Charles J. McCabe

Delayed appendectomy for appendicitis: Causes and consequences

This study was undertaken to describe the causes and consequences of delayed diagnosis and intervention in cases of appendicitis. The hospital records of adult patients undergoing appendectomy during a 4-year period (November 1989 to November 1993) were reviewed, with concentration on 40 patients who had a delay of 72 hours or more from initial symptoms to operation. The initial medical contact points for patients were walk-in clinics and community emergency departments. Definitive care was provided in a general hospital. Patients were adults with appendicitis who underwent an operation for definitive management 72 or more hours after the onset of symptoms. Length of hospital stay, reasons for delay in diagnosis, incidence of perforation, and complications were recorded. Delay in diagnosis and treatment was attributed to factors controlled by the patient in 15 cases (27.5%) and by the physician in 25 cases (62.5%). Perforation, postoperative complications, and hospital length of stay were related to the delay in diagnosis; with delay, the mean hospital length of stay was 9 days, the incidence of perforation was 90%, and major complications were recorded in 60% of the patients. Early diagnosis and surgical management for appendicitis remains an important and, at times, elusive goal. Delays of 72 hours or more have serious consequences. Patient education and the experience, intuitiveness, and persistence of the physician are important elements to improving these findings.

ULTRASONOGRAPHY BY EMERGENCY PHYSICIANS IN PATIENTS WITH SUSPECTED URETERAL COLIC

We performed a prospective study of patients with suspected ureteral colic to evaluate the test characteristics of bedside renal ultrasonography (US) performed by emergency physicians (EPs) for detecting hydronephrosis, and to evaluate how US can be used to predict the likelihood of nephrolithiasis. Thirteen EPs performed US, recorded the presence of hydronephrosis, and made an assessment of the likelihood of nephrolithiasis. All patients underwent i.v. pyelography (IVP) or unenhanced helical computed tomography (CT). There were 126 patients in the study: 84 underwent IVP; 42 underwent helical CT. Test characteristics of bedside US for detecting hydronephrosis were: sensitivity 72%, specificity 73%, positive predictive value (PPV) 85%, negative predictive value (NPV) 54%, accuracy 72%. The PPV and NPV for the ability of the EP to predict nephrolithiasis after performing US were 86% and 75%, respectively. We conclude that bedside US performed by EPs may be used to detect hydronephrosis and help predict the presence of nephrolithiasis.

Emergency intravenous access through the femoral vein

A study was undertaken to assess the efficacy and safety of femoral venous catheterization for resuscitation of critically ill patients in the emergency department setting. From May 1982 to April 1983, 100 attempts were made at percutaneous insertion of a large-bore catheter into the femoral veins of patients presenting to our emergency department in cardiac arrest or requiring rapid fluid resuscitation. Eighty-nine attempts were successful. Insertion was generally considered easy, and flow rates were excellent. The only noted complications were four arterial punctures and one minor groin hematoma. This study suggests that short-term percutaneous catheterization of the femoral vein provides rapid, safe, and effective intravenous access.

The computed tomography appearance of recurrent and chronic appendicitis

The objective of this study was to determine computed tomography (CT) appearance of recurrent and chronic appendicitis. In 100 consecutive appendiceal CT examinations of proven appendicitis, 18 patients met criteria for recurrent (multiple discrete episodes) or chronic (continuous symptoms > 3 weeks, pathological findings) appendicitis. CT findings were reviewed. Ten patients had recurrent appendicitis, 3 had chronic appendicitis, 3 had both, and 2 had pathological chronic appendicitis. CT findings in 18 recurrent/chronic cases were identical to 82 acute appendicitis cases, including pericecal stranding (both 100%), dilated (> 6 mm) appendix (88.9% versus 93.9%), apical thickening (66.7% versus 69.5%), adenopathy (66.7% versus 61.0%), appendolith(s) (50% versus 42.7%), arrowhead (27.8% versus 22.0%), abscess (11.1% versus 11.0%), phlegmon (11.1% versus 6.1%), and fluid (5.6% versus 19.5%). CT findings in recurrent and chronic appendicitis are the same as those in acute appendicitis. Appendiceal CT can be beneficial for evaluating patients with suspected recurrent or chronic appendicitis.

Acute traumatic disruption of the thoracic aorta: Emergency department management

STUDY OBJECTIVE To evaluate the safety and effectiveness of temporary IV antihypertensive therapy in patients with acute traumatic thoracic aortic disruption. DESIGN Retrospective chart review of all patients treated for proven traumatic aortic disruption during the ten-year period of 1980 through 1989. SETTING Emergency department of a large, urban, Level I trauma center. INTERVENTIONS Preoperative IV beta-blockade and nitroprusside after initial resuscitation in hemodynamically stable patients. RESULTS Thirty-seven patients with angiographically proven aortic disruption were separated retrospectively into one of three groups. Group 1 (15 patients without preoperative antihypertensive therapy) had two deaths. Group 2 (15 patients treated for two to seven hours [mean, 3.8 hours] before surgery with antihypertensives) had one death. Group 3 (seven patients treated with antihypertensives for 24 hours to four months before surgery to allow recovery from associated severe injuries) had one death. There were no complications resulting from antihypertensive therapy. CONCLUSION Temporary antihypertensive therapy appears to be safe and effective in patients with aortic disruption.

Improved limb salvage in popliteal artery injuries

This study reviews the recent experience with popliteal artery injuries at the Massachusetts General Hospital. Twenty-two patients suffered 24 injuries. The overall limb salvage was 83%. Blunt trauma accounted for 19 of the cases and was associated with femur fractures, knee dislocations, and tibia-fibular and plateau fractures: four amputations (21%) resulted. There were five penetrating injuries from three gunshot wounds, one stab wound, and one laceration: no amputations occurred. The major factor in the amputated limbs was delay in diagnosis and therapy of the arterial injury associated with blunt trauma. Arterial disruption secondary to penetrating injuries was recognized more quickly and had a better outcome. A higher index of suspicion in blunt trauma may improve results. Recommendations for therapy are: arterial reconstruction should generally precede orthopedic operation. Venous ligation was not associated with increased limb loss, but we recommend repair if possible. Arterial repair includes thrombo-embolectomy in distal arteries. If necessary, reverse saphenous vein is grafted. When operation is unsuccessful, revision should be performed.

Pediatric splenic trauma: Predicting the success of nonoperative therapy

The charts of all pediatric patients discharged from the Massachusetts General Hospital with a diagnosis of a ruptured spleen were reviewed over a six-year period to determine if any factors could be used to predict which children could be managed safely without operation. Seventy-five percent of these injuries were so managed. The patients who required surgical intervention were older (mean age, 17 years), had multiple injuries (mean ISS, 41), presented with more blood loss (mean hematocrit, 23.5%), and suffered their injuries as a result of a motor vehicle accident. The patients who were successfully managed nonoperatively were younger (mean age, 12 years), had fewer associated injuries (mean ISS, 18), required fewer blood transfusions, and suffered their traumas secondary to falls, sporting events, or altercations. We propose that the injury severity score, the number of units of blood transfused, patient age, as well as the type of trauma suffered be used to predict which patients can be safely managed nonoperatively.

Traumatic subarachnoid-pleural fistula: case report.

Traumatic subarachnoid-pleural fistula was recently diagnosed in an 18-year-old male after a gunshot wound in the chest and spinal column. The diagnosis was suggested by persistent pleural drainage and headache in the setting of signs of spinal injury at the thoracic level. Computed tomographic myelography delineated the dural injury. The fistulous connection was defined and repaired at operation. This paper describes the diagnostic and therapeutic features encountered in the management of this rare disorder.

A new helical computed tomographic technique for appendiceal imaging: Preliminary experience with the focused appendix computed tomographic examination

Our objective was to describe a new, helical computed tomographic (CT) technique for evaluating appendicitis, the focused appendix CT (FACT), and report preliminary experience with its use.Thirty-five consecutive patients were selected on the basis of clinical suspicion for appendicitis. Patients received oral and colon contrast media but not intravenous contrast medium before CT scanning. A thinsection, contiguous helical scan limited to the lower abdomen and upper pelvis was performed. Each scan was interpreted as positive or negative for appendicitis, and any alternative pathology was noted, if present.Seventeen patients had a final diagnosis of appendicitis at surgery and pathology, and 18 patients had appendicitis excluded at clinical follow-up for at least 3 months (17 patients) or at surgeryand pathology (1 patient). FACT interpretations were correct in all cases. Alternative pathology was noted in 13 of the 18 cases (72%) interpreted as negative for appendicitis.

Fatal overwhelming postsplenectomy infection

A total of 776 patients underwent splenectomy at the Massachusetts General Hospital between 1962 and 1972. Follow-up information was obtained on 637 patients (82 percent), including 584 adults and 53 children. There was a total of 4,837 person-years of follow-up with a mean observation interval of 8.4 years. Four cases of fatal overwhelming postsplenectomy infection were identified. In our pediatric population, the incidence of fatal overwhelming postsplenectomy infection was 3.77 percent, which was significantly higher than the incidence of 0.34 percent in our asplenic adults. Overwhelming postsplenectomy infection is a unique clinical entity distinguishable from other infections. It may occur during the lifetime of any asplenic patient and especially in those patients who have had a splenectomy in childhood. In asplenic adults, the incidence is low. The aggressive approach to splenic preservation in the adult should be tempered by these results.