Annals of emergency medicine
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Review Historical Article
Nonoperative management of abdominal gunshot wounds.
Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this past century. Although nonoperative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. ⋯ Although the physical examination remains the cornerstone in the evaluation of patients with gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and laparoscopy allow accurate determination of intra-abdominal injury. The ability to exclude internal organ injury nonoperatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective nonoperative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.
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We determine tetanus seroprotection rates and physician compliance with tetanus prophylaxis recommendations among patients presenting with wounds. ⋯ Although seroprotection rates are generally high in the United States, the risk of tetanus persists in the elderly, immigrants, and persons without education beyond grade school. There is substantial underimmunization in the ED (particularly with regard to use of tetanus immunoglobulin), leaving many patients, especially those from high-risk groups, unprotected. Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.
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The use of the International Classification of Diseases system to describe emergency department (ED) case mix has disadvantages. We therefore developed computer algorithms that recognize a combination of words, word fragments, and word patterns to link free-text complaint fields to 20 reason-for-visit categories. We examine the feasibility and reliability of applying these reason-for-visit categories to ED patient-visit databases. ⋯ The method by which free-text complaint fields are parsed into reason-for-visit categories is feasible and reasonably reliable; the finalized database 1 reason-for-visit category inclusion/exclusion terms lists required only modest changes to work well in database 2. The reason-for-visit categories used here are broadly defined to maximize the proportion of visits that they capture; more narrowly defined reason-for-visit categories will require more extensive revision of their inclusion/exclusion terms lists when used in different databases. A prospective, reason-for-visit-based ED classification system could have several useful applications (including syndromic surveillance), although content validity analysis will be necessary to investigate this hypothesis.
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We report testicular dislocation as an unusual complication of blunt abdominal trauma. ⋯ In blunt abdominal trauma patients, associated testicular dislocation is easily overlooked. A complete physical examination in the trauma patient, including palpation of both testes, is strongly recommended.