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BACKGROUND Hemoglobin-Based Oxygen Carriers (HBOCs) can act as an "oxygen bridge" in acute severe anemia when transfusion is indicated, but not possible. We present data on 10 Expanded Access (EA) patients treated with high cumulative doses of Hemopure (HBOC-201), to assess the ability of HBOC-201 to safely treat life threatening anemia in situations where high volumes of product were administered over an extended period of time. STUDY DESIGN AND METHODS Inclusion in this study required that the patient receive at least 10 units of HBOC-201 between 2014 and 2017 under the FDA-sanctioned EA program. Depending on a patient's geographical location, treatment with HBOC-201 was obtained through either a single patient emergency Investigational New Drug (IND) application, or an intermediate size population IND. Of the 41 patients who were treated during this period, 10 patients received 10 or more units of the product. Data were obtained from medical records. RESULTS Treatments with HBOC-201 started within 24 hours of signing consent and were administered at an average rate of 1.99 (SD 0.17) units per day over a mean of 8.2 days (SD 2.9), during which patients received on average 16.2 units (SD 5.7 units) of HBOC-201. The median pre-treatment nadir corpuscular hemoglobin (Hb) concentration was 3.3 (SD 0.9) g/dL and post-treatment Hemoglobin was 7.3 (SD 1.7) g/dL. Common side effects included methemoglobinemia, gastrointestinal symptoms, and hypertension. However, no product-related serious adverse events (SAEs) were noted. All patients survived. CONCLUSIONS Administration of HBOC-201 over an extended period is a feasible and safe oxygen bridge for severely anemic patients who cannot be transfused with RBC.

This case describes a 46-year-old male recipient of a kidney-pancreas transplant who is Jehovah's Witness. Early in the postoperative period, he was found to have splenic vein thrombosis requiring heparin infusion. Two days later, he developed severe symptomatic anemia (hemoglobin

Large-scale explosions and plane crashes are good models for sudden mass casualty incidents (SMCIs) and may cause a large number of deaths and dismembered or fragmented bodies.

One of the major controversies on prehospital care for sudden chemical mass casualty incidents (SCMCIs) is whether to perform mass decontamination at the scene or at the hospital.

This is not another chapter about blast injuries but rather a brief summary of the main challenges encountered when treating patients with these catastrophic injuries.

Sudden exposure of multiple people to a chemical agent may be classified as a sudden chemical mass casualty incident (SCMCI). The vast majority of the contaminated patients will be mildly contaminated (“walking wounded”). The majority of contaminated patients will self-evacuate or be transported by nonrescue personnel to local hospitals. Although decontamination at the scene is desirable, it is time consuming in an unplanned, sudden event, and therefore unrealistic. Most critical patients, usually those with respiratory distress, will probably expire by the time scene decontamination is available. Therefore, critical contaminated patients should be transported rapidly to hospitals by first responders who must have personal protective equipment (PPE). Removal of all clothing may reduce contamination by 80–90% and should be done prior to getting into the ambulance. Once in the ambulance, patient can be kept covered and warm with blankets and sheets. High probability that a large number of self-evacuated patients will flood the hospital campus. Hospitals should plan to prevent patient flooding, have a decontamination facility, and further manage patients from a SCMCI.

The use of tourniquets, as a temporary procedure to control extremity bleeding, may be life saving. For many years, the use of tourniquets was banned from civilian prehospital protocols for management of limb hemorrhage due to concerns for complications, mainly loss of limbs. Military studies published by the Israeli, Americans, and British in the past 15 years, show that tourniquets are effective to control bleeding in the battlefield, are associated with minor complications and no limb loss. These outcomes were replicated in civilian studies as well. Recently, the advanced trauma life support (ATLS®) course introduced tourniquet use as an alternative for management of limb hemorrhage, when direct pressure fails to control bleeding. Nevertheless, in some situations when improvised tourniquets (cloths, ropes, ties) are applied by untrained bystanders, the opposite effect may occur, and the bleeding may increase. Therefore, tourniquet application should be limited to trained personnel. Untrained bystanders should be allowed to hold pressure directly on the bleeding site until trained personnel arrive. The “Stop the Bleed” training program, recently introduced by the American College of Surgeons (ACS), should increase the number of bystanders trained to control the bleeding until EMS arrives.

Search and rescue (S&R) need to start as early as possible. Possibility of finding survivors beneath the rubble is directly proportional to time (Fig. 11.1).

Crush injury – Occurs as a result of pressure applied to any part of the body, usually extremities, for a prolonged period of time. It may be associated or not with limb fractures. Complications of a crush injury are crush syndrome and compartment syndrome.

The major distinction between planning the medical response to earthquakes and other sudden mass casualty incidents (SMCI) is related to how severe damage will be the infrastructure of the city where the earthquake occurred.

On a cruise ship, there is an average of two physicians and three nurses on call for emergencies 24 h a day. Both the doctors and nurses are emergency medicine specialists.

Key components for planning exercises and drills for sudden mass casualty incidents (SMCIs): A plan for response to a SMCI needs to be written before the drill. Provide lectures to explain the plan to all individuals who may be involved in the response: For pre-hospital: all first responders For hospital: all medical, support personnel and administrators Organize tabletop exercises: Designed to bring together, into one room, all “players” that will respond to a SMCI (police, fire, EMS, hospitals, incident command, regional emergency operations center (REOC)). A large-scale incident is presented to them, and they have to resolve all challenges and pitfalls that it presents. Conduct sectorial pre-hospital exercises (Fig. 19.1): Constructed to train portions of the pre-hospital response separately. Examples: Scene deployment to a SMCI and triage of patients: could be performed at the ambulance station parking lot, using inflatable dummies or cards with description of injuries. Interaction between various ambulances and incident control: could be performed at an empty stadium parking lot, using inflatable dummies, where a few ambulances are deployed simultaneously. All paramedics perform triage, and the scene commander decides on transport priorities. Conduct sectorial hospital exercises: Constructed to train portions of the hospital response separately. Examples: Deployment of triage, patient arrival and photography Routes for emptying the emergency department Routes for influx of patients Deployment of alternate care sites Deploy a full exercise, preferably with pre-hospital and hospital training together (Fig. 19.2). There is no substitute for a well-organized, full-scale exercise testing all components of the response simultaneously.

Telemedicine is gaining increasing popularity in recent years as a new approach to assist with patient care in remote locations, where expert physicians may not be available. Today, most medical personnel have cellular phones with cameras capable of transmitting still images and videos to experts all around the world. For these reasons, some advocate the use of telemedicine to manage disasters in remote locations.

Information about specific treatment of anthrax, smallpox, botulinum, Ebola, and other infectious diseases can be found elsewhere.

This chapter focuses on planning and response for other types of sudden mass casualty incidents (SMCIs).

This last chapter of the manual focuses on special challenges when managing sudden mass casualty incidents (SMCIs) and includes specific medical tips when handling patients suffering crush and blast injuries, the most common identification processes of disfigured victims or body parts following explosions, and the importance of performing frequent live exercises and drills. In addition, the questionable use of telemedicine in SMCIs is discussed. The final section, “The Ten Commandments for Management of Sudden Mass Casualty Incidents,” highlights the most important topics that need to be in place to successfully respond to an SMCI.

Previously in this manual, I discussed the difference between progressive disasters and sudden events and the importance of a specific plan that addresses both types separately.

The objective of this article is to characterize changes in vital signs of trauma victims from prehospital to hospital settings, their associations with injury severity, and the need for an emergency operation. Methods: a prospective cohort included 601 patients admitted to a level one trauma centre from 1 July to 30 September 2007. All prehospital and hospital admission values of Glasgow coma score (GCS), systolic blood pressure (SBP), heart rate (HR), respiratory rate (Resp) and oxygen saturation (SpO2) were recorded. All urgent major surgical procedures were graded in real-time as: emergency, urgent, or not urgent. Injury severity score (ISS) was calculated following completion of all the diagnostic work-up. Patients were classified as major trauma victims if their calculated ISS was 16 or greater, and those who needed an urgent intervention or intensive care. Vital signs trends were analyzed using the students' T—test. Associations with injury severity and the need for an emergency operation were analyzed using chi-squared test. The statistical significance level was set at 5% (P ≤ 0.05). Results: 243(40%) patients were classified as major trauma. 39(6.5%) patients required an emergency operative intervention—29 for active bleeding and 10 for imminent cerebral herniation. The time from injury to hospital arrival was 44.8 ± 17.63 minutes (mean±standard deviation), the time did not differ for those needing an emergency operation. Prehospital GCS ≤12 and SBP ≤90 were associated with a severe injury (a relative risk(RR) of 4.95, 95% confidence interval(CI) 3.25–7.58 for low GCS and 4.60, 2.67–7.94 for low SBP) and emergency surgical procedures (RR, 95% CI 4.43, 2.28–8.58 for low GCS and 11.69, 5.85–23.36 for low SBP). These values changed significantly from the field to the hospital with the mean GCS increasing 1.65 points and the mean SBP decreasing 7.23 mmHg (p90, and only 2/542(0.4%) patients with a SBP >90 on admission required emergency bleeding control (P

Laparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis.Prospective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort.Laparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20-73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD +/- 50 min), versus 3 h 5 min (SD +/- 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (+/- 2.47 days) for the laparoscopic group and 4.3 days (+/- 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3-7.The timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.

Transfusion is a cornerstone of early trauma care, but little is known regarding the consistency of transfusion practice in different regions of the world. We examined data available in the German Trauma Registry, the University of Miami Trauma Registry, and the Registry of the Shock Trauma Center in Baltimore to learn more regarding this question. We sought to identify the rate of transfusion of trauma patients during the resuscitative phase, the volume of transfusion administered, and the correlation of various levels of transfusion with clinical outcomes such as mortality, hospital length of stay, and the incidence of organ system failure. Mortality associated with transfusion was remarkably similar in all three systems, making it clear that the volume of blood received during early resuscitation is a strong predictor of outcome for patients presenting in hemorrhagic shock.

Background: The role of ultrasound (US) as a screening tool for the evaluation of blunt abdominal trauma is still controversial. Determining the types of missed injuries and the accuracy of US in patients with a low GCS will improve the evaluation of these blunt trauma patients. Methods: Prospectively collected data from the trauma registry of a Level I trauma center was reviewed. Results: 7,952 patients were included in the study. US examination had an accuracy of 89%, sensitivity of 77%, specificity of 97%, positive predictive value (PPV) of 78%, and negative predictive value (NPV) of 98%. GCS correlated with ISS and base deficit levels. US examination had a significantly lower accuracy in patients with a low GCS and in women. Conclusion: The sensitivity and specificity of US examination is similar in those with normal and low GCS. Therefore ultrasonographic examination may be considered a good screening tool for the evaluation of patients with blunt abdominal trauma, but its accuracy is diminished in patients with a low GCS. Further imaging may be warranted in these patients.

The purpose of this study was to ascertain risk factors for death from trauma. The large cohort allows for simultaneous evaluation of known mortality risk factors along with controlling for factors to assess the influence of each independently. Individually, base deficit, temperature, hypotension, age, and injury severity have been shown to be associated with an increased risk of death. However, in the English literature, there is no data on the independent predictive power and interaction of these risk factors. A review of trauma registry parameters from 1995 to 2000 was used. Demographics, injury severity, physiological and hematological parameters, and time data were evaluated in a univariate analysis. Variables significantly associated with mortality were entered into a stepwise backward multiple logistic regression. There were 1276 deaths (8.9%) with 25 per cent of the deaths within 3 hours. The top four predictors of mortality in this group were partial thromboplastin time (OR 3.37, 95% CI: 2.51–4.52), positive head computed tomography result (OR, 2.47; 95% CI, 1.95–3.04), initial hemoglobin (OR, 1.69; 95% CI, 1.23–2.31), base deficit (OR, 1.62; 95% CI, 1.29–2.04), and trauma resuscitation bay systolic blood pressure (OR, 1.45; 95% CI, 1.11–1.88). We conclude that prognostic indicators of all-cause mortality after trauma, which remain independent in the presence of all other factors and are potentially treatable, included low hemoglobin, elevated prothrombin and partial thromboplastin time, low scene and trauma bay systolic pressure, and elevated base deficit. The independent indicators of mortality, which are untreatable, included head injury, increasing age, and Injury Severity Score.

Background: Ultrasound (US) is commonly used for the diagnosis of hemo-peritoneum after blunt abdominal trauma, but the value of US as an aid for identification of operative lesions after penetrating trauma is not well documented. The purpose of this investigation was to determine the accuracy of US for the evaluation of penetrating torso trauma and to assess the impact of this information on patient management. Methods: We conducted a prospective cohort observational study of consecutive penetrating torso patients at a Level I trauma center. Results: During the 6-month trial period, 177 victims of penetrating torso trauma were assessed by our trauma teams. Ninety-two patients had stab wounds, 84 patients had gunshot wounds, and 1 patient had a puncture wound. All 28 patients with positive US examination had an exploratory laparotomy or thoracotomy (one patient had more than one procedure), resulting in 26 therapeutic operations. There were 149 negative US examinations, but in this group, 36 patients underwent laparotomy or thoracotomy, and 28 had therapeutic operations. The overall accuracy of the US examination was therefore 85%, the sensitivity was 48%, and the specificity was 98%. There were only three patients who had their initial management altered by a positive US examination. Conclusion: The US examination lacks sensitivity to be used alone in determining operative intervention after gunshot or stab wounds. Rarely does US information contribute to the management of patients with penetrating abdominal injuries.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Coagulopathy is the major cause of bleeding-related mortality in patients who survive the operating room. Its association with hypothermia and metabolic acidosis is common and constitutes a vicious cycle. Usually, post-traumatic coagulopathy is an early event and may be present during surgery. The pathogenesis of severe post-traumatic coagulopathy is complex and multifactorial. Virtually every aspect of the normal coagulation cascade is affected in the cold, acidotic, exsanguinating trauma patient. In the last decade many surgeons have emphasized the role of prevention or early treatment of this vicious cycle. Damage control surgery with planned re-operations has demonstrated superiority over the traditional approach in cases where the patients' condition is deteriorating. Early control of surgical bleeding and significant contamination, together with vigorous correction of hypothermia and continuous resuscitation, has improved the survival of these patients. Recently, a new adjunct to the treatment of coagulopathy in trauma patients has been reported and is undergoing controlled animal trials. Recombinant activated factor VII (rFVIIa) was originally developed as a pro-hemostatic agent for the treatment of bleeding episodes in hemophilia patients. rFVIIa has been successfully used in moribund trauma patients in whom standard procedures had failed to correct bleeding. Preliminary preclinical and clinical studies are under way.

Background: Administration of large amounts of fluids to trauma patients, in the absence of surgical control, may increase bleeding, cause hypothermia and coagulopathy which may worsen the bleeding and increase morbidity and mortality. The purpose of our study is to examine the impact of prehospital fluid administration to military combat casualties on core body temperature and coagulation functions. Methods: Prospective data were collected on all cases of moderately (9≤ISS≤14) and severely (ISS≥16) injured victims wounded in South Lebanon, treated by Israeli military physicians and evacuated to hospitals in Israel, over a two-year period. Data regarding prehospital phase of injury (timetables, amount of fluids) and upon hospital arrival (initial core body temperature, prothrombin time [PT], partial thromboplastin time [PTT]) were examined for monotonic relation using Spearman's non-parametric test. Results: Fifty-three moderately injured and 31 severely injured patients were included in the study. The average evacuation time for the moderately injured group was 109.3±44.8 min, and for the severely injured 100.3±38.4 min (P value=NS). The mean volume of fluids administered was 2.39±1.52 and 2.49±1.47 l, respectively (P=NS). No statistical correlation was found between core body temperature, PT or PTT, measured upon hospital arrival, and prehospital fluid treatment. In addition, no correlation was found between core body temperature on hospital arrival and prehospital time, or between prehospital fluid volumes and prehospital time. The mean core body temperature of the moderately injured patients was 36.8 °C, and that of severely injured was 35.8 °C (P=0.026). Conclusions: With proper control of blood loss and avoidance of excessive fluid administration, moderately and severely injured combat casualties in ‘low intensity conflict’ in South Lebanon can be resuscitated with fluid volumes that do not result in a coagulation deficit or hypothermia. The core body temperature on arrival at the hospital is related to the severity of the injury.

SUMMARY Background: Recombinant activated factor VII (rFVIIa) was approved for treatment of hemorrhages in patients with hemophilia who develop inhibitors to factors VIII or IX. Conditions with increased thromboembolic risk, including trauma with or without disseminated intravascular coagulation, were considered a contraindication for the drug. The mechanism of action of rFVIIa suggests enhancement of hemostasis limited to the site of injury without systemic activation of the coagulation cascade. Therefore, use of the drug in trauma patients suffering uncontrolled hemorrhage appears to be rational. Methods: Seven massively bleeding, multitransfused (median, 40 units [range, 25–49 units] of packed cells), coagulopathic trauma patients were treated with rFVIIa (median, 120 μg/kg [range, 120–212 μg/kg]) after failure of conventional measures to achieve hemostasis. Results: Administration of rFVIIa resulted in cessation of the diffuse bleed, with significant decrease of blood requirements to 2 units (range, 1–2 units) of packed cells (p < 0.05); shortening of prothrombin time and activated partial thromboplastin time from 24 seconds (range, 20–31.8 seconds) to 10.1 seconds (range, 8–12 seconds) (p < 0.005) and 79 seconds (range, 46–110 seconds) to 41 seconds (range, 28–46 seconds) (p < 0.05), respectively; and an increase of FVII level from 0.7 IU/mL (range,0.7-0.92 IU/mL) to 23.7 IU/mL (range, 18–44 IU/mL) (p < 0.05). Three of the seven patients died of reasons other than bleeding or thromboembolism. Conclusion: The results of this report suggest that in trauma patients rFVIIa may play a role as an adjunctive hemostatic measure, in addition to surgical hemostatic techniques, and provides the motivation for controlled animal and clinical trials.

Background: Prehospital blood transfusion for hemorrhaging trauma patients has been used infrequently and is controversial. Currently, there is no satisfactory nonsanguineous fluid therapy for use during prolonged transport, such as in military or rural trauma. Methods: We retrospectively reviewed prehospital data and hospital charts of all trauma patients in Israel who had received prehospital blood transfusion during a period of 30 months. Results: Forty patients received 60 U of Rh-positive type O packed red blood cells. Mean time from injury to hospital admission was 120 minutes. Twenty-one of 31 patients admitted to the hospital alive (68%) received additional blood transfusions during the initial resuscitation phase, justifying the prehospital transfusion. Of nine documented admissions with hemoglobin of less than 7 g/dL, one patient died of exsanguination. There was one case of a minor adverse reaction that could be attributed to prehospital transfusion. Conclusion: Prehospital blood transfusion is justified in certain trauma patients, especially when long prehospital transport is required. Blood may be safely maintained and used by physicians with little experience in care of major trauma.

Background: Critically ill trauma patients with gastric intramucosal acidosis, as measured by gastric tonometry, have an increased incidence of multiple organ dysfunction syndrome despite supranormal O 2 delivery. We altered our resuscitation protocol to maximize splanchnic blood flow and decrease oxygen-derived free radical damage. Design: Prospective clinical trial with historical controls. Methods: The protocol differed from control by including administration of folate, mannitol, and low-dose isoproterenol. All patients had gastric tonometers and pulmonary artery catheters. If the intramucosal pH (pH i ) was less than 7.25, splanchnic-sparing inotropic and vasodilatory agents were used to optimize systemic cardiac output. Two groups of trauma patients with persistent intramucosal acidosis at 24 hours (pH i < 7.25) were compared: a control group (n = 7), and patients who received the splanchnic/antioxidant protocol (n = 13). Results: The two groups were similar based on Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, age, cardiac index, oxygen delivery, and oxygen consumption. The splanchnic therapy group had fewer organ system failures as well as shortened length of intensive care unit and hospital stay. Three of 7 patients in the control group and 2 of 13 patients in the splanchnic therapy group had a final pHi < 7.25. Conclusion: Gastric tonometry-guided resuscitation and antioxidant/splanchnic therapy in critically ill trauma patients with persistent gastric mucosal acidosis may decrease multiple organ dysfunction syndrome.

We present a case of a 71-year-old male that was involved in a high-speed motor vehicle collision, as an unrestrained back seat passenger. On primary survey, decreased breath sounds and bowel sounds were auscultated in the left thorax. Secondary survey was positive for left anterior chest wall tenderness. Chest radiograph demonstrated multiple rib fractures, hemothorax, and diaphragmatic rupture with herniation of bowel loops into the chest cavity (Figure 1). Upon insertion of a nasogastric tube, repeat radiograph demonstrated the nasogastric tube to be in the left upper abdomen (Figure 2). The patient underwent emergency laparotomy for repair of his injury. Incidentally, a splenic laceration was identified intraoperatively. Successful repair of the diaphragmatic injury as well as splenectomy was achieved.

Objective Efficient triage may have a major influence on mortality and morbidity as well as financial consequences. A continuous effort to improve this decision making process and update the trauma alert criteria is being made. However, criteria for determining the evacuation priority are not well developed. We performed a prospective study to evaluate which pre-hospital parameters identify major trauma victims with an emphasis on a need for emergent surgical procedures. Methods A prospective cohort included 601 patients admitted to a level one trauma centre over a three months period. The pre-hospital trauma alert criteria were recorded and set as independent variables. All major surgical procedures were graded in real time as: emergent, urgent, or not urgent. The ISS was calculated after completion of all the diagnostic workup. Patients were classified as major trauma victims if their calculated ISS was 16 or greater, and those needed an urgent intervention or intensive care. The relative risks (RR) for major trauma and a need for an emergent operation were calculated. Results 243 (40%) patients were classified as having a major trauma. 39 (6.5%) patients required an emergent operative intervention: 24 for an active bleeding, 5 for a pericardial tamponade and 10 for an imminent cerebral herniation. Paramedic judgement and a penetrating injury to the trunk were the most common causes for over triage. However, a penetrating injury to the trunk had been the only clue that the victim needed an emergent operation in five cases. 128 patients had a pre-hospital Glasgow coma score (GCS) ≤12. Altered mental status was the most common and a significant predictor of both major trauma (RR of 3.00 with a 95% confidence interval (CI) of 1.98–4.53) and a need for an emergent operation (RR, 95% CI: 4.43, 2.28–8.58). Also, a systolic blood pressure ≤90 mmHg was highly associated with an emergent operation (RR, 95% CI: 11.69, 5.85–23.36). Conclusion For determining the evacuation priority, we suggest a triage system based on three major criteria: mental status, hypotension and a penetrating injury to the trunk. Overall, the set of trauma alert criteria system can be further simplified and enable better utilisation of resources.

The successful management of mass casualty incidents (MCIs) requires standardization of planning, training, and deployment of response. Recent events in the United States, most importantly the Hurricane season in 2005, demonstrated a lack of a unified response plan at local, regional, state, and federal levels. A standard Israeli protocol for hospital preparedness for conventional MCIs, produced by the Office of Emergency Preparedness of the Israeli Ministry of Health, has been reviewed, modified, adapted, and tested in both drills and actual events at a large university medical center in the United States. Lessons learned from this process are herein presented as the10 most important steps (ie, Commandments) to follow when preparing hospitals to be able to respond to conventional MCIs. The standard Israeli emergency protocols have proved to be universally adaptable, flexible, and designed to be adapted by any healthcare institution, regardless of its size and location.

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

The purpose of this study was to review our experience with a mass casualty incident resulting from a boiler room steam explosion aboard a cruise ship. Experience with major, moderate, and minor burns, steam inhalation, mass casualty response systems, and psychological sequelae will be discussed. Fifteen cruise ship employees were brought to the burn center after a boiler room explosion on a cruise ship. Eleven were triaged to the trauma resuscitation area and four to the surgical emergency room. Seven patients were intubated for respiratory distress or airway protection. Six patients had >80 per cent burns with steam inhalation, and all of these died. One of the 6 patients had 99 per cent burns with steam inhalation and died after withdrawal of support within the first several hours. All patients with major burns required escharotomy on arrival to trauma resuscitation. One patient died in the operating room, despite decompression by laparotomy for abdominal compartment syndrome and pericardiotomy via thoracotomy for cardiac tamponade. Four patients required crystalloid, 20,000 mls/m2–27,000 ml/m2 body surface area (BSA) in the first 48 hours to maintain blood pressure and urine output. Three of these four patients subsequently developed abdominal compartment syndrome and died in the first few days. The fourth patient of this group died after 26 days due to sepsis. Five patients had 13–20 per cent burns and four patients had less than 10 per cent burns. Two of the patients with 20 per cent burns developed edema of the vocal cords with mild hoarseness. They improved and recovered without intubation. The facility was prepared for the mass casualty event, having just completed a mass casualty drill several days earlier. Twenty-six beds were made available in 50 minutes for anticipated casualties. Fifteen physicians reported immediately to the trauma resuscitation area to assist in initial stabilization. The event occurred at shift change; thus, adequate support personnel were instantaneously to hand. Our mass casualty preparation proved useful in managing this event. Most of the patients who survived showed signs of post-traumatic stress syndrome, which was diagnosed and treated by the burn center psychology team. Despite our efforts at treating large burns (>80%) with steam inhalation, mortality was 100 per cent. Fluid requirements far exceeded those predicted by the Parkland (Baxter) formula. Abdominal compartment syndrome proved to be a significant complication of this fluid resuscitation. A coordinated effort by the facility and preparation for mass casualty events are needed to respond to such events.

Spine injuries after gunshot wounds are thought to be rare among asymptomatic patients. The occurrence of spine injuries among asymptomatic patients with gunshot wounds was studied to determine the necessity for mandatory spine immobilization and radiographic imaging.In this retrospective cohort study, initial physical examination, radiographic findings, and final diagnosis and treatment were reviewed. Patients were included if they were admitted to the authors' level 1 trauma center with gunshot wounds to the head, neck, or trunk during a 10-year period. Spine injuries were considered "significant" if the injury was associated with spinal cord injury or required spine-related surgical procedures or prolonged spine immobilization. Spine injuries were defined as "unsuspected" if there were no neurologic findings at admission.During the study period, 2,450 patients who survived more than 24 hours were admitted with gunshot wounds to the trunk, neck, or head. Of these patients, 244 (approximately 10%) had spine injuries, and 228 of them had complete records. Two thirds of the spine injuries were found to be significant, requiring surgery or prolonged immobilization, and 13% were unsuspected.Spine injuries without neurologic signs are not uncommon among patients with gunshot wounds. Complete radiographic spine imaging is therefore recommended to ensure that spine injuries are not missed in this population.

Approximately one third of stable patients with significant intra-abdominal injury do not have significant intraperitoneal blood evident on admission. We hypothesized that a delayed, repeat ultrasound study (Secondary Ultrasound--SUS) will reveal additional intra-abdominal injuries and hemoperitoneum.We performed a prospective observational study of trauma patients at our Level I trauma center from April 2003 to December 2003. Patients underwent an initial ultrasound (US), followed by a SUS examination within 24 hours of admission. Patients not eligible for a SUS because of early discharge, operative intervention or death were excluded. All US and SUS exams were performed and evaluated by surgical/emergency medicine house staff or surgical attendings.Five hundred forty-seven patients had both an initial US and a SUS examination. The sensitivity of the initial US in this patient population was 31.1% and increased to 72.1% on SUS (p0.001) for intra-abdominal injury or intra-abdominal fluid. The specificity for the initial US was 99.8% and 99.8% for SUS. The negative predictive value was 92.0% for the initial US and increased to 96.6% for SUS (p = 0.002). The accuracy of the initial ultrasound was 92.1% and increased to 96.7% on the SUS (p0.002). No patient with a negative SUS after 4 hours developed clinically significant hemoperitoneum.A secondary ultrasound of the abdomen significantly increases the sensitivity of ultrasound to detect intra-abdominal injury.