Surgical Casualty Research Articles

Surgical Casualty Care inContested Distributed Maritime Operations: Lessons Learned From the Falklands War.

The Falklands Campaign was fought a significant distance from the home base of the British Fleet. The planning and delivery of medical care during this campaign can provide significant lessons for strategic medical planning in other far spread geographic locations, including the Indo-Pacific region. Consideration of doctrine, including Role 1-4 facilities and the golden hour, may need to be reconsidered in light of changing scenarios. New concepts such as the "90-in-90" and "3-in-3" are also discussed as a framework for future planning in the U.S. Indo-Pacific Command area of responsibility.

Intussusception revealing right colonic adenocarcinoma in a 61-year-old woman: a case report

IntroductionAdult Intussusception is an uncommon diagnosis, with one to three cases occurring in a population of 1,000,000 per year, primarily due to underlying pathological lead points, of which 70% are malignant. Lipoma is the most common benign tumour, and primary adenocarcinoma is the most common malignant one. Early diagnosis and treatment are essential to reducing poor outcomes, including ischemia, perforation, and sepsis. Computed tomography imaging is a modality of choice for diagnosis. With a diagnostic accuracy of up to 100% and a specificity of up to 71%. Surgical intervention is the definitive treatment, and the decision is taken according to the situation.Case presentationA 61-year-old Black African female presented to our surgical casualty with intermittent colicky abdominal pain for 1 month. After that, she started to experience abdominal swelling in the right iliac fossa. A CT scan confirmed the presence of colo-colic Intussusception, cecum-ascending-transverse colon. Laparotomy was scheduled, and a right hemicolectomy was done accordingly. Diagnosis of adenocarcinoma (Dukes stage B2) was made histologically.ConclusionIntussusception in adults is a challenging diagnosis requiring high clinical suspicion and has a high incidence of fatal complications. Colonic cancer can be worsening by any infection and chronic medical problem. CT imaging is the lifesaving modality of choice for diagnosis. Good patient outcomes depend on timely diagnosis and recruitment of a multi-disciplinary team.

Trap gun: an unusual firearm injury pattern and injury severity score

Trap gun injury causes a substantial socio-economic and health burden to Sri Lanka. The key objectives of the study are to identify the Trap gun injury pattern, injury severity score, common geographical locations, and to identify the health burden. This is a retrospective descriptive cross-sectional study conducted at surgical units of Teaching Hospital Anuradhapura [THA]. Patients presented with trap gun injury as surgical casualty admissions were selected for the study. Injury severity score [ISS] is used as an indicator for anatomical injury severity. A total of 53 persons who suffered from trap gun injury in the north-central province of Sri Lanka in the year 2020 were studied. Our analysis shows that more than 64.1% of those have serious or severe injuries [ISS > 3], while injury to the lower limb accounts for 88.7%. Triangular distribution of geographical area within the north-central province of Sri Lanka is identified as the most vulnerable region. The cost of care of these patients results in a significant health burn to the free health system.

Neoplasms of the appendix: a retrospective analysis of 5-year data on histopathology of appendicectomy specimens in a tertiary care hospital

IntroductionRight iliac fossa pain due to appendicular disease is a common clinical presentation to a surgical casualty ward. Neoplasms of the appendix are rare but sometimes they present with acute symptoms similar to acute appendicitis. Studies on neoplasms of appendicectomy are sparse in Sri Lanka. Our objective is to study the epidemiological, demographic characteristics and histopathological data on appendicectomy specimens.MethodA retrospective descriptive study using the database on appendicectomy specimens in the pathology department of Colombo North teaching hospital, Ragama from January 2015 to December 2019.ResultsNeoplastic lesions were noted in 16[0.82%] among 1939 appendicectomy specimens. All [n=16, 100%] were primary neoplasms and the male to female ratio was 5:11. The percentage of neoplasms was higher in the elderly population compared to the young. Six of the 16 specimens [37.5%] had associated features of acute appendicitis. The commonest neoplasm was neuroendocrine neoplasm [including goblet cell carcinoid tumour] [n=9, 56.25%]. The mean age was 33 years and comprised 0.46% of the population. Mucinous neoplasms were noted in 6 [37.5%] and comprised 0.3% of the population. The median age was 59 years. The resection margin was well away from the tumour in all [n=9] Neuroendocrine neoplasms while the tumour had involved the resection margin in 4 out of 6 [66.6%] of mucinous neoplasms.ConclusionAppendicular neoplasms are rare but higher in the elderly population compared to the young. Neuroendocrine neoplasms are the commonest incidental tumours and they are less aggressive at the time of diagnosis. Meticulous dissection is important with a good clearance of the resection margin in suspected mucinous appendiceal neoplasms.

Risk factors and surgical management of sigmoid volvulus among patients attending Al-Karama Teaching Hospital of Iraq

Background: Sigmoid volvulus is defined as torsion of the sigmoid colon around its mesenteric axis, which leads to acute large intestine obstruction, which, if left untreated, often results in life-threatening complications, such as bowel ischemia, gangrene and perforation. The aim of this study was to analyse sigmoid colon volvulus when its presented as a surgical emergency.Methods: This was a prospective study of 25 patients presented with the features of strangulated sigmoid colon volvulus to Al-Karama Teaching Hospital (surgical casualty) from March 2014 to March 2018. Eighteen patients (72%) were males and seven patients (28%) were females. The age of the patients ranged from 20-70 years. The main risk factor was chronic constipation, laxative dependency and high fiber diet. The main presenting symptoms and signs were absolute constipation, generalized abdominal distension, tenderness, tachycardia and fever. The patients were investigated by plain abdominal X-ray and haematological investigations.Results: Among the 25 patients, 13 had distended gangrenous sigmoid colon volvulus, 9 out of the remaining 12 patients were discovered to have distended non-gangrenous sigmoid colon volvulus of the rest 3 patients, 2 were found to have Ileo-sigmoid knotting and the last patient had a perforated gangrenous sigmoid colon volvulus. Four patients developed postoperative complications and one patient died.Conclusions: Volvulus of the sigmoid colon is more predominant in males. Middle age individuals seem to be the most affected group by sigmoid colon volvulus. Majority of patients with sigmoid colon volvulus have history of chronic constipation, laxative dependency and high fiber diet.

Characteristics of the elderly patients admitted to surgical casualty due to falls: a study from northern Sri Lanka.

Characteristics of the elderly patients admitted to surgical casualty due to falls: a study from northern Sri Lanka.

A Spontaneous intramural small bowel haematoma

Spontaneous haemorrhage into small bowel wall leading to obstruction is a rare acute presentation among haemophilic patients. We present a case of a 46 year old male with haemophilia B, admitted to the surgical casualty ward with an acute abdominal pain suspicious of small bowel obstruction which was confirmed on erect abdominal radiograph and abdominal sonography. Contrast enhanced CT [CECT] abdomen revealed a segment of circumferentially thickened small bowel wall suggestive of bowel wall heamatoma. However, mild but appreciable contrast enhancement of the affected bowel wall raised the possibilities of a neoplastic or inflammatory process as differentials. Subsequent surgical intervention with resection of bowel after correction of factor IX and histology revealed intramural heamatoma of small bowel with no evidence of an inflammatory or neoplastic process. We believe that the bowel wall enhancement in CECT could be attributed to the enhancement of intact mucosa and sub mucosa predominating over non enhancing heamatoma which can be considered a diagnostic pitfall.

Primary Osteosarcoma of the Breast presenting as a Large Breast Abscess

ABSTRACTIntroductionPrimary extraosseous osteogenic sarcoma is one of the rarest forms of malignant tumor of the breast. It can arise as a result of osseous metaplasia of a preexisting neoplasm or from a none-phyllodes sarcoma of a previously normal breast. Due to its rarity, the natural history and optimal treatment methods remain unclear.Case presentationA 60 years old patient presented to the surgical casualty with a large breast abscess. Abscess wall histology revealed an osteosarcoma of the breast. Left total mastectomy with axillary clearance was performed. Histology and subsequent immunohistochemical studies confirmed the diagnosis of osteogenic sarcoma without lymph nodal metastasis. Patient was referred to the oncologist for further management.ConclusionRare types of breast tumors can be presented as breast abscess. Incision and drainage together with wall biopsy aid to exclude associated sinister pathologies. Diagnosis of primary osteosarcoma of the breast was made using histological and immunohistochemical findings once the possible primary from the bones of sternum and ribs was excluded. Treatment is as for sarcomas affecting other locations and should comprise a multidisciplinary approach.How to cite this articleNawarathna NJ, Chandrasekara D, Kumarasinghe NR, Balasooriya RS, Rathnayake P, Seneviratne RJ. Primary Osteosarcoma of the Breast presenting as a Large Breast Abscess. J Postgrad Med Edu Res 2016;50(2):96-99.

Primary osteosarcoma of the breast presenting as a large breast abscess

Primary extra osseous osteogenic sarcoma is one of the rarest forms of malignant tumor of the breast. It can arise as a result of osseous metaplasia of a preexisting neoplasm or from a none-phylloides sarcoma of a previously normal breast. Due to its rarity, the natural history and optimal treatment methods remain unclear. Sixty-year-old patient presented to the surgical casualty with a large breast abscess. Abscess wall histology revealed an osteosarcoma of the breast. Left total mastectomy with axillary clearance was performed. Histology and subsequent imunohistochemical studies confirmed the diagnosis of osteogenic sarcoma without lymph nodal metastasis. Patient was referred to the oncologist for further management. Rare types of breast tumors can be presented as breast abscess. Incision and drainage together with wall biopsy aid to exclude associated sinister pathologies. Diagnosis of primary osteosarcoma of the breast was made using histological and immunohistochemical findings once the possible primary from the bones of sternum and ribs was excluded. Treatment is as for sarcomas affecting other locations and should comprise a multidisciplinary approach.

Unusual presentation of primary extra osseous osteosarcoma: As breast abscess

Primary extra osseous osteogenic sarcoma is one of the rarest forms of malignant tumor of the breast. It can arise as a result of osseous metaplasia of a preexisting neoplasm or from a none-phylloides sarcoma of a previously normal breast. Due to its rarity, natural history and optimal treatment methods remain unclear. A 60-year-old patient presented to the surgical casualty with large breast abscess. Abscess wall histology revealed an osteosarcoma of the breast. Left total mastectomy with axillary clearance was performed. Histology and subsequent imunohistochemical studies confirmed the diagnosis of osteogenic sarcoma without lymph nodal metastasis. The patient was referred to the oncologist for further management. Rare types of breast tumors can be presented as breast abscess. Incision and drainage together with wall biopsy help to exclude associated sinister pathologies. Diagnosis of primary osteosarcoma of the breast was made using histological and immunohistochemical findings once the possible primary from the sternum and ribs were excluded. Treatment is as for sarcomas affecting other locations and should comprise a multidisciplinary approach.

Primary osteosarcoma of the breast presented as a large breast abscess

Primary extra osseous osteogenic sarcoma is one of the rarest forms of malignant tumor of the breast. It can arise as a result of osseous metaplasia of a preexisting neoplasm or from a none - phyllodes sarcoma of a previously normal breast. Due to its rarity, natural history and optimal treatment methods remain unclear. A 60-year-old patient presented to the surgical casualty with large breast abscess. Abscess wall histology revealed an osteosarcoma of the breast. Left total mastectomy with axillary clearance was performed. Histology and subsequent immunohistochemical studies confirmed the diagnosis of osteogenic sarcoma without lymph nodal metastasis. The patient was referred to the oncologist for further management. Rare types of breast tumors can be presented as breast abscess. Incision and drainage together with wall biopsy help to exclude associated sinister pathologies. Diagnosis of primary osteosarcoma of the breast was made using histological and immunohistochemical findings once the possible primary from the sternum and ribs were excluded. Treatment is as for sarcomas affecting other locations and should comprise a multidisciplinary approach.

Abdominal wall blow out causing bowel evisceration due to high voltage electrocution: A unique presentation

A 32-year-old male presented to surgical casualty after 3 h of sustaining high voltage electrocution through palm of the right upper limb with prolapse of bowel from the anterior abdominal wall. Apparently, the current flow through the right upper limb exited from the right lower abdomen wall resulting in full-thickness abdominal wall defect causing small bowel to prolapse. He had clawing of right hand and semi-flexion at elbow with blackening and dry gangrene from mid-arm onward with distal two-third of the right upper limb being parched and black. There was 9 cm × 7 cm wound over right abdominal wall through which small bowel had eviscerated with multiple perforations discharging feculent content. Exploratory laparotomy with resections of perforated segments of small bowel with end-to-end anastomosis and right mid-arm guillotine amputation were done. The abdominal wound was debrided and temporarily covered with overlay plastic bag to prevent bowel herniation. A small enterocutaneous fistula arising from the small bowel was noted through the abdominal wound of blow out site, which was managed conservatively. The entry point of electricity is usually the skull or the upper extremity with resultant exit through the lower extremity. The exit point through the abdominal wall with resultant abdominal wall loss is rare and even remorsely seen is the abdominal wall blow out with the evisceration of bowel, a rare phenomenon.

Unusual Clinical Presentation of a Rare Type of Breast Malignancy: A Case Report and a Short Review of Literature

Primary extra osseous osteogenic sarcoma is one of the rarest forms of malignant tumor of the breast. It can arise as a result of osseous metaplasia of a preexisting neoplasm or from a none-phyllodes sarcoma of a previously normal breast. Due to its rarity, natural history and optimal treatment methods remain unclear. A 60-year-old patient presented to the surgical casualty ward with large breast abscess. Abscess wall histology revealed an osteosarcoma of the breast. Left total mastectomy with axillary clearance was performed. Histology and subsequent imunohistochemical studies confirmed the diagnosis of osteogenic sarcoma without lymph nodal metastasis. The patient was referred to the oncologist for further management. Rare types of breast tumors could present as breast abscess. Incision and drainage, together with wall biopsy, helped to exclude associated sinister pathologies. Diagnosis of primary osteosarcoma of the breast was made using histological and immunohistochemical findings once the possible primary from the sternum and ribs were excluded. Treatment was similar to sarcomas affecting other locations and should comprise a multidisciplinary approach.

The psychological impact of war on health professionals : a preliminary study

Background: Working in direct contact with mass casualties is stressful. Studies on the impact of exposure to mass casualties over a prolonged period of time are sparse due to logistical reasons. The current paper studies the impacts of prolonged conflict and exposure to mass casualties among Iraqi health professionals in Kirkuk. Method: The Depression Anxiety and Stress Scale (DASS) was randomly distributed among staff of a teaching Hospital in Kirkuk, Iraq. Fifty nine health professionals returned the questionnaires. Of those who responded, 24 health professionals were from the surgical casualty department, 20 were employed in the mortuary and 15 were serving in medical wards not directly dealing with surgical incidents. Results: The impact of handling mass casualties has affected both genders and all age groups. There was a higher incidence of depression among females. Overall, the DASS score was highest among mortuary staff and lowest among medical ward health professionals who were not directly in contact with casualties. Conclusion: Health professionals exposed to mass casualties, especially those dealing directly with them, are likely to suffer from symptoms of depression, anxiety and stress. Monitoring their mental health will assist to minimise the psychological distress associated with their occupations. DOI: http://dx.doi.org/10.4038/sljpsyc.v5i1.6506 SL J Psychiatry 2014; 5 (1): 7-9

Incidence of facial soft tissue injuries among patients attending surgical casualty reception in Rojh-halat emergency hospital

Background and objective: Facial soft-tissue injuries are the most common injuries presenting to surgical causality reception. The present study aimed to provide a preliminary data base about the distribution, type, pattern and etiology of facial soft tissue injuries. Methods: In a prospective clinical study all patients with facial injury were enrolled in this study, over a ten months period (from 1st October 2010- 1st July 2011), who attended Surgical Casualty Reception in Rojh-halat Emergency Hospital. A questionnaire was used to collect patients’ database and relevant information. The wound configuration was divided as laceration, abrasion and contusion as well as the site of facial soft tissue injuries were recorded using the modified MCFONTZL system. Results: A total of 168 patients with facial soft tissue injuries were received and managed at Surgical Casualty Reception in Rojh-halat Emergency Hospital. The age of the patients were ranged from 1-80 years old. Most of the patients were within the age range of 1-10. Male patients constitute 62.5% of the cases. The most common etiology of facial soft tissue injury was falls. Regarding type of the injury, laceration was the most common type. The lips and chin region were mostly involved. Conclusion: Fall is the most common cause of facial injury. Lower third of the face is mostly involved. road traffic legislations have a role in decreasing road traffic accidents.

Mass Casualties in Tahrir Square at the Climax of the Egyptian Uprising

Documentation of the management of mass casualties in Tahrir Square. We documented the sequences of our medical response to mass casualties in Tahrir Square between January 28, 2011, and February 4, 2011, at "Kasr El-Ainy" Cairo University Hospital, the largest hospital in the Middle East and the tertiary referral center for all hospitals in Egypt that happened to be the closest to Tahrir Square. At the peak of Tahrir Square demonstrations, injured protesters received first aid in a makeshift clinic inside Tahrir Square, manned by volunteer doctors and nurses, before they were evacuated to the Cairo University Hospital Surgical Casualty Department. General surgeons, orthopedic surgeons, anesthesiologists, and critical care nurses from multidisciplinary teams hastily triaged and treated the incoming casualties. Thousands of casualties were seen at the peak of the uprising. This article provides a detailed review of mass casualties seen between January 28, 2011, and February 4, 2011. Of 3012 casualties, 453 were triaged as "immediate care" patients. On arrival, 339 of 453 patients (74.8%) needed surgical intervention within 6 hours of arrival whereas 74 of 453 patients (16.3%) were managed conservatively. Forty of 453 (8.8%) of patients did not survive their injuries. Most of the inpatients (302/453, 66.6%) were admitted within 10 hours on January 28, 2011, during which evidence of a pattern of regime's organized escalating violence emerged. We describe the pattern of injuries and our management of Tahrir Square mass casualties. We believe that forming multidisciplinary teams of surgeons, anesthesiologists, and nurses was the key to our effective management of such a huge event.

Efficacy of Canadian computed tomography head rule in predicting the need for a computed-axial tomography scans among patients with suspected head injuries

Context:The use of imaging modalities is crucial in the diagnostic field of critical medicine. However, the ethical and economic use of these techniques has become a major concern especially in resource-poor settings. The Canadian computed tomography Head Rule (CCHR) is being increasingly used all over the world to evaluate the necessity of a Computer-assisted Tomography (CT) scan in patients with suspected head injury.Aim:The aim of the current study is to evaluate the efficacy of CCHR to predict the occurrence of head injury, as evidenced radiologically by a CT Head, at a government tertiary care clinical setting in south India.Setting and Design:The design was that of a hospital-based cross-sectional survey conducted at the Medical College Hospital, Thiruvananthapuram (Kerala, India).Materials and Methods:The study subjects were patients with suspected head injury evaluated at the Surgical Casualty Department of the study setting. Fifty consecutive patients with suspected head injury were enrolled in the study.Statistical Analysis:The Chi-square test was used to assess the statistical significance of association between the outcome variable and the exposure characteristics. The diagnostic ability of the Glasgow Coma Scale (GCS) and CCHR were expressed in terms of sensitivity and specificity by considering CT diagnosed Head injury as the gold standard diagnostic tool.Results:Clinical manifestations as measured by a GCS score < 13 failed to significantly predict a head injury in the CT scan. However, the same became statistically significant when the CCHR was added to the GCS score as a predictor (P value < 0.001). The sensitivity of the tool in predicting a head injury rose from 23.3 to 96.7%.Conclusion:The current study suggested that the CCHR could act as an excellent decision rule to indicate the need of a CT scan. The need of a decision rule was warranted in the context of the growth of newer diagnostic imaging facilities in India.

Endourological procedures and sexual dysfunction: a prospective multivariate analysis

To investigate whether endourological interventions are associated with postoperative sexual dysfunction. The study comprises a consecutive and prospective series of patients, referred for endourological procedures. General anaesthesia was used and JJ stents were placed when required. Changes in sexual function, as assessed by the International Index of Erectile Function questionnaire that the participants filled in the day before the procedure and 1 month and up to 3 months afterwards, were analysed. The study group consisted of 50 men aged (mean ± SD) 45 ± 13 years, of whom 25 underwent ureteroscopy, 9 underwent retrograde intrarenal surgery (RIRS) and 16 underwent combined RIRS and percutaneous nephrolithotomy. JJ stents were postoperatively placed in 33 patients (66%). The study cohort self-reported a significant decrease in erectile function (P= 0.007), intercourse satisfaction (P < 0.001), orgasmic function (P= 0.001), sexual desire (P < 0.001) and overall satisfaction (P= 0.002) at 1 month following endourological procedures. This dysfunction was not related to chronic disease, age, smoking, preoperative or postoperative stenting, type of procedure, operative duration or surgeon expertise. The sexual function of all subjects returned to baseline within 3 months (P < 0.005). Postoperative erectile function in the stented group revealed a negative tendency that did not reach statistical significance. Endourological procedures are associated with temporary postoperative sexual dysfunction, which completely recovers within 3 months. The impact of postoperative stenting on sexual function was not significant. These findings contribute to enhanced preoperative patient counselling.

Lead poisoning associated with Ayurvedic drug presenting as intestinal obstruction: A case report

Introduction Lead poisoning is most commonly caused by occupational exposure. It presents with a myriad of signs and symptoms ranging from mild anemia to frank encephalopathy, depending on the blood lead levels as well as the duration of exposure. Intake of herbal/Ayurvedic medicine may also lead to plumbism as heavy metals are often incorporated in such medications with the belief that such metals have medicinal properties. Methods We report a case of lead poisoning caused by Ayurvedic medication. The patient presented with symptoms of intestinal obstruction to the surgical casualty. Results The patient presented with symptoms that mimicked intestinal obstruction. No specific etiology could be determined. Serum lead levels were determined and diagnosis of lead poisoning ascertained. The lead content of the medicine was analyzed and it contained 30% w/w lead. Conclusions The diagnosis of heavy metal poisoning consequent to intake of alternative medicine must be kept in mind when a patient presents with vague complaints.

Anesthesia and perioperative care of the combat casualty. Textbook of military medicine. Part IV – surgical combat casualty care, R. Zajtchuk, R. F. Rellamy and C. M. Grande (eds). 287 × 220 mm. Pp. 1931. Illustrated 1995. Tacoma, Washington: TMM Publications. Price not supplied

Anesthesia and perioperative care of the combat casualty. Textbook of military medicine. Part IV – surgical combat casualty care, R. Zajtchuk, R. F. Rellamy and C. M. Grande (eds). 287 × 220 mm. Pp. 1931. Illustrated 1995. Tacoma, Washington: TMM Publications. Price not supplied