Perforated jejunal diverticulitis: a rare but important differential in the acute abdomen

BACKGROUND

Diverticulosis of the small bowel is rare and, in most cases, discovered incidentally. However, diverticulitis and other complications are important to consider in the differential of an acute abdomen, especially in the elderly population.

CASE PRESENTATION

The patient was a 59-year-old female who presented with acute lower abdominal pain progressing to peritonitis. Computed tomography scan showed a large inflamed and perforated diverticulum on the mesenteric side of the jejunum. Exploratory laparotomy revealed a dilated proximal jejunum with a 5-cm inflamed and perforated mesenteric diverticulum. A small bowel resection with primary anastomosis was performed.

CONCLUSIONS

Jejunal diverticulitis remains a diagnostic challenge. Although uncommon, owing to its high mortality rate, it is an important clinical entity to consider and requires timely management.

Developing a methodology to improve the allocation of specialized health resources for acutely injured persons

Inappropriate triage following acute injury may result in misallocation of specialized health resources, increased health care costs, reduced or delayed access to care, and increased death and disability. Although triage criteria have been developed, they vary widely, and inappropriate triage rates are high (50% - 85%). The purpose of this project was to evaluate the ability of decision tree induction to predict need for specialized trauma resources in acutely injured persons. We considered any person who was admitted to the trauma center's ICU or died prior to being admitted to the ICU as needing specialized trauma resources.

Percutaneous central venous access for resuscitation in trauma

OBJECTIVE

To determine the safety of percutaneous central venous access when used for trauma resuscitation and whether the initial hemodynamic status of the patient or the site of placement affects the ease or success of line placement.

METHOD

Consecutive major-trauma patients were managed using a resuscitation protocol guiding intravenous line use. Percutaneous peripheral venous access was initially attempted in all patients. If this approach was unsuccessful or proved to be inadequate for volume resuscitation, venous access was attempted using central venous catheter-introducer sets. The site of the central venous access was determined by protocol. For thoracic injury, access was via the ipsilateral subclavian vein (SCV), the ipsilateral internal jugular vein (IJV), or the femoral vein. For suspected mediastinal injury, access was via the contralateral SCV or IJV, or the femoral vein. For abdominal or flank injury, access was via the SCV or IJV only. Multiple central venous access sites were used at the discretion of the trauma team.

RESULTS

Central venous access was successful at 144 of 147 sites (99%) used in 122 patients during the study period. There was only one major complication (rate = 0.7%; 95% CI 0.0-3.8%). Mean catheter placement time was 1.9 minutes, and cannulation occurred with a mean of 1.8 needle passes. Most patients (81/122) were hypotensive (blood pressure < or = 90 torr) at the time of line placement, including 44 who were in cardiac arrest and four awake patients who had no obtainable blood pressure. Neither the access site nor the presence of hypotension was associated with the mean time to obtain central venous access, the mean number of attempts, or the complication rate.

CONCLUSION

Percutaneous central venous access is relatively safe and reliable for gaining intravenous access when resuscitating trauma patients, when used in a center where physicians are experienced in the technique. Consideration should be given to expanding the use of central venous access in trauma resuscitation.

Relationship of NEO-PI to personality styles and severity of trauma in chronic PTSD victims

The relationship of the NEO-PI to personality disorders was evaluated in a clinical population. Eighty subjects with post-traumatic stress disorder (PTSD) were given this measure, along with the MCMI-II and PTSD and combat scales. Two questions were addressed: (1) What is the relationship of NEO-PI domains and facets to personality disorders?; and (2) What is this scale's relationship to PTSD problems? Results support previous studies that employed a clinical population, but with lower correlation coefficients. For the most part, then, the NEO-PI domains and facets correlated in expected ways with the MCMI-II. On PTSD measures, N accounted for the majority of the variance, but other domains were entered when independent regression equations were calculated to account for different personality disorders.

Hemodynamic responses to penetrating spinal cord injuries

Although the hemodynamic response to blunt spinal cord injury has been well described, much less is known about the responses to penetrating spinal cord injuries. In order to elucidate any differences, we reviewed the last 75 patients treated over the past 12 years with penetrating spinal cord injuries. There were 67 men and eight women; the mean age was 26.2 years (range, 15-59 years); 73 patients suffered 120 gunshot wounds; one patient was injured with an ice pick; one was stabbed twice. The offending missile causing spinal cord injury entered the neck in 24%, the thorax in 56%, and the abdomen in 20%. Nine patients (12%) were complete quadriplegics and 49 patients (65%) were complete paraplegics; 69 patients (92%) had no rectal tone; 17 patients (22%) had incomplete injuries. Despite the high proportion of complete spinal injury (78%), only 18 patients (24%) were hypotensive in the field. Five additional patients became hypotensive in the ED. Of the 23 patients with hypotension, 18 (74%) had significant blood loss to explain their low blood pressure. The mean HR was 100 beats/minute in the field (range, 50-130 beats/minute) and 90 beats/minute in the ED. Only five patients (7%) demonstrated the classic presentation of neurogenic shock (hypotension and bradycardia). This classic presentation of neurogenic shock is rare following penetrating spinal cord injury. Despite evidence of a complete spinal cord injury on initial physical examination, hypotension is usually secondary to blood loss in these patients. A careful search for sources of blood loss is mandatory before ascribing hypotension to spinal injury.

Packing and re-exploration for patients with nonhepatic injuries

We retrospectively reviewed the clinical records of 11 patients admitted to the trauma service at Kings County Hospital who underwent packing and temporary closure for severe nonhepatic injuries. The mean ISS was 37 and the mean Abdominal Trauma Index value was 48. Operative findings included 17 major vascular injuries. Although the mean blood pressure was 105 mm Hg during the procedure, the patients required an average of 17 units of blood and all were acidotic, hypothermic, and coagulopathic. Acidosis persisted in all patients and the mean base excess was -13 at closure. A conscious decision was made to terminate the procedure when surgical bleeding was controlled. Patients were resuscitated and warmed in the ICU and returned to the operating room within 48 hours. Seven of the 11 patients survived. Of the eight patients who survived to return to the operating room, all required gastrointestinal procedures at re-exploration. This preliminary experience supports packing to control coagulopathic bleeding, use of temporary abdominal closure, and further ICU resuscitation with a planned second laparotomy for definitive management of gastrointestinal injuries in patients with severe nonhepatic injuries.

Criterion for the Prevention of Core Fracture During Extrusion of Bimetal Rods

Based on the upper-bound theorem in limit analysis, a theoretical model for core fracture in bimetal rods during extrusion has been developed and a fracture criterion established. The variables affecting core fracture are: reduction in area (r%), die geometry, friction (m), relative size of the core and relative strength of the core. Within the wide range of possible combinations of these process variables, only a small range permits extrusion without fracture. With suitable modifications the present analysis can be extended to develop criteria for sleeve fracture during extrusion and for both core and sleeve fracture during drawing.

Improving emergency department care of the sexual assault victin

Victims of sexual assault face the multiple threats of disease, unwanted pregnancy, psychological trauma, and physical injury, which are further complicated by a comprehensive police investigation. An organized approach to the care of victims of sexual assault is presented, including guidelines for patient care and a discussion of police investigations, written consent forms, and physical evidence recovery kits. We recommend that the care of victims, from arrival in the emergency department until rehabilitation, be coordinated by a nurse. This specially trained individual serves as a liaison between the patient and the health professionals and police team.