Vulnus Ictum: Dr. Jeremia Samosir

VULNUS ICTUM
dr. Jeremia Samosir

Patient’s Identity
• Name : M r . A
• Sex : male
• Age : 50 y.o
• Date of Admission : 28/5/2021 ; 3:30 P M
Primary Survey
A. Airway and Cervical Spine
No sign of obstructed airway CLEAR

No Sign of cervical injury
B. Breathing and Ventilation
I : Ventilator Breathing
A : Vesicular breathing +/+, rh (-), wh (-) CLEAR
P : symmetrical
CONTINUE
Primary Survey
C. Circulation
Pallor (+), B P : 84/52mmHg, HR : 136 BPM,
C R T > 2 seconds, Tx : 37 C.
External hemorrhage : open wound and
active bleeding at wound site (abdomen)
1. Wound Care
2. NGT
3. Cavum Douglas Drain
Pallor (+), B P : 84/52, H R : 136 B PM,

CRT > 2 seconds, Tx : 37 C.
External haemorrhage: Bleeding Controlled, oozing(-) CLEAR
Drain Cavum Douglas : 100cc/24H blood, serous
minimal CONTINUE
Primary Survey
D. Disability
GCS on sedation, critically ill CLEAR
E. Exposure, Environment, Exray’s (Imaging)
Thorax X-Ray, CT scan performed
CONTINUE
Secondary Survey
S •Pain and bleeding at middle upper abdomen
A •Denied
M •Ketorolac 30 mg
P •-
L •+ 1 hour before admission
E
•Got Stabbed by his cousin’s knife when they were drunk
at drinking party
History Taking
History of Present Illness :
Patient got stabbed with

a knife in the upper
middle part of his Patient arrived,
stomach. Patient were handled by doctors. Patient under sedation,
stabbed by his cousin And wound treated, No dyspnea,
when they both drunk at bleeding controlled
bleeding (+)
drinking party
+ 1 hours before admission + 30 min before admission
Patient evacuated to ER Patient was treated at ER

History Taking
History of Past Illness :
• History of hypertension : (-)

• History of diabetes mellitus: (-)
• History of allergy : (-)
• History of trauma : (-)
• History of surgery : (-)
• History of asthma : (-)
• History of kidney problem : (-)
Physical Examination
Physical Examination :
• G C S : under sedation, critically ill
• Vital Sign :
• Blood pressure : 84/52 mmHg
• Heart Rate : 136 B P M
• Respiration Rate : Ventilator Installed
• Body Temperature : 37 o C
• SpO2 : 99 %
General Examination :
Organ Adjective
Head normocephalic, no deformity
Eyes Pallor Conjunctiva (+)

Icteric sclera -/-
Direct/indirect reflex (+/+),
pupil isochor, 3 mm/3 mm
Nose N o deformity
Organ Adjective
Lung
Inspection Symmetrical expansion
Palpation Symmetrical and adequate fremitus
Percution Sonor/sonor, symmetric
Auscultation Vesicular breath sounds +/+. rhonchi -/-, wheezing -/-
Heart
Inspection Chest deformity (-)
Palpation apical impulse at 5th intercostal space in midclavicular line
Auscultation Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
Organ Adjective
Abdomen
Inspection Convex, m as s (-)
Auscultation Bowel Sound (+) 6 times/minute
Palpation Supel, tenderness (-)
Percution Thymphani
Extremities Cold, C R T > 2 sec

Localist Status
There is a wound of inlet, present on upper
middle site of the abdomen, 1 cm bellow the
right nipple, 8 cm from right nipple. A penetrating
wound with inverted margin, 1 x 6 cm. The
wound edges are even, consisting of skin,
connective tissue and muscle as the base of the
wound, there is no abrasion or bruise of the
margins
Diagnosis
• Vulnus Ictum Regio Upper Middle Abdomen

Laboratory result :
Blood Routine 28/5/2021:
Parameter Result Normal Value Unit
Hb 3.24 13,3 - 16,6 g/dL
Hct 35.2 41,3 - 52,1 %
WBC 3.7 3,37-10 103 /uL
PLT 96 150 - 450 103/uL
Erytrocyte 3.51 3,69 - 5,46 106/uL
MCV 76.9 86,7 - 102,3 fL
MCH 27.1 27,1 - 32,4 pg
MCHC 32.4 29,7 - 33,1 g/dL

Laboratory result :
Haemostats 28/5/2021:
PT 13.2 9,7 - 13,1 Second
INR 1.22 Second
Control PT 10.5 Second
aPTT 24.1 23,9 - 39,8 Second
Control aPTT 21.8 Second

Laboratory result :
Renal Function 28/5/2021:
Creatinine 1.39 mg/dL
Ureum 31.9 mg/dL
Electrolyte 28/5/2021:
Natrium 136.5 mmol/L
Kalium 3.75 mmol/L
Chloride 107.3 mmol/L
Radiology
Thorax AP
Lung pattern is within normal range

With installed tracheal tube
Working Diagnosis :
• POD 1 DCD Explorasi Laparatomy surgical resucitation
stop bleeding + Splenectomy + Ligati A. Colica +
situational hecting GIT (Colon, jejunum, gaster) + HT
non facia a/I
• Trauma abdomen penentrans dengan shock
hipovolemic grade IV
• Ruptur lien grafe IV
• Ruptur arteri colica media
• Ruptur colon transversum
• Ruptur jejunum
• Ruptur tail of pancreas
• Ruptur gaster+ AKI + DIC perbaikan +
Hipoalbuminemia + Malaria falciparum
• Pro : laparotomi explorasi s/d jejunustomy s/d

colostomy s/d exenteriorisasi
Planning :
• Bolus RL 1L
• Tranexamat Acid inj
• Ceftriaxone inj
• Meropenem inj.
• Metronidazole inj.
• Gentamycin inj.
• OMZ inj.
• Ranitidin inj.
• Kalnex inj.
• Fluid balance
• Obs NGT drain
• Wound care/day or if oozing
Planning
• Advice from dr. Ronald, SpAn:
▫ RL : NS 1000/24H
▫ Albumin H1 100cc 20%
▫ PRC Transfusion in the afternoon(only 1 stock
left)
▫ Fentanyl
▫ Midazolam
▫ Rocuronium STOP
▫ NE, dobutamin target MAP 65
▫ Vit K 10mg/8H
SURGERY REPORT
29/05/2021
 Operator : dr. Putu Ayu Indra, Sp.B

 Anesthesiologist : dr. Ronald, Sp.An
 Pre-operative diagnosis : Vulnus Ictum with Ruptured
Epigastrium and Hemorraghic
Shock grade IV
 Post-operative diagnosis : Vulnus Ictum with Ruptured
Epigastrium and Hemorraghic
Shock grade IV
 Operation action : Exploration Laparotomy
(surgical resuscitation to stop
bleeding)
Cont…
Post operation plan
- IVFD RL 1000ml/24 h
- Fentanyl 20 meg/h
- Mydazolam 3mg/h
- Roculax 10mg/h
- NE 0.1-0.5 mcg/kg/min
- Dobutamin 1-5 mcg/kg/min
- Ca Gluconas 3gr/IV/30min after last transfusion
- Analgetic from Anesthesiologist
Follow Up
Follow up 29/05/2021
ICU
S: -
O: Sedated, BP : 68/50 mmHg, HR : 140 bpm, On Ventilator
VT 32cc 25x/min, Tax : 35.8c, SpO2 : 99% NC 2lpm, VAS :
3/10
A: POD Vulnus Ictum with Ruptured Epigastrium and
Hemorraghic Shock grade IV
P: - Fluid & analgetic from anesthesiologist
- IVFD RL 1000ml/24 h
- Fentanyl 20 meg/h
- Mydazolam 3mg/h
- Head up 30 degrees, periodic suction
- Blood Glucose Check/8h
- NE 0.1-1 mcg/kg/min
- Dobutamin 1-6 meg/kg/min
- Drip Roculax 10mg/h
Laboratory result :
Hb 8.2 13,3 - 16,6 g/dL
Hct 25.3 41,3 - 52,1 %
WBC 15.45 3,37-10 103 /uL
PLT 73 150 - 450 103/uL
Erytrocyte 3.51 3,69 - 5,46 106/uL
MVC 72.1 86,7 - 102,3 fL
MCH 23.4 27,1 - 32,4 pg
MCHC 32.4 29,7 - 33,1 g/dL

Laboratory result :
PT 19.1 9,7 - 13,1 Second
INR 1.77 Second
aPTT 33.3 23,9 - 39,8 Second

Laboratory result :
Creatinine 1.74mg/dL
Ureum 18.6 mg/dL
Kalium 3.6 mmol/L
Chloride 108 mmol/L
ICU
ANESTHESIOLOGIST
SURGEON
S: Patient under sedation
O: Sedated, BP : 84/52 mmHg, HR : 136 bpm,
O: Sedated, BP : 84/52 mmHg, HR : 136 bpm,
On Ventilator VT 32cc 26x/min, Tax : 37,
On Ventilator VT 32cc 26x/min, Tax : 37,
SpO2 : 99% NC 2lpm, VAS : 3/10.
SpO2 : 99% NC 2lpm, VAS : 3/10. Thorax:
A: POD Vulnus Ictum with Ruptured
normal range. Abdomen: Black NGT product,
Epigastrium and Hemorraghic Shock grade IV
Right Drain 100cc blood+serous, Left Drain
P: - IVFD RL:NS 1:1 1000ml/24 h
1000cc blood+serous, urine production 2-4- - Fentanyl 20 meg/h
2. Extremities: Warm, CRT < 2.
- Mydazolam 3mg/h
A: POD Vulnus Ictum with Ruptured - Head up 30 degrees
Epigastrium and Hemorraghic Shock grade IV
P: - Meropenem Inj 1g/8h - NE 0.1-1 mcg/kg/min
- Metronidazole 500mg/8h
- Dobutamin 1-6 meg/kg/min
- Gentamycin 80mg/12h
- Drip Roculax >> STOP
- OMZ 40mg/12h
- Vit. K inj. 10mg/8h
- Ranitidine 50mg/8h
- Albumin 20% transfusion 100cc in 4 hour
- Kalnex 1g/8h
- PRC transfusion 1kolf in 4 hour
Laboratory result :
Hb 8.6 13,3 - 16,6 g/dL
Hct 27.3 41,3 - 52,1 %
WBC 23.22 3,37-10 103 /uL
PLT 136 150 - 450 103/uL
Erytrocyte 3.79 3,69 - 5,46 106/uL
MCV 72 86,7 - 102,3 fL
MCH 22.7 27,1 - 32,4 pg
MCHC 31.5 29,7 - 33,1 g/dL

Laboratory result :
Ureum 96.9 mg/dL
Kalium 3.6 mmol/L
Chloride 108 mmol/L
ICU
SURGEON
S: Patient restless
O: Sedated, BP : 129/72 mmHg on NE 0.2
Dobu 5, HR : 107 bpm, On Ventilator VT 32cc
26x/min, Tax : 37, SpO2 : 99% NC 2lpm, VAS :
ANESTHESIOLOGIST
3/10. Thorax: normal range. Abdomen:
Blackened NGT, Right Drain 50cc serous, Left
O: Sedated, BP : 129/72 mmHg, HR : 107
Drain 90cc serous, urine production
bpm, On Ventilator VT 32cc 26x/min, Tax : 37,
114cc/24h. Extremities: Warm, CRT < 2.
SpO2 : 100% NC 2lpm.
A: POD II post op LE, AKI, hipoalbumin
A: POD II post op LE, AKI, hipoalbumin
P: - Meropenem Inj 1g/8h
P: - Ca gluconas 2gr/IV/15min
- Metronidazole 500mg/8h
- Albumin transfusion 100cc in 14 hour
- Gentamycin 80mg/12h
- OMZ 40mg/12h started from 00.00pm
- Furosemide 5mg/h
- Ranitidine 50mg/8h
- Kalnex 1g/8h
- Strict Fluid Balance
- Wound treatment
Laboratory result :
Hb 7.3 13,3 - 16,6 g/dL
Hct 21.9 41,3 - 52,1 %
WBC 20.61 3,37-10 103 /uL
PLT 130 150 - 450 103/uL
Erytrocyte 3.2 3,69 - 5,46 106/uL
MCV 68.4 86,7 - 102,3 fL
MCH 22.8 27,1 - 32,4 pg
MCHC 33.3 29,7 - 33,1 g/dL

Laboratory result :
PT 11.5 9,7 - 13,1 Second
INR 1.06 Second
aPTT 24.5 23,9 - 39,8 Second

Laboratory result :
PT 13.8 9,7 - 13,1 Second
INR 1.28 Second
aPTT 29.5 23,9 - 39,8 Second

Laboratory result :
Ureum 154.3 mg/dL
Kalium 5.11 mmol/L
Chloride 106.4 mmol/L
SECOND SURGERY REPORT
01/06/2021
 Operator : dr. Putu Ayu Indra, Sp.B

 Anesthesiologist : dr. Ronald, Sp.An
 Pre-operative diagnosis : Post DCS Laparotomy Surgical
Resuscitation
 Post-operative diagnosis : Exploration Laparotomy DCS
phase 2. Colon Transversum
Resection + Gaster Repair + Jejunostomy Feeding +
Colostomy Exteriorisation
 Operation action : Exploration Laparotomy
phase 2
Cont…
Follow up
01/06/2021
S: -
O: Sedated, BP : 124/72 mmHg, HR : 103 bpm, On Ventilator Pcontrol 13, Psupp
15, 28x/min, FiO2 80% Tax : 35.8c, SpO2 : 100%
A: Post LE DCS phase 2, Colon Transversum Resection, Gaster Repair,
Jejunostomy Feeding + History of Hemorrhagic Shock grade IV,
Hipoalbuminemia, Electrolyte Imbalance, Anemia, Malaria Tertiana
P:
- IVFD RL:NS 1:1 1000ml/24 h
- Intralipid 100cc/48h
- Albumin 100cc/4h IV
- Fentanyl 20 meg/h
- Mydazolam 3mg/h
- Head up 40-60 degrees
- NE 0.1-0.5 mcg/kg/min
- Dobutamin 5 meg/kg/min
- Omeprazole 40mg/IV + Ranitidine 50mg/IV
- Furosemide 5mg/h
- Vit K >>> Stop
Vulnus Ictum/Stab Wound
Vulnus Ictum/Stab Wound
 Stab wound is produced when force is
delivered along the long axis of a narrow or
pointed object such as knife, dagger, chisel,
sword, sickle, etc.
Driving the object into the body, or from the
body’s pressing or falling against the object
 Depth is more than the length and width.

Types
1. Penetrating wounds
 When the weapon enter the cavity of body or viscus.
2. Perforating wounds
When the weapon enters the body on one side and comes
out from the other side.
 Known as through and through puncture wounds.
 The entry wound is larger and with inverted edges.
 The exit wound is smaller and with everted edges.
Penetrating wound Perforating
wound
Characters
•1. Margins
 Edges are clean and inverted.
 The margins can be everted if wound is produced on
fatty area such as abdomen and gluteal region.
Usually there is no abrasion or bruise of the
margins, but in full penetration abrasion and bruise
may be found.
The margins may be abraded and ragged if the
cutting edge is blunt.
2. Length
Is slightly less than the width of the
weapon up to which it has been driven
in, because of stretching of the skin.
3. Width
The maximum possible width of the knife
can be approximately determined if the
gaping wounds are brought together
4. Depth
 It is greater than the width and length of the external injury.
The depth is usually equal to or less than the length of the

blade that was used in producing it, but on yielding surfaces
like the anterior wall, the depth of the wound may be greater ,
because the force of thrust may press the tissues underneath.
 The expansion and retraction of the chest is also considered.
 The mobility of the internal organ is taken into account.

Depth of stab wound depends on
1. Condition of the knife : sharpness of tip, thin slender,
double edged knife
2. Resistance offered by the organs or tissues
3. Clothing
4. Speed of the thrust of the knife
5. Stretched skin or lax skin
5. Shape
It depends on:
 the type of implement, cutting surface
 sharpness, width and shape of the weapon
 body region stabbed, the depth of insertion
 the angle of withdrawal, the direction of
thrust
 the movement of blade, cleavage direction
 the movement of the person stabbed, and
 condition of the tension or relaxation of the
skin.
Slit like Wedge shaped
Double-edged weapon
produces
Elliptical shaped Fishtailing
If a single-edged
weapon is used
Reasons for the stab wound
Suicidal:
 They are found over accessible parts of the body.
 The direction is upwards, backwards and to the right.
 The depth is variable.
Homicide:
 Most stab wounds are homicidal , especially found
in an inaccessible area.
Accidental:
 Wounds are rare
Complications
• Marked internal hemorrhage or injuries to internal
organs which is the primary cause of Hemorrhagic
Shock
• Wound may get infected due to the foreign material
carried into it.
• Air embolism may occur in a stab wound on the
neck which penetrates jugular veins. Air is sucked
into the vessels due to the negative pressure.
• Pneumothorax.
• Asphyxia due to inhalation of blood.
Hemorrhagic Shock
• Hemorrhagic shock is a form of Hypovolemic Shock
Inadequ
ate DE
AT
Severe oxygen
Blood delivery
Loss at
cellular
level H
• Causes vary widely, including:
 Trauma
 Maternal hemorrhage
 Gastrointestinal hemorrhage
 Perioperative hemorrhage
 Rupture of an aneurysm
Directions
• In solid organs, the principal direction should be noted first
and other next, e.g., backwards and to the right. If the
weapon is partially withdrawn and thrust again in a new
direction, two or more punctures are seen in the soft parts
with only one external wound.
• If it is perforating, it should be described in sequential
order:
• stab wound of the entrance
• path of the track, and its exit
• If it is penetrating, the wound of entrance should be
described first, then the depth and direction of wound
track.
Examination of the wound
• The following points should be noted :
• 1) Identification and labelling of cuts and damage to clothing.
• 2) Distribution of blood stains.
• 3) Removal of clothing, layer by layer.
• 4) Identification and labelling of wounds.
• 5) Wounds:
• Position (height from heels),
• location (measurements from fixed anatomical landmarks),
• description including margins, size, shape, ends, extension,
• direction,
• depth,
• trauma to viscera,
• estimation of force required,
• foreign bodies.
Before treating the wound………….
• Initial examination (primary survey, or ABCDEs) in patients
with penetrating stab wound of thoracic and abdominal
regions includes assessment of the following:
• Airway, breathing, circulation (ABCs): Includes vital signs
• level of consciousness (D, disability): To detect neurologic
deficits
• Location(s) of the wound(s) (E, exposure): Inspect all
body surfaces, and document all penetrating wounds
• Type of penetrating weapon or object
• Amount of blood loss
Debridement
• The first step in treating the stab wound is the
debridement i.e. removal of dead,damaged tissue
• Debridement removes dead, devitalized, or contaminated
tissue, and any foreign material from a wound, which helps
to reduce the number of microbes, toxins, and other
substances that inhibit healing
• There are five main methods of debridement:
surgical or sharp, autolytic, enzymatic, mechanical,
and biosurgical
• Surgical debridement is more preferable
• Surgical debridement is the fastest way to remove
dead tissue.
• It causes considerable pain, and hence,usage of local
anesthetics such as ketamine, lidocaine and enfluran
applied 30 to 45 minutes prior to debridement
• There may be some damage to viable tissue, and
bleeding is likely
• Mild to moderate bleeding could be controlled by the
application of pressure and a hemostatic calcium
alginate dressing.
Bouglé et al. Annals of Intensive Care 2013, 3:1 Page 3 of 9
Bouglé et al. Annals of Intensive Care 2013, 3:1 Page 3 of 9
Prognosis and Rehabilitation
• In general, simple open wounds that are treated promptly and
appropriately have good outcomes.
• The outcome is influenced by condition of surrounding tissues and type
of treatment
• Wounds with excessive damage to blood vessel and extensive tissue loss
may lead to loss of sensation,deformity,&disability
• Specific chemotherapy restores the normal function and sensation
in the affected region
• In case of diasability physical therapy may restore the original
function
• Jeremy B. Richards, MD, MA Division of Pulmonary, Critical Care, and Sleep
Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Diagnosis And
Management Of Shock In The Emergency Department. March 2014 Volume 16,
Number 3
• Jeremy W. Cannon, M.D. Hemorrhagic Shock. The new england journal of medicine
2018
• Adrien Bouglé1,2, Anatole Harrois1 and Jacques Duranteau1. Resuscitative
strategies in traumatic hemorrhagic shock. 2013
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1353488/
• http://www.mdguidelines.com/open-wound
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC470915/
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VULNUS ICTUM

dr. Jeremia Samosir

No sign of obstructed airway CLEAR

B. Breathing and Ventilation

Pallor (+), B P : 84/52, H R : 136 B PM,

GCS on sedation, critically ill CLEAR

E. Exposure, Environment, Exray’s (Imaging)

Thorax X-Ray, CT scan performed

L •+ 1 hour before admission

Patient got stabbed with

+ 1 hours before admission + 30 min before admission

Patient evacuated to ER Patient was treated at ER

• History of hypertension : (-)

Head normocephalic, no deformity

Eyes Pallor Conjunctiva (+)

Inspection Symmetrical expansion

Palpation Symmetrical and adequate fremitus

Percution Sonor/sonor, symmetric

Auscultation Vesicular breath sounds +/+. rhonchi -/-, wheezing -/-

Inspection Chest deformity (-)

Palpation apical impulse at 5th intercostal space in midclavicular line

Inspection Convex, m as s (-)

Auscultation Bowel Sound (+) 6 times/minute

Palpation Supel, tenderness (-)

Extremities Cold, C R T > 2 sec

• Vulnus Ictum Regio Upper Middle Abdomen

Parameter Result Normal Value Unit

Hb 3.24 13,3 - 16,6 g/dL

Hct 35.2 41,3 - 52,1 %

WBC 3.7 3,37-10 103 /uL

PLT 96 150 - 450 103/uL

Erytrocyte 3.51 3,69 - 5,46 106/uL

MCV 76.9 86,7 - 102,3 fL

MCH 27.1 27,1 - 32,4 pg

MCHC 32.4 29,7 - 33,1 g/dL

Parameter Result Normal Value Unit

PT 13.2 9,7 - 13,1 Second

INR 1.22 Second

Control PT 10.5 Second

aPTT 24.1 23,9 - 39,8 Second

Control aPTT 21.8 Second

Lung pattern is within normal range

• Pro : laparotomi explorasi s/d jejunustomy s/d

 Operator : dr. Putu Ayu Indra, Sp.B

Parameter Result Normal Value Unit

Hb 8.2 13,3 - 16,6 g/dL

Hct 25.3 41,3 - 52,1 %

WBC 15.45 3,37-10 103 /uL

PLT 73 150 - 450 103/uL

Erytrocyte 3.51 3,69 - 5,46 106/uL

MVC 72.1 86,7 - 102,3 fL

MCH 23.4 27,1 - 32,4 pg

MCHC 32.4 29,7 - 33,1 g/dL

Parameter Result Normal Value Unit

PT 19.1 9,7 - 13,1 Second

INR 1.77 Second

Control PT 11.8 Second

aPTT 33.3 23,9 - 39,8 Second

Control aPTT 22.8 Second