prescase 6

7/29/2019 PRESCASE 6

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CASE REPORT

I.I Patient Personal Data

Name : Mr. . FA

Age : 20 years

Gender: male

Address : Tegal Gubug

Occupation: Student

Religion : Islam

I.2 Anamnesis

The main complaint :Left abdominal pain

History Disease Now :

The patient came to the hospital emergency room complaining Arjawinangun with

abdominal pain left . Around 13:00 ( approximately 6 hours before MRS ) fell down the stairs with

a height of approximately 2 meters when renovating his house . At the time of fall hit the left

abdomen bamboo ladder . By the time the patient is still conscious fall , accompanied by pain in the

left abdomen . Patients do not feel dizzy , nauseated , or want to vomit .

Past history of disease :

History of Heart Disease ( - )

History of Renal Disease ( - )

Family history of disease :

History of heart disease ( - )

Disease history DM ( - )

History of allergy medicines ( - )

I.3 Physical Examination

General state : CM

Vital Sign :

TD : 130/80 , lying , right arm , the cuff adult

Nadi : 88x/menit , regular , pulse enough content , the quality is quite


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RR : 39.2 x / minute , regular

T : 36.5 degrees using axillary temperature

head :

Inspection : anemic conjunctiva - / - , sclera jaundice - / - , pupil isokor + / + , light reflex + / +

Palpation : hematoma - , crackles -

neck

Inspection : normocolli

Palpation : no palpable enlarged lymph nodes , there is no deviation of the trachea , JVP does not

increase

thorax

Pulmo :

Inspection : normal chest shape , symmetrical ( + / + ) , retraction ( - / - ) , motion lag ( - / - ) .Palpation : Vocal fremitus at the left and dextra

Percussion : resonant ( + ) on pulmonary and left dextra

Auscultation : basic sounds : vesicular in both lung fields

Additional sound : smooth ronkhi ( - / + ) , wheezing ( - / - )

cast :

Inspection : ICTUS cordis does not seem

Percussion : Top right : SIC II LPS Sinistra

Upper left : SIC II LPS dextra

Bottom right : SIC IV LPS dextra

Bottom left : SIC V 1 finger medial LMC Sinistra

palpation : ICTUS cordis is not strong lift

auscultation : S1 - S2 regular , noisy ( - )

abdomen

Inspection : flat , wound ( - ) , sikatrik ( - )

Auscultation : peristaltic ( + ) , normal

Palpation : outgoing, epigastric tenderness ( + ) , liver and spleen not palpable .

Percussion : timpani .

extremitas

Edema ( - / - ) , extremities warm , strong pulse .

Movement B / B

B / B

Muscle strength 5/5

5/5


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I.4 Examination Support

Plain photo abdomen ( BNO / Blass Neir Overzicht ) and LLD

impression :

Looked the picture of intestinal gas is floating

DARAH

LENGKAP

Hasil Nilai Normal

(Laki-laki)

Hemoglobin 13,2 g/dl 13,5-18

Hematokrit 39,2% 40-54

Hitung Eritrosit 5,10 juta/cmm 4,5-6,5

Hitung Leukosit 14.700 sel/cmm 4.000-11.000

Hitung Trombosit 385.000

sel/cmm

150.000-450.000

LED 114 mm/1 jam


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I.5 Diagnosis

Blunt Abdominal Trauma , Internal Bleeding Suspected intra-abdominal organs with signs of

peritonitis

I.6 Governance

O2 3-4 liters / minute

IVFD 26 TPM

Inj . 2x50 mg ranitidine

Inj . IM prophylaxis ATS 1500 iu / skin test

Inj . 3x500 mg amoxicillin / skin test


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CHAPTER II

Blunt abdominal trauma

Abdominal anatomy

Outside the abdomen

a.Abdomen

See that the abdomen to the thorax was partially due to the bottom, then the abdomen in the

superior part bounded by a line between mammary papilla , part of the inguinal ligament and the

inferior by the symphysis pubis , and laterally by the anterior axillary line .

b.Pinggang

This area is located between the anterior axillary and linea linea posterior axillary , and inpart limited by the superior and inferior SIC 6 bounded by the iliac crest . In contrast to the

abdominal wall is thin , the muscles of the abdominal wall at the waist is thicker and can be an

obstacle to penetrating injuries , particularly puncture wounds .

c.Punggung

This area is located at the back of the end linea posterior axillary scapula to the iliac crest .

Same with abdominal wall muscles on the side, back and paraspinal muscles act mostly as a barrier

penetrating injuries .

2.Anatomi abdomen in

a. The peritoneal cavity

The peritoneal cavity is divided into upper and lower sections thereof . Upper abdominal or

thoracoabdominal area covered by the bottom of the bony part of the thorax , including the

diaphragm , liver , spleen , transverse colon . The presence of bone costa makes this area difficult to

achieve with a full inspection and palpation . Because the diaphragm up to the SIC 4 at full

expiration , costa broken down or exit wound in the area or it can injure the contents of the

abdomen . Lower abdomen contains the small intestine and colon , uterus ( if gravid ) , and VU ( if

distended) . Perforation of organs is associated with the discovery of the physical examination and

is usually always manifest with pain from peritonitis .

b . pelvic cavity

Pelvic cavity surrounded by the pelvic bone , located at the bottom of the chamber

containing the retroperitoneum and VU , urethra , iliac vessels , rectum , small intestine and female


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internal genitalia ( ovaries , fallopian tubes , and uterus ) . Just like the thoracoabdominal region ,

examination to determine the structure of the pelvis injury complicated by bones on it .

c . cavity retroperitoneum

These areas include the abdominal aorta , inferior vena cava , a large part of the duodenum ,

pancreas , kidney , and urinary tract , the ascending colon and descending colon . Injury to this area

are difficult to identify by physical examination or DPL . Evaluation of structure in this region

requires a CT scan , angiography , and intravenous pyelogram .

Mechanism of trauma

Blunt abdominal trauma most often result in injury to the spleen ( 40-45 % ) , followed by

injuries to the liver ( 35-45 % ) and small intestine ( 5-10 % ) . In addition 15 % had retroperitonealhematoma .

Several mechanisms may explain the pathophysiology of blunt abdominal trauma . Broadly

speaking blunt abdominal trauma ( non penetrtaing trauma ) is divided into three , namely:

1 . compression trauma

Traumatic compression occurs when the front of the body stopped moving , while the back

and inside to keep moving forward . Organs squeezed from behind by the back thorakoabdominal

and vetebralis column and in front by the sandwiched structure . Abdominal trauma describe

specific mechanisms of variation trauma and emphasizes the principle that the state of the network

at the time of transfer of energy influencing tissue damage . In the collision , then the patient will

reflexively inhale and hold it by closing the glottis . Abdominal compression mengkibatkan

intrabdominal increased pressure and can cause rupture of the diaphragm and the translocation of

the abdominal organs into the chest cavity . Transient hepatic kongestion with blood as a result of

actions followed Valsalva sudden abdominal compression can cause rupture of the liver . Similar

situation may occur in the small intestine when intestinal closed loop sandwiched between multiple

spinal and incorrect seatbelt use .

2 . Trauma seat belt (seat belt )

Three-point seat belts when used properly , reduce the mortality of 65% -70 % and reduce

up to 10 times the weight of trauma . If not worn properly , seat belts can cause trauma . To function

properly , pengamna belt must be worn under the anterior superior iliac spine , and at the top of the

femur , can not slack off during a collision and passengers must bind properly . When used too high

( above SIAS ) the liver , spleen , pancreas , small intestine , diodenum , and kidneys will be


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sandwiched between the seat belt and the spine , and the resulting burst injury or laceration .

Hyperflexion vetebra lumbar belt due to high yangterlalu cause anterior compression fracture and

lumbar vetebra .

3 . Injury acceleration / deceleration .

Trauma occurs when deceleration stabilize parts of organs, such as renal pedicle ,

ligamentum teres stop moving , while the organ is stabilized to keep moving . Shear force occurs

when this movement continues, kidney and spleen samples on premises pedikelnya , liver laceration

of the liver 's central part , deceleration occurs when the right and left lobes around the ligamentum

teres .

History of traumaIn general , do not ask for a complete history to life-threatening injuries are identified and

receive appropriate treatment . AMPLE is often used to remember the key of history , ie Allergies ,

medications , Past medical history , Last meal or other intake , Events leading to the presentation .

History of trauma is very important to assess patients injured in motor vehicle collisions . This

information can be provided by the patient , other passengers , police or emergency medical

personnel in the field . Information regarding vital signs , visible injuries , and the response to the

pre - hospital care should also be given by the officers who provide pre - hospital care . At blunt

abdominal trauma is primarily a result of a traffic accident , the medical officer must ask the

following :

fatality from the incident ?

vehicle type and speed ?

whether the vehicle rolled over ?

how the condition of the other passengers ?

location of the patient in the vehicle ?

the severity of damage to the vehicle ?

deformity of the steering wheel ?

whether the victim using a seat belt ? Type of seat belts ?

whether the airbag on the side and front of the victim's work when the incident ?

whether there is a history of the use of alcohol and drugs before?

The severity of injuries to pedestrians varies depending on the speed and size of vehicles

that hit it . Bumper height versus height is a critical factor in patients with trauma . In adults in a

standing position , beginning with the bumper collisions are usually on the legs and pelvis . Knee


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trauma occurs as often as pelvic trauma . Children are more likely to be exposed TRUMA chest and

abdomen . Pedestrians often suffer injury triad ie legs, torso and cranium , as a result of the trauma

mechanism bumper collision , collision windshield and hood of the car , as well as a clash of heads

in the ground . Injury to one part of the evaluation requires a more immediate than injuries to other

body parts .

History and chronology of events is important, but the mechanism itself can not determine

whether or not required emergency laparotomy . Mechanisms and chronology of events must be

accompanied by other data such as prehospital vital signs , physical examination , diagnostic tests ,

and underlying health conditions .

Primary evaluation and management

Initial resuscitation and management of trauma patients based on the Advanced Trauma LifeSupport protocol . Initial assessment ( Primary Survey ) following ABCDE pattern , ie Airway ,

Breathing , Circulation , Disability ( neurologic status ) , and Exposure .

A.Intial assessment

Blunt abdominal trauma will appear in the manifestation of a very varied , ranging from

patients with normal vital signs and complaints of patients with minor to severe shock . Patients

could have come up with the initial symptoms are mild even though there is a severe intra-

abdominal injury . If there is evidence of injury extraabdominal , should be suspected intra-

abdominal injury , although the patient hemodynamically stable and no abdominal complaints . In

patients with hemodynamic instability , resuscitation and assessment should be carried out

immediately . Physical examination of the abdomen should be done carefully and systematically ,

with the order of inspection , auscultation , percussion , and palpation . Positive and negative

inventions should carefully recorded in the medical record .

1.Inspeksi

Patients should be opened all the clothes to make it easier . When fitted clothing Pneumatic

Anti- Shock Garment and hemodynamically stable patients , abdominal segments dikempeskan

blood pressure while the patient is monitored carefully . Decrease in systolic blood pressure of 5

mmHg is more adari sign to add fluid resuscitation before continuing pengempesan ( deflation ) .

Stomach front and rear , and also the bottom of the chest and perineum , should be checked if there

are scratches , rips , ekomosis , penetrating injuries , foreign bodies stuck , discharge omentum or

small intestine , and pregnancy status . Seat belt sign , the sign of the constitution or abrasion on the

lower abdomen , usually very berhubungna with intraperitoneal injury . Abdominal distention ,


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which is usually associated with pneumoperitoneum , gastric dilatation , or ileus as a result of

peritoneal irritation is an important thing that must be considered . Involving the presence of bluish

flank region , lower back ( Grey Turner sign ) indicates a retroperitoneal hemorrhage involving the

pancreas , kidney , or pelvic fractures . Bluish around the umbilicus ( Cullen sign ) indicates the

peritoneal bleeding will usually involve bleeding pancreas , but these signs are usually only found

after a few hours or days . Costa fractures involving the lower chest , usually associated with the

spleen or liver injury .

2.Auskultasi

Through auscultation of bowel sounds is determined whether there is or not . Decrease in

bowel sounds may come from the presence of chemical peritonitis due to bleeding or rupture of a

hollow organ . Injury to adjacent structures such as ribs , spine or pelvis can also cause ileusalthough no intra-abdominal injury , so the absence of bowel sounds does not mean that there must

be an injury intrabdominal . Presence of bowel sounds in the thorax indicates injury to the

diaphragm .

3.Perkusi

This maneuver causes the movement of the peritoneum , and may indicate the presence of

peritonitis are still dubious . Percussion may also indicate the presence of tympanic sound in upper

quadrant due to acute gastric dilatation or sound dim when there hemoperitoneum .

4.Palpasi

Tendency to harden the abdominal wall (voluntary guarding ) can complicate abdominal

examination . Instead defans muscular ( involuntary guarding ) is a reliable sign of peritoneal

irritation . Palpation goal is to get if found to determine the location of pain and superficial

tenderness , the tenderness , or pain off the press . Pain usually indicates a loose tap peritonitis

caused by the presence of blood or intestinal contents . At TRUMA blunt abdominal suspicion

should also be accompanied by pelvic fracture . To assess the stability of the pelvis , in particular by

emphasizing hands - on tualng iliac spine to generate abnormal movements or bone pain that

indicate pelvic fractures .

Although it can be detected through physical examination intraperitoneal injury , the

accuracy of physical examination in patients with blunt abdominal trauma ranged between 55-65

% . The absence of signs and symptoms found in the physical examination does not rule out the

existence of a serious injury , so that the necessary checks are more specific to avoid missed injury .


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Although not found signs and symptoms , sensory changes or injury extraabdominal that

ache in patients with blunt abdominal trauma should be directed to the injury intrabdominal . More

than 10 % of patients with closed head injury , along with intra-abdominal injuries , and 7 % of

patients with blunt trauma injuries extraabdominal have intraabdominal injury , although without

the pain .

In conscious patients without visible external injuries , the most visible symptoms of blunt

abdominal trauma is pain and peritoneal findings . In 90% of cases , patients with visceral injury

comes with local pain or general pain . These signs are not a specific sign , because it can also be

found in isolated thoracoabdominal wall fracture costa constitution or the bottom . And most

importantly , the absence of pain in the conscious patient and more stable indicating the absence of

injury . However , injury may occur in patients intrabdominal conscious and without pain .

Hypotension in blunt abdominal trauma is often as a result of bleeding or abdominal solidorgan abdominal injury vasa . Although the source of bleeding extraabdominal ( eg , scalp

lacerations , chest injury , or fracture of long bones ) should be addressed immediately , but the

evaluation of the peritoneal cavity also should not be overlooked . Patients with mild head injury

can not cause shock , except in patients with intracranial injury , or in infants with intracranial

hemorrhage or cephalohematoma .

Rarely rectal examination showed the presence of blood or subcutaneous emphysema , but if

found , the signs associated with abdominal injuries . Evaluation of rectal tone is a very important

part for patients with suspicion of spinal injury . High - riding prostate palpation direct indication of

the urethral injury .

Laboratory studies

Blood typing

In trauma patients should be checked blood type and cross -match , in case at any time

required transfusion , especially in patients with life-threatening bleeding .

Hematocrit

Hematocrit may be useful as the basis of assessment in patients with abdominal trauma ,

previously to measure it regularly for ongoing bleeding .

Leukocyte count

At blunt abdominal trauma , acute nonspecific leukocyte count . Ephinefrin tibuh released

during trauma may cause demarginasi and can increase the number of leukocytes reached 12000-

20000/mm3 with a moderate shift to a kir .

Pancreatic enzymes

Levels of serum amylase and lipase in the not too has significance for diagnostic support .


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Amylase and lipase levels were normal in the serum can not afford to get rid of adanay suspicion of

pancreatic trauma . Increase may lead to pancreatic injury , but may also be of non- pancreatic

abdominal injury . If there is suspicion of pancreatic injury , still need further investigation , eg CT

scan .

Liver function tests

Liver injury can increase in serum transaminase levels , but this increase will not occur in

minor constitution . Denagn comorbid patients as in patients with alcohol -induced liver disease

may have an abnormal transaminase levels

Toxicology analysis

Skrening routine drug and alcohol abuse have not been conducted on the management of

blunt abdominal trauma , especially in patients with a normal mental status .

UrinalysisGross hematuri lead to serious kidney injury and require further investigai . Also required an

examination of the micro hematuri Cedra which can indicate serious . Therefore, it is important

dialakukan microscopic examination or dipstick urinalysis in all patients with blunt abdominal

trayma . Presence of abdominal pain and hematuri has the sensitivity of 64 % and 94 % specific for

intra-abdominal injury that has dibuktilkan through a CT scan .

Specific Diagnostic Studies

A. Radiology

Radiology tests can convey important information for the management of blunt abdominal

trauma patients . Radiological examination is indicated in patients with stable , if a physical

examination and lab can not be inferred Diagnostics .

Uncooperative patients , may interfere with the test results and radiology can be at risk of spinal

injury . The cause of this koopertatif patients should be evaluated , such as hypoxia or brain injury .

For smooth , these patients can be considered to be a sedative .

X-rays for screening is Ro - photograph lateral cervical , thoracic AP , and AP pelvis in patients

with blunt trauma multitrauma . Abdominal x-ray photo 3 positions ( supine , semi- erect and lateral

decubitus ) allows you to see free air under the diaphragm or the air outside the lumen in the

retroperitoneum , that if there is to be a clue both to do a laparotomy . The loss of the psoas shadow

retroperitoneal indicate the possibility of injury . Plain abdominal have limited usefulness , and has

been replaced by CT - scan and ultrasound

B. Computed Tomography ( CT - scan )

CT is a diagnostic procedure that requires transport patients to the scanner , oral and


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intravenous contrast administration , and scanning of the abdomen and pelvis down . This process

takes time and is only used in patients with normal hemodynamics . CT - scan is able to provide

information relating to specific organ injury and severity , and can also diagnose injuries

retroperitoneum and pelvic organs that are difficult to access through a physical examination and

DPL . Kotraindikasi relative to the use of CT scanners include delays due to waiting , pendrita

uncooperative , and allergies terhdap contrast material .

Advantages CT - scan :

1.Non invasive

2.mendeteksi organ injury and the potential for non- operative management of liver and spleen

injuries

3.mendeteksi the bleeding and find out where the source of bleeding4.retroperitoneum and columna vetebra can be seen

Additional 5.imaging can be done if necessary

Weakness CT - scan

1.kurang sensitive to pancreatic injury , diaphragm , intestine , and mesentery

2.diperlukan intravenous contrast

3.mahal

4.Not can be performed on patients who are not stable

C. Ultrasound

Ultrasound is used to detect the presence of blood intraperitonum after blunt trauma . USG

is focused on areas where often found intraperitoneal blood accumulation , namely the

1.kuadran upper right abdomen ( Morison 's the space between the liver right kidney )

2.kuadran ats left abdomen ( perisplenic and left perirenal )

3.Suprapubic region ( perivesical area )

4.Subxyphoid region ( pericardiumhepatorenal space )

Anechoic areas due to the presence of blood can be seen most clearly when compared with

the surrounding solid organ . Many retrospective studies state the benefits of ultrasound in patients

with hemodynamically stable or unstable to detect intraperitoneal bleeding . Some RCTs

demonstrated the use of FAST for patients with diagnostic will produce better care outcomes .


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Advantages of ultrasound :

1.portabel

2.Can be implemented quickly

3.tingkat sesitifitas by 65-95 % in the detection of at least 100 ml of intraperitoneal fluid .

4.spesifik for hemoperitoneum

5.tanpa radiation or kotras

6.mudah dilakuakn serial examinations if necessary

7.tekniknya easy to learn

8.Non invasive

9.lebih cheap compared to CT - scan or peritoneal lavage

weakness ultrasound1.cedera dense parenchyma , retroperitoneum , or the diaphragm can not be seen well

2.kualitas image will be affected in patients who are not cooperative , obesity , presence of

intestinal gas , and subcutaneous air

3.darah indistinguishable from ascites

4.Not sensitive for detecting bowel injury .

Methods of ultrasound examination in the case of blunt abdominal trauma is FAST

( Focused Abdominal Sonogram for Trauma ) . The primary goal of FAST is to identify adanyan

hemoperitonium suspicion in patients with intra - abdominal injuries . FAST is an indication of

hemodynamically unstable patients with suspicion of abdominal injury and similar patients who

also had extra - abdominal injuries significantly ( orthopedic , spine , thorax , etc. . ) That require

non - abdominal surgical emergency .

FAST should be performed by surgeons who were present at that time in the ER / ICU as a

bedside procedure while resuscitation can continue. FAST recommended using a 3.5 or 5 MHz

sector ultrasound transducer probe and gray scale ' B ' mode ultrasound scanning .

Scan starts from the sub - xiphoid region in the sagittal plane . Probe is then moved to the right to

examine Morrison 's pouch ( hepato - renal ) ( sagittal plane ) . After that , the probe is moved to the

left to to assess the spleno - renal cavity ( sagittal plane ) . In this situation , it is recommended that

the bladder is filled with 200-300 ml of normal sterile solution through a urinary catheter which is

then clamped . This will provide excellent sonological window to visualize the pelvis ( transverse

plane ) . In patients with suspected bladder injury , avoid charging procedure above . Replace with


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bag laying on top hipogastrium saline , thereby causing acoustic window for pelvis.Waktu total

required for the entire procedure should be between 5-8 minutes .

D. Diagnostic peritoneal lavage

Diagnostic peritoneal lavage ( DPL ) has a major role in the management of blunt abdominal trauma

. DPL most useful in patients who have a high risk of hollow organ injury , especially if from the

CT - scan and ultrasound detected only a little fluid , and in patients with fever were real ,

peritonitis , or both . This situation lasted for 6-12 hours after injury hollow organs .

indications :

Changes in sensorium - head injury , alcohol intoxication , drug use .

The mood change - injury spinal cord tissue .

Injury to adjacent structures - below the rib cage , pelvis , spine of the lower back ( lumbar spine ) .Physical examination of the doubt .

Traditionally , DPL dialakukan through 2 stages , the first stage is the aspiration of free

intraperitoneal blood ( diagnostic peritoneal tap , DPT ) . If blood is aspirated 10 ml or more , stop

the procedure because it indicates the presence of intraperitoneal injury . If not available from DPT

blood , do peritoneal lavage with normal saline and immediately send the results to the lab weeks to

be evaluated .

Patients who require immediate laparotomy is the only counter- indication for DPL or DPT .

History of abdominal surgery , abdominal infection , coagulopathy , obesity and pregnancy

trimester 2 or 3 merupakn relative contraindications .

DPL profit / DPT

1.triase multisystem trauma patients with hemodynamic instability , bleeding through spending

intapertoneal

2.Can detect minor bleeding in patients with hemodynamically stable .

Drawbacks and complications DPL / DPT

1.infeksi local or systemic ( at less than 0.3 % of cases )

2.cedera intaperitoneal

3.positif false because the insertion of a needle through the abdominal wall hematoma or in

disorders of hemostasis

DPL interpretation


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At blunt abdominal trauma , aspiration of blood as much as 10 ml or more on suspicions

DPT showed more than 90 % against the intaperitoneal injury . If the results of lavage of patients

who are sent to RBC's lab showed more than can be said 100.000/mm3 then positive for intra-

abdominal injury . If the results of positive aspirations and an increase in RBC lavge indicate

injury , especially solid viscera and vascular structures , but it is not enough to indicate laparotomy .

In patients with pelvic fractures , should aware of the existence of false positives in the DPL .

Nevertheless, more than 85 % of cases , patients with pelvic fractures positive aspirations DPT

indicating intraperitoneal injury . Negative aspiration in patients with pelvic fractures hemodynamic

instability showed retroperitoneal bleeding , if so needed angiography with embolization .

Increased WBC occurred after 3-6 hours after the injury , so it does not really matter on the

interpretation of DPL . Increased amylase is also not specific and are not sensitive to Cedra

pancreas .

Kriteria untuk trauma abdomen yang positif DPL berikut tumpul

Index Positive Equivocal

Aspirate

Blood >10 mL -

Fluid Enteric contents -

Lavage

Red blood cells >1.000.000 / mm3 >20.000 / mm3

White blood cells >1.000.000 / mm3

>500 / mm3

Enzyme Amylase >20 IU/L and

alkaline phosphatase >3

IU/L

Amilase >20 IU/L or

alkaline phosphatase >3

IU/L

Bile Confirmed

biomechanically

-

Advanced management

Blunt abdominal trauma patients should be evaluated further operative treatment is needed

or not . After resuscitation and initial management by ATLS protocol , should be considered anindication for laparotomy through a physical examination , ultrasound ( U.S. ) , computed

tomography ( CT ) , and DPT / DPL


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Examination Procedure algorithms in Blunt Abdominal Trauma

REFERENCES

American College of Surgeon. 2004. Advanced Trauma Life Support. Terjemahan IKABI

(Ikatan Ahli Bedah Indonesia). First Impression :USA

Jong, Wim de. 2004.Buku Ajar Ilmu Bedah Edisi 2 . EGC : Jakarta


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King, Maurice . 2002.Bedah Primer Trauma. EGC : Jakarta

Marijata. 2006.Pengantar Dasar Bedah Klinis. Unit Pelayanan Kampus fakultas Kedokteran

Universitas Gajah Mada : Yogyakarta

Richard A Hodin, MD. 2007. General Approach to Blunt Abdominal Trauma in Adult.

UpToDate

Sabiston, David C. 1994.Buku Ajar Bedah Bagian 1. EGC : Jakarta

Sandy Craig, MD. 2006.Abdominal Blunt Trauma. E-Medicin

http://www.dokterbedahherryyudha.com
http://www.emedicine.com/cgi-bin/foxweb.exe/screen@/em/ga?book=emerg&authorid=3007&topicid=41http://www.dokterbedahherryyudha.com/2012/02/nephrolithiasis.htmlhttp://www.emedicine.com/cgi-bin/foxweb.exe/screen@/em/ga?book=emerg&authorid=3007&topicid=41http://www.dokterbedahherryyudha.com/2012/02/nephrolithiasis.html

prescase 6

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