EMERGENCY CASE REPORTS

Sunday, November 15th, 2010

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
No. 2
Name : Mr. A Sex : Male
Age : 38 years old No. Reg : 44 79 41

Chief complaint : Stab wound at left chest

History taking : Suffered since 4 hours before admitted to the hospital
due to fighting. History loss of consciousness (+)
vomiting (-). Prior medical care at Akademis Hospital.
Mechanism of : He was take a rest at security pos suddenly he was
injury attack by unknown people using a sharp weapon. He
was stabbed at left chest and left arm.

Injury sustain : Chest, abdomen, arm

Symptom & sign : Stab wound
Examination : Physical examination, laboratory examination, thorax X
ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR :24 x/minute, spontaneous, symmetric, thoraco

abdominal type

C: BP :110/ 70 mmHg, HR :84 x/minute, regular, adequate

D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5 mm , LR +/+

E: T (ax) : 36,7 oC
Secondary Survey
Right zygoma region :
I : Seen lacerated wound size 3 x 0,5 cm, edema(-),
hematoma(-), active bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)

Left arm region :

I : Seen lacerated wound size 4 x 0,5 cm, edema(-),
hematoma(-), active bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)
Secondary Survey
Thorax region :
I : Movement of the left hemithorax is later than
right hemithorax, seen stab wound at left
hemithorax, with protrusion of omentum
P : Vocal fremitus of the left hemithorax was less
than right, tenderness (+)
P : sonor, left < right side
A : Breath sound left < right hemithorax
Secondary Survey
Abomen :
I : Seen stab wound at left hemithorax size 4 x 0,5
cm with protrusion of omentum,active bleeding (+)
A : Peristaltic bowel sound (+), decrease.
P : Tympani, Tapping pain (+), Shifting dullness (+).
P : Tenderness (+) ,defans muscular (+)
Laboratory Result
WBC : 18, 65 x 103 / L

RBC : 4.54 x 106 / L

HGB : 13,7 g/dL

HCT : 38, 7 %

PLT : 321 x 103 / L

CT / BT : 700 / 300

Blood Sugar : 206 mg/dl

Ureum : 28 mg/dl

Creatinin : 1, 0 mg/dl

SGOT/SGPT : 21 / 22 u/l
Thorax AP X-Ray
WORKING DIAGNOSE : Stab wound penetrans suspect spleen
rupture

MANAGEMENT : O2
IVFD + resuscitation
Medicaments
Report to Senior Digestif surgeon,
advice : Immediately laparatomy
exploration
 Operation Procedure
Patient lied supine under epidural and GA
Desinfection & drapping Procedure
Midline incision 2 finger under Proc. Xyphoideus until 3
finger upper SOP
Open peritoneum Identification solid organ seen hilus lymph
laceration perform splenectomy.
Identified diaphragm seen rupture at posterior perform
stitch with continuous suture
Identified hollow viscous didnt found any abnormalities
Wash peritoneal cavity with normal saline.
Stitch the wound layer by layer and leaving 2 drain
Continue with chest tube on left hemithorax
POST : Stab wound penetran with spleen rupture
OPERATIVE grade IV
DIAGNOSIS left diaphragm rupture

PROGNOSIS : Good

FOLLOW UP : Vital Sign