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Thermal injuries have always been a source of morbidity and mortality in times of war. Historically, they constitute 5% to 20% of all injuries and approximately 4% mortality. Although burn patients constitute a small number of casualties, they consume a disproportionate amount of resources and require specialized care. The current conflicts in the Middle East report similar numbers for thermal injuries despite improvement in predeployment education to reduce noncombat-related burns, flame retardant military clothing, and decline of war patterns usually associated with increased thermal injuries. However, the increased use of improvised explosive devices and vehicle-borne improvised explosive devices presents a new source of potential thermal injury. Indeed, the burden of explosion-related burns has increased as has its associated Injury Severity Score. As has been the case in previous conflicts, most burns are hand and head burns. Although usually not life threatening, burns to hands and face lead to significant physical and psychologic morbidities. In this paper, we will review the currently available literature on war-related thermal injuries in Operation Iraqi and Operation Enduring Freedom. We will describe the epidemiology of burn injuries, prewar preparation to prevent and treat thermal injuries, and the assessment, triage, and final treatment of burn patients. In addition, we will discuss the associated physical and psychologic morbidities and, finally, the role of plastic surgeon in burn rehabilitation and reconstruction.

Background For logistics, the US Army recommends Hextend (Hospira; 6% hetastarch in buffered electrolyte, HET) for battlefield resuscitation. To support this practice, there are laboratory data, but none in humans. To test the hypothesis that HET is safe and effective in trauma, we reviewed our first 6 months of use at a civilian level 1 trauma center. Study Design From June 2008 to December 2008, trauma patients received standard of care (SOC) ± 500 to 1,000 mL of HET within 2 hours of admission at surgeon discretion. Each case was reviewed, with waiver of consent. Results There were 1,714 admissions; 805 received HET and 909 did not. With HET versus SOC, overall mortality was 5.2% versus 8.9% (p = 0.0035) by univariate analysis. Results were similar after penetrating injury only (p = 0.0016) and in those with severe injury, defined by Glasgow Coma Scale 26 (p = 0.0142). After HET, more patients required ICU admission (40.9% vs. 34.5%; p=0.0334) and transfusions of blood (34.4% vs. 20.2%; p=0.0014) or plasma (20.7% vs. 12.2%; p=0.0251), but there were no treatment-related differences in prothrombin time or partial thromboplastin time. The 24-hour urine outputs and requirements for blood, plasma, and other fluids were similar. However, increased early deaths with SOC implicate possible selection bias. If that factor was controlled for with multivariate analysis, the same trends were present, but the apparent treatment effects of HET were no longer statistically significant. Conclusions In the first trial to date in hemodynamically unstable trauma patients, and the largest trial to date in any population of surgical patients, initial resuscitation with HET was associated with reduced mortality and no obvious coagulopathy. A randomized blinded trial is necessary before these results can be accepted with confidence.

ObjectiveVascular disease is the most prevalent condition in patients aged >60 years, leading to increasing complications associated with their comorbid conditions. Poor medical compliance could be one reason why the rate of complications may be higher in this patient population, particularly the uninsured. This study was conducted to better assess rates of medication compliance in vascular surgical patients.MethodsConsecutive patients seen in vascular clinics at a busy tertiary academic center were prospectively studied. Physicians and physician assistants used a standardized questionnaire to collect patient data and evaluated patients for coexisting medical conditions and medication use. Optimal medical therapy was defined according to the 2006 American Heart Association (AHA)/American College of Cardiology (ACC) “Guidelines for Secondary Prevention for Atherosclerotic Vascular Disease.” Data were analyzed using multivariate regression.ResultsDuring the 4-month study period, 180 consecutive patients (47% men) were seen in vascular surgery clinics. Most patients (79%) were nonsmokers and only 21% admitted to smoking. Comorbid conditions surveyed included hypertension in 141, diabetes mellitus in 56, coronary artery disease in 24, hypercholesterolemia in 89, and chronic renal failure in 13; of these, 61% were insured and 39% had no insurance. Overall, only 31% of all patients were receiving adequate medical therapy for their comorbid conditions, and about 66% were receiving suboptimal medical treatment for their vascular disease. Uninsured patients were less likely (19%) than insured patients (39%) to receive optimal medical therapy (P = .012). Lack of insurance was a predictor of suboptimal medical therapy for hypertension (odds ratio [OR], 3.13; 95% confidence interval [CI], 1.20-8.16; P = .016), hypercholesterolemia (OR, 5.1; 95% CI, 1.87-13.88; P = .001), peripheral arterial disease (OR, 13.32; 95% CI, 2.84-62.54, P < .001), and any disease overall (OR, 2.43; 95% CI, 1.21-4.88, P = .012). Overall, men and women were equally likely (68%) to receive suboptimal medical therapy; however, women were significantly more likely to be undertreated for coronary artery disease (OR, 0.022; 95% CI, 0.0017-0.293; P < .001).ConclusionsCompliance with optimal medical therapy for secondary risk factor management amongst our vascular surgery patients is low. Uninsured patients are less likely to receive optimal medical therapy than their insured counterparts. This survey provides sobering statistics regarding medical compliance in our population. This issue deserves further study and may indirectly affect outcomes in minority groups that are disproportionately represented in our uninsured patients.

Background: Prehospital triage of patients with trauma is routinely challenging, but more so in mass casualty situations and military operations. The purpose of this study was to prospectively test whether heart rate variability (HRV) could be used as a triage tool during helicopter transport of civilian patients with trauma. Methods: After institutional review board approval and waiver of informed consent, 75 patients with trauma requiring prehospital helicopter transport to our level I center (from December 2007 to November 2008) were prospectively instrumented with a 2-Channel SEER Light recorder (GE Healthcare, Milwaukee, WI). HRV was analyzed with a Mars Holter monitor system and proprietary software. SDNN (standard deviation [SD] of the normal-to-normal R-R interval), as an index of HRV, was correlated with prehospital trauma triage criteria, base deficit, seriousness of injury, operative interventions, outcome, and other data extracted from the patients' medical records. There were no interventions or medical decisions based on HRV. Data were excluded only if there was measurement artifact or technical problems with the recordings. Results: The demographics were mean age 47 years, 63% men, 88% blunt, 25% traumatic brain injury, 9% mortality. Prehospital SDNN predicted patients with base excess ≤-6, those defined as seriously injured and benefiting from trauma center care, as well as patients requiring a life-saving procedure in the operating room. No other available data, including prehospital en-route vital signs, predicted any of these. The sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 75%, 33%, 96%, respectively, with and an overall accuracy of 76% for predicting a life-saving intervention in the operating room. Conclusions: This is the first demonstration that prehospital HRV (specifically SDNN) predicts base excess and operating room life-saving opportunities. HRV triages and discriminates severely injured patients better than routine trauma criteria or en-route prehospital vital signs. HRV may be a useful civilian or military triage tool to avoid unnecessary helicopter evacuation for minimally injured patients. A prospective, randomized trial in a larger patient population is indicated.

Background: The Electronic Medical Record (EMR) has been proposed as a way to reduce medical errors. It can also be used to document clinician involvement, which may affect outcomes. We sought to determine whether the EMR could be used to improve attending involvement in daily care, enhance surgical revenue, and lower mortality of patients with trauma. Methods: In 2004, the Trauma Division adopted a software program (CARE, Miami, FL) for creating an EMR and implemented a weekly report that was distributed to all members of the division and also to Departmental decision makers. Before initiation, explicit instructions were given to all surgeons that daily notes in the EMR were expected and would be followed by weekly reports. Before this, most notes were recorded in the paper chart and were difficult to track. Differences among proportions were determined with z test or X 2 , where appropriate with significance defined as p < 0.05. Results: With implementation of the EMR, daily and weekly reports were immediately available. Both attending surgeon documented notes and divisional annual revenue increased. A reduction in mortality was also observed. Conclusion: The EMR can be used to change attending surgeon involvement in patient care and procedures. The increase in attending involvement was associated with an increase in revenue. Use of the EMR was associated with a significant reduction in hospital mortality.

Background: Preventable deaths due to errors in trauma patients with otherwise survivable injuries account for up to 10% of fatalities in Level I trauma centers, 50% of these errors occur in the intensive care unit (ICU). The root cause of 67% of the Joint Commission sentinel events is communication errors. The objective is (1) to study how critical information degrades and how it is lost over 24 hours and (2) to determine whether a structured checklist for ICU handoffs prevents information loss. Methods: Prospective cohort study of trauma and surgical ICU teams observed with and without use of the checklist. An observational period (control group) was followed by a didactic session on the science and use of a checklist (study group), which was used for patient management and handoffs. Information was tracked for a 24-hour period and all handoffs. Comparisons use X 2 or Fisher's exact test and a value

Trauma centers have been created to bring traumatized patients together with experienced surgeons. We reviewed our outcomes to determine if mortality rates for high Injury Severity Scores (or= 35) correlate with surgeon experience at our trauma center.Using our prospectively collected database, we compared our results with mean mortality for high-volume American College of Surgeon-certified trauma centers reporting to the National Trauma Data Bank. Mortality rates for our 11 trauma surgeons were correlated with years of experience as faculty surgeons at our institution during a 2-year period. Statistical analysis was done with chi-square or weighted linear regression; significance was defined as p0.05.Our trauma center mortality rates were significantly below the mean rates of National Trauma Data Bank at all levels of injury (chi-square, p0.05). Despite this success, there was a significant correlation between years of experience as a surgeon at our institution and improved outcomes for patients with an Injury Severity Scoreor= 35 (weighted linear regression, p0.05). It took, on average, 7.9 years of experience at our trauma center to reach benchmark mortality rates.Mortality rates for severely injured patients correlate significantly with surgeon experience at our institution. The training process does not end with fellowship or surgical residency, and surgeons new to an institution should be closely monitored and mentored to minimize mortality rates of severely injured patients. Even at a very high volume trauma center with overall results substantially better than mean expected survival, we can demonstrate that experience makes a difference.

The current standard for the evaluation of children with blunt abdominal trauma (BAT) consists of physical examination, screening lab values, and computed tomography (CT) scan. We sought to determine if the focused assessment with sonography for trauma (FAST) combined with elevated liver transaminases (AST/ALT) could be used as a screening tool for intra-abdominal injury (IAI) in pediatric patients with BAT.Registry data at a level 1 trauma center was retrospectively reviewed from 1991-2007. Data collected on BAT patients under the age of 16 y included demographics, injury mechanism, ISS, GCS, imaging studies, serum ALT and AST levels, and disposition. AST and ALT were considered positive if either one was100 IU/L.Overall, 3171 cases were identified. A total of 1008 (31.8%) patients received CT scan, 1148 (36.2%) had FAST, and 497 (15.7%) patients received both. Of the 497 patients, 400 (87.1%) also had AST and ALT measured. FAST was 50% sensitive, 91% specific, with a positive predictive value (PPV) of 68%, negative predictive value (NPV) of 83%, and accuracy of 80%. Combining FAST with elevated AST or ALT resulted in a statistically significant increase in all measures (sensitivity 88%, specificity 98%, PPV 94%, NPV 96%, accuracy 96%).FAST combined with AST or ALT100 IU/L is an effective screening tool for IAI in children following BAT. Pediatric patients with a negative FAST and liver transaminases100 IU/L should be observed rather than subjected to the radiation risk of CT.

The incidence of obstructive sleep apnea has been underestimated in morbidly obese patients who present for evaluation for weight loss surgery. This retrospective study shows that the incidence of obstructive sleep apnea in this patient population is greater than 70 per cent and increases in incidence as the body mass index increases. Obstructive sleep apnea (OSA) is a common comorbidity in obese patients who present for evaluation for gastric bypass surgery. The incidence of sleep apnea in obese patients has been reported to be as high as 40 per cent. A retrospective review of our prospectively collected database was performed. All patients being evaluated for weight loss surgery for obesity were screened preoperatively for OSA using a sleep study. The overall incidence of sleep apnea in our patients was 78 per cent (227 of 290). All 227 were diagnosed by formal sleep study. There were 63 (22%) males and 227 (78%) females. The mean age was 43 years (range, 17-75 years). The mean body mass index (BMI) was 52 kg/m2 (range, 31-94 kg/m2). The prevalence of OSA in the severely obese group (BMI 35-39.9 kg/m2) was 71 per cent. For the morbidly obese group (BMI 40-40.9 kg/m2), the prevalence was 74 per cent and for the superobese group (BMI 50-59.9 kg/m2) 77 per cent. Those with a BMI 60 kg/m2 or greater, the prevalence of OSA rose to 95 per cent. The incidence of sleep apnea in patients presenting for weight loss surgery was greater than 70 per cent in our study. Patients presenting for weight loss surgery should undergo a formal sleep study to diagnose OSA before bariatric surgery.

Fluid resuscitation after thermal injury in a child or infant can pose a set of unique and significant challenges. Many approaches to fluid resuscitation of children after burns exist, and most are nonevidence based. This review will highlight the important concepts involved in pediatric fluid resuscitation from thermal injury.

Nutritional support is one of the many important considerations when treating severe burn injury in children. The type, route, timing, amount, and monitoring of nutritional support have been widely investigated, yet many questions remain. This review will highlight the current state of knowledge and the important aspects of nutritional support in severe burn injury in children.

Proximal embolization of the splenic artery (PSAE) has recently been reported for traumatic splenic injury. The suggested mechanism of action entails a decrease in the splenic blood pressure without ischemia due to collateral blood supply. The main complications of selective embolization are continuous bleeding, splenic infarcts and splenic abscesses. The main complications of observation alone are continuous bleeding and formation of splenic pseudoaneurysms. Our aim was to assess the efficacy of PSAE in the cessation of bleeding without formation of pseudoaneurysms, and the outcome of the spleen after such intervention. A prospective observational study of all patients undergoing PSAE for traumatic splenic injury in our institution over a 33-month period. Clinical and Doppler sonographic examinations were performed to assess cessation of bleeding, splenic blood flow, and formation of splenic pseudoaneurysms, infarcts or abscesses. During 33 months, 11 patients with blunt abdominal trauma and tomographic evidence of either high grade or actively bleeding splenic injuries were treated by PSAE. During follow-up, no patient underwent surgery or repeated embolization. Preserved blood flow was found on Doppler sonography in 82% of the patients and no pseudoaneurysms were demonstrated. A perisplenic collection was found in one patient and responded well to percutaneous drainage. Proximal embolization of the splenic artery for severe splenic injury is highly successful in cessation of bleeding while preserving splenic architecture. There were minimal complications in this series demonstrated by clinical and Doppler examinations.

Staged excision and grafting remains the mainstay of the surgical treatment of large burn injuries since Jackson and colleagues demonstrated a decreased mortality with excisions of 20% or less in 1960 [1]. The major factors limiting these excisions are blood loss and hypothermia. Despite these known limitations, little progress had been made in combating the hypothermia that comes with a large excision. The current re-warming strategies include: increasing ambient room temperature, infusing warm intravenous fluids, and using hot air technologies such as the Bair Hugger, but no single solution or combination of solutions has proven adequate [2]. Recently at our institution, a new intravascular warming catheter was used to perform a large burn excision with excellent results.

Aortic injuries were traditionally thought to be the result of severe frontal crashes. Newer data has suggested other crash types such as nearside crashes may also be important in aortic injury. We hypothesized the implementation of recent safety measures would decrease the incidence of aortic injury associated with fatal motor vehicle crashes.The autopsy reports of all traffic fatalities for motor vehicle occupants in a large urban county for the years 1993 to 2004 were examined. The demographics, impact types, safety measures used, and the presence of any aortic injury were recorded. Trends were evaluated for significance by weighted linear regression.The incidence of aortic injury associated with fatal motor vehicle crashes has remained unchanged during the past 12 years (r = 0.057, p = 0.45). There is a trend toward decreased aortic injuries associated with frontal crashes (r = 0.26, p = 0.089) but no change in aortic injuries associated with nearside or farside crashes (r = 0.053, p = 0.47), when the crash resulted in a fatality. This is despite an increase in seat belt use and increased presence of airbags during the same time period.Despite improved safety measures designed to minimize the occurrence of aortic injuries, the incidence of blunt aortic injury in fatal motor vehicle crashes has not decreased during the past decade. Although not statistically significant, there is a trend toward decreased frontal impacts in fatal motor vehicle crashes associated with aortic injuries. The nearside crash mechanism continues to play a prominent role, and efforts at improving vehicle safety should be focused on crash mechanisms as they relate to aortic injury.

To evaluate the efficacy and safety of inhaled tobramycin (TOBI) in the treatment of ventilator-associated pneumonia (VAP) in a randomized, double-blind pilot study.Ten patients from a cohort of 108 mechanically ventilated patients with documented clinical and bacteriological evidence of VAP caused by Pseudomonas aeruginosa or Acinetobacter spp. in the surgical and trauma intensive care units of a university teaching hospital were randomized to receive either TOBI (n = 5) or intravenous tobramycin (TOBRA; n = 5). The two groups were similar in their Acute Physiology and Chronic Health Evaluation (APACHE) score, Clinical Pulmonary Infection Score (CPIS), and Multiple Organ Dysfunction Score (MODS) prior to randomization. The primary outcome measure was resolution of pneumonia. The CPIS and MODS were used as objective indicators of clinical progress.All TOBI patients had clinical resolution of VAP. Two TOBRA patients were considered failures. One had deterioration in MODS, and the other had doubling of his serum creatinine concentration. The patients treated with TOBI may have had more ventilator-free days than those receiving TOBRA, but the difference was not statistically significant owing to the small sample size (24 +/- 3 vs. 14 +/- 13 days; p = 0.12).Aerosolized tobramycin for the treatment of VAP appeared safe and effective in this pilot study. A larger study is warranted to determine if aerosolized tobramycin will lead to better outcomes than intravenous tobramycin when used for the treatment of VAP.

Introduction In the new era of resident work hour restrictions and an emphasis on minimally invasive surgery, experience in performing open biliary surgery is diminishing. We sought to review our resident operative experience to determine if it appears adequate for a well-trained general surgeon. Methods The case logs of the General Surgery, Oncology, and Trauma/Emergency General Surgery (EGS) services were reviewed for a 1-year period. All biliary procedures that included the potential for gallbladder or bile duct surgery were reviewed. Results We performed 745 laparoscopic cholecystectomies last year on our General Surgery, Oncology, and Trauma/EGS services. Conversion to open procedure was 4.5% (16/364) on our elective services and 6% (23/381) on our Trauma/EGS services. Effective clearance of common bile duct stones performed retrograde by endoscopy and transhepatically by interventional radiology limited our residents’ experience performing common bile duct surgery for stones to 13 performed laparoscopically and 10 performed open. Other operations that included open cholecystectomies and common bile duct procedures were pancreatico-duodenectomy (87), biliary bypass (22), biliary resection/reconstruction (20), hepatic lobectomy (48), sphincteroplasty and ampullectomy (6). Conclusions The small number of conversions from laparoscopic to open cholecystectomies and the few common bile duct explorations performed for stone disease would be inadequate to train our six categorical surgical residents to perform open cholecystectomies and common bile duct procedures without a training program that augments this by providing a strong hepato-biliary-pancreatic experience. Programs without a strong hepato-biliary-pancreatic program should review their residents’ operative experience.

Statement of purpose In July 2000, Florida’s universal helmet law was lessened to a partial helmet law despite unhelmeted riders being more likely to suffer serious and fatal head injuries. In response to these legislative changes and the increasing use of motorcycles among Floridians, we created an education program to teach early recognition of injuries with optimisation of care to prehospital personnel. This tertiary prevention program aims to mitigate the effect of motorcycle crash injuries by providing education focused on paramedic judgement for triage decisions, motorcycle injury patterns, and medical techniques, including fluid resuscitation, tourniquet use, helmet removal, cricothyroidotomy, and needle decompression. Methods/Approach Prospective surveys given to 610 prehospital staff throughout the state of Florida from January 2012 to November 2013 were evaluated. Prehospital staff were generally male (80%) and had an average professional experience of 12 years. Biases toward motorcycle riders and pre-/post-test knowledge were evaluated. Subjects with previous motorcycle experience (n = 216) were compared to those with no motorcycle experience (n = 394). A Z-test for independent proportions was used where appropriate to compare test responses. Results Subjects with previous motorcycle experience were significantly more likely to disagree or strongly disagree with the following statements when compared to those with no motorcycle experience: “Motorcycle crash victims are typically responsible for the crashes they get in” (60.4% vs. 45.1%; p Conclusions Our findings may suggest that individuals with previous motorcycle experience may be less likely to agree with the idea that motorcycle crash victims are typically responsible for the crashes they get in, and that most traumas are the result of lack of ability, ignorance, laziness, or all three of these factors. This difference in attitude may be worth evaluating further to determine whether there is a difference in approach to care. Significance and contribution to the field We aim to highlight the purpose of this tertiary prevention program and the need for similar programs in other states without universal helmet laws. We will discuss particular management approaches unique to motorcyclists, the need for coordination and multidisciplinary care, triage and transport, and injuries commonly encountered in motorcyclists. We aim to improve the assessment, evaluation, transport time, and definitive management of the motorcycle crash patient, through education and by assessing potential biases of prehospital personnel. We hope to empower health care providers as stakeholders in the solution to take a more active role in prehospital education.

The rate of trauma in the elderly is growing.To evaluate the characteristics of non-hip fracture-associated trauma in elderly patients at a level I trauma center.The study database of this retrospective cohort study was the trauma registry of a level I trauma center. Trauma patients admitted from January 2001 to December 2003 were stratified into different age groups. Patients with the diagnosis of hip fracture were excluded.The study group comprised 7629 patients. The non-hip fracture elderly group consisted of 1067 patients, 63.3% women and 36.7% men. The predominant mechanism of injury was falls (70.5%) and most of the injuries were blunt (94.1%). Injury Severity Score was found to increase significantly with age. The average mortality rate among the elderly was 6.1%. Age, ISS, Glasgow Coma Score on admission, and systolic blood pressure on admission were found to be independent predictors of mortality.Falls remain the predominant cause of injury in the elderly. Since risk factors for mortality can be identified, an effective community prevention program can help combat the future expected increase in morbidity and mortality associated with trauma in the elderly.

The contribution of drugs and alcohol to current trauma-related morbidity and mortality in Israel is not known. Identification of these factors in the fast-changing demographics of the Israeli population might lead to better care and, no less importantly, to targeted prevention measures.To determine the incidence of alcohol-related trauma, and to specify the time of day, the cause of trauma, and the morbidity and mortality rates as compared to non-alcohol-associated trauma in the tertiary trauma unit of a large medical center in Tel Aviv.Data were obtained from the Israel National Trauma Registry, based on patient records in our institution (Tel Aviv Sourasky Medical Center) from January 2001 to December 2003.Of the 5529 patients in the study, 170 had high alcohol blood levels (50 mg/dl). Patients intoxicated with alcohol had higher rates of road accident injuries (35% versus 24% non-intoxicated) and stab wounds (29% vs. 7%). The Injury Severity Score of the alcohol-intoxicated patients was higher (32%or = 16 vs. 12%16). The alcohol-intoxicated patients were more likely to be non-Jewish (34% vs. 9%), young (82% aged 15-44 years) and males (91%). Most of the alcohol-related injuries occurred during the weekend (47%) and during evening-late night hours (from 11 p.m. to 7 a.m., 55%).Alcohol-associated trauma differs from non-alcohol-associated trauma in many ways. Since the population at risk can be identified, it is important that legislative, social, enforcement and educational measures be adopted to reduce the extent of alcohol abuse and thereby improve the level of public safety.

The utility of obtaining a routine cystogram after the repair of intraperitoneal bladder disruption before urethral catheter removal is unknown. This study was designed to examine whether follow-up cystogram evaluation after traumatic bladder disruption affected the clinical management of these injuries. We hypothesized that routine cystograms, after operative repair of intraperitoneal bladder disruptions, provide no clinically useful information and may be eliminated in the management of these injuries.Our prospectively collected trauma database was retrospectively reviewed for all ICD-9 867.0 and 867.1 coded bladder injuries over a 6-year period ending in June 2004. Demographics, clinical injury data, detailed operative records, and imaging studies were reviewed for each patient. Bladder injuries were categorized as intraperitoneal (IP) or extraperitoneal (EP) bladder disruptions based on imaging results and operative exploration. Patients with IP injuries were further subdivided into those with "simple" dome disruptions or through-and-through penetrating injuries and "complex" injuries involving the trigone or ureter reimplantation. All patients sustaining isolated ureteric or urethral injury were excluded from further analysis.In all, 20,647 trauma patients were screened for bladder injury. Out of this group, there were 50 IP (47 simple, 3 complex) and 37 EP injuries available for analysis. All IP injuries underwent operative repair. Eight of the IP injuries (all simple) had no postoperative cystogram and all were doing well at 1- to 4-week follow-up. The remaining 42 patients underwent a postoperative cystogram at 15.3 +/- 7.3 days (range 7 to 36 days). All simple IP injuries had a negative postoperative cystogram. The only positive study was in one of the three complex IP injuries. In the EP group, 21.6% had positive cystograms requiring further follow-up and intervention.Patients sustaining extraperitoneal and complex intraperitoneal bladder disruptions require routine cystogram follow-up. In those patients undergoing repair of a simple intraperitoneal bladder disruption, however, routine follow-up cystograms did not affect clinical management. Further prospective evaluation to determine the optimal timing of catheter removal in this patient population is warranted.

Sepsis remains a common source of morbidity and mortality for seriously burned patients. Sources of sepsis are varied, although some are dramatically more common than others. Rarely, the burn surgeon may be confronted with an infectious source that remains unelucidated until postmortem examination. This case report describes the hospital course and subsequent death of a severely burned patient with sepsis, the source of which was only discovered on postmortem examination by our county medical examiner.

Learning Objectives: Mobile technologies harbor the potential to transform healthcare by improving clinician workflow and decision-making, which ultimately enhances quality of care and patient outcomes. The time sensitive nature inherent in trauma and critical care requires physicians to quickly access information to make correct decisions. In the past 5 years, we have been developing a mobile software platform and data management system that combines clinical documentation, education and telemedicine/decision-support. The goal is to provide clinicians with an integrated system of tools to facilitate the process of care. MobileCARE delivers a suite of integrated applications that completely supports a physician's workflow. Clinicians are able to create documentation, view test results, medical notes and surgical documentation in real time. It also provides access to a mobile learning trauma and critical care curriculum and the ability to communicate through telemedicine with other team members. To better understand the use of mobile technologies in the clinical environment, we conduct usability and user acceptance testing as a guide to implementation. We also have conducted knowledge and skill acquisitions tests of the learning modules.The system are currently being evaluated in the trauma intensive care unit of a busy urban Level 1 trauma center. Physicians use it to document patient admissions and daily patient status with the information immediately available to all users across multiple platforms. Knowledge and skill acquisition tests have demonstrated that the mobile learning modules are equivalent to traditional classroom lectures (Figure 1), and that their use improved performance in the simulated environment (Figure 2). MobileCare is a complete software solution that provides significant functionality in the clinical environment. The impact on the safe and efficient delivery of care will continue to be realized. This technology is especially beneficial where continuity of care is required, as with patients with chronic disease or multiple acute conditions.

A technique is described for the intra-operative positioning of the burn patient, which allows circumferential access without the need for specialized equipment or extra personnel. The equipment is available in any standard operating room and table without the need for redesign or new construction. In addition, it allows full 360 degrees access and eliminates the need for extra personnel to hold proper positioning. This allows for more efficient operating and should minimize the unwanted sequelae of hypothermia and blood loss. Operating time may be decreased and the patient may require less operative procedures. The same or more work can be done by less personnel, in less time, with no added cost.

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.

Background There is controversy about the optimal method to detect common bile duct (CBD) stones in patients with mild resolving gallstone pancreatitis. The aim of this study was to evaluate magnetic resonance cholangiopancreatography (MRCP) in detecting choledocholithiasis in this group of patients. Study design A prospective randomized trial was conducted. Patients randomized to group 1 (n = 34) underwent laparoscopic cholecystectomy (LC) and intraoperative cholangiography (IOC). Those randomized to group 2 (n = 29) had preoperative MRCP, of these, patients with negative MRCP underwent LC and IOC, patients with positive MRCP had preoperative ERCP followed by LC. Results Sixty-three patients were randomized (34 to group 1 and 29 to group 2). CBD stones were found in 5 patients in group 1. CBD exploration was performed in 2 patients, preoperative ERCP in 1, and postoperative ERCP in the other 2. MRCP showed CBD stones in 4 patients in group 2. There were two false-positive MRCPs. Four patients with a negative MRCP did not have IOC or ERCP, the remaining 21 patients with a negative MRCP had a negative IOC. The MRCP sensitivity was 100% (95% CI, 16–100%), specificity 91% (95% CI, 72–99%), positive predictive value 50% (95% CI, 7–93%), negative predictive value 100% (95% CI, 84–100%), and accuracy 92% (95% CI, 74–99%). Conclusions Patients with resolving gallstone pancreatitis and a negative MRCP do not need preoperative ERCP or IOC. Only patients with a positive MRCP will require preoperative ERCP.

This study examines the hypotheses that TNF-alpha causes a dose-dependent increase in the microvascular permeability of ex vivo buffer perfused lungs that is quantitatively similar to that caused by lipopolysaccharide (LPS) or thromboxane A2 (TxA2). We also postulated that TNF-alpha potentiates the effect of interleukin-1beta (IL-1beta) or TxA2 receptor activation on pulmonary microvascular permeability. Lungs harvested from Wistar rats were perfused ex vivo with Krebs-Henseleit buffer containing 0, 10, 100, or 1000 ng/mL recombinant rat TNF-alpha. Twenty minutes later pulmonary microvascular permeability was determined by measuring the capillary filtration coefficient (Kf) using a gravimetric technique. The effect of TNF-alpha (100 ng/mL) on pulmonary Kf was compared with that of lungs exposed to LPS (400 microg/mL; E. coli 0111:B4) or a TxA2 receptor agonist (U-46619; 7 x 10(-8)). In other experiments, perfused lungs were exposed to TNF-alpha plus IL-1beta (1 ng/mL) or TNF-alpha plus U-46619 after which Kf was measured. Exposure of ex vivo buffer perfused lungs to 10-1000 ng/mL TNF-alpha had no effect on Kf whereas LPS and U-46619 was associated with a two- and six-fold increase in Kf, respectively (P < 0.05). The Kf of lungs exposed to TNF-alpha plus IL-1 was similar to that of lungs exposed to TNF-alpha alone. Lastly, the Kf of lungs exposed to TNF-alpha plus U-46619 was not different than that of lungs exposed to U-46619 alone. In conclusion, TNF-alpha at least when administered for a relatively brief period of time does not affect microvascular permeability in an isolated, buffer-perfused lung model.

Even in the absence of inhalational injury, acute lung injury is a common cause of morbidity and mortality for patients sustaining severe burns. Other than general supportive measures, there are few therapeutic options for improving survival in these critically ill patients. Numerous clinical and laboratory studies have implicated tumor necrosis factor (TNF)-a and neutrophils as important participants in the pathogenesis of burn-induced lung injury. There is, however, little information regarding the mechanism by which these and other pro-inflammatory mediators affect the movement of fluid and protein across the microvascular barrier into the interstitium of the lung. In addition to reviewing the evidence implicating TNF-a and neutrophils in the pathophysiology of burn-induced lung injury, this report summarizes current theories regarding potential mechanisms by which these mediators may alter microvascular barrier function to lead ultimately to the development of pulmonary edema.

IntroductionTrauma teams are comprised of a diverse group of interprofessional providers. While there are different configurations, teams commonly consist of physicians, nurses, emergency medical technicians, various hospital-based technicians and administrative staff. There are currently a plethora

We evaluated the impact of increasing the interval between routine central venous catheter exchanges from every 3 days to every 4 days on the rate of catheter infections and catheter-related bacteremia. Computer records of catheter tip and blood culture results in burn patients were reviewed. The change to every 4 day catheter exchange occurred in November 2000 and data were collected until June 2001. One hundred and ninety-six guidewire exchanges were performed in the every 3 day (q3day) group, and 164 guidewire exchanges were performed in the every 4 day (q4day) group. The rate of catheter infections (>15 colony forming units) was 11% in the q3day group and 28% in the q4day group. Catheter-related blood stream infection occurred in 4% of patients in q3day group and 12% of patients in q4day group. A prospective review of this change in practice revealed that there was a significantly greater risk of infections in the q4day group. The increase in infected central venous catheter segments was associated with an increase in blood stream infections.