Am J Emerg Med

The computed tomography appearance of recurrent and chronic appendicitis.

Rao PM. Rhea JT. Novelline RA. McCabe CJ.
Department of Radiology, Massachusetts General Hospital, Boston 02114, USA.
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.

Injuries distracting from intraabdominal injuries after blunt trauma.

Year 1998
Ferrera PC. Verdile VP. Bartfield JM. Snyder HS. Salluzzo RF.
Department of Emergency Medicine, Albany Medical Center, NY 12208, USA.
While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Diagnosis and follow-up of Chlamydia trachomatis infections in the ED.

Year 1998
Kuhn GJ. Campbell A. Merline J. O'Neil BJ.
Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA.
The purpose of this study was to determine the impact on patient care and the cost effectiveness of testing for chlamydial infection in the emergency department. All patients tested for chlamydial infection in three emergency departments between October 1, 1993 and January 31, 1994 were retrospectively reviewed for charges and adequacy of therapy. In one hospital, the effectiveness of a call-back system to enhance proper therapy of inadequately treated patients was evaluated. Of 2,416 test results, 249 were positive, and 197 of these charts were available for review. All 16 male patients were treated appropriately at the initial visit; 105 of 181 female patients were inadequately treated at the initial visit. The charge to identify each patient inadequately treated was $981.22 ($103,000 for 105). Of the 28 inadequately treated patients receiving a follow-up call, 20 sought treatment. The high cost of testing patients cannot be justified without an adequate surveillance system to enhance proper follow-up treatment.

Large-diameter suction tubing significantly improves evacuation time of simulated vomitus.

Year 1998
Vandenberg JT. Rudman NT. Burke TF. Ramos DE.
Department of Emergency Medicine, Madigan Army Medical Center, Ft Lewis, WA 98431, USA.
Current suction equipment is often inadequate at clearing the oropharynx. This study tested the hypothesis that evacuation times of simulated vomitus could be significantly improved by increasing suction tube and connection port diameters. Two standard suction systems and a new large-diameter suction system were tested. Mean evacuation times for 90 mL (an average mouthful) of three different vomitus-simulating substances--water, activated charcoal, and Progresso vegetable soup--were compared. All parameters other than suction tubing and attachment port diameters remained constant. The data were analyzed with analysis of variance and Fisher's protected least significant difference post hoc test. Use of large-diameter suction tubing significantly (P < .0001) improved evacuation time for each of the three substances. This improvement was most evident in the trials with activated charcoal and the vegetable soup, where there was a tenfold decrease in mean evacuation time. These results show that large-diameter 3/4-inch suction tubing connected to the 1-inch port is superior to the standard 1/4-inch tubing and connection ports currently used. The tenfold reduction in evacuation time of viscous and particulate materials may have important clinical implications in preventing or minimizing complications from aspiration.