MORNING REPORT

Laporan jaga tanggal 6 Juni 2015

(21.00-07.00)
Dokter Jaga: dr Wirdasari
Coass Jaga : Agustian Deny

Pasien lelaki usia 64 tahun

datang ke IGD pukul 23.05
dengan luka tusuk pada perut
kiri bawah.

Primary Survey
O A: Bersih, tidak ada sumbatan jalan napas
O B: RR 24 kali/menit, Sp02 97%, tidak

diberikan oksigen
O C : Nadi 97 kali/menit, reguler; akral
hangat; CRT < 2 detik, TD 80/60 mmHg
=> Fluid rescusitation IV NaCl 1 L dalam
15 menit
O D : GCS E4V5M6, motorik: 5/5/5/5,
sensorik: normal
O E : Jejas berupa luka tusuk di regio inguinal
sinistra
Pasien masuk ke prioritas 1

Secondary Survey (Identitas)

O Nama

: Tn. D
O Jenis Kelamin : Lelaki
O Umur
: 64 tahun
O Pekerjaan
: Swasta

Secondary Survey
(Anamnesis)

O Keluhan Utama

Luka tusuk pada perut kiri bawah.

O Riwayat Penyakit Sekarang

Pasien mengalami luka tusuk pada perut kiri

bawah menggunakan pisau 1 jam SMRS.
Luka tusuk diikuti dengan keluarnya usus dari
sumber luka. Pasien belum mendapatkan
penanganan hingga di bawa ke RS.
(tanyakan AMPLE)

Secondary Survey (Pemeriksaan

Fisik)
O Abdomen:
- Penetrating trauma pada regio inguinal

sinistra dan eviserasi rectum/sigmoid

(In patients with life-threatening injuries,

the secondary survey may be delayed for
operative therapy.)

Rencana Pemeriksaan
Blood type and cross-match
Complete blood count (CBC)
Glucose level
Prothrombin time (PT)/activated partial
thromboplastin time (aPTT)
Urinalisis

Focused abdominal sonography for

trauma (FAST)
O It consists of imaging of the four Ps.
Morrisons pouch, pouch of Douglas (or
pelvic), perisplenic, and pericardium.
O It is used to identify the peritoneal cavity
as a source of signifi cant haemorrhage.
O It is also used as a screening test for
patients without major risk factors for
abdominal injury.

Diagnosis
O Diagnosis Kerja:
O Vulnus scizum a/r inguinal sinistral
O Eviserasi

Penanganan awal:
O Observasi tanda-tanda shock: hemodinamik (TTV), peritonitis,

perdarahan
O Cairan 2000 cc/24 jam (RL:D5 = 1:1)
O Expose the area around the open abdominal wound by removing

the clothing around the wound.

O Do not touch the exposed organ with your hands or try to push the
organ back into the body.
O Cover organs with non-stick dressing (if unavailable, clean dressing
kept wet or plastic wrap)
O Inj. Anti tetanus serum 10.000 IU IM
O Inj. Cefoperazon 2 x 1 g IV
O Inj. Metronidazol 3 x 500 mg IV
O Puasa (persiapan sito OP)

Management
Indications for urgent laparotomy
O Blunt trauma with positive DPL or free blood on
ultrasound and an unstable circulatory status.
O Blunt trauma with CT features of solid organ injury
not suitable for conservative management.
O Clinical features of peritonitis.
O Any knife injury associated with visible viscera,
clinical features of peritonitis, haemodynamic
instability, or developing fever/signs of sepsis.
O Any gunshot wound.

selesaaaaii