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    Dr. Ahmat Umar, SP.B, SP - BTKV: Emergency Surgical Services Wednesday, August 5 2020

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    Deo Valendra
    1. The document summarizes 3 surgical cases handled at the emergency surgical services of a hospital on August 5th, 2020. It includes details of the patients' conditions, diagnostic findings, surgical procedures, and post-operative diagnoses and management. 2. The first case was a 41-year-old man with a blunt thoracic injury and left hematothorax who underwent an exploration thoracotomy. The second case was a 23-year-old man with fractures of the right radius and ulna bones. The third case was a 42-year-old man diagnosed with descending necrotizing mediastinitis who underwent a cervicotomy and mediastinostomy.

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    Dr. Ahmat Umar, SP.B, SP - BTKV: Emergency Surgical Services Wednesday, August 5 2020

    Uploaded by

    Deo Valendra
    45 views34 pages
    1. The document summarizes 3 surgical cases handled at the emergency surgical services of a hospital on August 5th, 2020. It includes details of the patients' conditions, diagnostic findings, surgical procedures, and post-operative diagnoses and management. 2. The first case was a 41-year-old man with a blunt thoracic injury and left hematothorax who underwent an exploration thoracotomy. The second case was a 23-year-old man with fractures of the right radius and ulna bones. The third case was a 42-year-old man diagnosed with descending necrotizing mediastinitis who underwent a cervicotomy and mediastinostomy.

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    1. The document summarizes 3 surgical cases handled at the emergency surgical services of a hospital on August 5th, 2020. It includes details of the patients' conditions, diagnostic findings, surgical procedures, and post-operative diagnoses and management. 2. The first case was a 41-year-old man with a blunt thoracic injury and left hematothorax who underwent an exploration thoracotomy. The second case was a 23-year-old man with fractures of the right radius and ulna bones. The third case was a 42-year-old man diagnosed with descending necrotizing mediastinitis who underwent a cervicotomy and mediastinostomy.

    Copyright:

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

    Dr. Ahmat Umar, SP.B, SP - BTKV: Emergency Surgical Services Wednesday, August 5 2020

    Uploaded by

    Deo Valendra
    1. The document summarizes 3 surgical cases handled at the emergency surgical services of a hospital on August 5th, 2020. It includes details of the patients' conditions, diagnostic findings, surgical procedures, and post-operative diagnoses and management. 2. The first case was a 41-year-old man with a blunt thoracic injury and left hematothorax who underwent an exploration thoracotomy. The second case was a 23-year-old man with fractures of the right radius and ulna bones. The third case was a 42-year-old man diagnosed with descending necrotizing mediastinitis who underwent a cervicotomy and mediastinostomy.

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    You are on page 1of 34

    EMERGENCY SURGICAL SERVICES

    Wednesday, August 5th 2020


    Consultant On Site :
    dr. Ahmat Umar, Sp.B, Sp.BTKV

    The Attending Doctor :


    Chief : dr. Bela Ronaldoe
    Pra Chief : dr. Afif Heldian
    Captain : dr. Ivan Rayka
    P1 / P2 : dr. Bram Permadi Tanto
    Circular : dr. Deo Valendra
    dr. Suci Rahmaniar
    Trauma patient : 2 patient
    Non trauma patient : 1 patient
    Total : 3 patient
    TRAUMA CASES (2)

    1. Aswandi bin Mahdin/ ♂ / 41 Years Old


    Dx. Blunt thoracic injury with left hematothorax + Multiple Laceration of left
    lower lung lobe

    2. Agung Dwi Septian / ♂ / 23 Years Old


    Closed fracture of middle third of the right radius bone, oblique, displaced
    Closed fracture of middle third of the right ulnar bone, oblique, displaced
    NON TRAUMA CASES (1)

    1. Rustawan / ♂ / 42 Years Old


    Dx. Descending necrotizing mediastinitis
    TRAUMA CASES
    1. Aswandi bin Mahdin/ ♂ / 41 Years Old
    Admitted on Wednesday August 5th 2020 at 06.45 AM

    ANAMNESIS
    Shortness of breath after falling from the height.
    ± 5 days before admission, he fell from the height ± 2.5 meters. He fell
    with his left chest hit the hard thing. Shortness of breath (+)
    History of left chest tube in RSUD Pali (4/8/20) [initial blood ± 1500 cc].
    (Reffered from RSUD Pali)

    PRIMARY SURVEY
    A. Clear
    B. RR : 25 x/min
    C. BP : 140/90 mmHg
    PR : 88 x/min
    D. GCS : E4M6V5 : 15
    NPRS : 4
    SECONDARY SURVEY

    Thoracic region
    I: symmetric, bruise (-), chest tube
    (+) at left hemithorax, at the level
    of ICS IV anterior mid-axillary line
    Undulation (+)
    Air bubble (-)
    forced expiratory bubble (+)
    Production (+) blood ± 400 cc
    P: dullness at lower region of left
    hemithorax
    A :vesicular decreased on left
    hemithorax
    RADIOLOGY FINDING
    Chest X-Ray (RSUD Pali August 4th 2020)
    Left Hematothorax
    RADIOLOGY FINDING
    Chest X-Ray after inserting WSD (RSUD Pali August 4th 2020)
    Left chest tube at the level ICS IV, Left Hemopneumothorax
    decreased slightly
    RADIOLOGY FINDING
    Chest X-Ray 16 hours after left chest tube (RSMH August 5th 2020)
    Left lower lobe of the lung is not expand
    LABORATORY FINDING (RSUD Pali, August 5th 2020)
    Hb : 9.0 gr/dl (12-16 gr/dl)
    Ht : 28 vol % ( 40-48vol%)

    LABORATORY FINDING (RSMH, August 5th 2020)


    Hb : 10.4 gr/dl (12-16 gr/dl)
    Ht : 33 vol % ( 40-48vol%)
    Leukosit : 9100 /mm3 (5000-10000/mm3)
    Trombosit : 412.000 /mm3 (150.000-450.000/mm3)
    M : he fell from the height ± 2.5 meters with his left chest hit the
    hard thing.
    I : Lung, Pleura
    S : Shortness of breath
    T : IVFD RL gtt XXV/ min (Fluid demand 1800 cc / 24 hours IV)
    Inj Ceftriaxone 1 gram / 12 hours IV
    Inj Ketorolac 30mg/8hours IV
    Pro exploration thoracotomy
    DIAGNOSIS
    Blunt thoracic injury with left hematothorax + susp. Laceration of left
    lower lung lobe post left chest tube POD I

    MANAGEMENT
     IVFD RL gtt XXV/ min (Fluid demand 1800 cc / 24 hours IV)
     Inj Ceftriaxone 2 gram / 24 hours IV
     Inj Ketorolac 30 mg/8 hours IV
     Pro exploration thoracotomy
    INTRAOPERATIVE
     We performed thoracotomy with
    posterolateral approach on left
    hemithorax
     In exploration of thoracic cavity, we
    found clots that covering all the field of
    lung lobes
     We performed irrigation with Normal
    saline and evacuate the clots
     In further exploration we found
    lacerations at 3 places in left lower
    lobe of the lung
     We repaired it with horizontal mattress
    and running suture with non-
    absorbable monofilament 3.0R
     Left chest tube is maintained
    POSTOPERATIVE DIAGNOSIS
    Blunt thoracic injury with left hematothorax + Multiple Laceration of left
    lower lung lobe

    Patient was treated at ward


    2. Agung Dwi Septian / ♂ / 23 Years Old
    Admitted on Wednesday, August 6th 2020 at 05.44 AM

    ANAMNESIS
    Pain and difficulty to move his right arm
    The patient’s motorcycle was slipped. Patient fell with his right arm hit
    the hard thing. Open wound (-), active bleeding (-)
    (± about 30 minutes before admission)

    PRIMARY SURVEY
    A. Clear
    B. RR : 20 x/min
    C. BP : 120/80 mmHg
    PR : 84 x/min
    T : 36.7° C
    D. GCS : E4M6V5 : 15
    NPRS : 6
    SECONDARY SURVEY

    Right Forearm and Hand Region :


    I : Excoriation (+) on dorsal side of forearm and
    hand, swelling (+), Deformity (+).
    F : Pain (+), crepitation (+), distal sensory (+),
    CRT < 2 second
    M : ROM active pasive were limited
    RADIOLOGY FINDING
    Right Forearm X-Ray
    Fracture of middle third of right radius bone, oblique, displaced
    Fracture of middle third of right ulnar bone, oblique, displaced
    RADIOLOGY FINDING
    Right Manus X-Ray
    Fracture (-)
    M : The patient’s motorcycle was slipped. Patient fell his right
    arm hit the hard thing.
    I : Radius and ulnar bone
    S : Pain and difficulty to move his right arm
    T : IVFD RL gtt XXX/ m (fluid demand 2100 cc / 24 hours IV)
    Inj ceftriaxone 1 g/ 12 hours IV
    Inj ketorolac 30 mg/ 8 hours IV
    ORIF elective
    LABORATORY FINDING
    Hb : 12,4 g/dl (12-16 gr/dl)
    Ht : 37 vol % ( 40-48vol%)

    DIAGNOSIS
    Closed fracture of middle third of the right radius bone, oblique, displaced
    Closed fracture of middle third of the right ulnar bone, oblique, displaced

    MANAGEMENT:
     IVFD RL gtt XXX/ min (fluid demand 2100 cc / 24 hours IV)
     Inj ceftriaxone 1 g/12 hours IV
     Inj ketorolac 30mg/ 8 hours IV
     Immobilization with wood splint
     ORIF radius and ulnar bone fracture electively
    NON TRAUMA CASES
    1. Rustawan / ♂ / 42 Years Old
    Admitted on Wednesday, August 5th 2020 at 10.13 AM
    ALLOANAMNESIS
    Swelling and necrotic skin at the neck.
    Since 2 weeks before admission, Patient complained swelling and
    redness at the neck region continued by blackened of the skin
    progressively (in 6 days). shortness of breath (-), dysphagia (-),
    chest pain (+) at the redness region, fever (+), seizure (-), body
    weakness (+).
    History of teeth cavities (+) since 1 month before. History of poor
    oral hygiene

    VITAL SIGN
    Sens : Compos mentis
    BP : 110/60 mmHg
    HR : 94 x/min
    RR : 22 x/min
    T : 37,3°C
    NPRS :5
    PHYSICAL EXAMINATION
    Intraoral region
    I : trismus (+), cavities in premolar 1 and
    molar 1, discharge (-)

    Neck Region
    I : Swelling (+), bulging (-), necrotic wound
    (+), reddish (+) on the side of necrotic
    wound.
    P : fluctuated (-), pain (+), crepitation (+),
    warm (-)

    Thoracic Region
    I : Symmetric, reddish of the skin on
    superior side of the thorax
    P : Sonor on both hemithorax
    A : Vesicular on both hemithorax
    RADIOLOGY FINDING
    Soft Tissue Neck X-Ray AP/L (RSMH August 5th 2020)
    emphysema on pre-vertebral soft tissue, emphysema on anterior-
    superior side of thoracic region
    RADIOLOGY FINDING
    Rontgen Thorax AP (RSMH August 5th 2020)
    Widening mediastinum (-)
    RADIOLOGY FINDING
    Chest CT Scan (RSMH August 5th 2020)
    emphysema on pre-vertebral soft tissue, emphysema on anterior-
    superior side of thoracic region
    RADIOLOGY FINDING
    Chest CT Scan (RSMH August 5th 2020)
    emphysema on pre-vertebral soft tissue, emphysema on anterior-
    superior side of thoracic region
    LABORATORY FINDING
    Hb : 10.7 gr/dl (12-16 gr/dl)
    Ht : 34 vol % ( 40-48vol%)
    Leukosit : 14.090 /mm3 (5000-10000/mm3)
    Trombosit : 752.000 /mm3 (150.000-450.000/mm3)
    Ureum : 64 mg/dL (16.6-48.5 mg/dL)
    Kreatinin : 0.75 mg/dL (0.70-1.20 mg/dL)
    BSS : 124 mg/dL (<200mg/dL)
    Natrium : 145 mEq/L (135-155 mEq/L)
    Kalium : 4.5 mEq/L (3.5-5.5 mEq/L)
    EMERGENCY REPORT
    DIAGNOSIS
    Descending necrotizing mediastinitis

    THERAPY:
     IVFD RL gtt XXX/min (Fluid demand 1950 ml/24 hours)
     Inj. Ceftriaxone 2 gram /24 hours IV
     Inj. Ketorolac 30 mg /8 hours
     Pro Cervicotomy and Mediastinostomy

    Patient was treated in the ward


    INTRAOPERATIVE
     We performed incision on cervical collar until the sternum
    longitudinally and in to retrosternal space above incisura jugularis
     We eliminate necrotic wound and we found pus (+) about 400 ml
     We performed necrotomy and then dilution by irrigating normal
    saline fluid to the wound
     Wound is treated open

    POSTOPERATIVE DIAGNOSIS
    Descending necrotizing mediastinitis

    Patient was treated at ward


    1. Fadlan Dhiaurrahman / ♂ / 1 Years Old
    Admitted on Monday, August 3rd 2020 at 11.00 AM
    PRE OPERATIVE DIAGNOSIS
    Obstructed ileus due to adhesive + post Laparotomy
    and pacreatectomy due to pancreatic tumor

    INTRA OPERATIVE
    We performed incision on the old scar
    Incision deepened until abdominal cavity
    In abdominal cavity, we found collapsed bowel on
    the distal of obstruction and distended bowel on the
    proximal of obstruction
    In further exploration we found band from Meckel
    Diverticle 100 cm from Treitz ligament
    We released band, and we performed ileo-ileal
    anostomosis resection
    We cleansed abdominal cavity with NaCl 0,9%

    POST OPERATIF DIAGNOSIS


    Obstructed ileus due to band of Meckel diverticle

    Patient was treated in PICU


    2. Henny Seth /♀ / 61 Years Old
    Admitted on Monday, July 31st 2020 at 15.00PM
    PRE OPERATIVE DIAGNOSIS
    Obstructed Ileus due to Adhesive + Post Rerouting after Hartmann procedure
    INTRA OPERATIVE
     We performed midline incision on the old scar
     We deepened incision until peritoneum
     We found severe adhesive bowel to bowel, bowel to abdominal wall, and distended
    bowel.
     We performed adhesiolysis, and in further identification we found multiple perforation
    at jejunum ± 120 cm, 130 cm, 135 cm, from Treitz ligament
     We performed resection and then ejunostomy
     We cleansed abdominal cavity with NaCl 0,9%

    POST OPERATIVE DIAGNOSIS


    Obstructed iIeus due to severe adhesive + multiple perforation of jejunum
    Patient was treated in ward
    THANK YOU

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