoroe (+), rhinoroe (-)
Maxilofacial : Jejas (+) vulnus appertum regio supraorbita S, floating maxilla (-), maloklusi
(-)
Thorax : Jejas (-), Simetris +/+, vesikuler +/+, sonor +/+,Krepitasi (-)
Abdomen : Jejas (-), distensi (-),bising usus (+), Nyeri Tekan (-), defans (-)
Extremitas : akral hangat, CRT < 2” ,
Trauma Score : 14
 Status Lokalis
• Regio Extremitas Inferior Kiri :
L :Deformitas (+),edema (-),bone expossed (-)
F : Nyeri tekan (+) krepitasi (+), A dorsalis pedis (+) teraba
M : ROM terbatas
• Regio Wrist Kanan :
L : Exoriasi (+), deformitas (+), edema (+), bone expossed (-)
F : Nyeri Tekan (+), Krepitasi (+),
M : ROM terbatas
Foto Klinis
Assesment
• CKS (E2V2M5)
• Fr Depressed Os frontal
• Syok hipovolemik
• Susp CF Femur
• Susp OF Wrist D

Planning
• Head CT Scan
• Thoraks x-ray,X-ray Cervical Ap/lat,wrist ap/lat Femur X-ray, Pelvis X-ray
CT Scan kepala
X-ray
Cervical X - ray Ray Lateral View
Chest X Ray AP View
Pelvic X-Ray AP View
Right Wrist X-Ray AP/Lateral View
Left Wrist X-Ray AP/Lateral View
Right Thigh X-Ray AP/Lateral View
 Laboratory
Hematologi: • PPT : 15,8
• INR : 1,33
• Hb : 12,98 • APTT : 31,0
• Ht : 39,03 • SGOT : 195,1
• Plt : 266 • SGPT : 93,90
• Wbc : 26,5 • BS acak : 172
• K : 3,04
• Na : 137
• Cl : 98,5
Assesment Planning
• CKS (E2V2M5) • Head up 30’
• Fr Depressed Os frontal • Oxygen Face Mask 8 ltpm
• Brain Swelling • Loading RL 2000ml
• SAH Falx • IVFD HES 500ml
• Syok Hipovolemik rapid respons • Ceftriaxone 2 x 1 gr
• Acute Pain
• Paracetamol 3 x 1gr
• CF Right Superior Pubic Rami
• Phenitoin 3 x 100 mg
• CF Left Superior Inferior Pubic Rami
• Debridement + Elevasi + primer Hecting
• Closed Fracture Right Femur Distal Third
• Immobilisation with skin traction 5 Kg load
• Epiphysiolisis Right Distal Radius SH Type II
• Epiphysiolisis Left Distal Radius SH Type II (Minimal Displaced) • Closed Reduction + Immobilization with LAC (Right wrist)
• Closed Reduction + Immobilization with SAC (Left wrist)
ICD 10
S09.90 Moderate injury of head
S06.360A Traumatic hemorrhage of cerebrum. ICD 9
S02.1 Fracture of base of skull 99.2 Injection or infusion of other therapeutic or prophylactic substance
G93.6 Cerebral edema 93.96 supplemental oxygen therapy
R57.1 Hypovolemic shock
86.28 Debridement of wound
G89.1 Acute Pain
S32.810A Multiple fractures of pelvis with stable disruption 86.59 Closure of skin and subcutaneous
of pelvic ring 86.01 Operations On Skin And Subcutaneous Tissue
S72.01 Fracture of femur 808.43 Multiple closed pelvic fractures with disruption of pelvic circle
S52.501 fracture of the lower end of right radius