Casualty Report

Day/ date: Sunday / July 22nd 2018

Doctors on duty: Rizka, MD / Tika, MD / Tara, MD – Dessy, MD /
Gita, MD – Rindy, MD

Consultant on duty:
Mirta Hediyati, MD, ORL, PhD
Bronchoesophagology Consultant on Duty :
Elvie Zulka, MD, ORL, PhD
Identity & Chief Complaint

Female, 59 years old

Patient consulted from

Plastic Surgery Department
for evaluation due to
suspect of inhalation
trauma
Medical History

Patient exposed to explosion of gas stove in

the kitchen (closed room) 15 hours prior
admission and got burnt on face, neck, both
arms and legs (VAS 5)

Patient was taken to Primary Health Care

Service and referred to RS Arya Medika
and treated with IV Fluid 2000ml and
observation of fluid balance with catheter

Patient was referred to CMER and has

difficulty of breath and hoarseness 
suspect of inhalation trauma
Primary Survey

A: Clear, burn injury in the face

B: Spontan, RR: 20, SaO2: 100% on NRM

C: BP 120/90, HR 82x/m

D: Compos Mentis, E4M6V5

E: Mid dermal burn injury 38%TBSA

 ENT Examination

Ear Nose Throat

• Right and left • Right and left nasal • Symmetric
ear: cavity : nose hair is pharyngeal arch,
• wide ear canal, burned, there were uvula in the middle,
no discharge, no carbon soot, wide hyperemic posterior
minimal nasal cavity, inferior pharyngeal wall,
cerumen, intact turbinate eutrophic, there were no carbon
tympanic no discharge, no soot
membrane septal deviation, • Lung : Vesicular
good air passage sound symmetric, no
rhales nor wheezing.
 ENT Examination

Face : swelling, and

hyperemic, there was
crust
RFL CMER (February, 19th 2018)
Laboratory Examination CMER
(February 19th, 2019)

 Hb : 16,1 mg/dl  pH : 7,4

 Ht : 50,2 %  pCO2 : 38,2
 WBC : 6090 u/l  PO2 : 164
 Platelet : 255.000 u/l  SO2 : 99.4
 PT : 9,5 (10,0)
 BE : 0,4
 APTT : 31,6(33,4)
 Std HCO3 : 24,8
 Ureum : 18,3 mg/dl
 HCO3 : 24,3
 Creatinine : 0,738 mg/dl
 AST : 18  Total CO2 : 25,5
 ALT : 15
 BGL : 141 mg/dl
 Sodium : 139 mEq
 Potassium : 3,8 mEq
 Chlorida : 111 mEq
 Radiological Findings CMER
(February 19th, 2019)
 Chest X Ray:
 There were no abnormality
in the heart and lung
Working Diagnosis

There were no sign of airway

obstruction and inhalation trauma

Mid dermal to full thickness

burn injury 38.5% TBSA (T31.2)
Management
 Report to Susyana Tamin, MD, ORL, PhD :
▪ Antibiotic and analgetic according to Surgery
Department
▪ Epinephrine inhalation according to Surgery
Department
▪ Suggestion:
▪ Diagnostic Bronchoscopy  Currently ENT-
Bronchoesophagology Division is not able to this due to the
malfunctioned of equipment  Consult to Pulmonology if
needed