M/M/27 yo

85.51.15
Chief complaint: Pain on the face

The patient had a traffic accident half an hour before

entering the hospital. The patient was riding a motorcycle
and then suddenly stopped because the car in front of him
and the patient hit the pavement and fell down. The
patient is not wearing a helmet. After the accident the
patient remains conscious and able to walk. Fainting (-)
vomiting (-) ghosting vision (-). After that, the patient went
straight to the hospital for further treatmentandangan
berbayang (-). Setelah itu pasien langsung ke rumah sakit
untuk dapat penanganan lebih lanjut
 Primary Survey
A : Clear
B : Spontaneous, RR : 20 x/i, SaO2: 97% r
C : active bleeding (-), warm Acral, HR : 80 bpm,
BP : 140/103 mmHg, CRT<2”
D : GCS 15, pupil isocor (3mm/3mm), light reflex
(+/+)
E : T 36C
 AMPLE
– A : No history of allergy
– M: no history
– P : No history of past illness
– L : Last meal 3 hour before accidents
– E : on the road
 Secondary Survey
• Head : laserasi luka (+) perdarahan aktif
intraoral (+)
• Neck : no abnormality was found
• Chest : no abnormality was found
• Abdomen : no abnormality was found
• Back : no abnormality was found
• Genitalia : male, no abnormality was found
• Extremities : cruris R laseration (+), plantar pedis L
lateration (+)
Localized State
Head:
• 1/3 mid Face :
L : Pupil’s diameter 3 mm /3 mm, Light reflex (+/+), eye
ball movement on 8 direction, visual acuity 6/6,
dystopia (-), periorbita Hematoma (-/-), nasal deviation
(-), diplopia (-).
exoriation wound o/t zigomaticum, irregular-edged,
bone based, bone fragment (+), active bleeding (-),
sized7×1cm, contamination (+), F : crepitation (-)

• 1/3 lower face:

exoriation wound o/t mandibula R, active bleeding (-),
sized 2×2cm, contamination (+), F : crepitation (-)
Intraoral: step off deformity (+), teeth avulsion (+)
lower incisivus, active bleeding (+), floating maxilla (-),
malocclusion (+), crepitation on the R mandibulla (+)
• Extremities:
there is vulnus excoriation on the right cruris,
size 10x5, contamination (+), crepitus (-) edema
(-)
there is a vulnus laceration on the left pedis,size
2x2cm with contamination and without crepitus
 Laboratory finding :
• Hb / Hct / WBC / PLT : 15.3/44/13.510/322.000
Chest X-Ray
Schuller
 Working Diagnosis :

Segmental Mandibulla Fracture

 Treatment at the ER :
• R/
- CT Scan 3D Midface
- Barton Bandage
- Rawat inap
- ORIF Elective