mild head injury + open depressed fracture of the frontalis sinus

8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus

1/23

Bedah Saraf

Mild head injury + Open depressed

fracture of the frontalis sinus


2/23

Patient identity

Name : Zulfahmi

Age : 23 years old

Sex : Male Address : Pesantren darul

hijrah,

Samahani, Aceh Besar

MR

: 987808

Phone : 085260422626

Drive license : (-)

Patient came at: 09.00 AM


3/23

Chief complaintDecrease of consciousness


4/23

Patient illnes historyThe patient was referred from private clinic to ZainoEmergency Room with decrease of consciousness for 1 houcomplaint started when he was riding motorcycle withoand suddenly strucked with another motorcycle from besidthen his head hit to the asphalt. History of decrease of cons(-). History of nausea and vomiting (+).


5/23

Physical examination

Primary survey :

A: Clear

B: Spontaneous, RR: 20 breaths/ minute, C: Pulse 82 beats/minute, Blood Pressure:

110/80 mmHg

D: GCS: 14 (E3M6V5) ; isochoric pupil Right3mm/ Left 3mm,

E:


6/23

L/S at the right frontal region

L: Wound (-), Swelling (+)

F: Deformity (+)

L/S at the upper face region

L: Hematoma (+), Edeme(+)

L/S at the mid face region

L: Swellling (-)

F: maxilla floating (+)

L/S at the lower face region

L: Swelling (-)

F: mandible floating (+)


7/23


8/23

Assessments:Mild head injury + Maxillofacial fracture (Le Fort II) + Mandfracture


9/23

Management

Stop oral intake

Head up 30

Oxygen 4 litre via canule

IVFDNaCl 0,9 % 20 drips/minutes

Urinary Catheter

Ceftriaxone inj. 1 gr

Metamizol Sodium inj 1 gr

Laboratory examination Radiology examination


10/23

Laboratory result Hb

: 11,8 gr/dl

White blood count : 8.500 /ul

Platelet : 239.000 /ul

CT : 7 minute

BT : 2 minute Ht : 35 %

Blood glucose ad random: 98 mg/dl


11/23

Radiology result

Head CT-Scan:

SCALP hematome ar the frontal region

There was depressed fracture at the right frontalregion

Sulcy and gyrus in normal limit

Ventricle and cysterna system in normal limit

There was no midline shift.

Scheddle AP / Lat

Parasymphisis of mandible fracture


12/23


13/23


14/23


15/23

Diagnose:Mild head injury + Open depressed fracture of the frontalis Maxillofacial fracture (Le Fort II) + Parasymphisis mandible fAnemia


16/23

Consult to Neurosurgery Division :Craniotomy depressed fracture elevated


17/23

Consult to Plastic surgery ORIF Elective

Head CT 3D

Oral hygiene


18/23

Intra operative

Patient in supine position, head up 300 with general anesthesia.

Performed aseptic and anti septic procedure

Performed linear incision at the frontal until bone

Identified depressed fracture at the anterior and posterior wall of frontalsinus

Irrigated wound with perhydrol 3% + povidone iodine 10% + normal salin0,9 %

Bone was removed with canable

Duramater intact and not tension

Performed decortication

Bleeding control

Bone was returned with mozaic position Wound closed by primary suture.


19/23

Post Operative diagnose

Mild head injury (ICD 10 CM S.06) + Open depressed fractfrontalis sinus (ICD 10 CM S.06) + Maxillofacial fracture ((ICD 10 CM S.06) + Parasymphisis mandible fracture (ICS02.60) + Anemia (ICD 10 CM D50)


20/23


21/23


22/23


23/23

Date S O A P

22/1/2014

POD I

Pain

(-)

VS/

BP : 110/70

mmHgPulse: 80

beats/mnt

RR:20

breaths/minute

GCS : E4 M6 V5

= 15

isochoric pupil

Mild head

injury (ICD 10

CM S.06) +Open

depressed

fracture of the

frontalis sinus

(ICD 10 CM

S.06) +

Maxillofacial

fracture (LeFort II) (ICD

10 CM S.06) +

Parasymphisis

mandible

fracture (ICD

10 CM S02.60)

+ Anemia (ICD

10 CM D50)

IVFD NaCl 0,9 % 30

drips/minutes

Ceftriaxone inj 2g/24hours

Ranitidin inj 25 mg

/12 hours

Metamizol Sodium 1

gr/8 hours

Liquid diet 6 x 100 cc

Oral hygiene

mild head injury + open depressed fracture of the frontalis sinus

Documents