Case Report

“BLUNT TRAUMA IN ACCIDENT

CASE”

INAYAH
H1A013030

SPV : dr. Arfi Syamsun, Sp.KF, M.Si.Med

BACKGROUND
 Trauma is a disorder that results in loss of continuity of
body tissue due to violence, trauna is divided into two
namely mechanical trauma and thermal trauma.
 Ways The incidence of blunt trauma is more often caused
due to accidents or abuse, rarely due to suicide. The types
of injuries caused by blunt force trauma that are often
found in cases of traffic accidents include bruises,
abrasions, torn wounds with uneven edges, and broken
bones.
PATIENT’S IDENTITY
 Name : Nn. R
 Age : 23 yo
 Sex : Female
 Religion : Moslem
 Address :Ampenan
 MR : 027585
 Date of examination : Apr 11th 2019
ANAMNESIS
 The patient came to the General Hospital of the General
Hospital with complaints of left chest pain and injuries
due to traffic accidents experienced on Thursday, Apr 11
2019 at 17.00 WITA. The patient was riding a motorcycle
and crashed into a car that suddenly brake and suddenly
stopped. When crashing into a car, the patient
immediately falls off the motorbike and hits the road
asphalt.
 The patient was immediately referred to the Province of
NTB RUSD, patients also complained of heartburn and
tightness. Patients also experience facial and leg injuries.
PHYSICAL EXAMINATION

 GCS: 15(E4V5M6)
 BP : 110/70 mmhg
 HR : 80 bpm
 RR : 22 tpm
 Temperature : 36,7 oC
 SpO2 : 98 %
WOUND DESCRIPTION
 Regio: face
 Koordinat:
1. 3 centimeters from the front line of the body, 2 centimeters
from the chin
2. 5 centimeters from the front line of the body, 8 centimeters
from the left ear
3. The upper and lower lips, 1 centimeter from the front line
of the body, 5 centimeters from the chin.
2 3
 Wound type : abrasions
 Wounds Characteristics :
1. The form of a linear wound, bounded firmly, the epidermis
appears coarse and thin reddish-colored, the edges of the
wound are brownish, there is a network bridge and no
bone appears
1
2. The shape of the wound is round, well-defined, reddish
around the wound and the edge of the brownish wound
3. The shape of the oval wound, firmly defined, appears
reddish around the wound, appears to be a network bridge
and does not appear to be bone
 Wound size:
1. The length of the wound is 3 centimeters and the width of
the wound is 2 centimeters
2. The diameter of the wound is 0 point 2 centimeters
3. The length of the wound is 3 centimeters and the width of
the wound is 5 centimeters
WOUND DESCRIPTION
 Regio: Legs
 Koordinat: 10 centimeters from the right
knee and 5 centimeters from the center of
the front body
 Wound type : abrasions
 Wounds Characteristics :
The shape of the oval wound,
bounded firmly, the epidermis looks
rough and thin reddish-colored brown
edges of the wound, the skin around the
intact wound and reddish, the bridge
appears and does not appear bone tissue
 Wound size:
The length of the wound is 8
centimeters and the width of the
wound is 4 centimeters
TREATMENT
 Treatment of patients was: IVFD RL 20 tpm, oxygen
3 lpm, injection of ceftriaxone 1 gr, injection of
ranitidine 50 mg, injection of ketorolac 30 mg, and
wound care.
LITERATURE REVIEW
 Based on the Chapter I Article 1 Paragraph (24) of the
Implementation of the 2009 Road Traffic and Transport
Law, traffic accidents are events on unexpected and
unintentional roads involving vehicles with or other road
users, resulting in human casualties or loss of property
 Wound is the loss or destruction of the continuity or
loss of the relationship between the network
(discontinuous tissue) such as skin tissue, soft tissue,
muscle , blood vessel, nerve and bone.

 The types of injuries caused by blunt force trauma that

are often found in cases of traffic accidents include
bruises, abrasions, torn wounds with uneven edges, and
broken bones.
Degree of injury
According to KUHP
 Mild injuries is a wound that doesn’t cause disease or obstacles in carrying out the job or
livelihood.
 Moderate wound is a wound that causes illness or obstacles in carrying out his job or livelihood
for a while.
 Severe injuries (Pasal 90 KUHP)
• Falling sick or getting injured does not give hope to be healed at all, or that poses a danger of
death.
• Unable to continue to carry out job duties or search jobs
• Losing one of the senses
• Get a heavy disability
• Suffered paralyzed
• Strikes her thoughts for four more weeks
• Fall or death of a woman's content
DISCUSSION
 Based on the case of this patient, there was a type of
wound which was a blister on the face and legs. The
wound is classified as a wound due to blunt trauma or
from a blunt object. For example in the case on the skin
the patient experiences contact or is eroded by asphalt
during an accident
 According to Law No. 20 of 2009 and Criminal Code
article 90, injuries to these patients are classified as minor
injuries. Based on the applicable law stated in the law, this
case is regulated in Law No. 22 of 2009 concerning Traffic,
namely Obligations and Responsibilities of Drivers,
Owners of Motorized Vehicles, and or Transport
Companies, which are listed in Article 234 - 239
 In addition, victims' rights are stated in article 240 which
states that "Traffic Accident Victims are entitled to: a) help
and care from the party responsible for the occurrence of
Traffic Accidents and or the Government; b)
compensation from the party responsible for the
occurrence of a Traffic Accident; and c) Traffic Accident
compensation from insurance companies ". Whereas
Article 241 states that "Every victim of a Traffic Accident
has the right to prioritize first aid and care at the nearest
hospital in accordance with the provisions of legislation".
CONCLUSION
From the facts found from the examination of the patient at the
RSUP NTB that a female patient has been examined, Twenty-
Three years old, weighed fivety kilograms, height of one
hundred and fifty five centimeters with good nutritional status,
From patient examination, then I conclude that:

1. There are abrasions on the chin, cheeks, lips, and feet,

injuries caused by contact with blunt objects due to accidents.
2. Medical treatment has been carried out according to hospital
standards
3. Wounds do not cause illness or obstruction in carrying out
occupation or employment
BIBLIOGRAPHY
 Apuranto, H., Hoediyanto, 2006, Ilmu Kedokteran Forensik dan Medikolegal,
Edisi 2, Bagian Ilmu kedokteran Forensik dan Medikolegal Fakultas
Kedokteran Universitas Airlangga, Surabaya
 Kementrian Kesehatan Republik Indonesia. Riset Kesehatan Dasar [pdf].
2013
 Satyo, A. C. Aspek Medikolegal Luka pada Forensik Klinik. Majalah Nusantara
vol 39, no 4. 2007
 Undang-Undang Republik Indonesia Nomor 22 Tahun 2009 Tentang Lalu
Lintas dan Angkutan Jalan
 Syamsun A. Panduan Penulisan Visum et Repertum. Mataram: Penerbit Arga
Puji Press; 2014
 Parinduri, AG. 2017. Trauma Tumpul. Ibnu Sina Biomedika Volume 1, No. 2.
Unit Penelitian dan Pengabdian Masyarakat. Bagian Ilmu Kedokteran
Forensik dan Medikolegal RSUD Deli Serdang Lubuk Pakam / FK UMSU
 Khan, S. Bagian Ilmu Kedokteran Forensik dan Medikolegal Fakultas
Kedokteran Universitas Hasanudin. 2010
 THANK YOU