Blunt trauma in intoxicated patients: is computed tomography of the abdomen always necessary?

BACKGROUND: Physical examination to detect abdominal injuries has been considered unreliable in alcohol-intoxicated trauma patients. Computed tomography (CT) plays the primary role in these abdominal evaluations. METHODS: We reviewed medical records of all blunt trauma patients admitted to our trauma service from January 1, 1992, to March 31, 1998. Study patients had a blood alcohol level > or =80 mg/dL, Glasgow Coma Scale (GCS) score of 15, and unremarkable abdominal examination. RESULTS: Of 324 patients studied, 317 (98%) had CT scans negative for abdominal injury. Abdominal injuries were identified in 7 patients (2%), with only 2 (0.6%) requiring abdominal exploration. A significant association was found between major chest injury and abdominal injury. CONCLUSION: The incidence of abdominal injury in intoxicated, hemodynamically stable, blunt trauma patients with a normal abdominal examination and normal mentation is low. Physical examination and attention to clinical risk factors allow accurate abdominal evaluation without CT.

A new economic benchmark for surgical treatment of appendicitis.

Cost reduction in the management of common surgical diseases such as appendicitis has become paramount for the survival of children's hospitals. We designed a clinical pathway to treat appendicitis with the goal of reducing cost and hospital length of stay (LOS) while maintaining quality of care. From September 1995 through December 1996, patients with nonperforated appendicitis (NPApp) and perforated appendicitis with peritonitis (PApp) were enrolled into a clinical pathway. NPApp patients were discharged when tolerating a regular diet. PApp patients were discharged if the following criteria were met: temperature < 38.5 degrees C for 24 hours, WBC < 14,000 on postoperative day 3, tolerating diet, and transition to oral analgesics accomplished. Hospital LOS and actual hospital costs in pathway patients were compared with those of historic controls. Patients with appendicitis from the Pediatric Health Information Systems (PHIS) database, a consortium of 20 children's hospitals in the United States, served as concurrent controls. Hospital LOS and hospital charges in PHIS NPApp and PApp patients from our institution were compared with national PHIS database patients. Mean LOS and hospital costs for both NPApp and PApp pathway patients were significantly decreased compared with historic controls (P < 0.05). Mean LOS and hospital charges in our institution's PHIS NPApp and PApp patients were also significantly decreased compared with the national PHIS database (P < 0.05). Innovative approaches such as these are necessary for the survival of children's hospitals in an increasingly cost competitive healthcare market.

Minimally invasive surgery: the pediatric surgery experience.

BACKGROUND: Minimally invasive surgery (MIS) has become an important aspect of general surgery. The degree to which pediatric surgeons have incorporated MIS into their practice is not known. STUDY DESIGN: An MIS survey was sent to all members of the American Pediatric Surgical Association. Respondents were separated into two groups: nonperformers and performers of MIS. Performers were asked how they were trained in MIS and the total number and types of minimally invasive procedures they have performed. RESULTS: Eighty-two percent of surveyed pediatric surgeons perform MIS. Eighty-seven percent received some or all of their training in a postgraduate course. Two percent received their only training during their general surgery residency. Forty-seven percent of performers reported 50 or fewer total procedures. A wide variety of procedures were reported, but laparoscopic cholecystectomy (95%) was the procedure most frequently reported. Thoracoscopic procedures (71%) were also reported at high rates. CONCLUSIONS: Most pediatric surgeons in our survey perform MIS. The high rate of laparoscopic cholecystectomies reported suggests that the initial MIS experience of pediatric surgeons in our survey is similar to adult general surgeons. The frequency, however, of thoracic cases reported indicates that MIS techniques are being applied to all areas of pediatric surgery. The total minimally invasive procedure experience of our respondents also suggests that pediatric surgeons are early in their learning curve.