Tag Archives: surgical


Appendicitis policy

The American College of Emergency Physicians has produced a policy entitled: ‘Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

It contains the following questions and recommendations:

1. Can clinical findings be used to guide decisionmaking in the risk stratification of patients with possible appendicitis?

Level B recommendations. In patients with suspected acute appendicitis, use clinical findings (ie, signs and symptoms) to risk-stratify patients and guide decisions about further testing (eg, no further testing, laboratory tests, and/or imaging studies), and management (eg, discharge, observation, and/or surgical consultation).

2. In adult patients with suspected acute appendicitis who are undergoing a CT scan, what is the role of contrast?

Level B recommendations. In adult patients undergoing a CT scan for suspected appendicitis, perform abdominal and pelvic CT scan with or without contrast (intravenous [IV], oral, or rectal). The addition of IV and oral contrast may increase the sensitivity of the CT scan for the diagnosis of appendicitis.

3. In children with suspected acute appendicitis who undergo diagnostic imaging, what are the roles of CT and ultrasound in diagnosing acute appendicitis?

Level B recommendations.
1. In children, use ultrasound to confirm acute appendicitis but not to definitively exclude acute appendicitis.
2. In children, use an abdominal and pelvic CT to confirm or exclude acute appendicitis.
Level C recommendations. Given the concern over exposing children to ionizing radiation, consider using ultrasound as the initial imaging modality. In cases in which the diagnosis remains uncertain after ultrasound, CT may be performed.

The full document contains a helpful summary of existing literature on clinical scoring systems and laboratory investigations, including positive and negative likelihood ratios for various tests.

Rectal exam has lousy test characteristics

A comprehensive review of the literature, the findings of which showed ‘compelling’ consistency: digital rectal examination (DRE) as a screening test had sensitivities ranging from 0% to 50%, had consistently high false-positive and false-negative rates, and did not improve the predictive value of the other components of a typical trauma examination.

Based on case reports of five patients, the authors suggest DRE may be of value during trauma evaluation in the following settings: (1) patients with evidence of penetrating trauma in the vicinity of the rectum, (2) cases in which the presence of neurologic injury is neither completely supported nor refuted by the clinical findings, and (3) before pharmacologic paralysis. A selective approach is therefore recommended. Some good news for your patients if this will persuade you to discard another piece of longstanding dogma perpetuated in basic trauma teaching.

Should the digital rectal examination be a part of the trauma secondary survey?
Ann Emerg Med. 2009 Feb;53(2):208-12

Delays to neurosurgery

Further evidence from the UK shows that patients with acute traumatic brain injury suffer delays in the neurosurgical evacuation of intracranial haematomas which are increased from an average of 3.7 hours to 5.4 hours if they have to undergo interhospital transfer. Coordinated regional trauma systems please!

A prospective study of the time to evacuate acute subdural and extradural haematomas.
Anaesthesia. 2009 Mar;64(3):277-81