Roy Hendriko Lubis/Lk/24th

Roy Hendriko Lubis/Lk/24th64.10.92IGD(2-5-15; 21.45)KU: Penurunan kesadaranDialami 22 jam SMRS, pasien jatuh dari sepeda motor. Mekanisme trauma tidak jelas(+). Pingsan(+). Muntah(-). Kejang(-).Primary survey:- A: Clear- B: Spontan- C: Akral hangat; TD 110/70; N 72x/mnt- D: GCS 12(E3M5V4)- E: Log roll jejas(-)Secondary survey:- Kepala: Mata: CA-/-, SI-/-, pupil isokor, 3/3mm, rc+/+. Wajah: Asimetris(+), Malocclusi(+)- Thorax: L: simetris, jejas (-) L: vesikuler kanan dan kiri F: sonor kanan dan kiri- Abdomen: L: simetris, jejas (+) L: peristaltik (+) F: soepel- Extremitas: deformitas(-)

Head CT Scan: Contusio(R)TemporalRontgen Schaedel AP/Lat: Fr. (R)Maxilla, Mandibula dan Zygoma)Foto cervical Lat : dalam batas normalFoto thorax AP: dalam batas normalFoto Pelvic AP: dalam batas normalLaboratorium 2 Mei 2015Hb/Ht/Leu/Plt: 15,4/43,9/19,6/201Ur/Cr: 69,6/4,6Na/K/Cl: 141/6,0/110

Assesment Bedah saraf: Rawat konservative di ruangan.Assesment Bedah plastik: ORIF (R)maxilla-mandibula + zygoma elektif

NCCT2 Mei 2015

Diagnosa: HI GCS 12 + Contusio (R) temporal + SDH(R) minimal Frontal + maxillofacial injuryTerapi:- O2 10 l/i (face mask)- IVFD R-Sol 20gtt/I- Tetagam 250iu- Inj. Ceftriaxone 1gr/12jam- Inj. Ketorolac 30mg/8jam- Inj. Ranitidine 50mg/12jam- Inj. Fenitoin 100mg/8jam3-5-154-5-155-5-156-5-157-5-15S: Penurunan KesadaranS: StabilS: StabilS: StabilS: StabilO: GCS 12(E3M5V4)Pupil isokor, 3/3mm, rc+/+O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+A: HI GCS 12+Contusio(R)Temporal+ SDH(R) minimal Frontal + Maxillofacial injuryA: HI GCS 11+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryA: HI GCS 11+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryA: HI GCS 11+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryA: HI GCS 11+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryP: -O2 rebreathing 10lpm-Banton Bandage- IVFD R-Sol 20gtt/I- Tetagam 250iu- Inj. Ceftriaxone 1gr/12jam- Inj. Ketorolac 30mg/8jam- Inj. Ranitidine 50mg/12jam- Inj. Fenitoin 100mg/8jam

P: -O2 rebreathing 10lpm-Banton Bandage - IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ketorolac 30mg/8jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamDiet 2000kkal+60gr protein

P: -O2 rebreathing 10lpm-Banton Bandage- IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ketorolac 30mg/8jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamNimotop 3x30mgCPZ 3x50mgDiet 2000kkal+60gr proteinDrip manitol 125cc/6jam(H+1)P: -O2 rebreathing 10lpm-Banton Bandage - IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ketorolac 30mg/8jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamNimotop 3x30mgCPZ 3x50mgParacetamol tab 3 x 500 mgDiet 2000kkal+60gr proteinDrip manitol 125cc/6jam(H+2)P: -O2 rebreathing 10lpm-Banton Bandage- IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamNimotop 3x30mgCPZ 3x50mgParacetamol tab 3 x 500 mgDiet 2000kkal+60gr proteinDrip manitol 125cc/6jam(H+3)PCT 3x500mg/NGTLab 5-5-15:-Hb 11.3-Ureum 45-Kreatinin 18-5-1507.309-5-1507.3010-5-1507.3011-5-1512-5-1507.30S: Diare 8xS: Diare(+) 3xS: Diare(-)S: Penurunan KesadaranS: Sesak napas(+)O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+O: GCS 11(E3M5V3)Pupil isokor, 3/3mm, rc+/+O: GCS 9(E2M5V2)Pupil anisokor, 4/3mm, rc+/+TD 130/70 mmHg FP: 32 x/i FN 126 x/i T 37.5 CO: GCS 9(E2M5V2)Pupil anisokor, 4/3mm, rc+/+Torak: bronkovesikuler, rh+/+.TD 120/70 mmHg FP: 36 x/i FN 130 x/i Sat 95% T: 39,2 CA: HI GCS 12+Contusio(R)Temporal+Maxillofacial injuryA: HI GCS 11+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryA: HI GCS 11+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryA: HI GCS 9+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryA: HI GCS 9+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injuryP: -O2 rebreathing 10lpm-Banton Bandage - Inj. Ceftriaxone 1gr/12jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamNimotop 3x30mgCPZ 3x50mgDiet 2000kkal+60gr proteinDrip manitol 125cc/8jam(H+3)Metronidazole 3x500mg/NGTNew diatab 3x1/NGTZink tab 1x1/NGTParacetamol tab 3 x 500 mgP: -O2 rebreathing 10lpm-Banton Bandage - Inj. Ceftriaxone 1gr/12jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamNimotop 3x30mgCPZ 3x50mgDiet 2000kkal+60gr proteinDrip manitol 125cc/12jam(H+4)Metronidazole 3x500mg/NGTNew diatab 3x1/NGTZink tab 1x1/NGTParacetamol tab 3 x 500 mgP: - O2Nasal kanule 3 lpm - IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamCPZ 3x50mgDiet 2000kkal+60gr proteinDrip manitol 100cc/24jam(H+5)terakhirParacetamol tab 3 x 500 mgP: - Pindah kamar 3-1-CT Scan brain non kontras cito-O2 rebreathing 10lpm - IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jamParacetamol tab 3 x 500 mgDiet 2000kkal+60gr proteinDrip manitol loading 300cc 125cc/6jamCek DL, KGD, Elektrolit, RFT, Albumin.Konsul ICUP: -CT Scan brain non kontras cito-O2 rebreathing 10lpm - IVFD R-Sol 20gtt/I- Inj. Ceftriaxone 1gr/12jam- Inj. Ranitidine 50mg/12jamInj. Fenitoin 100mg/8jam Paracetamol drip 1000 mg/8 jamDiet 2000kkal+60gr proteinDrip manitol loading 300cc 125cc/6jamAFF dan direncanakan diberikan Totilac namun tidak ada di depo RSLab 11-5-15:-Hb 3.2-Eritrosit 1.03-Lekosit 19.35-Albumin 2.1-Ureum 131.60-Kreatinin 2.36-Konsul Interna CITO(Cek Urinalisa, RFT/3 hr) -Tranfusi PRC 12 bag12-5-1517.0012-5-201519.0012-5-201523.0013-5-201504.0013-5-201504.20S: Sesak napas(+)

S: Sesak napas(+)

S: Sesak napas(+)

S: cardiac arrest dan apnoeS:cardiac arrest dan apnoeO: GCS 9(E2M5V2)Pupil anisokor, 4/3mm, rc+/+Torak: bronkovesikuler, rh+/+.TD 130/70 mmHg FP: 36 x/i FN 140 x/i Sat 90 - 95% T: 39,2 C

O: GCS 8(E2M4V2)Pupil anisokor, 4/3mm, rc+/+Torak: bronkovesikuler, rh+/+.TD 130/70 mmHg FP: 36 x/i FN 144 x/i Sat 90 - 95% T: 38,5 C

O: GCS 2t (E1M1Vt)Pupil anisokor, 4/3mm, rc+/+Torak: bronkovesikuler, rh+/+.TD 109/60 mmHg FP: 36 x/i FN 147 x/i Sat 85 95 % T: 38,5 C

O: FN : - FP: - TD -/-Pupil isokor 5/5 mm RC -/-O: FN: - FP: - TD -/-Pupil isokor 5/5 mm RC -/-Dolls eye phenomenon (-/-)Refleks kornea (-/-)A: HI GCS 9+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injury

A: HI GCS 8+Contusio(R)Temporal+ SAH+ SDH(R) minimal Frontal+ Maxillofacial injury

A: HI GCS 2t + Contusio(R)Temporal + SAH+ SDH(R) minimal Frontal+ Maxillofacial injury

A: Cardiac arrest + ApnoeA: Exitus

P: O2 15l/i via face mask konsul perawatan ICU konsul paru

Jawaban konsul ICU ICU penuh Jawaban konsul paru dx: pneumonia Th/ - Inj Ceftriaxone 2 gr/12 jam - Drip Ciprofloxacin 400 mg/12 jam - Kultur sputum dan darah

P: Konsul bedah umum Konsul perawatan ICU Cek lab cito (DL, AGDA, elektrolit, KGD)

Jawaban konsul ICU: - Pemasangan ETT - ICU dalam keadaan penuh

P:Jawaban konsul bedah umum: tidak dijumpai tanda-tanda akut abdomen pada pasien iniRencana pindah ICU RS luar, telah dihubungi 6 RS luar, namun RS yang menerima BPJS tidak tersedia ICU yang kosongP:RJPO selama 20 menitPasien dinyatakan meninggal di hadapan keluarga pasien