Air riffle wound, eko indra, www.senseheal.blogspot.com

1. F/M/13 yo

2. 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 (+).

3. Primary Survey
A: clear
B: spontaneous, RR: 20 times/minute
C: warm acral, HR: 88 times/minute, BP: 110/70
mmHg
D: GCS 15
E: undress, log roll  bruise (-)

4. Secondary Survey
• Head: air riffle shot wound on the forehead,
Ø 2 mm, regular edge, active bleeding (-
), pain (-)
• Neck: no abnormalities

5. • Chest: L: symmetrical
L: vesicular on both hemithorax
F: pain (-)
• Abdomen: L: symmetrical, distension (-)
L: peristaltic (+) normal
F: supple
• Extremities: no abnormalities

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

11. Working diagnosis: air riffle shot wound o/t
forehead

12. Management in the Emergency room:
• IVFD crystalloid
• Antibiotic injection
• Analgesic injection
• ATS injection
• Patient was prepared for elective corpal
extraction in the outpatient clinic