Mark E. Falimirski

The Role of Presacral Drainage in the Management of Penetrating Rectal Injuries

PURPOSE To compare in a randomized, prospective manner infectious complication rates associated with presacral drainage versus no drainage in the presence of penetrating rectal injury. METHODS During a 45-month period, 48 patients with penetrating rectal injuries were entered into a randomized, prospective study at an urban Level I trauma center. The patients were randomized to a presacral drainage group or a nondrainage group. Randomization was performed after detection of the rectal injury. Forty-four injuries were identified by proctoscopy (92%), with the rest detected intraoperatively or by physical examination. All patients with rectal injuries were included regardless of age, associated injuries, time from injury to operation, blood loss, severity of rectal injury, other abdominal organs injured, or hemodynamic stability. Rectal injuries were defined as those injuries to the large bowel distal to the peritoneal reflection. All rectal injuries underwent fecal diversion, and all drainage was accomplished using closed Jackson-Pratt drainage. RESULTS Forty-eight patients were studied, of whom 25 were randomized to no drainage and 23 were randomized to presacral drainage. The average age for the nondrainage group was 21.9 years, and the average age for the presacral drainage group 26.0 years. The average Penetrating Abdominal Trauma Index score was 34.3 for the nondrainage group and 32.4 for the presacral drainage group. There were two (8%) septic complications (one perirectal and one perivesical abscess) associated with the rectal injuries in the presacral drainage group. The abscesses in the drainage group resolved after computed tomography-guided drainage. There was one (4%) septic complication (rectocutaneous fistula) in the nondrainage group, which was associated with a retained missile fragment. The fistula resolved after bedside percutaneous removal of the missile fragment. CONCLUSION We conclude that presacral drainage for penetrating rectal injuries has no effect on infectious complications associated with the rectal injuries.

The need for head computed tomography in patients sustaining loss of consciousness after mild head injury.

BACKGROUND Many management schemes have incorporated mandatory head computed tomography (HCT) to evaluate a patient sustaining blunt head trauma with a history of loss of consciousness (LOC). Commonly, this is despite physical examination findings warranting such a workup. This study is intended to better identify the significance of selective criteria, a set of constitutional signs and symptoms (CSS) for head injury, to screen patients sustaining blunt head trauma and LOC. METHODS Over a 141/2-month period, data were prospectively collected on adults with a history of LOC and a Glasgow Coma Scale score of 14 to 15. Patients were screened for the presence of 10 typical CSS for head injury at admission before undergoing computed tomography of the head. Data collected also included mechanism of injury and alcohol intoxication. RESULTS Three hundred thirty-one patients met criteria, of which 195 showed no CSS for head injury. Eleven (5.6%) of these patients were found to have HCT evidence of intracranial injury but resulted in no acute medical intervention. One hundred thirty-six patients had CSS, of which 29 (21.3%) had HCT evidence of injury and resulted in a lengthier hospital stay. CONCLUSION The liberal use of HCT in patients without CSS for head injury did not influence patient care, with no increase in morbidity or mortality. These results suggest that LOC alone is not predictive of significant head injury and is not an absolute indications for HCT. More objective criteria, such as CSS, should be used before initiating a costly workup where further diagnostic and therapeutic intervention is unlikely after mild head injury.