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As the roles of trauma/acute care surgeons continue to evolve, it is imperative that health-care systems adapt to meet workforce needs. Tailoring retention strategies that elicit workforce satisfaction ensure continued coverage that is mutually beneficial to surgeons and health-care systems. We sought to elicit factors related to career characteristics and expectations of the trauma/acute care surgery (ACS) workforce to assist with such future progress. In this study, 1552 Eastern Association for the Surgery of Trauma members were anonymously surveyed. Data collected included demographics, career expectations, and motivators of trauma/ACS. Four hundred eight (26%) Eastern Association for the Surgery of Trauma members responded. Respondents were 78 per cent male and had a median age of 47.3 years. Forty-six per cent of surgeons reported earning $351K–$475K and 23 per cent >$475K. At this point in their career, 49 per cent of surgeons felt quality of life was “most important”, followed by 31 per cent career ambitions and 13 per cent salary. Prominent career satisfiers were patient care and teaching. Greatest detractors were burnout, bureaucracy, and work environment. Eighty per cent would change jobs in the final 10 years of practice, 31 per cent because of family/retirement, 29 per cent because of professional growth, 24 per cent because of workload, and 7 per cent because of salary. This study could be used to help develop trauma/ACS workforce strategies. This workforce remains mobile into late career; personal happiness and patient ownership overshadow financial rewards, and most prefer a total and shared patient care model compared with no patient ownership. Burnout, bureaucracy, and work environment are dominant detractors of job satisfaction among surveyed trauma/ACS surgeons.

BACKGROUND The integrity of the blood-brain barrier (BBB) is paramount in limiting vasogenic edema following traumatic brain injury (TBI). The purpose of this study was to ascertain if quetiapine, an atypical antipsychotic commonly used in trauma/critical care for delirium, protects the BBB and attenuates hyperpermeability in TBI. METHODS The effect of quetiapine on hyperpermeability was examined through molecular modeling, cellular models in vitro and small animal models in vivo. Molecular docking was performed with AutoDock Vina to matrix metalloproteinase-9. Rat brain microvascular endothelial cells (BMECs) were pretreated with quetiapine (20 μM; 1 hour) followed by an inflammatory activator (20 μg/mL chitosan; 2 hours) and compared to controls. Immunofluorescence localization for tight junction proteins zonula occludens-1 and adherens junction protein β-catenin was performed. Human BMECs were grown as a monolayer and pretreated with quetiapine (20 μM; 1 hour) followed by chitosan (20 μg/mL; 2 hours), and transendothelial electrical resistance was measured. C57BL/6 mice (n = 5/group) underwent mild to moderate TBI (controlled cortical impactor) or sham craniotomy. The treatment group was given 10 mg/kg quetiapine intravenously 10 minutes after TBI. The difference in fluorescence intensity between intravascular and interstitium (ΔI) represented BBB hyperpermeability. A matrix metalloproteinase-9 activity assay was performed in brain tissue from animals in the experimental groups ex vivo. RESULTS In silico studies showed quetiapine thermodynamically favorable binding to MMP-9. Junctional localization of zonula occludens-1 and β-catenin showed retained integrity in quetiapine-treated cells as compared with the chitosan group in rat BMECs. Quetiapine attenuated monolayer permeability compared with chitosan group (p < 0.05) in human BMECs. In the animal studies, there was a significant decrease in BBB hyperpermeability and MMP-9 activity when compared between the TBI and TBI plus quetiapine groups (p < 0.05). CONCLUSION Quetiapine treatment may have novel anti-inflammatory properties to provide protection to the BBB by preserving tight junction integrity. LEVEL OF EVIDENCE level IV.

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the "Orange Book" transfer criteria and who had a length of stay of48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5-16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089-34,087), whereas ED charges were ($40,440; IQR: $26,150-65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.

Background A new proprietary negative pressure wound device has been developed to apply negative pressure therapy to closed wounds (closed-NPWT). We postulated that closed-NPWT management of contaminated and dirty wounds would lead to faster wound healing and no significant difference in wound complications. Study Design An IRB approved, prospective randomized trial was performed. Patients were consented preoperatively, but not entered nor assigned treatment until intraoperative findings were known. Patients were randomly assigned to either open-NPWT or a wound closed with skin staples and external closed-NPWT. Primary outcome was time to complete wound healing, defined as complete epithelization of the wound. Secondary outcomes were wound complications including wound infection, seroma, and dehiscence. Statistical analysis was performed using chi-square test, Fisher exact test, t -test, and Wilcoxon Rank-Sum test with significance of p Results Twenty-five closed-NPWT and 24 open-NPWT patients were analyzed. There were no significant differences in sex, mean age, BMI, smoking history, steroid use, comorbidities, or indication for surgery in the 2 groups. One patient in the open-NPWT group and 2 patients in the closed-NPWT group developed a wound infection (p = 1.0). Four open-NPWT and 3 closed-NPWT patients died from complications unrelated to the wound. Wound healing occurred at a median of 48 days (range 6 to 126 days) for the open-NPWT group vs a median of 7 days (range 6 to 12 days) for the closed-NPWT group (p Conclusions Wound healing was significantly faster in contaminated and dirty wounds when managed with closed-NPWT. There was no difference in wound complications between the 2 treatment groups. This approach shows promise for closed management of contaminated and dirty wounds and warrants additional prospective studies with larger patient groups.

Background Enteral nutrition has been demonstrated to reduce ventilator days and the incidence of pneumonia, but the safest route for providing enteral nutrition to mechanically ventilated patients is unclear. Our objective was to determine if there is a difference between the incidences of microaspiration of gastric secretions in patients fed via a nasogastric tube vs a postpyloric tube while undergoing rotational therapy for acute respiratory distress syndrome (ARDS). Materials and methods Institutional review board approval was obtained for this prospective, randomized study. Patients were randomized to gastric or postpyloric enteral feedings. Daily tracheal secretion samples were collected, and we used an immunoassay to detect pepsin. Using the data for aspiration and tube type, a univariate unadjusted odds ratio was calculated to assess the risk of aspiration between the 2 tube types. An independent samples t test was used to analyze the hypothesis that microaspiration significantly affects lung recovery from ARDS. Results Of the 20 study patients, 9 (45%) received nasogastric feeds and 11 (55%) received postpyloric feeds. Western blot analysis for the presence of pepsin in each tracheal aspirate revealed microaspiration in 2 nasogastric (22%) and 2 (18%) postpyloric patients. The nasogastric tube provided a protective effect for aspirating with an odds ratio of .778 (95% confidence interval, .09-6.98). An independent samples t test was used and showed no significant change in PaO(2):FiO(2) ratio in the aspirating vs nonaspirating group (P = .552). Conclusion The results of this study indicate that enteral nutrition should not be delayed or stopped to position the tube in patients with ARDS on rotational therapy.

Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.

To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care.Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members.This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM.Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion.Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Posttraumatic coagulopathy is a major cause of morbidity. This prospective study evaluated the thrombelastography (TEG) system and PlateletMapping (Haemoscope Corporation, Niles, Ill) values posttrauma, and it correlated those values with transfusions and fatalities. After institutional review board approval, assays were performed on 161 trauma patients. One citrated blood sample was collected onsite (OS), and 1 citrate and 1 heparinized sample were collected within 1 h of arrival to the emergency department (ED). Paired and unpaired t-testing was performed for nominal data with chi square testing for categorical values. Except for a slight increase in clot strength (maximal amplitude (MA)), there were no significant changes from OS to the ED. None of the TEG parameters were significantly different for the 22 patients who required transfusion. PlateletMapping showed lower platelet adenosine diphosphate (ADP) responsiveness in patients who needed transfusions (MA = 22.7 +/- 17.1 vs MA = 35.7 +/- 19.3, P = 0.004) and a correlation of fibrinogen100 mg/dL with fatalities (P = 0.013). For the 14 fatalities, TEG reaction (R) time was 3703 +/- 11,618 versus 270 +/- 393 s (P =0.001), and MA was 46.4 +/- 22.4 versus 64.7 +/- 9.8 mm (P0.001). Hyperfibrinolysis (percent fibrinolysis after 60 min (LY60)15%) was observed in 3 patients in the ED with a 67% fatality rate (P =0.001 by chi-square testing). PlateletMapping assays correlated with the need for blood transfusion. The abnormal TEG System parameters correlated with fatality. These coagulopathies were already evident OS. The TEG assays can assess coagulopathy, platelet dysfunction, and hyperfibrinolysis at an early stage posttrauma and suggest more effective interventions.

STATEMENT OF THE PROBLEM Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent on the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10% to 20% with stab wounds. The management of injuries to the neck that penetrate the platysma is dependent on the anatomic level of injury. The neck has been divided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common and can affect length of stay. Mortality, particularly for major vascular injuries may reach 50%. Delayed complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes. Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, immediate operative management may be indicated. Controversy arises over management of the patient without significant symptoms. The management of these patients has been evolving from an era of mandatory exploration to an era of more selective management. Mandatory exploration, while seemingly safe and conservative, led to many nontherapeutic operations. This fact, along with advances in technology, such as high resolution computed tomography (CT), may eliminate the need to explore the neck to determine whether there are injuries. Also during the time that technology had been advancing, many reports have documented the safety of selective management of neck injuries that penetrate the platysma. This experience has demonstrated that physical examination may be reliable and that not all injuries to vital structures in the neck need surgical intervention for repair. This guideline was therefore initiated to examine the specific roles of mandatory exploration versus selective management based on physical examination and current imaging technologies for penetrating neck trauma.

Fractures to the thoracolumbar spine (TLS) commonly occur because of major trauma mechanisms. In one series, 4.4% of all patients arriving at a Level I trauma center were diagnosed as having TLS fracture. Approximately 19% to 50% of these fractures in the TLS region will be associated with neurologic damage to the spinal cord. To date there are no randomized studies and only a few prospective studies specifically addressing the subject. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the diagnosis of TLS fractures.A computerized search of the National Library of Medicine and the National Institutes of Health MEDLINE database was undertaken using the PubMed Entrez (www.pubmed.gov) interface. The primary search strategy was developed to retrieve English language articles focusing on diagnostic examination of potential TLS injury published between 1995 and March 2005. Articles were screened based on the following questions. (1) Does a patient who is awake, nonintoxicated, without distracting injuries require radiographic workup or a clinical examination only? (2) Does a patient with a distracting injury, altered mental status, or pain require radiographic examination? (3) Does the obtunded patient require radiographic examination?Sixty-nine articles were identified after the initial screening process, all of which dealt with blunt injury to the TLS, along with clinical, radiographic, fluoroscopic, and magnetic resonance imaging evaluation. From this group, 32 articles were selected. The reviewers identified 27 articles that dealt with the initial evaluation of TLS injury after trauma.Computed tomography (CT) scan imaging of the bony spine has advanced with helical and currently multidetector images to allow reformatted axial collimation of images into two-dimensional and three-dimensional images. As a result, bony injuries to the TLS are commonly being identified. Most blunt trauma patients require CT to screen for other injuries. This has allowed the single admitting series of CT scans to also include screening for bony spine injuries. However, all of the publications fail to clearly define the criteria used to decide who gets radiographs or CT scans. No study has carefully conducted long-term follow-up on all of their trauma patients to identify all cases of TLS injury missed in the acute setting.

STATEMENT OF THE PROBLEM Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock (defined as inadequate tissue oxygenation to meet tissue O2 requirements), including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis (compensated shock), which may lead to organ dysfunction and death. Use of the endpoints discussed in this guideline may allow early detection and reversal of this state, with the potential to decrease morbidity and mortality from trauma. Without doubt, resuscitation from hemorrhagic shock is impossible without hemostasis. Fluid resuscitation strategies before obtaining hemostasis in patients with uncontrolled hemorrhage, usually victims of penetrating trauma, remain controversial. Withholding fluid resuscitation may lead to death from exsanguination, whereas aggressive fluid resuscitation may disrupt the clot and lead to more bleeding. “Limited,” “hypotensive,” and/or “delayed” fluid resuscitation may be beneficial, but clinical trials have yielded conflicting results. This clinical practice guideline will focus on resuscitation after achieving hemostasis and will not address the issue of uncontrolled hemorrhage further. Use of the traditional markers of successful resuscitation, including restoration of normal blood pressure, heart rate, and urine output, remain the standard of care per the Advanced Trauma Life Support Course. When these parameters remain abnormal, i.e., uncompensated shock, the need for additional resuscitation is clear. After normalization of these parameters, up to 85% of severely injured trauma victims still have evidence of inadequate tissue oxygenation based on findings of an ongoing metabolic acidosis or evidence of gastric mucosal ischemia. This condition has been described as compensated shock. Recognition of this state and its rapid reversal are critical to minimize risk of MODS or death. Consequently, better markers of adequate resuscitation for severely injured trauma victims are needed. This guideline committee sought to evaluate the current state of the literature regarding use of potential markers and related goals of resuscitation, focusing on those that have been tested in human trauma victims. This manuscript is part of an ongoing process of guideline development that includes periodic (every 3–4 years) review of the topic and the recommendations in light of new data. The goal is for these guidelines to assist clinicians in assuring adequate resuscitation of trauma patients, ultimately improving patient outcomes.

Despite current recommendations by the Brain Trauma Foundation regarding the placement of intracranial pressure (ICP) monitoring devices, advances in computed tomographic (CT) scan technology have led to the suggestion that increased ICP may be predicted by findings on admission head CT scan and that patients without such findings do not require such monitoring. A linear relationship exists between characteristics of admission head CT scan and initial ICP level, allowing for selective placement of ICP monitoring devices.From 1997 to 2001, a retrospective review of patients admitted with a Glasgow Coma Scale (GCS) score8 and head CT scan who underwent ventriculostomy placement at our institution, was conducted. Patients undergoing craniotomy with evacuation of mass lesions before ventriculostomy placement were excluded. Age, sex, mechanism of injury, anoxia, osmotic treatment, presence of drugs/alcohol, initial mean arterial pressure, initial GCS score, and initial ICP were recorded. Initial head CT scans were reviewed independently by two neuroradiologists who were blinded to ICP measurements, neurosurgical treatment, patient outcome, and each other's interpretation. Initial CT scans were evaluated and scored on a 1 (normal) to 3 (abnormal) scale with respect to ventricle size, basilar cistern size, sulci size, degree of transfalcine herniation, and gray/white matter differentiation. Initial ICP readings and CT scan findings were compared to determine whether a significant linear relationship existed between the above CT scan findings and ICPs. Logistic and univariate linear regression were used to compare averaged radiologist score versus dichotomized ICP at baseline.Initial head CT scan characteristics show a linear relationship to baseline ICPs. These findings are associative, but are not uniformly predictive.Therefore, the current Brain Trauma Foundation recommendation of ICP monitoring in those patients presenting with a GCS score8 with an abnormal CT scan or a normal CT scan with age40 years, systolic blood pressure90 mm Hg, or exhibiting posturing should be followed.

Missile embolism to the pulmonary artery is a rare event. We present a complicated case of missile embolism from the inferior vena cava to the pulmonary artery. The case illustrates the potential pitfalls in the management of these patients.

Blunt hollow viscus injury (HVI) is uncommon. No sufficiently large series has studied the prevalence of these injuries in blunt trauma patients. This study defines the prevalence of blunt HVI, in addition to the associated morbidity and mortality rates for this diagnosis on the basis of a series of over 275,000 trauma admissions.Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Each HVI patient (case) was matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have HVI (control). Patient level data were abstracted by individual chart review. Institution level data were collected on total numbers for trauma admission demographics and on total diagnostic examinations performed.From 275,557 trauma admissions, 227,972 blunt injury patients were identified. HVI was rare, with 2,632 patients identified from this group. Perforating small bowel injury accounted for less than 0.3% of blunt admissions. Mortality and morbidity were high for HVI. Controlling for injury severity, patients with HVI were usually at higher risk of death than non-HVI patients.HVI is a rare but deadly phenomenon. The high mortality rates reflect the severity of the HVI and associated injuries. HVI patients should be carefully monitored for related injuries and complications.

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.

BACKGROUND Florida State has one of the largest geriatric populations in the United States. However, recent data show that up to the year 2010, geriatric trauma patients were least served by designated trauma centers (TCs). One existing TC and five provisional Level 2 TCs were combined to create a large-scale trauma network (TN). The new TCs were placed in those areas with the lowest ratios of TC to residents based on census data. The aim of this study was to measure the TN impact on the population of geriatric trauma patients. METHODS Data from the Florida State Agency for Health Care Administration were used to determine mortality, length of stay, and complication rates for geriatric trauma patients (≥ 65 years). The potential effect of the TN was measured by comparing outcomes before and after the initiation of the TN. A total of 165,640 geriatric patients were evaluated. Multivariate regression methods were used to match and adjust for age, injury status (penetrating vs. nonpenetrating), sex, race, comorbidity, and injury severity (DRG International Classification of Diseases-9th Rev. Injury Severity Score). RESULTS Since the advent of the TN, an additional 1,711 geriatric patients were treated compared with the previous period. The TN was responsible 86% of these new patients. There was a temporal association with a decrease in both mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) and length of stay (p < 0.0001) for geriatric patients since the advent of the TN. The improved access was associated with a significant decrease in mortality in the regions serviced by the TN. CONCLUSION Geriatric patients make up a significant proportion of trauma patients within the TN. The temporal improvement in outcomes may be associated with the increased proportion of patients being treated in state-designated TCs as a result of the addition of the TN. LEVEL OF EVIDENCE Epidemiologic study, level III.

Blunt traumatic carotid artery dissection remains controversial in terms of diagnostic screening, reported incidence, and management. Treatment options include observation, anticoagulation and endovascular stenting, and aggressive surgical repair of the carotid artery injury. Blunt traumatic carotid artery dissections were reviewed through a retrospective study of trauma registry records. Seven patients were identified from 3342 patients over 3 years. Six patients were identified incidentally during magnetic resonance imaging (MRI) cervical spine/brain screening and one patient during angiographic evaluation for possible penetrating neck injury without MRI/magnetic resonance angiography (MRA). A total of 189 patients underwent MRI screening over this 3-year period, demonstrating a relative incidence of 3.7 per cent, contrasting with the reported incidence of 0.08 to 0.4 per cent for all trauma patients. All seven patients suffered severe head injuries (mean Glasgow Coma Score = 4.7) requiring mean intensive care unit and hospital stays of 15.6 and 23.7 days, respectively. None of the patients showed evidence of stroke with CT scanning on presentation. None of the patients demonstrated clinical focal neurologic signs or symptoms indicating carotid injury or stroke. Six patients survived their acute trauma and were discharged to rehabilitation after initiation of observation (one patient) or anticoagulation (five patients). All six patients showed neurological improvement without deterioration clinically or radiographically. In conclusion we propose early aggressive screening through MRI/MRA of severely injured patients to detect occult carotid artery dissections. Conservative medical treatment for this occult injury has been effective in this series of patients.

To analyze the cofactors of alcohol-related trauma at a rural, Level II trauma center, 127 admitted trauma patients were interviewed about psychological problems, social factors, and medical histories. Patients were divided into two groups, blood alcohol content (BAC) positive and BAC negative, for analysis. Seventy-one patients (56%) were BAC negative; 56 (44%) were BAC positive. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) (P = .01). Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC-negative patients (41%) (P = .0001). Ten of the 12 patients (83%) who were recently unemployed were BAC positive, compared with 46 of the 115 patients (40%) who were not recently unemployed (P = .004). Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens (P = .0005). These results show that there are important cofactors of alcohol-related trauma in rural areas.

Diagnosing blunt cardiac injury (BCI) can be difficult. Many patients with mechanism for BCI are admitted to the critical care setting based on associated injuries; however, debate surrounds those patients who are hemodynamically stable and do not otherwise require a higher level of care. To allow safe discharge home or admission to a nonmonitored setting, BCI should be definitively ruled out in those at risk.This Eastern Association for the Surgery of Trauma (EAST) practice management guideline (PMG) updates the original from 1998. English-language citations were queried for BCI from March 1997 through December 2011, using the PubMed Entrez interface. Of 599 articles identified, prospective or retrospective studies examining BCI were selected. Each article was reviewed by two members of the EAST BCI PMG workgroup. Data were collated, and a consensus was obtained for the recommendations.We identified 35 institutional studies evaluating the diagnosis of adult patients with suspected BCI. This PMG has 10 total recommendations, including two Level 2 updates, two upgrades from Level 3 to Level 2, and three new recommendations.Electrocardiogram (ECG) alone is not sufficient to rule out BCI. Based on four studies showing that the addition of troponin I to ECG improved the negative predictive value to 100%, we recommend obtaining an admission ECG and troponin I from all patients in whom BCI is suspected. BCI can be ruled out only if both ECG result and troponin I level are normal, a significant change from the previous guideline. Patients with new ECG changes and/or elevated troponin I should be admitted for monitoring. Echocardiogram is not beneficial as a screening tool for BCI and should be reserved for patients with hypotension and/or arrhythmias. The presence of a sternal fracture alone does not predict BCI. Cardiac computed tomography or magnetic resonance imaging can be used to differentiate acute myocardial infarction from BCI in trauma patients.

Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.

Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States with the majority of these injuries diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. With screening, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score ofor=16. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the screening, diagnosis, and treatment of BCVI.A computerized search of the National Library of Medicine/National Institute of Health, Medline database was performed using citations from 1965 to 2005 inclusive. Titles and abstracts were reviewed to determine relevance, and isolated case reports, small case series, editorials, letters to the editor, and review articles were eliminated. The bibliographies of the resulting full-text articles were searched for other relevant citations, and these were obtained as needed. These papers were reviewed based on the following questions: 1. What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI? 2. What is the appropriate modality for the screening and diagnosis of BCVI? 3. How should BCVI be treated? 4. If indicated, for how long should antithrombotic therapy be administered? 5. How should one monitor the response to therapy?One hundred seventy-nine articles were selected for review, and of these, 68 met inclusion criteria and are excerpted in the attached evidentiary table and used to make recommendations.The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified (see ), screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (or==8 slice) CT angiography may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population.

STATEMENT OF THE PROBLEM The ideal time for performing a tracheostomy has not been clearly established. Periods ranging from 3 days to 3 weeks have been suggested in the literature. With current operative methods, it has been established that tracheostomy can be performed with a low rate of complications. In a review of 281 tracheostomies, as well as another 2,862 cases in the literature, Zeitouni and Kost1 reported 0% mortality in their series and 0.3% mortality in the other series since 1973. The risks of prolonged endotracheal intubation—such as patient discomfort, necessitating increased sedation; sinusitis; inadvertent extubation; and laryngeal injury—have become increasingly apparent. Selection of patients who might benefit from conversion of a translaryngeal tube to a tracheostomy tube is a complex medical decision. Furthermore, different subgroups may benefit from tracheostomy at different times in their hospital course. Management of patients with a single organ failure (head injury or respiratory failure) may differ from that of the multiple injury trauma patient. With the lack of clear guidelines for selecting patients for tracheostomy, considerable variability exists in the timing of the procedure, with local practice preferences guiding care, rather than patient considerations. We initiated our review by converting the need for information about optimal timing of tracheostomy into several answerable questions: 1. Does performance of an “early” tracheostomy provide a survival benefit for the recipients? 2. What patient populations benefit from an “early” tracheostomy? 3. Does “early” tracheostomy reduce the number of days on mechanical ventilation and intensive care unit length of stay (ICU LOS)? 4. Does “early” tracheostomy influence the rate of ventilatorassociated pneumonia?

Background: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. Methods: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. Results: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients ≥ 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients ≥ 55 was significantly greater than patients < 55 (43% vs. 23%). Patients ≥ 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women ≥ 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). Conclusion: Patients ≥ 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women ≥ 55 had significantly greater mortality and failure of NOM than women < 55.