Dead case

Patient List
Admission
No Identity Diagnosis Planning
to ER
1 Tn. Prantalodi/24 September, 30th Severe head injury + DAI + Treatment in ER :
yo 2018 Cerebral edem + Fracture NRBM 10 lpm
15.50 WITA maxilla lefort 1 + Close Head up 30
fracture of left condylar IVFD NS 20 tpm
mandible displaced + Inj. Ceftriaxone 2x1 gr
Open fracture of Sympisis Inj. Ranitidin 2x50 mg
mandible displaced + Inj. Keteroloc 3x30 mg
Fracture nasalis + Dental Complete blood count
avulsion (Left Incisor + Head CT Scan
Left premolar) DC
Consult to Neurosurgery :
Conservative
Patient passed away Consult to Plastic Surgery :
Pro ORIF elective
Consult to orthopaedic Surgery:
Skin traction
Pro ORIF elective
 1. Tn. Prantalodi/ 24 y.o
September 30th 2018 at 15:50 WITA
Chief Complain: Loss of consciousness

History:
Patient came to ER with the chief complaint is loss of consciousness
since 4 days before admission, after hit by a pile of wood while
working. History of seizure (-), nausea (-), vomiting (-), bloody othore (-)
and bloody rhinore (+).
After that the patient taken to Palangkaraya Hospital and cared for 2
days and than patient refer to Ulin Hospital for advanced care.
Primary Survey

A
• Clear (-),
• Without C-Spine control (-), snoring (+), gurgling (-) 
Intubation (-) denied (+)

B
• Clear (+)
• Lesion (-), RR: 50 bpm, , vesicular breath sound (+/+),
saturation 91% with O2 10 lpm

C • HR: 132 bpm regular weak, BP: 150/80 mmHg, IV line

NaCl (+), Urine cateter (+).

D • GCS E2V2M4 (8), Pupil : equal 3mm/3mm, light reflect (+/+),

Lateralization (-)
Secondary Survey
A -
Inj. Ceftriaxone 2x1gr, Ketorolac
M 3x30mg, Ranitidin 2x50mg

P -
L 4 days

Kampung prepai, Central of

E Borneo
Physical Examination
• Head : Hematome (-), BO (-/-), BR (-/-), Racoon eyes (-/-), Pale
Head conjunctiva (-/-), icteric sclera (-/-) Pupil Equal (3mm/3mm) light
reflex (+/+)

• I : symmetrical respiratory movement, retraction (-),

Chest • P : sonor at all lung fields
• A : symmetrical VS, no ronchi, no wheezing

• I : distension (-), surgical wound (+), mass (-), scar (-)

• A : Bowel sound (+)
Abdomen • P : defence muscular (-), tenderness (-)
• P : timpani at all abdomen region

Extremities • warm extremities (+/+), edema (-/-), lateralization (-/-)

Neurology Status
Physiological reflex
• BPR +2/ +2
• KPR +2 / +2
• TPR +2 / +2
• APR +2 / +2
Pathology reflex
• Chaddock -/-
• Babinski -/-
• Meningeal sign (-)
Status Maxilofacial
• I: deformity (-/-), swelling (-/-)
a/r Frontalis • P: crepitation (+)

• I : Deformity (+/-), hematom (+/-), subconjungtiva bleeding (+/-)

a/r Orbita • P: crepitation (+)

• I : Deformity (-/-), swelling (-), epistaksis (-)

a/r Zygoma • P: crepitation (+/-)

• I: deformity (+/+), flattening (-), Epistaksis (-)

a/r Nasalis • P: pain (-), Crepitation (+)
Status Maxilofacial

• I: deformity (+/+), swelling (-/-)

a/r Maxilaris • P: Floating Maxilla (+)

• I : Deformity (+), swelling (-), hecting (+), vulnus laseratum (+)

a/r Mandibula • P: crepitation (+), mandibula unstabil (+)

• I : Bleeding (-/-), dental avulsi (+)

a/r Intra Orbital • P: pain (-), alveolar bone unstabil (-)
Status Lokalis

• L: Spalk (+), Deformity

wound (-), swelling (-)
• F: tenderness (-), Pulsasi a.
a/r femur dextra dorsalis pedis (+), CRT < 2
detik
• M: Rom active and passive
knee joint
Clinical Picture
Clinical Picture
Head CT Scan
• 1. SCALP: hematom (-)
• 2. Bone: Fracture (-)
• 3. Epidural Hematom: (-)
• 4. subdural lesion: (-)
• 5. intra cerebral lesion: (-)
• 6. Sulcus gyrus: Grey and white
matter invisible/disappear
• 7. System Ventricel: normal limited
• 8. cysterna basalis : normal limit
• 5. Midline shift (-)
Chest X-ray
Cruris X-ray
Pelvic X-ray
 Laboratory Finding September, 27th 2018
Examination Result Normal Value
Hemoglobin 9.2 14,00-18,00 g/dl

2.0
Leukosit 4,0-10,5 ribu/ul

Eritrosit 3.08 4,00-5,50 juta/ul

Hematokrit 28.7 32,00-44,00 vol%
Trombosit 208 /150-450 ribu/ul
RDW-CV 12.4 11,5-14,7 %
MCV 93.2 80,0-97,0 fl
MCH 29.9 27,0-32,0 pg
MCHC 32.1 32,0- 38,0 %
Gran% 45.9 50.0-70.0%
Limfosit % 49.5 25.0-40.0%
Gran # 0.90 2,50-7,00 ribu/ul
Limfosit # 1.00 1,25-4,0 ribu/ul
 Examination Result Normal Value

PT 10.1 9,9-13,5 detik

INR 0.94

APTT 24.8 22,2-37,0 detik

Blood Sugar Random 163 <200

SGOT 167 0-46 U/l

SGPT 39 0-45 U/l

Ureum 108 10-50 mg/dl

Creatinin 1.79 0,7-1,4 mg/dl

Examination Result Normal value

Electrolyte

Natrium 158 Meq/L

136-145

Kalium 4.4 Meq/L

3.5-5.1

Chlorida 127 Meq/L

98-107
 Working Diagnosis

Moderate head injury + DAI + Cerebral edem +

Fracture maxilla lefort 1 + Close fracture of left
condylar mandible displaced + Open fracture of
Sympisis mandible displaced + Fracture nasalis +
Dental avulsion (Left Incisor + Left premolar)
 Management

Treatment in ER : Consult to Neurosurgery :

• NRBM 10 lpm • Conservative
• Head up 30 Consult to Plastic Surgery :
• IVFD NS 20 tpm • Pro ORIF elective
• Inj. Ceftriaxone 2x1 gr Consult to orthopaedic Surgery:
• Inj. Ranitidin 2x50 mg
• Inj. Keteroloc 3x30 mg • Skin traction
• Complete blood count • Pro ORIF elective
• Head CT Scan
• DC