Progression of Intracranial Hemorrhage After Chemical Prophylaxis Using Low-Molecular-Weight Heparin in Patients With Traumatic Brain Injury.

INTRODUCTION: Chemical prophylaxis using low-molecular-weight heparin (LMWH) is considered a standard of care for venous thromboembolism in trauma patients. Our center performs a head computed tomography (CT) scan 24 hours after initiation with prophylactic LMWH in the setting of a known traumatic brain injury (TBI). The purpose was to determine the overall incidence of ICH progression after chemoprophylaxis in patients with a TBI. METHODS: This retrospective study was performed at a Level I trauma center, from 1/1/2014 to 12/31/2017. Study patients were drawn from the institution's trauma registry based on Abbreviated Injury Score codes. RESULTS: 778 patients met all inclusion criteria after initial chart review. The proportion of patients with an observed radiographic progression of intracranial hemorrhage after LMWH was 5.8%. 3.1% of patients had a change in clinical management. Observed radiographic progression after LMWH prophylaxis and the presence of SDH on initial CT, the bilateral absence of pupillary response in the emergency department, and a diagnosis of dementia were found to have statistically significant correlation with bleed progression after LMWH was initiated. CONCLUSION: Over a 4-year period, the use of CT to evaluate for radiographic progression of traumatic intracranial hemorrhage 24 hours after receiving LMWH resulted in a change in clinical management for 3.1% of patients. The odds of intracranial hemorrhage progression were approximately 6.5× greater in patients with subdural hemorrhage on initial CT, 3.1× greater in patients with lack of bilateral pupillary response in ED, and 4.2× greater in patients who had been diagnosed with dementia.

Ingested foreign body mimicking acute appendicitis.

INTRODUCTION: The incidence of acute appendicitis is approximately 250,000 cases per year in the United States with a lifetime risk of 7% (Gupta & Dupuy, 1997). However, despite strongly associated clinical signs, diagnostic accuracy based on history and physical exam alone is only 70% (Jess et al., 1981). This is in large part due to the multitude of mimics found in the differential diagnosis of appendicitis. As a result highly sensitive imaging such as computed tomography scan has become standard of care. PRESENTATION OF CASE: We present a case of an otherwise healthy 20year old male presenting to the emergency department with acute onset of right lower quadrant pain and leukocytosis consistent with a diagnosis of appendicitis. Ultrasonography was grossly negative as was a computed tomography scan. Given the peritoneal nature of the patient's abdominal exam, general surgery was consulted. The patient was taken for exploratory laparoscopy where a long, thin, metallic foreign body was found to have perforated the small intestine. DISCUSSION: Discussion includes a literature review of computed tomography negative appendicitis, as well as the frequency of foreign body mimicking appendicitis. This case demonstrates the importance of the clinical exam even in the face of negative highly sensitive imaging modalities. CONCLUSION: In conclusion, there are several mimics of acute appendicitis and we present an unusual case of a foreign body mimicking this disorder in a young person. Highly sensitive imaging coupled with history and physical examination remains the standard of care for diagnosing appendicitis; however, clinical acumen must be utilized to formulate a broad differential.