Rectal foreign bodies: A case report and review of the literature

INTRODUCTION

Rectal foreign bodies (RFB) present the modern surgeon with a difficult management dilemma, as the type of object, host anatomy, time from insertion, associated injuries and amount of local contamination may vary widely. Reluctance to seek medical help and to provide details about the incident often makes diagnosis difficult. Management of these patients may be challenging, as presentation is usually delayed after multiple attempts at removal by the patients themselves have proven unsuccessful.

PRESENTATION OF CASE

In this article we report the case of a male who presented with a large ovoid rectal object wedged into his pelvis. As we were unable to extract the object with routine transanal and laparotomy approach, we performed a pubic symphysiotomy that helped widen the pelvic inlet and allow transanal extraction.

DISCUSSION

We review currently available literature on RFB and propose an evaluation and management algorithm of patients that present with RFB.

CONCLUSION

Management of patients with rectal foreign bodies can be challenging and a systematic approach should be employed. The majority of cases can be successfully managed conservatively, but occasional surgical intervention is warranted. If large objects, tightly wedged in the pelvis cannot be removed with laparotomy, pubic symphysiotomy should be considered.

Early mobilization in critically ill patients: patients' mobilization level depends on health care provider's profession

OBJECTIVE

To evaluate whether the level of mobilization achieved and the barriers for progressing to the next mobilization level differ between nurses and physical therapists.

DESIGN

Prospective, observational study.

SETTING

Twenty-bed surgical intensive care unit (SICU) of the Massachusetts General Hospital.

PARTICIPANTS

Sixty-three critically ill patients.

METHODS

Physical therapists and nurses performed 179 mobilization therapies with 63 patients.

OUTCOME MEASUREMENT

Mobilization was defined as the process of enhancing mobility in the SICU, including bed mobility, edge of bed activities, transfers out of bed to a chair, and gait training; the mobilization level was measured on the SICU optimal mobilization scale, a 5-point (0-4) numerical rating scale.

RESULTS

Patients' level of mobilization achieved by physical therapists was significantly higher compared with that achieved by nurses (2.3 ± 1.2 mean ± SD versus 1.2 ± 1.2, respectively P < .0001). Different barriers for mobilization were identified by physical therapists and nurses: hemodynamic instability (26% versus 12%, P = .03) and renal replacement therapy (12% versus 1%, P = .03) were barriers rated higher by nurses, whereas neurologic impairment was rated higher by physical therapists providers (18% versus 38%, P = .002). No mobilization-associated adverse events were observed in this study.

CONCLUSIONS

This study showed that physical therapists mobilize their critically ill patients to higher levels compared with nurses. Nurse and physical therapists identify different barriers for mobilization. Routine involvement of physical therapists in directing mobilization treatment may promote early mobilization of critically ill patients.

Indications for Routine Repeat Head Computed Tomography (CT) Stratified by Severity of Traumatic Brain Injury

BACKGROUND

Controversy exists as to the role of a routine repeat head computed tomography (CT) for patients with traumatic brain injury and an initially abnormal head CT. The specific aim of this study is to identify patients with head injuries who would benefit from a routine repeat head CT.

METHODS

This was a 2-year (2003 and 2004) prospective study of all patients with blunt trauma admitted to an urban, Level I trauma center that presented with an abnormal head CT. Results of initial head CT and indications for repeat head CT (routine vs. neurologic change) were recorded. Interventions were both medical (diuresis, hyperventilation, barbiturates) and surgical (intracranial pressure monitor placement or craniotomy). Patients were categorized by Glasgow Coma Scale (GCS) score as having mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS < or = 8) head injury.

RESULTS

There were 354 patients admitted with an initially abnormal head CT. The 37 (10%) patients who went directly to craniotomy and the 43 (12%) patients who died within 24 hours of admission were excluded from analysis. The remaining 274 patients (44 years old, 70% male, mean injury severity score = 19, mean GCS = 10) are the focus of this analysis. After admission, 163 patients underwent a total of 241 repeat CT scans. Of the repeat scans obtained, 102 scans (43%) were unchanged, 54 scans (22%) were better, and 85 scans (35%) were worse. Neurologic deterioration prompted 45 repeat scans (19%), and 196 repeat scans (81%) were obtained routinely after admission without change in neurologic status. The 45 CT scans obtained for neurologic change led to medical or surgical intervention in 38% (n = 17) of cases, whereas scans obtained led to an intervention in only two patients (1%). Both patients who underwent an intervention after a routine scan had a GCS score < or =8 at admission and at the time of routine repeat head CT. One patient had an intracranial pressure monitor placed and the other was taken for craniotomy. No patient with a mild or moderate traumatic brain injury underwent an intervention after a routine repeat head CT.

CONCLUSIONS

Patients with any head injury (mild, moderate, or severe) should undergo a repeat head CT after neurologic deterioration, because it leads to intervention in over one-third of patients. Routine repeat head CT is indicated for patients with a GCS score < or =8, as results might lead to intervention without neurologic change.

Management of blunt hepatic and splenic trauma in a Greek level I trauma centre

BACKGROUND AND PURPOSES

Non-operative management (NOM) has revolutionized the care of blunt hepatic and splenic trauma patients. The objective of this study is to evaluate treatment of such patients in a Greek level I trauma centre, to identify factors that are important for selecting them for NOM and to investigate for predictors of NOM failure.

MATERIAL AND METHODS

We reviewed the Trauma Registry data of 96 consecutive adult patients admitted with blunt liver and/or splenic injuries over a 4-year period.

RESULTS

Immediately operated patients (32.3%) had lower diastolic arterial pressure (p = 0.02), lower International Classification of Diseases -9th revision Injury Severity Score (ICISS) (p = 0.01), and a higher grade of splenic injury (p = 0.002) than NOM patients. NOM success rate was 80%. No predictors of NOM failure were found ; however, isolated splenic trauma patients failed NOM more frequently than hepatic patients (p = 0.02).

CONCLUSIONS

NOM of adult blunt hepatic and splenic trauma patients is safe and efficient. Haemodynamic stability, ICISS and the grade of splenic injury are important for selecting these patients for NOM while splenic trauma patients need more intense observation.

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation

BACKGROUND

Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI.

METHODS

Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT.

RESULTS

Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1).

CONCLUSIONS

Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.