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    Emergency Olis 2

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    Akmalia Hardini
    This document contains medical records for a 19-year-old male patient who was in a motorcycle accident. He experienced bleeding from the mouth and nose after being hit by a truck. On examination, he had lacerations and fractures to the face, mouth, and jaw. Tests showed mild head injury and fractures of the orbital rims, nasal bone, maxilla, palate, and mandible. He received wound debridement, suturing, and interdental wiring as treatment.

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    Emergency Olis 2

    Uploaded by

    Akmalia Hardini
    44 views34 pages
    This document contains medical records for a 19-year-old male patient who was in a motorcycle accident. He experienced bleeding from the mouth and nose after being hit by a truck. On examination, he had lacerations and fractures to the face, mouth, and jaw. Tests showed mild head injury and fractures of the orbital rims, nasal bone, maxilla, palate, and mandible. He received wound debridement, suturing, and interdental wiring as treatment.

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    This document contains medical records for a 19-year-old male patient who was in a motorcycle accident. He experienced bleeding from the mouth and nose after being hit by a truck. On examination, he had lacerations and fractures to the face, mouth, and jaw. Tests showed mild head injury and fractures of the orbital rims, nasal bone, maxilla, palate, and mandible. He received wound debridement, suturing, and interdental wiring as treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    44 views34 pages

    Emergency Olis 2

    Uploaded by

    Akmalia Hardini
    This document contains medical records for a 19-year-old male patient who was in a motorcycle accident. He experienced bleeding from the mouth and nose after being hit by a truck. On examination, he had lacerations and fractures to the face, mouth, and jaw. Tests showed mild head injury and fractures of the orbital rims, nasal bone, maxilla, palate, and mandible. He received wound debridement, suturing, and interdental wiring as treatment.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 34

    Disusun oleh:

    Akmalia hardini

    Pembimbing : dr, Beny Atmadja Wirjomartani Sp.bs


    Name : Olis Setiawan
    Sex : Male
    Age : 19 years old
    Address : Rancah, Ciamis
    Religion : Moslem
    Status : Not Married
    Medical Rec No. : 1644318
    Time of arrival : 05.09 PM
    Phone Number : 082217859946
    Working Time : 2 hours
    PS : Bleeding from mouth
    S:
    A 19 y.o male patient with bleeding from mouth and nose.
    ± 12 hours prior to admission, when the patients was riding
    a motorcycle with medium speed at Garut area, suddenly
    came a truck from opposite direction hit the patient, caused
    him lose his balance and fell down with unknown
    mechanism. History of using Helmet (+) half face, history
    of unconsciousness (+) ± 10 minute , nausea and vomiting
    (-), bleeding from mouth and nose (+), bleeding from ear (-
    ). Then he was brought to general hospital at Garut area and
    was performed suturing at left eyelid, head x-ray and
    received infusion of electrolyte, injection of ATS-TT. Then
    the patient was referred to Hasan Sadikin Hospital
    Emergency Department.
    Primary survey
    A : Clear
    B : Symmetrical shape and movement, VBS R=L , R :18x/min
    C : BP: 110/70 mmHg P : 86 x/min,
    D : GCS 15 (E4M6V5) Pupils round equal ODS Ø 3 mm
    light reflex (+/+), Parese -/-, motoric +/+

    Secondary Survey
    Within normal limit
    General status :

    Skin : Turgor (+)


    Head : Asymmetrical face, edema and hematome at right
    periorbital
    Eye : Non anemic conjunctiva, non icteric sclera.
    Neck : JVP not increased, submandible lymphe node not
    palpable, no pain
    Thorax : Symmetrical shape and movement
    Pulmo : VBS R=L, Rh -/-, Wh -/-
    Cor : Regular pure heart sounds
    Abdomen : Soft and flat, bowel sound (+) N
    Hepar/Lien: not palpable
    Extremity : Warm, cyanosis -/-, edema -/-, CRT < 2”
    Local status :
    Extra Oral :
    • Asymmetrical face, edema and hematome at right periorbita
    • Edema at upper and lower lip
    • Abrassive wound at right eyelid 1x0,5 cm in size
    • Post suturing at left eyebrow 2x1 cm in size
    Intra Oral :
    • Lips : Lacerated wound at lower lip with 1.5 x0,5x0,5cm
    in size, irregular edge, muscle based , Edema and
    abrassive wound at upper and lower lip.
    • Gingiva : Lacerated wound at gingiva of teeth 11-21 and 41
    with 1,5x0,5x0,5 and 0,5x0,5x0,5 cm in size,
    irregular edge, bone based.
    • Palate : Lacerated wound at palatum with 3x0,5x0,3cm
    in size, irregular edge, bone based
    Laboratory Findings:
    1. Hematology
     PT : 17.3 11-15 second
     INR : 1.30 0.8-1.2 second
     APTT : 35.10 21-41 second
     Hb : 11.3 M(13,5-17,5) g/dL
     Ht : 35.4 M(40-52) %
     WBC : 14.170 (4,400-11,300) /mm3
     RBC : 5,95 M(4,50-6,50) milion/uL
     Platelet : 211.000 (150,000-450,000)/mm3

    2. Chemical Blood Component


     SGOT : 47 M(15-37) U/L 37O C
     SGPT : 41 M(16-63) U/L 37O C
     Ureum : 42 15-50 mg/dL
     Creatinin : 1,06 0,7-1,2 mg/dL
     Timely blood glucose : 93 <140 mg/dL
     Alfa Amilase : 498 25-115 U/L
     Lipase : 105 73-393 U/L
     Sodium : 150 135-145 mEq/L
     Potassium : 1.8 3.6-5.5 mEq/L
    Impression:
    • No sign of costae, scapulae,clavicle fracture
    • No sign of cardiomegaly
    L

    Impression :
    • within normal limit
    L

    Impression :
    • within normal limit
    NOVEMBER 6TH

    # #
    #
    #

    # #

    #
    Impression :
    • Discontinuity of right orbital rim inferior aspect #
    • Discontinuity of left orbital rim inferior aspect
    • Discontinuity of Nasal bone
    • Discontinuity of left maxillary bone
    • Discontinuity of right body and simphysis of mandible bone
    Assesment:

    • Mild HI
    • Fracture of right orbital rim inferior aspect + Fracture of left orbital
    rim inferior aspect + Fracture of nasal bone + Fracture of left
    maxillary bone + Fracture of palate type 2 + Incomplete Fracture
    of right corpus of mandible + Fracture of simphysis of mandible
    • Dentoalveolar fracture of teeth 11-21,41 with avulsion of teeth
    21,41 and mobility grade 3 of tooth 11
    • Lacerated wound at palatum, lower lip and gingival of teeth 11-
    21, 41
    P : Treatment

     Skull AP Lateral x-ray


     Wound debridement
     Suturing lacerated wound IO
     Interdental wiring at upper jaw (17-27) and lower jaw (37-47)
    Management of Head injury
    patient
    Grade I Alert and oriented without neurological deficit. May have
    headache, nausea, or vomiting
    Grade II Impaired conscioussness but able to follow at least a simple
    command, or alert with a focal neurological deficit
    Grade Unable to follow even a single simple command because of
    III impaired consciousness

    Grade IV No evidence of brain function


     History: Type and time of accident, loss of consciousness,
    amnesia, headache.
     General examination
     Neurological examnation
     Skull radiographs
     Cervical spine and other radiograph
     Blood alcohol level, urine for toxic screen
     CT scan of the head
     History: Type and time of accident, loss of consciousness, amnesia,
    headache.
     General examination
     Neurological examnation
     Skull readiographs
     Cervical spine and other radiograph
     Blood alcohol level, urine for toxic screen
     Blood sample to the blood bank for typing
     Baseline blood test and EKG
     Anticonvulsants
     CT scan of the head
     Observation
    •Drug or alcohol intake
    History •Age
    •Progression of vital sign, Pat medical history

    •Airway intubate early


    Cardiopulmonary •Blood pressure normalize with saline or blood
    •Catheters nasogatrictube, foley
    stabilizIation •Diagnostic film

    General examination

    • Tracheostomy
    Emergency measures for •Chest tube
    associated injuries •Neck stabilization
    •Abdominal paracentesis

    • GCS
    Neurological examination • Pupillary
    • Lateralization

    Therapeutic Agents

    Diagnostic Test •CT Scan


    Maxilofacial fracture
    Tissue
    Bony
    Injuries
    Lacerated Fracture of the upper
    wound third of the face

    Skin Abrasion Fracture of the middle


    third of the face:
    • Nasal fracture
    • Maxillary fracture
    Parotid gland • Zygomatic fracture
    injuries • Orbital Fracture

    Eyelid injury
    Fracture of the lower
    third of the face

    Ear injury

    Nasal Injury
     LE FORT I
     LE FORT II
     LE FORT III
     PALATE FRACTURE
    TYPE Ia TYPE Ib TYPE II TYPE III
    (Alveolus Anterior) (Posterolateral) (SAGITAL) (PARASAGITAL)

    TYPE IV TYPE V TYPE VI


    (PARAALVEOLAR) (KOMPLEKS/COMMINUTED) (TRANSVERSE)
    • Identifying of fracture maxillofacial fracture
    • Type Ia :
    Erich arch bar segmental or orthodontic bracket without fiksasi
    intermaxilla

    • Type Ib :
    Arch bar and ORIF
     Type II, III, IV dan VI
    - Palatal rigid internal fixation
    (2 plat = anterior dan posterior)
    - Aplication of plat at piriformis and
    zygomaticomaxillary buttress

     Type V
    - acrylic palatal splint

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