Hikmal Fadilah/L/12 tahun (05-05-2006)/BW: 50 kg

MR :0001742236-190003907/ADM : 01-02-2019
DPJP : dr. Kurniawan Oki, SpBA

Resume
Pasien laki-laki 12 tahun masuk IGD RSHS dengan keluhan nyeri perut, 3 jam
sebelum masuk RS saat pasien sedang mengendarai motor di daerah Cijerah, tiba-
tiba pasien ditabrak oleh mobil dari arah depan dengan kecepetan sedang. Pasien
tidak menggunakan helm. Bagian dada dan perut pasien membentur aspal. Pasien
mengeluhkan nyeri pada bagian perut. Tidak ada riwayat penurunan kesadaran,
pingsan, muntah, maupun perdarahan dari telinga hidung dan mulut. Pasien belum
ada BAB. BAK tidak ada keluhan.
Setelah kejadian pasien dibawa ke RS Rajawali, kemudian pasien diperiksakan darah,
rontgen dan dilakukan penjahitan luka di daerah paha kiri. Kemudian pasien dirujuk
ke RSHS untuk penanganan selanjutnya.

Dari pemeriksaan thorax a/r left shoulder terdapat luka ekskoriasi

Dari pemeriksaan abdomen terdapat jejas di flank bilateral. Dari palpasi lembut,
terdapat nyeri tekan di abdomen bagian atas, tidak ada defense muscular
Diagnosis
Perdarahan intraabdomen ec. suspek trauma liver ec trauma tumpul abdomen dengan
hemodinamik stabil + Pneumothorax dextra

Rencana
Non Operative Management
Clinical Picture
Clinical Picture
Clinical Picture
Clinical Picture
Clinical Picture
 Hikmal Fadilah/L/12 tahun (05-05-2006)/BW: 50 kg
Perdarahan intra abdomen ec suspek trauma hepar dengan hemodinamik +
pneumothorax dextra
 Hikmal Fadilah/L/12 tahun (05-05-2006)/BW: 50 kg
Perdarahan intra abdomen ec suspek trauma hepar dengan hemodinamik +
pneumothorax dextra
 Hikmal Fadilah/L/12 tahun (05-05-2006)/BW: 50 kg
Perdarahan intra abdomen ec suspek trauma hepar dengan hemodinamik +
pneumothorax dextra
 Status present
04-02-2019

S: A:
Nyeri perut berkurang, kembung (-) Perdarahan intraabdomen ec. suspek trauma liver
Demam tidak ada, sesak berkurang ec trauma tumpul abdomen dengan
hemodinamik stabil yang telah dilakukan Non
operative management POD 3+ Pneumothorax
O: dextra post CTT POD 3
Composmentis
Frekuensi nadi 92 x/menit P:
Frekuensi napas 22 x/menit, • Feeding diet cair
Suhu 370 C • Observasi tanda vital
Thoraks : Bentuk dan gerakan simetris kiri kanan, • Ceftriaxone 2 x 1 Gram IV
suara nafas vesikuler kiri dan kanan, rhonki -/-
terpasang thoraks tube • Metronidazol 3 x 500mg IV
WSD : Undulasi (+) Bubble (-) produksi • Paracetamol 3 x 500mg IV
serosanguine + 20ml/jam • Wound care
Abdomen : datar, Lembut, bising usus (+), • Monitoring WSD dan X-ray thorak serial
terdapat jejas di flank bilateral
Inguinal sinistra : vulnus laceratum, jahitan intak.
Ekstremetas : Akral hangat, CRT> 2 detik
 Laboratorium

Parameter 01-02-19 02-02-19 02-02-19

19.42 01.50 08.01
Hb/Ht/L/Tr 9,7/27,2/38.090/243.00 8,2/23,2/23.690/214.000 7,8/22,3/14.890/208.000
0
CRP 0.40
GDS 187
PT/INR/APTT 14,6/1,32/26,5
SGOT/SGPT 86/44
Prot/Alb 6/3
Ur/Cr 32/1,4
Na/K 135/3.6
Asam Laktat 7.7
Amilase/Lipase 90/373
pH/pCO2/pO2 7,326/28,4/230,7
HCO3/tCO2/st BE- 15/15,9/-9,2/99,1
b/Sat O2
 Laboratorium

Parameter 02-02-19 03-02-19

19.11 06.26
Hb/Ht/L/Tr 9.0/25.3/11.840/173.00 8.3/23.5/11.720/197.000
0
CRP
GDS
PT/INR/APTT
SGOT/SGPT
Prot/Alb
Ur/Cr
Na/K 129/4.5
Asam Laktat
Amilase/Lipase
pH/pCO2/pO2
HCO3/tCO2/st BE-
b/Sat O2
 Femur X-Ray
01-01-19, Rajawali Hospital
 Pelvis X Ray
01-02-19, Rajawali Hospital
 Chest X-Ray
01-01-19, RSHS
 Cervical X Ray
01-02-19, RSHS
 Pelvis X Ray
01-02-19, RSHS
 Pelvis X Ray
01-02-19, RSHS
 Pelvis X Ray
01-02-19, RSHS
 FAST
01-02-19, RSHS
 FAST
01-02-19, RSHS
 FAST
01-02-19, RSHS
Working Diagnosis :
Intraabdominal bleeding due to suspected Liver Injury due to Abdominal blunt trauma
with stable hemodynamic + Pneumothorax Dextra

Management :
Non-operative management start from 01-02-19 23.00 am
• O2 via NRM 10 L/min
• Fasting
• Insertion of OGT no 12 Fr
• Insertion of folley catheter no 12 Fr
• Loading NaCl 0,9% 20 cc/kgBW
• PRC Transfusion 10 cc/kgBW
• IVFD NaCl 0,9% 2100 ml/24 hrs
• Ceftriaxone 1 x 2 g IV
• Paracetamol 4 x 500 m g IV
• Serial blood examination Hb/Ht
• Plan to do Abdominal CT Scan  the device under maintanence  plan to do CT
Scan at working hour
• Plan for Chest Tube Thoracostomy Dextra
 Observation Table
Date & Conscious HR RR BP Temp Urine Output Extremities SpO2 Notes
time ness (mlBW/hour)
01-02- E4M6V5 120 35 70/50 36.4 Initial urine 150 ml, cold, CRT 98 O2 via NRM 10 L/min
19 clear >2” Insertion of OGT no 14 Fr
19.00 Loading NaCl 0,9% 20 cc/kgBW
Insertion of folley catheter no 14 Fr
Ceftriaxone 2 x 1 gr IV
Paracetamol 4 x 1 gr IV
Plan for Chest Tube Thoracostomy
Dextra
19.30 E4M6V5 108 32 100/50 36.3 1,5 cc/Kg BW/Hour cold, CRT 100 O2 via NRM 10 L/min
>2” IVFD RL 2100 ml/24 hr

20.00 E4M6V5 98 32 100/50 36.7 1,8 cc/Kg BW/Hour Warm, CRT 100 IVFD NaCl 0,9% 2100 ml/24 hrs
< 2” Monitoring urine output & vital
signs

21.00 E4M6V5 100 35 110/60 36,5 1,6 cc/Kg BW/Hour Warm, CRT 100 FAST  Fluid collection at
< 2” hepatorenal and retrovesica space
Plan to do Abdominal CT Scan 
the device under maintanence 
plan to do CT Scan at working hour
22.00 E4M6V5 100 37 100/60 36,2 1,3 cc/Kg BW/Hour warm, CRT 98 IVFD RL 2100 ml/24 hr
2” Monitoring urine output & vital
signs
23.00 E4M6V5 92 32 110/70 36,3 1,2 cc/Kg BW/Hour warm, CRT 94 IVFD RL 2100 ml/24 hr
2” O2 via NRM 10 L/min
Monitoring urine output & vital
signs
 Observation Table
Date & Conscious HR RR BP Temp Urine Output Extremities SpO2 Notes
time ness (mlBW/hour)

02-02- E4M6V5 94 44 100/70 36,4 Urine output 1,6 Warm, CRT 98 IVFD RL 2100 ml/24 hr
19 cc/BW/hour < 2” O2 via NRM 10 L/min
00.00 Monitoring urine output & vital signs

01.00 E4M6V5 98 40 100/60 36,6 1,5 cc/Kg BW/Hour Warm, CRT 99 IVFD RL 2100 ml/24 hr
< 2” O2 via NRM 10 L/min
Monitoring urine output & vital signs
02.00 E4M6V5 96 38 110/70 36,5 1,3 cc/Kg BW/Hour warm, CRT 99 Paracetamol 4 x 1 gr IV
2” IVFD RL 2100 ml/24 hr
O2 via NRM 10 L/min
Monitoring urine output & vital signs
03.00 E4M6V5 94 36 100/60 36,3 1,6 cc/Kg BW/Hour warm, CRT 98 IVFD RL 2100 ml/24 hr
2” O2 via NRM 10 L/min
Monitoring urine output & vital signs

04.00 E4M6V5 82 31 100/60 36,1 1,6 cc/Kg BW/Hour warm, CRT 100 IVFD RL 2100 ml/24 hr
2” O2 via NRM 10 L/min
Monitoring urine output & vital signs

05.00 E4M6V5 96 32 110/70 36,4 1,4 cc/Kg BW/Hour warm, CRT 100 IVFD RL 2100 ml/24 hr
2” O2 via NRM 10 L/min
Monitoring urine output & vital signs
 Observation Table
Date Consciou HR RR BP Temp Urine Output Extremitie SpO2 Notes
& sness (mlBW/hour) s
time
06.00 E4M6V5 94 34 110/70 36,4 1,4 cc/Kg warm, CRT 100 IVFD RL 2100 ml/24 hr
BW/Hour 2” O2 via NRM 10 L/min
Monitoring urine output & vital
signs
07.00 E4M6V5 92 36 110/70 36,4 1,4 cc/Kg warm, CRT 98 IVFD RL 2100 ml/24 hr
BW/Hour 2” O2 via NRM 10 L/min
Monitoring urine output & vital
signs
08.00 E4M6V5 96 32 110/70 36,4 1,4 cc/Kg warm, CRT 94 IVFD RL 2100 ml/24 hr
BW/Hour 2” O2 via NRM 10 L/min
Monitoring urine output & vital
signs
Ceftriaxone 2 x 1 gr iv
Paracetamol 4 x 1 gr iv
Chest X-Ray (Post Chest Tube insertion)
02-02-19, RSHS