A/M/17yo

77.38.04
Chief Complain : Swelling on the Mouth
It had been suffered by patient since 6 hours
before admission to Adam Malik Hospital.
Previously the patient was riding motorcycle and
the patient fell off the motorcycle while avoiding
another motorcycle. Patient’s face bump to the
road. Patient was not wearing helmet. History of
vomiting (-), unconsciousness (+), and seizure
(-). Patient was refered from district hospital.
 PRIMARY SURVEY
A : Clear
B : Spontan, RR : 20 times/minute
C : Warm acral, CRT <2”, HR : 88
beats/minute, BP : 110/70 mmHg
D : GCS 15 (E4V5M6)
E : Logroll and undressed → lacerated
wound o/t upper lips, upper gum rupture
VAS : 4
 AMPLE
A : No history of Allergy
M : No history of Medication
P : No history of Past Illness
L : Last meal 4 hours before accident
E : Street
 SECONDARY SURVEY
• Head : In localized state
• Neck : No abnormality was found
• Chest : No abnormality was found
• Abdomen : No abnormality was found
• Genitalia : Male, no abnormality was found
• Extremities : No abnormality was found
 Localized State
Head :
• Eye : equal pupil’s diameter 3mm/3mm, light
reflex +/+, diplopia (-), visus (+) normal.
Hematom (-), eye ball movement (+) normal

• Face : symmetric, crepitation (-), swelling (-), pain

(+), lacerated wound o/t upper lips 3 x 1 x 1 cm,
regular edge, minimal contamination

• Intra oral : floating maxilla (-), Malocclusion (+)

 Laboratory Findings
• Hb/Ht/WBC/PLT : 13,9/42/16.290/207.000
• Na/K/Cl : 145/4.2/110
• Ur/Cr : 32/0.98
• Random Blood Sugar : 157
CT-Scan 3D Midface
Chest X-Ray
Head CT-Scan
Working Diagnose:
HI GCS 15 + Dentoalveolar Fracture + Incisvus 1-
2 fracture + Lacerated Wound o/t upper lips
Treatment at ER :
• IVFD Crystaloid  Asering 20 drips/min
• Inj. Analgetic  Ketorolac Injection 30 mg
• Inj. Antibiotic  Ceftriaxone injextion 1 gr
• Inj. ATS
• Inj. TT
Prepare for :
Arch bar instalation + Primary Suture
 Operating Theater
• Patient in supine position with GA-ETT
• Aseptic and antiseptic procedure was done
• Insertion of soft wire on interdental maxilla
• Dentoalveolar reduction was done using soft wire
• Arch bar was installed in maxilla
• Bleeding Control
• Lacerated wound on lips’ mucose was sewed with Vicryl 4.0
• Operation was done
Post Op Operation