EDH GCS 10 With Suture Diastasis - Dhany Febriantara

Moderate Head Injury GCS 10 Due to
Acute Epidural Hematoma at The Left

Fronto-Temporo-Parietal Region
ICD10 : S06.4 MORNING REPORT
SKDI : 3B DHANY FEBRIANTARA
1808436201
Morning Report 2019 Surgery Department of Arifin Achmad General Hospital - Medical Faculty of Riau University
Patients Identity
Name : RES
Age : 17 years old
Sex : Male
Admission to Hospital : 19th of October 2019
Date of Examination : 19th of October 2019
Medical Record : 01 01 56 77
Primary Survey
Male, 17th years old came to emergency room with decrease of conciousness after had a traffic
accident 7 hours before admitted to the hospital, respon verbal (AVPU assessment)
ASSESS
 Airways and C-Spine Control

 Breathing and Ventilation
 Circulation and Haemmorage Control
 Dissability/Neurologic Evalutation
 Exposure/Environmental Control
Airway and C-Spine Control
Objectives
Patient came with inappropriate word
Additional breath sounds: gurgling (-), stridor (-), snoring (-)
Assessments
Airway clear
Actions
O2 NRM 10 L/min
Attached pulse oxymetri
Semi rigid neck collar application
Breathing and Ventilation
Objectives Objectives
Inspection Palpation
◦ RR 20x/minutes, reguler ◦ Crepitation (-)
◦ Symmetrical chest wall movement and no
sign of wound and laceration Auscultation
◦ Midline trachea ◦ Symmetric vesicular sound
◦ Neck vein distention (-) ◦ Normal S1 S2 heart sound
◦ “Sucking chest wound” (-)
Assessments
Breathing in normal condition
Actions
Monitoring O2 saturation
Circulation and Haemmorage Control
Objectives
◦ Pulse : 79 x/minutes
◦ Blood Pressure : 120/70 mmHg
◦ Warm extremieties
◦ CRT < 2 second
Assessments
Shock (-)
Actions
IVFD Ringer’s Lactate 20 dpm
Disability/Neurologic Evaluation
Objectives
◦ GCS (E2 M5 V3)
◦ Anisochoric pupil ø 2mm/4mm, direct and indirect light reflex (+/+)
◦ Muscle strength asymetrically abnormal (right hemiparesis)
Assessments
Lateralizations (+)
Exposure/Environmental Control
Objectives
◦ No sign of laceration or wound in entire body
◦ Temperature : 36,9 °C
Assessments
Hypothermia (-)
Actions
Blanket the patient
Secondary Survey
Chief Complaint
Male, 17th years old came to emergency room with decrease of conciousness after had a traffic
accident 7 hours before admitted to the hospital
AMPLE
- Allergies : (-)
- Medications : patient wasn’t in medication or alcohol
- Past illnesses : (-)
- Last meal : 13 hours before the accident
- Events : trauma mechanism
History of Present illness and Trauma
Mechanism
7 hours before admitted to the hospital, patients had a traffic accident when avoiding a motorbike
that was driving quickly on the road. At the time of accident, he was suffering pain and still had
response to people around. During the accident, patient wore a helmet. After thirty minutes from
accident, patient had projectile vomiting with decrease of conciousness.
Active bleeding from nose (-), active bleeding from the ear (-).
Patient was immediately taken to primary health care and then reffered to secondary health care
provider (Aulia Hospital). After he got early management of trauma, he was transferred to RSUD
Arifin Ahmad due to PICU was occupied.
Past illness history
No relation between past illness and present complaint.
Family illness history

No relation between family illness and present complaint.
Physical Examinations
General Status
General appereance : severe illness
Conciousness : apathy
Vital signs
◦ Blood pressure : 120/70 mmHg
◦ Heart rate : 79 beats/minutes
◦ Respiratory rate : 20 breaths/minutes
◦ Temperature : 36,9 °C
Head and Neck : localized status
Chest : with in normal limit
Abdomen : with in normal limit
Extremity : localized status
Genitourinatius : with in normal limit
Localized Status: Head and Neck
Face and head
Inspection
Vulnus excoriation in the left frontal region
Palpation
Minimal soft tissue swelling in the left temporo-parietal region
Neck
Lession (-), swelling (-)
Eyes
◦ Brill hematoma (-)
◦ Subconjungtival bleeding (-)
◦ Anisochoric pupille (diameter 2mm/4mm)
◦ Direct/indirect pupillary light reflex (+/+)
◦ Visual acuity on the right and left eye was difficult to assess
◦ Eye movement was difficult to assess
◦ Funduscopy was not done
Ear
Battle sign (-)
Localized Status: Extremity and Vertebrae
Extremity
◦ Right hemiparesis
◦ Difficult to assess strength muscle score due to decrease of conciousness
Vertebrae
• Laceration(-)
• Step off vertebrae(-)
Working Diagnose
MODERATE HEAD INJURY GCS 10
Work Up
Laboratory findings Radiologic findings
◦ Hb 14,6 g/dl - Chest X Ray AP
◦ HCT 45% - Head CT Scan
◦ WBC 22.700/ml
◦ PLT 211.000/ml
◦ Ureum 18 mg/dl
◦ Creatinin 0,9 mg/dl
◦ Bleeding Time 2 minutes
◦ Clotting Time 4 minutes
◦ HIV non reactive
◦ HbsAg non reactive
Work Up
• Appropriate identity
• Marker “Right”
• Photo quality is enough
• Midline trachea
• Intact bone
• Normally vertebrae
• Sharp costrophrenic angle
• Slippery diaphragm
• CTR < 50%
Conclusion: normally cor and pulmo
Work Up
o Soft tissue swelling
o Narrow sulcus with thickness of gyrus
o Hyperdense biconvek lesion in the right fronto-
temporo-parietal region, volume 60 ml
o Midline shifting to the right 5 mm
o Asymetrically ventricle system
o Narrow basal cistern
Work Up
Bone Window Head CT Scan
Diagnose
MODERATE HEAD INJURY GCS 10 DUE TO ACUTE EPIDURAL
HEMATOM AT LEFT FRONTO-TEMPORO-PARIETAL REGION WITH LEFT
LINEAR FRACTURE OS TEMPORAL
Treatment
Nonpharmacologic
• Head up 30°
• O2 NRM 10L/min
• Cervical immobilization with semi rigid collar neck
• Urine catheter and NGT insertion
• Craniotomy evacuation EDH
Pharmacologic
• IVFD Manitol 20%, 4x125 cc, bolus in 10-20 minutes
• Inject Ranitidin 3x50 mg IV
• Inject Ketorolac 3x30 mg IV
• Loading Phenitoin 1000 mg IV (dilute with 100 cc NaCl 0,9%) and maintain with continuous infusion 125
mg/12 hours
• In emergency room AA hospital, neurosurgeon give 100 mg phenitoin loading dose and 3x100 mg for
maintenance
Surgical Procedure
Epidural hematoma evacuation Linear fracture with suture diastasis

Final Diagnose
MODERATE HEAD INJURY GCS 10 DUE TO ACUTE EPIDURAL
HEMATOM AT LEFT FRONTO -TEMPORO-PARIETAL REGION WITH LEFT
LINEAR FRACTURE OS TEMPORAL WITH SUTURE DIASTASIS
Literature Reviews
Anatomy
Ellis H. Anatomy of head injury. Surgery. 2012:30(3);99-101.
Monroe-Kellie Doctrine
Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. Journal of
Cerebral Blood Flow & Metabolisme. 2016;36(8):1338-50.
Tim Neurotrauma. Pedoman tatalaksana cedera otak (Guideline in Mangement of Traumatic Brain Injury). Fakultas Kedokteran Universitas
Airlangga. 2014;2:16.
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EDH GCS 10 With Suture Diastasis - Dhany Febriantara

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Moderate Head Injury GCS 10 Due to

Acute Epidural Hematoma at The Left

 Airways and C-Spine Control

Family illness history

Epidural hematoma evacuation Linear fracture with suture diastasis

Ellis H. Anatomy of head injury. Surgery. 2012:30(3);99-101.

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