G/M/25yo

81.10.93
Chief complaint : Lacerated wound o/t right cruris.
It has been suffered by the patient since 2 hours before
admission to Haji Adam Malik Hospital. Previously, the
patient was replacing the window glass of his house.
Accidentally the window glass was slipped off and
shattered. Patient was skidded, then patient's right leg
was exposed to glass shards. History of immunization
was unclear.
 Present State
• Awareness : Alert
• BP : 110/70 mmHg
• HR : 88 x/minute
• RR : 20 x/minute
• Temp : 36,2 0 C
• VAS :4
 Secondary Survey

• Head : No abnormality was found

• Neck : No abnormality was found
• Chest : No abnormality was found
• Abdomen : No abnormality was found
• Genitalia : Male, no abnormality was found
• Extremities : In Localized state
 Localized State

(R) Inferior Extremity:

Look: Lacerated wound base o/t right
lower leg, reguler edge, subcutis
based, active bleeding (-), minimal
contamination, size 7 x 1 x 0.5 cm.
Feel: Warm acral, CRT<2”, pulsation A.
Anterior Tibial (+) Normal, A.
Dorsalis Pedis (+) Normal
Move: ROM (+) Normal
 Working Diagnosis

• Lacerated Wound o/t (R) Lower Leg

 Management at Emergency Room

• Paracetamol tab 3x500 mg

• Cefadroxil tab. 500 mg
• Inj ATS 3000 IU IM
• Inj. TT 0,5 cc IM
• Wound toilet + Primary Suture
 Primary suture
• Patient in supine position
• Infiltration of local anesthesia lidocaine 2% around the wound.
• Wound was washed with normal saline until clean.
• Aseptic and antiseptic procedure was performed.
• Identification of the wound, there was a Incised wound o/t right cruris
region, size 7x1x0,5 cm, irregular edge, contaminated, subcutaneous
based
• Wound was washed with normal saline untill debris were removed.
• Wound edge was refreshed. Bleeding was controlled.
• Wound was sutured with monofilament non-absorbable 3/0 cutting
bodied by simple interrupted sutures.
• Primary suture was done.
Post Suture