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  • Laporan Kasus Sulit Intubasi 26 Mei 2020

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    WanditoGayuhUtomo
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    This document summarizes a case report of an 18-year-old male patient with a history of mandible fracture surgery who now requires re-debridement surgery and mandible reconstruction. On examination, the patient has mouth opening limited to 2 fingers, is obese, and has a Mallampati score of 3, making intubation difficult. Based on the airway assessment, intubation is rated as moderately difficult due to limitations visualizing the vocal cords and applying the 3-3-2 rule due to obesity.

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    This document summarizes a case report of an 18-year-old male patient with a history of mandible fracture surgery who now requires re-debridement surgery and mandible reconstruction. On examination, the patient has mouth opening limited to 2 fingers, is obese, and has a Mallampati score of 3, making intubation difficult. Based on the airway assessment, intubation is rated as moderately difficult due to limitations visualizing the vocal cords and applying the 3-3-2 rule due to obesity.

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    © All Rights Reserved
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    18 views11 pages

    Laporan Kasus Sulit Intubasi 26 Mei 2020

    Uploaded by

    WanditoGayuhUtomo
    This document summarizes a case report of an 18-year-old male patient with a history of mandible fracture surgery who now requires re-debridement surgery and mandible reconstruction. On examination, the patient has mouth opening limited to 2 fingers, is obese, and has a Mallampati score of 3, making intubation difficult. Based on the airway assessment, intubation is rated as moderately difficult due to limitations visualizing the vocal cords and applying the 3-3-2 rule due to obesity.

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    of 11

    LAPORAN KASUS

    SULIT INTUBASI

    TGL : 26 MEI 2020 GBST 5.03


    RESIDEN : EZA/GUY/NAN
    KONSULEN : DR CALCARINA FITRIANI SPAN KIC

    Bagian Anestesi & Terapi Intensif


    RSUP Dr Sardjito/FK UGM
    IDENTITAS: SDR. FATHONI DAYATULLOH/ 18 TAHUN/ 01923280
    DX : VULNUS GRANULOSUM POST ORIF SIMPHISIS MANDIBULA
    OP : DEBRIDEMEN LUKA SD REKONSTRUKSI ULANG MANDIBULA

    RPS :

    BENGKAK DAN NYERI DI RAHANG KIRI, SESAK NAPAS (-), DEMAM (-), BATUK (-), PILEK (-)
    HT(-) ASMA(-) ALERGI (-) PENYAKIT JANTUNG (-), PEROKOK (+), KEJANG (-)
    RIW KLL KENDARAAN BERMOTOR 29/01 2020, OPERASI ORIF MANDIBULA 07/02 2020
    PENGOBATAN (-)
    PX FISIK :
    KU : BAIK
    A : SNORING/GURGLING - BUKA MULUT 2 JARI, MALLAMPATI 3
    B : SPONTAN, RR 18, VES +/+, WH -/-, RH -/-
    C : TD 180/90 MMHG, HR 80 BPM REGULER, S1S2 REG MURMUR(-)
    D : CM GCS E4V5M6, EDEMA -/-

    BB : 119 KG. IMT 38

    TB : 175 CM
    Px Penunjang : tgl 19/05 2020

    Hb/Ht = 16,3/45,6
    Al/AT = 7430/363
    APPT = 41,9
    PPT = 15,0
    INR = 1,15
    Na/K/Cl = 141/5,67/109
    Alb = 5,01
    GDS = 109
    BUN/Cret= 7,10/1,15
    HEAD CT SCAN
    Penilaian :
    - ASA 2 dengan Obese gr 2, Hipertensi
    PENILAIAN JALAN NAFAS SULIT PASIEN INI
     Sulit LMA : 0/4
    SULIT VENTILASI : 1/5
    Restriction on mouth opening (-)
    RESTRICTION/RADIATION (-)
    Obstruction/Obese (+)
    OBSTRUCTION/OBESE (+)
    Disturbed on airway (-)
    MASK SEAL (-)
    Stiff (-)
    AGE (-)
    NO TEETH (-)
     Sulit Krikotiroidektomi : 0/5
    SULIT LARINGOSKOPI/INTUBASI : 3/5 Surgery/airway disruption (-)
    Hematoma/mass (-)
    LOOK EXTERNALLY (+)
    Obstruction (-)
    EVALUATE 3-3-2 RULE (+)
    Restriction/deformity (-)
    MALLAMPATI (+)
    Tumor (-)
    OBSTRUCTION (-)
    NECK MOBILITY (-)
    TERIMA KASIH

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