Air Riffle Wound - Eko Indra

F/M/13 yo

Chief complain: air riffle shot wound on the forehead

It has been suffered since 2 hours before admitted to hospital. He was carrying an air riffle when he fell down and accidentally shot his forehead. History of decrease consciousness (-), decrease vision (+).

Primary SurveyA: clearB: spontaneous, RR: 20 times/minuteC: warm acral, HR: 88 times/minute, BP: 110/70 mmHgD: GCS 15E: undress, log roll bruise (-)

Secondary Survey• Head: air riffle shot wound on the forehead,

Ø 2 mm, regular edge, active bleeding (-), pain (-)

• Neck: no abnormalities

• Chest: L: symmetrical L: vesicular on both hemithorax F: pain (-)

• Abdomen: L: symmetrical, distension (-)L: peristaltic (+)

normalF: supple

• Extremities: no abnormalities

Laboratory findingsHb/Hct/Leu/Plt : 14.3/39.5/11.18/248Na/K/Cl : 130/4.3/100Ur/Cr : 17.65/0.57KGD : 119.53

Working diagnosis: air riffle shot wound o/t forehead

Management in the Emergency room:• IVFD crystalloid• Antibiotic injection• Analgesic injection• ATS injection• Patient was prepared for elective corpal

extraction in the outpatient clinic