EMERGENCY SURGICAL SERVICES

Wednesday, August 5th 2020

Consultant On Site :
dr. Ahmat Umar, Sp.B, Sp.BTKV

The Attending Doctor :

Chief : dr. Bela Ronaldoe
Pra Chief : dr. Afif Heldian
Captain : dr. Ivan Rayka
P1 / P2 : dr. Bram Permadi Tanto
Circular : dr. Deo Valendra
dr. Suci Rahmaniar
Trauma patient : 2 patient
Non trauma patient : 1 patient
Total : 3 patient
 TRAUMA CASES (2)

1. Aswandi bin Mahdin/ ♂ / 41 Years Old

Dx. Blunt thoracic injury with left hematothorax + Multiple Laceration of left
lower lung lobe

2. Agung Dwi Septian / ♂ / 23 Years Old

Closed fracture of middle third of the right radius bone, oblique, displaced
Closed fracture of middle third of the right ulnar bone, oblique, displaced
 NON TRAUMA CASES (1)

1. Rustawan / ♂ / 42 Years Old

Dx. Descending necrotizing mediastinitis
TRAUMA CASES
1. Aswandi bin Mahdin/ ♂ / 41 Years Old
Admitted on Wednesday August 5th 2020 at 06.45 AM

ANAMNESIS
Shortness of breath after falling from the height.
± 5 days before admission, he fell from the height ± 2.5 meters. He fell
with his left chest hit the hard thing. Shortness of breath (+)
History of left chest tube in RSUD Pali (4/8/20) [initial blood ± 1500 cc].
(Reffered from RSUD Pali)

PRIMARY SURVEY
A. Clear
B. RR : 25 x/min
C. BP : 140/90 mmHg
PR : 88 x/min
D. GCS : E4M6V5 : 15
NPRS : 4
SECONDARY SURVEY

Thoracic region
I: symmetric, bruise (-), chest tube
(+) at left hemithorax, at the level
of ICS IV anterior mid-axillary line
Undulation (+)
Air bubble (-)
forced expiratory bubble (+)
Production (+) blood ± 400 cc
P: dullness at lower region of left
hemithorax
A :vesicular decreased on left
hemithorax
RADIOLOGY FINDING
Chest X-Ray (RSUD Pali August 4th 2020)
Left Hematothorax
RADIOLOGY FINDING
Chest X-Ray after inserting WSD (RSUD Pali August 4th 2020)
Left chest tube at the level ICS IV, Left Hemopneumothorax
decreased slightly
RADIOLOGY FINDING
Chest X-Ray 16 hours after left chest tube (RSMH August 5th 2020)
Left lower lobe of the lung is not expand
LABORATORY FINDING (RSUD Pali, August 5th 2020)
Hb : 9.0 gr/dl (12-16 gr/dl)
Ht : 28 vol % ( 40-48vol%)

LABORATORY FINDING (RSMH, August 5th 2020)

Hb : 10.4 gr/dl (12-16 gr/dl)
Ht : 33 vol % ( 40-48vol%)
Leukosit : 9100 /mm3 (5000-10000/mm3)
Trombosit : 412.000 /mm3 (150.000-450.000/mm3)
M : he fell from the height ± 2.5 meters with his left chest hit the
hard thing.
I : Lung, Pleura
S : Shortness of breath
T : IVFD RL gtt XXV/ min (Fluid demand 1800 cc / 24 hours IV)
Inj Ceftriaxone 1 gram / 12 hours IV
Inj Ketorolac 30mg/8hours IV
Pro exploration thoracotomy
DIAGNOSIS
Blunt thoracic injury with left hematothorax + susp. Laceration of left
lower lung lobe post left chest tube POD I

MANAGEMENT
 IVFD RL gtt XXV/ min (Fluid demand 1800 cc / 24 hours IV)
 Inj Ceftriaxone 2 gram / 24 hours IV
 Inj Ketorolac 30 mg/8 hours IV
 Pro exploration thoracotomy
INTRAOPERATIVE
 We performed thoracotomy with
posterolateral approach on left
hemithorax
 In exploration of thoracic cavity, we
found clots that covering all the field of
lung lobes
 We performed irrigation with Normal
saline and evacuate the clots
 In further exploration we found
lacerations at 3 places in left lower
lobe of the lung
 We repaired it with horizontal mattress
and running suture with non-
absorbable monofilament 3.0R
 Left chest tube is maintained
POSTOPERATIVE DIAGNOSIS
Blunt thoracic injury with left hematothorax + Multiple Laceration of left
lower lung lobe

Patient was treated at ward

2. Agung Dwi Septian / ♂ / 23 Years Old
Admitted on Wednesday, August 6th 2020 at 05.44 AM

ANAMNESIS
Pain and difficulty to move his right arm
The patient’s motorcycle was slipped. Patient fell with his right arm hit
the hard thing. Open wound (-), active bleeding (-)
(± about 30 minutes before admission)

PRIMARY SURVEY
A. Clear
B. RR : 20 x/min
C. BP : 120/80 mmHg
PR : 84 x/min
T : 36.7° C
D. GCS : E4M6V5 : 15
NPRS : 6
SECONDARY SURVEY

Right Forearm and Hand Region :

I : Excoriation (+) on dorsal side of forearm and
hand, swelling (+), Deformity (+).
F : Pain (+), crepitation (+), distal sensory (+),
CRT < 2 second
M : ROM active pasive were limited
RADIOLOGY FINDING
Right Forearm X-Ray
Fracture of middle third of right radius bone, oblique, displaced
Fracture of middle third of right ulnar bone, oblique, displaced
RADIOLOGY FINDING
Right Manus X-Ray
Fracture (-)
M : The patient’s motorcycle was slipped. Patient fell his right
arm hit the hard thing.
I : Radius and ulnar bone
S : Pain and difficulty to move his right arm
T : IVFD RL gtt XXX/ m (fluid demand 2100 cc / 24 hours IV)
Inj ceftriaxone 1 g/ 12 hours IV
Inj ketorolac 30 mg/ 8 hours IV
ORIF elective
LABORATORY FINDING
Hb : 12,4 g/dl (12-16 gr/dl)
Ht : 37 vol % ( 40-48vol%)

DIAGNOSIS
Closed fracture of middle third of the right radius bone, oblique, displaced
Closed fracture of middle third of the right ulnar bone, oblique, displaced

MANAGEMENT:
 IVFD RL gtt XXX/ min (fluid demand 2100 cc / 24 hours IV)
 Inj ceftriaxone 1 g/12 hours IV
 Inj ketorolac 30mg/ 8 hours IV
 Immobilization with wood splint
 ORIF radius and ulnar bone fracture electively
NON TRAUMA CASES
1. Rustawan / ♂ / 42 Years Old
Admitted on Wednesday, August 5th 2020 at 10.13 AM
ALLOANAMNESIS
Swelling and necrotic skin at the neck.
Since 2 weeks before admission, Patient complained swelling and
redness at the neck region continued by blackened of the skin
progressively (in 6 days). shortness of breath (-), dysphagia (-),
chest pain (+) at the redness region, fever (+), seizure (-), body
weakness (+).
History of teeth cavities (+) since 1 month before. History of poor
oral hygiene

VITAL SIGN
Sens : Compos mentis
BP : 110/60 mmHg
HR : 94 x/min
RR : 22 x/min
T : 37,3°C
NPRS :5
PHYSICAL EXAMINATION
Intraoral region
I : trismus (+), cavities in premolar 1 and
molar 1, discharge (-)

Neck Region
I : Swelling (+), bulging (-), necrotic wound
(+), reddish (+) on the side of necrotic
wound.
P : fluctuated (-), pain (+), crepitation (+),
warm (-)

Thoracic Region
I : Symmetric, reddish of the skin on
superior side of the thorax
P : Sonor on both hemithorax
A : Vesicular on both hemithorax
RADIOLOGY FINDING
Soft Tissue Neck X-Ray AP/L (RSMH August 5th 2020)
emphysema on pre-vertebral soft tissue, emphysema on anterior-
superior side of thoracic region
RADIOLOGY FINDING
Rontgen Thorax AP (RSMH August 5th 2020)
Widening mediastinum (-)
RADIOLOGY FINDING
Chest CT Scan (RSMH August 5th 2020)
emphysema on pre-vertebral soft tissue, emphysema on anterior-
superior side of thoracic region
RADIOLOGY FINDING
Chest CT Scan (RSMH August 5th 2020)
emphysema on pre-vertebral soft tissue, emphysema on anterior-
superior side of thoracic region
LABORATORY FINDING
Hb : 10.7 gr/dl (12-16 gr/dl)
Ht : 34 vol % ( 40-48vol%)
Leukosit : 14.090 /mm3 (5000-10000/mm3)
Trombosit : 752.000 /mm3 (150.000-450.000/mm3)
Ureum : 64 mg/dL (16.6-48.5 mg/dL)
Kreatinin : 0.75 mg/dL (0.70-1.20 mg/dL)
BSS : 124 mg/dL (<200mg/dL)
Natrium : 145 mEq/L (135-155 mEq/L)
Kalium : 4.5 mEq/L (3.5-5.5 mEq/L)
EMERGENCY REPORT
DIAGNOSIS
Descending necrotizing mediastinitis

THERAPY:
 IVFD RL gtt XXX/min (Fluid demand 1950 ml/24 hours)
 Inj. Ceftriaxone 2 gram /24 hours IV
 Inj. Ketorolac 30 mg /8 hours
 Pro Cervicotomy and Mediastinostomy

Patient was treated in the ward

INTRAOPERATIVE
 We performed incision on cervical collar until the sternum
longitudinally and in to retrosternal space above incisura jugularis
 We eliminate necrotic wound and we found pus (+) about 400 ml
 We performed necrotomy and then dilution by irrigating normal
saline fluid to the wound
 Wound is treated open

POSTOPERATIVE DIAGNOSIS
Descending necrotizing mediastinitis

Patient was treated at ward

1. Fadlan Dhiaurrahman / ♂ / 1 Years Old
Admitted on Monday, August 3rd 2020 at 11.00 AM
PRE OPERATIVE DIAGNOSIS
Obstructed ileus due to adhesive + post Laparotomy
and pacreatectomy due to pancreatic tumor

INTRA OPERATIVE
We performed incision on the old scar
Incision deepened until abdominal cavity
In abdominal cavity, we found collapsed bowel on
the distal of obstruction and distended bowel on the
proximal of obstruction
In further exploration we found band from Meckel
Diverticle 100 cm from Treitz ligament
We released band, and we performed ileo-ileal
anostomosis resection
We cleansed abdominal cavity with NaCl 0,9%

POST OPERATIF DIAGNOSIS

Obstructed ileus due to band of Meckel diverticle

Patient was treated in PICU

2. Henny Seth /♀ / 61 Years Old
Admitted on Monday, July 31st 2020 at 15.00PM
PRE OPERATIVE DIAGNOSIS
Obstructed Ileus due to Adhesive + Post Rerouting after Hartmann procedure
INTRA OPERATIVE
 We performed midline incision on the old scar
 We deepened incision until peritoneum
 We found severe adhesive bowel to bowel, bowel to abdominal wall, and distended
bowel.
 We performed adhesiolysis, and in further identification we found multiple perforation
at jejunum ± 120 cm, 130 cm, 135 cm, from Treitz ligament
 We performed resection and then ejunostomy
 We cleansed abdominal cavity with NaCl 0,9%

POST OPERATIVE DIAGNOSIS

Obstructed iIeus due to severe adhesive + multiple perforation of jejunum
Patient was treated in ward
THANK YOU