H/F/28 yo

83.12.32
 Chief complaint: Stab wound on the
thoracoabdominal and right upper arm
It has been suffered by patient 30 minutes before
admitted to the Adam Malik Hospital. The patient
was attacked twice using kitchen knife by a person
with the same height, first she was stabbed at the
thoracoabdominal and then slashed at the right
upper arm. Active bleeding was found from the
wound on the right arm. History of loss of
consciousness, shortness of breath and vomiting
was not found.
Defecation and micturition was normal. History of
immunization was unclear.
 Primary Survey:
• A: Clear
• B: Spontaneous, RR: 24x/min, SpO2 99% with nasal canule 3
L/mnt
• C: warm acral, BP: 100/70 mmHg, HR: 108 bpm, active
bleeding (+) from the (R) upper arm  bandaged, iv cath
insertion 18 FR, urinary catheter insertion and loading RL
30cc/kgbb  1.500cc  BP: 110/80, HR: 96 bpm, UOP:
50cc/h
• D: GCS 15 (E4V5M6), pupil isochore  3mm/3mm
• E: undressed, log roll  stab wound on the left
thoracoabdominal region and (R) upper arm region
 AMPLE
A : No history of Allergic
M : No history of Medication
P : No history of Past Illness
L : 6 hours before accident
E : at home
 Secondary Survey
• Head : no abnormality was found
• Neck : no abnormality was found
• Chest : In localized state
• Abdomen : In localized state
• Genitalia : Female, no abnormality was found
• Extremity : In localized state
Localized State
Chest :
• I : symmetrical, lag of movement
(-), Stab wound (+) with size 5 cm x
1 cm o/t (L) thoracoabdominal
region, 1 cm below arcus costae,
regular edge, contamination (-),
active bleeding (-)
• A : vesicular sound of breath o/t
both hemithorax
• P : tactile fremitus equal on the
both hemithorax
• P : resonance on the both
hemithorax
 Localized State
Abdomen :
I: Symmetrical, distention (-), Stab wound
(+) with size 3 cm x 1 cm o/t (L)
thoracoabdominal region, o/t (L)
thoracoabdominal region, 1 cm below
arcus costae, regular edge,
contamination (-), active bleeding (-),
evisceration (-), bowel content
discharge (-)
A: Peristaltic (+) normal
P: supple, muscular rigidity (-), tenderness
around the wound (+)
P: tympani
Digital Rectal Examination:
Perineum was normal, tight anal sphincter
tone, smooth mucosal layer, pain (-), ampulla
was filled with feces.
Gloves: feces (+), blood (-), mucous (-)
Localized State
(R) Arm :
• L : slash wound o/t anteromedial upper arm, 8cm
above cubiti, sized 14x5cm, soft tissue based, mild
contamination, regular edge, active bleeding (+).
SpO2 of all fingers 95-99%, deformity (-)
• F: Tenderness (+), crepitation (-), brachial artery
pulsation (+), radial and ulnar artery pulsation
reduced, sensory function was decreased on the
palmar region of thumb, index and middle finger,
numbness (+)
• M: AROM shoulder joint normal
AROM elbow joint limited d/t pain
AROM wrist joint: decreased (flexion and
pronation)
AROM of fingers: flexion of thumb,
index and middle finger decreased
 Laboratory finding
• Hb / Hct / WBC / PLT : 8.8 /39/29.270 /368.000
Ur / Cr : 19 / 0.62
• Na/K/Cl : 142/3,4/103
• Random blood glucose : 166
• Rapid Antigen covid 19: non reactive
 FAST

Collecting fluid (-) o/t hepatorenal pouch Collecting fluid (-) o/t Splenorenal pouch
 FAST

Collecting fluid (-) o/t Douglas’s pouch

Chest X-ray
 Working Diagnosis
Penetrating thoracoabdominal stab wound +
Slash wound o/t (R) upper arm with Susp. (R)
brachial artery rupture and median nerve
rupture
 Treatment at the ER :
• Nil per mouth
• IVFD Crystalloid  RL 20 dpm
• Insertion of urinary catheter  came out initial clear yellow urine for
about 100 cc  UOP 50 cc/hour
• Insertion of NGT  came out clear fluid 10 cc
• Inj Antibiotic  Ceftriaxone 1gr IV
• Inj Analgesic  Ketorolac 30mg IV
• ATS Injection 3.000 IU/IM
• TT Injection 0.5 cc
Plan :
• Thoracoabdominal stab wound  local wound exploration at the ER
• Slash wound o/t (R) upper arm  wound exploration at the OR
 At The Emergency Room
• In supine position, under local
anesthesia, aseptic and antiseptic
procedure was performed.
• Extend the skin incision from the
stab wound.
• Skin was retracted, identification
base of the wound  peritoneum
was breached, with sized 2x1 cm.
Omentum was seen. Active
bleeding, pus, bowel or gastric
content was not found.
 At The Emergency Room
• Wound was cleaned with sterile wet gauze,debris
and necrotic tissue were removed
• Wound was closed layer by layer
• Wound exploration was done
 At operating theatre
• In supine position, general anesthesia,
aseptic and antiseptic procedure was
performed.
• Extend the skin incision from the
wound.
• Identification of the wound, sized
14x5cm, muscle based,
contamination(-), regular edge.
• Wound was cleaned with normosaline,
debris and necrotic tissue were
removed
• Short and long head of biceps brachii
muscle was ruptured.
• There were total rupture of (R) brachial
artery and vein, also total rupture of (R)
median nerve
 At operating theatre
• Excised the proximal and distal of brachial
artery punctum and inserting NG tube no.
3,5 to both punctum, injection of heparin
solution  backflow (+), pulse (+).
• Perform end to end anastomosis of the
artery using non absorbable monofilament
material 7-0 rb  leakage (-), pulse (+),
tension (-)
• Refreshing the proximal and distal of
brachial vein punctum and inserting NG
tube no. 3,5 to both punctum, injection of
heparin solution  backflow (+)
• Perform end to end anastomosis of the
vein using non absorbable monofilament
material 7-0 rb  leakage (-), tension (-)
 At operating theatre
• Identification of proximal and
distal of median nerve, perform
end to end anastomosis using
non absorbable monofilament
material 6-0 rb.
• Wound was washed with
normal saline until clean
• Short and long head of biceps
muscle was sutured.
• Wound was sutured layer by
layer by leaving 1 drainage on
subcutaneous.
• Operation was done.