EMERGENCY CASE REPORTS

Tuesday, June 6th 2023

SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
 VISI MISI
PRODI ILMU BEDAH
FK UNHAS
 VISI
Menjadi Pusat Pendidikan Dokter Spesialis Ilmu
Bedah yang setara di tingkat Nasional dan
bereputasi Internasional pada tahun 2025.
 MISI
Menyelenggarakan pendidikan dan pelatihan
Dokter Spesialis Ilmu Bedah untuk menjadi
Dokter Spesialis Ilmu Bedah yang berbudi luhur,
kompeten, inovatif, dan berstandar global.
 MISI
Melaksanakan evaluasi mutu pendidikan secara
berkala dengan senantiasa menyempurnakan
kurikulum pendidikan sejalan dengan perkembangan
dunia dalam ilmu dan teknologi kedokteran.
 MISI
Menyelenggarakan penelitian dasar dan terapan
yang inovatif dan terpublikasi internasional serta
melakukan pengabdian pada masyarakat dalam
bidang Spesialis Ilmu Bedah.
 MISI
Menyelenggarakan kegiatan pendidikan
berkelanjutan untuk menjaga kemampuan
profesional Dokter Spesialis Ilmu Bedah pada
tingkat yang setara di tingkat nasional dan
bereputasi internasional.
EMERGENCY CASE REPORT
Tuesday, June 6th 2023
Ambulation : 1 Patient
Hospitalized
: 11 Patient

Observation : - Patient
Operated : - Patient
Death : - Patient
Total : 12 Patients

Wahidin Sudirohusodo General Hospital

Makassar
 NEW PATIENT’S DATA
SURGERY ER - RSUP WAHIDIN SUDIROHUSODO
Tuesday, March 28th 2023

No. Name Age Gender MR DPJP Diagnosis

1. By. Muh. Nadhir 5 L 1024343 dr. NT High Anorectal Malformations with Perianal Fistule
month
870625

2. Mr. H. Irwanto 48 L dr. WH Squamous Cell Carcinoma of Tongue

3. Mr. Ridwan 24 L 1008907  dr. RL Rectosigmoid Adenocarcinoma with Anemia + Hypokalemia +

Hyponatremia

4. Mr. Wahyu 9 L 665892 dr. AW Anorectal Malformation + Rectovesical Fistule + Post Colostomy
+ Post PSARP + Eterovesical Fistule
 Name : Mr. T No. Reg : 1024887
Age : 29 yo DPJP : Prof. AAI

Chief complain : Unconsciousness

History taking : The patient complaints of decreased consciousness accompanied by
pain in the left side of the head since 1 day ago after having a traffic
accident. Pain in the patient's head is felt continuously. The history of
being unconscious after the incident lasted for about 1 hour, after that
he became conscious but the patient tends to be restless until now.
There is no history of seizures. History of vomiting with a frequency of
1 time, spraying, containing food scraps and red-black blood, history
of bleeding from left - right ear and both noses. The previous accident
history was in 2021 which caused it to be difficult for the patient's left
eye to see. There is no history of previous operations.
Mechanisme of : The patient rides a motorbike at high speed and not wearing a
Trauma helmet. Then the patient collided with another vehicle going in the
opposite direction.
Sustain Injury : Head
 Physical Examination
Primary Survey
A: Clear, patent, with controlled c-spine
B: Respiration: 22 bpm, symmetrical chest
respiratory movement and breath sounds
C: Pulse: 92 bpm, regular, adequate.
Blood pressure: 110/70 mmHg
D: GCS 13 E3M5V5, Pupil isochoric 2,5/2,5 mm,
direct and indirect light reflex +/+, pupil
cataract visible, no lateralization
E: T: 36.5 oC
 Physical Examination
Neurological Status
GCS 13 E3M5V5
Ishocor pupil 2.5/2.5 mm.
Direct Light Reflexes +/+, Indirect Light Reflexes +/+

No other cranial nerves deficit

Motoric : 5/5 5/5
Sensibillity : Within normal limits
Autonom : Urination via catheter, Defecation has not
been 2 days
 Secondary Survey
Local Status :
Head
Regio Capitis :
Inspection : There is sutured wound in the
left frontal area measuring 4 x 0.5 cm
Palpation : There is tenderness, palpable
crepitus in the left temporal area

Regio Palpebra Superior:

Inspection : Visible hematoma, visible
sutured wound measuring 4 x 0.3 cm, no
active bleeding

Regio Auricula Dextra et Sinistra :

Inspection : Visible bleeding in the right &
left MAE, blood clot (+), halo test (-)
 Clinical Diagnosis
• Moderate Traumatic Brain Injury GCS 13
(E3M5V5)
• Laceration Wound on the Left Upper
Palpebrae
Skull X-ray AP Lateral
CT Scan non Contrast : Axial
CT Scan non Contrast : 3D
Chest X-ray AP
 Laboratory Finding
 HB : 10.9  Na : 150
 WBC : 9.400 K : 4,7
 PLT : 270.000  Cl : 116
 SGOT : 104
 SGPT : 43
 Ur : 70
 Cr : 0.99
 GDS : 126
WORKING DIAGNOSIS : • Moderate TBI GCS 13 (E3M5V6)
• Laceration Wound on the Left Upper
Palpebrae
• Epidural hematoma regio Left
Frontotemporal
• Left Zygomaticomaxilla Fracture
• Elevated Liver Enzyme

MANAGEMENT : • Head up 30 degress

• O2 8 lpm via NRM
• IVFD Natrium Chlorida 0,9% 28 tpm
• Ceftriaxone 1gr / 12 hrs / iv
• Metamizole 1gr / 8 hrs / iv
• Ranitidin 50mg / 12 hrs / iv
• Urinary Catheter

PLAN : • Craniotomy Hematome Evacuation

• Consultation with Plastic Surgery (pro ORIF)
Operation Finding
 Operation Report
1. The patient lies supine facing to the right under general anesthesia
2. Disinfection procedures and left temporal rapping
3. Horseshoe incision in the left temporal region, deepened to the skull, scalp flap
directed forward
4. Four burholes were performed on the left temporal bone, the bone was cut using a
giggli saw, the temporal bone flap was removed
5. An epidural hematoma was seen, the dura was hung circumferentially, then an
evacuation of the hematoma of approximately 20 milliliters was carried out using
suction
6. Control of bleeding using surgical and bipolar
7. Cranioplasty was performed, the bones were reassembled and fixed using 8 mini
screws 1.6 x 4.00 millimeters and 4 miniplates
8. Re-approximation of the muscles, the surgical wound is closed layer by layer leaving
1 piece of subgaleal vacuum drain
9. The operation was done
POST OPERATIVE : • Moderate TBI GCS 13 (E3M5V6)
DIAGNOSIS • Laceration Wound on the Left Upper
Palpebrae
• Epidural hematoma regio Left
Frontotemporal
• Left Zygomaticomaxilla Fracture
• Elevated Liver Enzyme
FOLLOW UP : • Vital sign
• Signs of increased ICT
• Operation wound
• Wound care
• Production of drains

PROGNOSIS : • Dubia ad Bonam

Thank you