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Ruptured abdominal aortic aneurysms (AAAs) are associated with a 90% overall mortality and $150 000 cost of care per patient. Despite improvements in intensive care and surgical technology, morbidity and mortality remain unchanged over the past 20 years. The most significant predictor of survival is time from the door of the hospital to the operating room. To streamline operational efficiency, a team utilized Lean Six Sigma methodologies, team training, and intentional clinical process design to institute changes in our clinical processes, enhance care coordination, and improve communication. Changes led to a $1.8 million profit on operations, 10-day reduction in length of stay, and 89% survival rate among patients with ruptured AAA.

Background: Checklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, "TRAUMA LIFE", was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the "TRAUMA LIFE" process implementation on quality metrics and on patient/family communication in the TICU., Methods: "TRAUMA LIFE" was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the "Family Message" (FM), a part of the "TRAUMA LIFE" communication process, was analyzed in 2016., Results: Improvement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record., Conclusion: Implementation of "TRAUMA LIFE" was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas., Methods: The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations., Results: Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction., Conclusion: Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy., Level of Evidence: Systematic review, level III.

Background: The term spirituality is highly subjective. No common or universally accepted definition for the term exists. Without a clear definition, each nurse must reconcile his or her own beliefs within a framework mutually suitable for both nurse and patient., Objectives: To examine individual critical care nurses' definition of spirituality, their comfort in providing spiritual care to patients, and their perceived need for education in providing this care., Methods: Individual interviews with 30 nurses who worked in a critical care unit at a large Midwestern teaching hospital., Results: Nurses generally feel comfortable providing spiritual care to critically ill patients but need further education about multicultural considerations. Nurses identified opportunities to address spiritual needs throughout a patient's stay but noted that these needs are usually not addressed until the end of life., Conclusions: A working definition for spirituality in health care was developed: That part of person that gives meaning and purpose to the person's life. Belief in a higher power that may inspire hope, seek resolution, and transcend physical and conscious constraints., (©2016 American Association of Critical-Care Nurses.)

Background: Domain loss following damage-control laparotomy is a challenging problem many surgeons face. The authors recently developed trans-abdominal wall traction, which closed 100 percent of domain loss abdomens in the acute setting. They hypothesized that it can be used successfully in patients with chronic giant ventral defects., Methods: From 2008 to 2013, 44 patients with acute loss of domain and 10 with chronically giant ventral defects were enrolled in the open abdomen protocol with subsequent placement of the trans-abdominal wall traction device., Results: Patients' average age in the acute and chronic groups was 28.2 and 35.3 years and average body mass index was 26.4 and 32.4 kg/m2, respectively. Ventral hernia size was reduced with the first trans-abdominal wall traction insertion from 610.5 cm2 to 274.6 cm2 in the acute setting and from 598 cm2 to 236.9 cm2 in the chronic setting. Average time from damage-control laparotomy to device insertion was 12.9 days in the acute group and more than 3 years in the chronic group. Lost domain was achieved with an average of less than 2.5 trans-abdominal wall traction tightenings, correlating to 9.2 and 8.2 days in the acute and chronic groups, respectively. Enterocutaneous fistula occurrence was 9 percent in the acute group and 0 percent in the chronic group., Conclusions: All patients were successfully closed after reestablishment of the lost domain. Trans-abdominal wall traction is an effective means of reestablishing abdominal domain and achieving primary abdominal wall closure in all patients with giant ventral defects, both acute and chronic.

Background: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST., Methods: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair., Results: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines., Conclusion: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

An increasing number of patients are presenting to trauma units with head injuries on antiplatelet therapy (APT). The influence of APT on these patients is poorly defined. This study examines the outcomes of patients on APT presenting to the hospital with blunt head trauma (BHT). Registries of two Level I trauma centers were reviewed for patients older than 40 years of age from January 2008 to December 2011 with BHT. Patients on APT were compared with control subjects. Primary outcome measures were in-hospital mortality, intracranial hemorrhage (ICH), and need for neurosurgical intervention (NI). Hospital length of stay (LOS) was a secondary outcome measure. Multivariate analysis was used and adjusted models included antiplatelet status, age, Injury Severity Score (ISS), and Glasgow coma scale (GCS). Patients meeting inclusion criteria and having complete data (n = 1547) were included in the analysis; 422 (27%) patients were taking APT. Rates of ICH, NI, and in-hospital mortality of patients with BHT in our study were 45.4, 3.1, and 5.8 per cent, respectively. Controlling for age, ISS, and GCS, there was no significant difference in ICH (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.61 to 1.16), NI (OR, 1.26; 95% CI, 0.60 to 2.67), or mortality (OR, 1.79; 95% CI, 0.89 to 3.59) associated with APT. Subgroup analysis revealed that patients with ISS 20 or greater on APT had increased in-hospital mortality (OR, 2.34; 95% CI, 1.03 to 5.31). LOS greater than 14 days was more likely in the APT group than those in the non-APT group (OR, 1.85; 95% CI, 1.09 to 3.12). The effects of antiplatelet therapy in patients with BHT aged 40 years and older showed no difference in ICH, NI, and in-hospital mortality.

Background: Damage-control laparotomy (DCL) has revolutionized the surgery of injury. However, this has led to the dilemma of the nonclosable abdomen. Subsequently, there exists a subgroup of patients who after resuscitation and diuresis, remain nonclosable. Before the adoption of our open abdomen protocol (OAP) and use of transabdominal wall traction (TAWT), these patients required skin grafting and a planned ventral hernia. We hypothesize that our OAP and TAWT device, which use full abdominal wall thickness sutures to dynamically distribute midline traction, achieve an improved method of fascial reapproximation., Methods: From 2008 to 2011, all DCL and decompressive laparotomy patients in our urban trauma center were managed by our OAP. Thirty two were noncloseable "domain loss abdomens" after achieving physiologic steady state and near dry weight. All patients received the TAWT device when near dry weight was achieved. Wound size, days to closure, days to TAWT, and TAWT to closure were tracked., Results: During this 36-month period, OAP/TAWT was applied to 32 patients. All patients demonstrated domain loss precluding fascial closure. Average wound size was 18.5-cm width by 30.5-cm length. Mean time DCL surgery to TAWT was 9.5 days. At time of placement, TAWT decreased initial wound width by an average of 9.8 cm (51.4%). Patients returned to the operating room for tightening/washout an average of 2.2 times (excluding TAWT insertion and final closure operations). Mean time TAWT to closure was 8.7 days. Mean time from admission surgery to primary closure was 18.2 days. All patients achieved primary fascial closure using this method without components separation or biologic bridge operations., Conclusion: OAP/TAWT has revolutionized the way we manage "domain loss" open abdomen patients and has virtually eliminated the acceptance of planned ventral hernia. TAWT consistently recaptures lost domain, preserves the leading fascial edge, and eliminates the need for biologic bridges, components separation, or skin grafting., Level of Evidence: Therapeutic study, level III.

Objective: This study piloted the use of the Primary Care PTSD (PC-PTSD) screening tool in an outpatient setting to determine its utility for broader use and to gather data on traumatic stress symptoms among direct (patients) and indirect (families) survivors of traumatic injuries., Methods: Using the PC-PTSD plus one question exploring openness to seeking help, participants were screened for PTSD in the outpatient clinic of an urban Level 1 trauma center. The survey was distributed during a 23-week period from April to September 2011. The screen was self-administered, a sample of convenience, and participation was voluntary and anonymous., Results: With a response rate of 66%, 307 surveys were completed. Forty-two percent of participants had a positive screen. Patients greater than 30 and 90 days from injury had 1.5 and 1.7 times more positive screens than those less than 30 days. Patients with gunshot wounds were 13 times as likely as those with falls and twice as likely as those in a motor vehicle crash to have a positive screen. Sixty percent of patients with a positive screen noted it would be helpful to talk to someone., Conclusion: The PC-PTSD was an easy to administer screening tool. Patients reported PTSD symptoms at higher rates than previous studies. Patients with gunshot wounds and those injured greater than 30 days from the time of the screen were more likely to report PTSD symptoms. Although males represented 82% of positive screens, there was no statistical difference in PTSD symptoms between male and female participants because of the small number of females represented. Families also reported significant levels of PTSD. Both patients and families may benefit from additional screening and intervention in the early posttrauma period.

Background: An estimated 10,000 Americans suffer cervical spine injuries each year. More than 800,000 cervical spine radiographs (CSR) are ordered annually. The human and healthcare costs associated with these injuries are enormous especially when diagnosis is delayed. Controversy exists in the literature concerning the diagnostic accuracy of CSR, with reported sensitivity ranging from 32% to 89%. We sought to compare prospectively the sensitivity of cervical CT (CCT) to CSR in the initial diagnosis of blunt cervical spine injury for patients meeting one or more of the NEXUS criteria., Methods: The study prospectively compared the diagnostic accuracy of CSR to CCT in consecutive patients evaluated for blunt trauma during 23 months at an urban, public teaching hospital and Level I Trauma Center. Inclusion criteria were adult patient, evaluated for blunt cervical spine injury, meeting one or more of the NEXUS criteria. All patients received both three-view CSR and CCT as part of a standard diagnostic protocol. Each CSR and CCT study was interpreted independently by a different radiology attending who was blinded to the results of the other study. Clinically significant injuries were defined as those requiring one or more of the following interventions: operative procedure, halo application, and/or rigid cervical collar., Results: Of 1,583 consecutive patients evaluated for blunt cervical spine trauma, 78 (4.9%) patients received only CCT or CSR and were excluded from the study. Of the remaining 1,505 patients, 78 (4.9%) had evidence of a radiographic injury by CSR or CCT. Of these 78 patients with radiographic injury, 50 (3.3%) patients had clinically significant injuries. CCT detected all patients with clinically significant injuries (100% sensitive), whereas CSR detected only 18 (36% sensitive). Of the 50 patients, 15 were at high risk, 19 at moderate risk, and 16 at low risk for cervical spine injury according to previously published risk stratification. CSR detected clinically significant injury in 7 high risk (46% sensitive), 7 moderate risk (37% sensitive), and 4 low risk patients (25% sensitive)., Conclusion: Our results demonstrate the superiority of CCT compared with CSR for the detection of clinically significant cervical spine injury. The improved ability to exclude injury rapidly provides further evidence that CCT should replace CSR for the initial evaluation of blunt cervical spine injury in patients at any risk for injury.

Objective: Electromuscular incapacitation (EMI) devices are being used and evaluated by both military and law enforcement agencies. Although the gross muscular response is obvious, physiological responses to these devices are poorly understood. We hypothesized that the intense, repetitive, muscle contractions evoked by EMI devices would cause dose-dependent metabolic acidosis, accompanied by neuromuscular or cardiac injury., Methods: Using an approved protocol, 26 Yucatan mini-pigs (22 experimental animals and 4 control animals) were anesthetized with ketamine and xylazine. Experimental animals were exposed to MK63 (Aegis Industries, Bellevue, Idaho) discharges over the left anterior hind limb for 10, 20, 40, or 80 seconds. Electrocardiograms, electromyograms, troponin I levels, blood gas values, and electrolyte levels were recorded before and 5, 15, 30, and 60 minutes and 24, 48, and 72 hours after discharge. Skin, muscle, and nerve biopsies were taken from the shocked and contralateral sides., Results: Core body temperature significantly decreased (1.0-1.5 degrees C) in all shocked animals but not in sham-treated control animals. No cardiac dysrhythmias or deaths were seen, and heart rate was unaffected. No clinically significant changes were seen in troponin I, myoglobin, or creatine kinase-MB levels. Central venous blood pH decreased, whereas carbon dioxide pressure and lactate levels increased for 60 minutes after discharge. All values returned to normal by 24 hours after discharge, and no significant histological or electromyographic changes were found., Conclusions: Changes in blood chemistry were observed but were of little clinical significance, and no neuromuscular damage was detected. Therefore, within the limitations of this model, it appears that EMI can safely be achieved by using this device, even for lengthy periods, without causing significant injury.

Background: Stun guns or electromuscular incapacitation devices (EMIs) generate between 25,000 and 250,000 V and can be discharged continuously for as long as 5 to 10 min. In the United States, over 200,000 individuals have been exposed to discharges from the most common type of device used. EMI devices are being used increasingly despite a lack of objective laboratory data describing the physiological effects and safety of these devices. An increasing amount of morbidity, and even death, is associated with EMI device use. To examine this type of electrical injury, we hypothesized that EMI discharges will induce acute or delayed cardiac arrhythmia and neuromuscular injury in an animal model., Methods: Using an IACUC approved protocol, from May 2005 through June 2006 in a teaching hospital research setting, 30 Yucatan mini-pigs (24 experimentals and 6 sham controls) were deeply anesthetized with ketamine and xylazine without paralytics. Experimentals were exposed to discharges from an EID (MK63; Aegis Industries, Bellevue, ID) over the femoral nerve on the anterior left hind limb for an 80 s exposure delivered as two 40 s discharges. EKGs, EMGs, troponin I, CK-MB, potassium, and myoglobin levels were obtained pre-discharge and post-discharge at 5, 15, 30, and 60 min, 24, 48, and 72 h (n = 6 animals) and 5, 15, and 30 d post-discharge (n = 6 animals at each time point). Skin, skeletal muscle, and peripheral nerve biopsies were studied bilaterally. Data were compared using one-way analysis of variance and paired t-tests. P-values <0.05 were considered significant., Results: No cardiac arrhythmias or sudden deaths were seen in any animals at any time point. No evidence of skeletal muscle damage was detected. No significant changes were seen in troponin I, myoglobin, CK-MB, potassium, or creatinine levels. There were no significant changes in compound muscle action potentials (CMAP). No evidence of conduction block, conduction slowing, or axonal loss were detected on EMG. M-wave latency (M(lat), ms), amplitude (M(amp), mV), area (M(area), mV-ms), and duration (M(dur), ms) were not significantly affected by MK63 discharge compared with contralateral or sham controls. F-wave latency (F(lat), ms), a sensitive indicator of retrograde nerve conduction and function, was not significantly affected by MK63 discharge compared with contralateral or sham controls. No significant histological changes were seen at any time point in skeletal muscle or peripheral nerve biopsies although mild skin inflammation was evident., Conclusions: There was no evidence of acute arrhythmia from MK63 discharges. No clinically significant changes were seen in any of the physiological parameters measured here at any time point. Neuromuscular function was not significantly altered by the MK63 discharge. In this animal model, even lengthy MK63 discharges did not induce muscle or nerve injury as seen using EMG, blood chemistry, or histology.

Background: Little objective laboratory data are available describing the physiologic effects of stun guns or electromuscular incapacitation (EMI) devices, but increasing morbidity and even deaths are associated with their use. We hypothesized that exposure to EMI discharges in a model animal system would induce clinically significant acidosis and cardiac arrhythmia., Methods: Ten Yucatan mini-pigs, six experimental and four sham controls, were anesthetized with ketamine, xylazine, and glycopyrrolate. Experimental pigs were exposed to two 40-second discharges from an EMI device over the left thorax. Electrocardiograms, troponin I, blood gases, and lactate levels were obtained pre-exposure, at 5, 15, 30, 60 minutes, and at 24, 48, and 72 hours postdischarge., Results: No acute or delayed cardiac arrhythmias were seen. Heart rate was not affected significantly (p>0.05). A subclinical increase in troponin I was seen at 24 hours postdischarge (0.040+/-0.030 ng/mL, p>0.05). Central venous blood pH (7.432+/-0.014) and pCO2 (36.1+/-0.9 mm Hg) were not changed significantly (p>0.05) during the 60-minute postdischarge period. A moderate significant increase in lactate occurred in the 5-minute postdischarge group (4.9+/-0.3 mmol/L, p=0.0179). All blood chemistry and vital signs were normal at 24, 48, and 72 hours postdischarge., Conclusions: Although significant changes in some parameters were seen, these changes were small and of little clinical significance. Lengthy EMI exposures did not cause extreme acidosis or cardiac arrhythmias. These findings may differ from those seen with other EMI devices because of the unique MK63 waveform characteristics or to specific characteristics of the model systems.

Background: The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF)., Methods: A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve., Results: Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R)., Conclusion: Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.

Objective: To determine whether presumptive antibiotics reduce the risk of empyema or pneumonia following tube thoracostomy for traumatic hemopneumothorax., Methods: A prospective, randomized, double-blind trial was performed comparing the use of cefazolin for duration of tube thoracostomy placement (Group A) versus 24 hours (Group B) versus placebo (Group C)., Results: A total of 224 patients received 229 tube thoracostomies. Logistic regression analysis revealed that duration of tube placement and thoracic acute injury score were predictive of empyema (p <0.05). Empyema tended to occur more frequently in patients with penetrating injuries (p=0.09). chi analysis showed pneumonia occurred significantly more frequently in blunt than penetrating injuries (p <0.05). Presumptive antibiotic use did not significantly effect the incidence of empyema or pneumonia, although no empyemas occurred in Group A., Conclusions: The incidence of empyema was low and the use of presumptive antibiotics did not appear to reduce the risk of empyema or pneumonia.

Background: After some abdominal surgical procedures, the abdominal wall defect may be too large for closure by tension-free approximation of the wound margins because of tissue loss or swelling of the abdominal viscera. A variety of absorbable and nonabsorbable prosthetic materials have been used for emergency abdominal wall reconstruction. Of these materials, polytetrafluoroethylene (PTFE) sheets have proved to be the most efficacious., Methods: This study compared the efficacy of allogenic acellular dermal matrix (ADM) and PTFE as prosthetic materials for wound closure in rats with surgical, full-thickness, 2 x 3-cm abdominal wounds. Healing was studied among animals with and those without experimentally induced peritonitis for 21 days after surgery., Results: Acellular dermal matrix became vascularized and incorporated into the wound bed and was partially or fully epithelialized without the need for skin grafting. As a result, little superficial bleeding was seen, and ADM effectively closed the wounds even in the presence of peritonitis. Wounds treated with ADM also showed a significant reduction in wound area (sterile:p < 0.001; contaminated:p < 0.05). In contrast, PTFE temporarily closed the wounds, but was not incorporated into them. It consequently evoked the formation of extensive underlying granulation tissue that showed significant superficial bleeding when the PTFE was removed. Very limited wound contraction occurred in PTFE-treated wounds, and some instances of evisceration and fistula formation were observed. Wounds treated with both types of material showed significant amounts of adhesion to visceral organs underlying the wound site., Conclusions: Acellular dermal matrix exhibits a number of favorable features relative to PTFE for closing sterile or contaminated full-thickness abdominal wall defects.

A prospective blinded pilot study was performed at an urban level 1 trauma center to evaluate the efficacy of ultrasound in ruling out penetrating visceral truncal injury. For 8 months, 49 nonconsecutive patients who presented with truncal gunshot and stab wounds were evaluated by a 10-MHz ultrasound tranducer probe. The deepest muscle bundle and the fascia enveloping it was examined by ultrasound. These images were compared to the equivalent contralateral unaffected side of the patient. All the patients then underwent standard testing to evaluate for potential intracavitary injury. Forty-nine patients with a mean age of 28 years (SD, 8.8) were evaluated by ultrasound. A total of 58 injuries were evaluated of which 37 were stab wounds and 21 were gunshot wounds. Thoracoabdominal and back and flank injuries were the most commonly evaluated injuries. There were 20 true positives, 20 false positives, and 18 true negatives, each with approximately twice as many stab as gunshot wounds. There were no false negatives. The sensitivity and negative predictive value of ultrasound in determining clinically significant truncal visceral injury in penetrating truncal trauma is 100 per cent. The specificity and positive predictive value are both approximately 50 per cent. Ultrasonic examination of the injured abdominal wall layers in truncal penetrating trauma is an excellent screening tool. Simple comparative assessment with the unaffected contralateral side allows a highly sensitive method of decreasing the number of potentially morbid, time consuming, and expensive tests that are currently employed to rule out visceral injury.

Background: Chest radiographs are routine for patients presenting with blunt and penetrating chest trauma. The accuracy of physical examination in the diagnosis of hemopneumothorax in these patients is unclear. A prospective study was performed to define the utility of routine portable chest radiographs in 676 trauma patients., Methods: Over 19 months (January 2000-July 2001), 676 patients who presented with penetrating or blunt chest trauma were interviewed and examined for signs and symptoms of hemopneumothorax. The incidence of chest pain or tenderness and tachypnea was noted and both lung fields were auscultated. A portable chest radiograph was then performed on all the patients., Results: All the patients were hemodynamically stable. Five hundred twenty-three patients sustained blunt trauma, with seven hemopneumothoraces (1.3%). The negative predictive values of auscultation, pain or tenderness, and tachypnea were 99& to 100%. One hundred fifty-three patients sustained penetrating chest trauma. Of these injuries, 68 were gunshot wounds and 85 were stab wounds. Twenty-four (16%) of these patients had hemopneumothoraces. The sensitivities of auscultation, pain or tenderness, and tachypnea were 50%, 25%, and 32%, respectively. The negative predictive values of these tests were < 91%., Conclusion: Blunt chest trauma patients who are hemodynamically stable with a normal physical examination do not require a routine chest radiograph. In contrast, all victims of penetrating trauma require chest radiographs because many will have hemopneumothorax in the absence of clinical findings.