BEDAH 1

BIMBEL UKDI MANTAP

dr. Andreas W Wicaksono
dr. Anindya K Zahra
dr. Arius Suwondo
dr. M. Dzulfikar Lingga Q M
dr. Marika Suwondo
dr. Alexey Fernanda N
dr. Denise Utami Putri
dr. Aditya Wicaksana
dr. Renaldo Faisal H

Batch Mei 2019

 Content

Thoracic and Cardiovascular Surgery

Neurosurgery

Pediatric Surgery

Plastic Surgery
Thoracic and Cardiovascular
Surgery
Trauma Algorithm
 Trauma Thorax
“PRIMARY SURVEY” – EMERGENCY

Airway • Gangguan jalan nafas

• Pneumotoraks terbuka
Breathing • Pneumotoraks tension
• “Flail Chest”

• Hematoraks masif
Circulation • Tamponade kordis
Hematothorax
Definition :
accumulation of blood
in pleural cavity
• Simple
• Massive :
> 1.5litres blood on
chest drainage or >
200cc blood/ hour on
drainage
 Etiology
• Trauma : ruptur arteri di dinding thorax
ataupun internal organ di thorax
– A. thoracica interna and it’s branches
– A. intercostalis
– A. bronchialis
 Physical Exam
• Sign : dyspneu

• I : Jejas (+), ketinggalan gerak (+)

• P : Fremitus taktil menurun
• P : Redup (+)
• A : Vesikuler turun, normal heart sound
Tube Thoracostomy / Chest Tube
Water Sealed Drainage
Pneumothorax

Definition :
accumulation of air
or gas in pleural
cavity
 Klasifikasi Pneumotoraks

Berdasarkan • Traumatika
terjadinya • Spontan (primer dan sekunder)

Berdasarkan • Terbuka/open
• Tertutup/closed
fistulanya • Tension

Berdasarkan • Total
derajat kolaps • Parsial
 Physical Exam
• Sign : Dyspneu, subcutis emfisem

• I : Jejas (+), ketingalan gerak (+)

• P : Fremitus taktil menurun
• P : Hipersonor
• A : Vesikuler turun/hilang, normal heart sound
 Open Pneumothorax
 Etiology : Penetrating Trauma  lubang dinding dada
(ukuran mendekati diameter trakea (>2/3 diameter
trakea))
 “Mediastinal Flutter“
 “Sucking Chest Wound“
 Treatment
Occlusive dressing tape in 3
sides.
• the dressing prevents atmospheric
air from entering the chest wall
during inspiration but allows any
intrapleural air out during
expiration
Closed Pneumothorax

• Etiology : blunt trauma,

spontaneous rupture of
pleurae  air leakage to
pleural cavity
• Can developed into
Tension Pneumothorax
• Tx : Chest Tube
Tension Pneumothorax
• Clinical sign :
• Himpitan vena cava
• Shock
• JVP ↑
• Himpitan paru
kontra lateral
• distress nafas
• deviasi trakhea
• Tx :
– Neddle
thoracostomy
(decompression)
– Chest tube
Tension Pneumothorax
 Needle Thoracostomy (Needle
Decompression / Needle Thoracocentesis)
Lokasi :
SIC II / III Linea
Midclavicula
(ATLS 9th ed)

Tindakan
emergensi untuk
mengubah tension
pneumothorax
New Update ATLS 10th ed menjadi simple
• Adult SIC V Midaxillary Line
• Child SIC II Midclavicular Line pneumothorax
Cardiac Tamponade
• Etiology : blunt or
penetrating trauma
in mid-chest
• Nomal breath sound
• Sign Trias Beck
1. Increase JVP
2. Hypotension
3. Muffled Heart
sound
• Tx :
pericardiocentesis
Pericardiocentesis
 Flail Chest
• Fraktur costae  segmental, multipel,
berurutan
– Segmental  fraktur komplit pada 2 tempat atau
lebih pada costa
– Multipel berurutan  terjadi pada 2 atau lebih
costa berurutan
• Severe respiratory distress
• Paradoxal movement
• Asymmetrical and uncoordinated chest wall
movement
• Crepitation on palpation
• Pain>>>>
Flail Chest
 Management
• ABCDE
• Adequate ventilation, oxygenation, cairan,
analgesia
Neurosurgery
 Cedera Otak
Cedera Otak Primer
• Kepala diam dibentur oleh benda yang bergerak
• Kepala yang bergerak membentur benda yang diam. (Proses
aselerasi & deselarasi)

Cedera Otak Sekunder

• Terjadi sesudah lesi otak primer
• Akibat dikeluarkannya zat-zat neurotoksis (interleukin, radikal
bebas, aspartat, dll)
• Menyebabkan  hipotensi, gangguan aliran darah, hipoksia,
peningkatan TIK, vasospasme,edema
 Primary Brain Injury
• The damaged caused to the brain at the moment
of impact
 Concussion
 Temporary neuronal dysfunction after blunt head trauma
 Head CT is normal, deficits resolve over minutes to hours
Contusion/laseration
 Bruise of the brain
 Breakdown of small vessels and extravasation of blood into the brain
Diffuse axonal injury
 Damage to axons throughout the brain
 Most frequent finding in patients who die from severe head injury
Cedera Kepala

Klasifikasi klinis cedera kepala

berdasarkan GCS :

• Cedera Kepala Ringan (CKR)

– GCS 13-15
– Kesadaran menurun ≤10 menit
– Defisit neurologis (-)
– CT SCAN normal
• Cedera Kepala Sedang (CKS)
– GCS 9-12
– Kesadaran menurun >10 menit s/d <6 jam
– Defisit neurologis (+)
– CT SCAN abnormal
• Cedera Kepala Berat (CKB)
– GCS 3-8
– Kesadaran menurun >6 jam
– Defisit neurologis (+)
– CT SCAN abnormal
 Epidural Hemorrhage

>>a. meningea media, temporo parietal, biconvex/lenticular,

lucid interval, unilateral dilated pupil on side of injury,
hemiparesis or hemiplegia on side of body opposite
injury
 Subdural Hemorrhage

Bridging vein, semilunar, countre-coup injury

 Subarachnoid hemorrhage

Aneurisma, AVM
Thunderclap headache, Muntah, stiff neck, meningeal
irritation, confusion / penkes
 Intracerebral hemorrhage

Parenkim otak
Brain trauma atau spontan pada hemorrhagic stroke.
Basis Cranii
 Classification

Anterior Skull • Posterior frontal sinus, roof of ethmoid,

cribriform, and orbital roof, sphenoid
Base Fracture bone

Middle Skull • Temporal bone

Base Fracture

Posterior Skull • Clivus occipital, condylus occipital

Base Fracture
 Clinical sign :
• Presentation with anterior cranial fossa fractures is with CSF rhinorrhea
and bruising around the eyes "raccoon eyes."

• Patients with fractures of the petrous temporal bone present with CSF
otorrhea and bruising over the mastoids “Battle sign. “

• Longitudinal temporal bone fractures result in ossicular chain disruption

and conductive deafness of greater than 30 dB that lasts longer than 6-7
weeks.
• Transverse temporal bone fractures involve the VIII cranial nerve and the
labyrinth, resulting in nystagmus, ataxia, and permanent neural hearing
loss.

• Occipital condylar fracture is a very rare and serious injury. Most of the
patients are in a coma and have other associated cervical spinal injuries.
These patients may also present with other lower cranial nerve injuries
and quadriplegia.
 Halo Sign
(Ring sign/Target sign)

• Tanda CSF leak:

– Glucose (+)
– Halo sign (+)
– Beta-2-transferrin (+)  highly specific to CSF, not present
in plasma, nasal secretion, tear, saliva, or other fluid.
Brain Herniation
 Brain Herniation
Supratentorial herniation
• Subfalcine (Cingulate) herniation
• Central herniation
• Transtentorial lateral (Uncal) herniation
• Transcalvarial herniation

Infratentorial herniation
• Upward cerebellar herniation
• Downward cerebellar (Tonsillar) herniation
 Uncal herniation
• Herniation of the medial temporal lobe inferiorly through
the tentorial notch

Clinical triad associated with uncal herniation :

– Dilated pupil ipsilateral
– Hemiplegia contralateral
– Coma

• compressed ipsilateral to herniation: hemiplegia will be on

the contralateral side of the body (axons decussate at
pyramidal decussation)
compressed contralateral to herniation: If the herniation is
very severe, the contralateral cerebral peduncle may be
compressed by the opposite side of the tentorial notch
leading to an ipsilateral (to the herniation) hemiplegia
(Kernohan's phenomenon).
CT-Scan
 Indikasi CT SCAN pada Cedera Kepala Ringan
(ATLS 9th ed & 10th ed)
CKR (bila disaksikan mengalami hilang kesadaran, amnesia
yang jelas, atau disaksikan mengalami disorientasi dengan
skor GCS 13-15) dengan salah satu tanda dibawah ini
• GCS<15 setelah 2 jam paska trauma
• Dicurigai adanya fraktur impresi terbuka atau tertutup
• Adanya tanda-tanda fraktur basis cranii
• Muntah (>2 kali)
• Usia >65 tahun
• Hilang kesadaran >5 menit
• Amnesia retrograde >30 menit
• Mekanisme Berbahaya (jatuh lebih dari 1m, pedestrian vs
motor vehicle, ejeksi dari kendaraan dsb)
MRI
Specific for
Soft Tissue
 Manajemen Cedera Kepala
Prinsip penanganan cedera kepala adalah mencegah cedera kepala sekunder (ATLS)

Posisi tidur dengan leher lurus & head up 15-300

• Meningkatkan venous return  menurunkan TIK

Usahakan tekanan darah optimal

• TD terlalu tinggi  edema cerebri, TD terlalu rendah  iskemia otak  edema dan meningkatkan
TIK.
• Jaga TDS >100 (usia 50-69 th) atau >110 (usia 15-49 atau >70 th) , jaga euvolemia dengan NS 0,9%
Atasi kejang, nyeri, dan cemas
• Meningkatkan demand metabolisme otak
• Profilaksis kejang diindikasikan
• Benzodiazepine, opioid

Menjaga suhu tubuh normal (<37,50C)

Hindari batuk, mengejan, dan suction jalan napas yang berlebihan

 Manajemen Cedera Kepala
Koreksi kelainan metabolik dan elektrolit
• Hiperglikemia memperburuk outcome cedera kepala

Atasi hipoksia
• PaCO2 dijaga pada level yang mendukung CBF (35 mmHg). Hiperkarbia menyebabkan
vasodilatasi  meningkatkan TIK
• Hiperventilasi terkontrol. Hiperventilasi berlebihan menyebabkan vasokonstriksi iskemia 
edema cerebri  meningkatkan TIK
Osmoterapi
• Manitol 20%/20g manitol per 100 ml pelarut  dosis 0,25-1 g/kgBB (diulangi 2-6 jam
kemudian, osmolaritas dijaga 310-320 mOsm/L)
• Furosemide (efek sinergis bila dikombinasikan dengan manitol, efek terbaik bila diberikan 15
menit setelah manitol)
• Salin hipertonik (alternatif pengganti manitol pada kondisi tertentu seperti gangguan fungsi
ginjal
Antikonvulsan
• Feniton  1 g IV kecepatan 50 mg/menit, maintenance 100 mg/8 jam
Pediatric Surgery
 Atresia Esophageal

• The first sign of esophageal atresia in the fetus may be polyhydramnios in

the mother.
• Prematurity has also been associated with esophageal atresia.
• Classically, presents with copious, fine, white, frothy bubbles of mucus in
the mouth and, sometimes, the nose.
• The infant may have rattling respirations and episodes of coughing, choking
and cyanosis, may be exaggerated during feeding.
Diagnosis

• (A) Diagnosis of esophageal atresia is confirmed when a 10-gauge

(French) catheter cannot be passed beyond 10 cm from the gums.

• (B) A smaller-caliber tube is not used because it may curl up in the upper
esophageal segment, giving a false impression of esophageal continuity.

• The normal distance to an infant's gastric cardia is approximately 17 cm

chest radiographs should be obtained to confirm the position of the tube. The
radiograph should include the entire abdomen. In patients with esophageal
atresia, air in the stomach confirms the presence of a distal fistula, and the
presence of bowel gas rules out duodenal atresia

The Gasless Abdomen

• Absence of gas in the
abdomen suggests that
the patient has either
atresia without a fistula
or atresia with a
proximal fistula only
 Hypertrophy Pyloric Stenosis
• Hipertrofi m.sphincter pylorus
• Stenosis > canalis pyloricus

• Klinis :
– 1-12 minggu, muntah proyektil, bile
free, bolus+gastric juice
– Baby looks hungry, fluid deficiency
and electrolyte imbalance
– Palpable mass (olive) in the RUQ
• Dx :
– Plain photo (Single bubble sign)
– Barium meal / OMD (Umbrella sign)
• Komplikasi : dehidrasi & aspirasi
• Tx :
– Non surgery : resusitasi cairan
– Surgery : pyloromyotomy
 Radiographic Features
Umbrella / Mushroom / String / Double-
Single Bubble sign track / Shoulder / Beak sign
(Plain Photo) (Barium Meal)
 Atresia / Stenosis Duodeni
• Atresia: complete
obstruction; stenosis:
partial obstruction
• Lokasi tersering di
duodenum pars
horizontal
• Symptom: regurgitasi &
vomit (bilous vomit)
• Dx : (double bubble)
– Plain photo In approximately 80% of affected
neonates, the site of duodenal atresia is
– Barium meal / OMD postampullary, so that the patient may
present with bilious vomiting.
Double bubble Sign

• Plain film radiograph

“Double bubble” Sign Barium meal / OMD
(gas-filled stomach and duodenum
dilatation with no distal gas)
• Without abdominal distension
Intestinal Obstruction
(jejunoileal obstruction)
Classic signs of patients with jejunoileal atresia :

• Bilious vomit
• Abdominal distention (in distal atresia)
• Jaundice (32%) which is characteristically due to indirect
hyperbilirubinemia
• Failure to pass meconium in the first 24 hours (rule out Hirschsprung
disease; passage of meconium does not rule out intestinal atresia)
• Abdominal distention is most evident in cases of ileal atresias, in which it
is diffuse, as opposed to proximal jejunal atresias, in which the upper
abdomen is distended and the lower abdomen is scaphoid.
• Intestinal loops and their peristalsis may be seen through the thin
abdominal wall of newborns.
Atresia Jejunum

• Triple bubble sign

• With abdominal
distension
• No gas in pelvic
cavity
Hirschprung Disease
• Kelainan kongenital akibat kegagalan
migrasi krista neuralis ke colon.
• Tidak terbentuk sel ganglionik pd
plexus myentericus (Auerbach) dan
plexus submucosal (Meissner)
• 80%  rectosigmoid
• Klinis :
– Delayed meconium (>24h)
– Abdominal distention
– Bilous vomiting
– Severe diarrhea alternating with
constipation
• Dx :
– Barium enema
– Rectal biopsy
– Anorectal manometry
Sign and Symptoms

• Symptoms may recur after previously

resolving with laxatives, or feeding
changes.

• Digital Rectal examination may

demonstrate a tight anal sphincter
and explosive discharge of stool and
gas.
- Frog-like abdomen
- Darm contour
- Darm steifung
- Metallic sound
 Radiographic Features
• Imaging can help diagnose • Contrast barium enema radiographs,
Hirschsprung’s disease. A plain After the dilation process begins, the
abdominal radiograph may show diseased portion of the colon will
a dilated small bowel or proximal appear normal and the more proximal
colon (no air in the rectum) colon will be dilated. A “transition zone”
(the point where the normal bowel
becomes aganglionic) may be visible on
a contrast enema radiograph
 Anorectal
Malformations
• The resulting malformations range from
isolated imperforate anus to persistent cloaca.

• Atresia ani (imperforate anus) is a congenital abnormality characterized by

persistence of the anal membrane resulting in a thin membrane covering
the normal anal canal or is the failure of the anal membrane to break
down (Noden and Lahunta 1985)

• If, after 24 hours, there is no meconium on the perineum, we recommend

performing a cross-table lateral x-ray with the baby in knee chest (prone)
position.

useful in determining the

level of atresia
 Klasifikasi Atresia Ani
• Menurut Berdon, membagi atresia ani berdasarkan
tinggi rendahnya kelainan, yakni :
~ Atresia ani letak tinggi : bagian distal rectum
berakhir di atas muskulus levator ani (jarak > 1,5 cm
dengan kulit luar)
~ Atresia ani letak rendah : bagian distal rectum
melewati musculus levator ani (jarak < 1,5cm dari kulit
luar)

• Menurut Stephen, membagi atresia ani

berdasarkan pada garis pubococcygeal :
~ Atresia ani letak tinggi : bagian distal rectum
terletak di atas garis pubococcygeal.
~ Atresia ani letak rendah: bagian distal rectum
terletak di bawah garis pubococcygeal.

“high” supralevator lesions are typically associated

with fistulas
Invertogram
PSARP = posterosagittal anorectoplasty
Bukti klinis atresia ani letak rendah = perineal fistula, bucket handle, midline raphe fistula, stenosis anal, anal
membrane
Bukti klinis atresia ani letak tinggi = flat bottom, fistula rectovesica
 Intussusception
(Invagination)
• Invagination of a proximal portion of intestine (intussusceptum) into a
more distal portion (intussuscipiens), is one of the most common causes
of bowel obstruction in infants and toddlers.
• > 80% involves the ileocecal region.

• Occur in children less than one year of age, with a peak incidence
of between 6-10 months. (>> 9 months)

TRIAS :
• Colicky & Cramping abdominal pain
• Bilious vomiting
• Mucous-red “currant jelly stools”

Physical Exam :
• Palpable abdominal mass
(Sausage Appearance)
• Dance ‘s sign
 Radiographic Features Intussusception
USG :
• Target or doughnut sign (Transverse cross section)
• Sandwich sign, pseudokidney sign (Longitudinal
section)

Pseudokidney sign
Barium Enema : Cupping sign
(as a diagnostic) or therapeutic  (non-
operative reduction)
 Volvulus

• Volvulus of the intestine, the twisting of a segment of intestine on its

mesentery, can be a primary pathology or secondary to malrotation of the
intestine. Clinical presentations vary from acute abdominal emergency
requiring immediate surgical intervention to insidious history of colicky
abdominal pain.

• Volvulus of the small intestine is commonly associated with abnormality

of intestinal rotation and fixation. This is due to failure of fixation and
narrow mesenteric base which allow volvulus to occur. Midgut volvulus
can lead to irreversible intestinal necrosis, which is potentially fatal.

• Large bowel volvulus on the other hand is rare in children; it usually

occurs as a result of redundant sigmoid colon and affects mainly adults.
• Up to 80% of patients present in the first month of life (20% of patients
present after the first year of life) and in this age group the cardinal
symptom is bile (green) vomiting due to duodenal obstruction through
midgut volvulus.
• Pain, irritability, and other non-specific symptoms (anorexia or nausea was
noted) are more common in toddlers and older children.
• The coffee-bean sign (also known as bent inner tube sign) is a sign on an
abdominal plain film.
• This thick 'inner wall' represents the double wall thickness of opposed
loops of bowel, with thinner outer walls due single thickness.
Gastroschisis
• Definition : defect
in development of
abdominal wall
results in
protrusion of
abdominal viscera
without a visceral
sac
Omphalocele
• Definition : defect
in development of
abdominal wall
results in
protrusion of
abdominal viscera
in a visceral sac
Plastic Surgery
ATLS 9th Ed, 10th Ed

Advance Burn Life Support (2007) /Burn Clinical Practice Guideline Texas EMS Trauma & Acute Care Foundation Trauma Division (2016)
 Superficial Partial
Thickness Burn (IIa)
 Deep Partial
Thickness Burn (IIb)
Full Thickness Burn
(III)
 Total Body
Surface Area

To estimate scattered burns: patient's

palm surface = 1% total body surface
Parkland formula = Baxter formula area
New Update – ATLS 10th ed
 Indikasi Rawat Inap
Menurut American Burn Association/Texas EMS Trauma, ATLS 9th & 10th ed, seorang
pasien diindikasikan untuk dirawat inap bila:

1. Partial thickness burns greater than 10 percent of the patient’s TBSA.

2. Burns that involve the face, hands, feet, genitalia, perineum or major joints.
3. Third-degree burns in any age group.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury in patients with pre-existing medical disorders that could complicate
management, prolong recovery or affect mortality (e.g.,diabetes, renal failure).
8. Any patient with burns and concomitant trauma (such as fractures) in which the
burn injury poses the greatest risk of morbidity or mortality. In such cases, if
the trauma poses the greater immediate risk, the patient initially may be
stabilized in a trauma center before being transferred to a burn unit. Physician
judgment will be necessary in such situations and should be in concert with the
regional medical control plan and triage protocols.
9. Burned children in hospitals without qualifed personnel or equipment for the
care of children.
10. Burn injury in patients who will require special social, emotional or
rehabilitative intervention.
 Indikasi klinis adanya trauma inhalasi
Luka bakar yang mengenai wajah dan/atau leher

Alis mata dan bulu hidung hangus

Adanya timbunan karbon dan tanda peradangan akut orofaring

Sputum yang mengandung karbon/arang

Suara serak

Riwayat gangguan mengunyah dan/atau terkurung dalam api

Luka bakar kepala dan badan akibat ledakan

Secure airway (pembebasan jalan nafas) segera dengan airway definitif (intubasi)
 Luka Bakar Sirkumferensial
Luka bakar ekstremitas
(terutama bila • Cek tanda-tanda sindrom kompartemen (5P)

sirkumferensial)

Lepaskan semua perhiasan

yang menempel pada • Menurunkan efek tekanan

ekstremitas

Nilai status sirkulasi distal • Cyanosis, penurunan CRT, parestesia, nyeri jaringan dalam). Paling baik dengan
Doppler USG flowmetri
ekstremitas

• Menurunkan tekanan intrakompartemen (sebaiknya konsul dengan dokter bedah

Escharotomy terlebih dahulu)

• Walaupun jarang digunakan, fasciotomy dapat memperbaiki sirkulasi ekstremitas

Fasciotomy pada pasien dengan trauma skeletal, crush injury, LUKA BAKAR LISTRIK TEGANGAN
TINGGI, luka bakar yang melibatkan jaringan hingga fascia
 Luka Bakar Listrik
• Akibat kontak sumber listrik dengan tubuh  tubuh
berperan sebagai konduktor  kerusakan jaringan
timbul akibat panas yang dihasilkan
• Kulit tampak relatif normal namun jaringan otot
dibawahnya nekrosis
• Arus listrik yang berjalan di dalam pembuluh darah dan
saraf  trombosis dan cedera saraf
• Rhabdomiolisis  mioglobin meningkat  AKI
• Arus listrik dapat mengganggu sistem konduksi jantung
dan menyebabkan aritmia
• Urin gelap menandakan hemokromogens
 Luka Bakar Listrik

Stabilisasi airway dan breathing

Jalur IV, monitor EKG, pemasangan kateter urin

Kerusakan otot luas  sindrom kompartemen  SERING

MEMBUTUHKAN FASCIOTOMY

Rhabdomyolisis  pelepasan myoglobin  myoglobinuria 

gagal ginjal akut
• Pencegahan: curigai adanya rhabdomyolisis bila urin pasien gelap 
administrasikan cairan untuk membuat urine output 100 cc/jam (dewasa) atau
2 cc/kg/jam (anak < 30 kg)
 Luka Bakar Kimia
• Perhatikan kerusakan yang progresif
• Perhatikan kerusakan organ (mata, telinga,
dlsb)
• Prinsip penanganan  dilusi
• Jangan mencoba menetralisir asam dengan
basa, vice versa

(ANZBA, 2013)
 The Neonatal Period
• Surgical Repair
– Cleft Lip
• In US - “the rule of tens” - 10 wks, 10 pounds/lbs, Hgb
10 (+ leucocyte count ≤ 10,000u/L
• Lip adhesion vs baby plates
– Cleft Palate
• Varies from 6-18 months - most around 10 mo
• Early repair may lead to midface retrusion
• Early repair improves speech
Le Fort fracture classification
TemporoMandibular Joint Dislocation
(Locked Jaw)

Type :
• Anterior
• Posterior
• Superior

Unilateral /
Bilateral
The patient is unable to close the mouth and may have garbled speech,
drooling and in pain .
A depression may be noted in the preauricular area. Palpation of the TMJ
reveals one or both of the condyles trapped in front of the articular eminence
and spasm of the muscles of mastication.
In addition, the coronoid process of the mandible becomes prominent and
palpable just below the maxilla

Treatment depends on
patient status and varies
from simple reduction to
surgical intervention.
Manual closed Reduction (Classic)
Barton bandage
• Application of a Barton bandage
after reduction (for 2-3 days)
• Apply warm compresses to the TMJ
area for 24 hours
• Avoid extreme opening of the jaw
for three weeks. In some patients,
placement of a padded rigid cervical
collar.
• Support the lower jaw when
yawning.
• Maintain a soft diet for one week.
• Take nonsteroidal anti-
inflammatory agents (eg ibuprofen
10 mg/kg orally every six hours as
needed, maximum single dose : 800
mg) as needed for pain and swelling.