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Introduction Tracheostomy has been proposed for patients with expected prolonged intubation and it has been shown to be beneficial for trauma patients with severe brain injury; however, the benefit of performing tracheostomy on burn inhalation injuries has not been extensively investigated. Our study aims to determine the outcomes of performing tracheostomy on patients with burn inhalation injuries requiring mechanical ventilation. Methods Retrospective review of our institutional burn registry from 2011 to 2019. We compared the outcomes of all burn patients that met our inclusion criteria which included: adequate data recording of inhalation injury within the registry, ventilator support for at least 24 hours, and a TBSA burn injury of < 15%. We stratified the patients into two groups: tracheostomy (group 1) versus no tracheostomy (group 2). Outcome measures included: in-hospital mortality rate, hospital length of stay, ICU length of stay, ventilator days, and ventilator associated pneumonia (VAP). Chi-squared and t-test analyses were used with significance defined as p< 0.05. Results A total of 33 burn patients met our inclusion criteria. Group 1 consisted of 10 patients and group 2 consisted of 23 patients. There was no statistically significant difference between the two groups in terms of %TBSA (p =0.24, t-test). There was a significantly higher ICU length of stay at 23.8 days in group 1 compared to 3.16 days in group 2 (p=0.0001, χ2). There was a significantly higher hospital length of stay at 28.4 days in group 1 compared to 5.26 days in group 2 (p=0.0001, χ2). Ventilator days was also significantly higher in group 1 with 20.8 days compared to 2.5 days in group 2. There was no statistically significant difference between the two groups in terms of mortality, however, the incidence of VAP was significantly higher in group 1 than in group 2, with six cases compared to zero cases, respectively(p=0.0001, χ2). Conclusions The ideal timing and implementation of tracheostomy with inhalational injury has yet to be determined. In our study, tracheostomy was associated with much longer lengths of stay and pneumonia. The impact of the underlying lung injury, versus the tracheostomy itself on these observations, is unclear. The challenge of characterizing the severity of an inhalation injury based on early visual inspection remains.

Background Multi-drug resistant (MDR) organisms in intensive care units (ICUs) are a growing concern. The emergence of several infections with MDR Acinetobacter baumannii prompted a review of cases and evaluation of the efficacy of intervention. Objective To determine the rate of clinical cure, the incidence of drug resistance, and the mortality rate associated with A. baumannii infection. Method Retrospective review of A. baumannii infections in three surgical ICUs between January, 2004 and November, 2005. Infection was identified in 291 patients, 20 of whom were excluded because of incomplete documentation. Of the remaining 271 patients, 71% were male, and the mean age was 47 +/- 18 years (range 13-90 years). Results Patients had a mean length of stay in the ICU of 14 days (range 0-136 days) before infection. The initial positive cultures were from bronchoalveolar lavage fluid (BAL) in 72.3%, blood in 16.2%, a catheter tip in 6.3%, urine in 1.8%, wound in 2.2%, and abscess in 1.1%. In 46.9% of patients, the first culture was polymicrobial. The Acinetobacter isolates were resistant or intermediate-resistant to imipenem-cilastatin in 81.2% of cases; 19.9% were resistant to all drugs except colistin, and two were resistant to all tested drugs. Colistin was used in 75.6% of patients (intravenous 61.5%, nebulized 38.5%). The mean duration of treatment was 13 +/- 8.9 days (range 0-56 days), and clinical cure was achieved in 73.8% of patients. Recurrent infection after initial cure was found in 19.2% of patients. There was no significant difference in clinical cure rates between patients treated with colistin and those treated with other culture-directed drugs (75.1% vs. 69.7%), or between patients treated with intravenous vs. nebulized colistin (72.4% vs. 79.5%). The mortality rate was 26.2% for the entire group and was significantly higher in the subgroup of transplant patients (n = 31) (64.5% vs. 21.4%; p Conclusion The majority of A. baumannii isolates were MDR, and a significant proportion were sensitive only to colistin. Treatment of A. baumannii infection with colistin is effective by both intravenous and nebulized routes of administration. However, infection with A. baumannii in critically ill surgical patients is associated with a high mortality rate, particularly in transplant patients.

Intensive care unit (ICU) patients comprise a small proportion of patients in the hospital but consume a disproportionate amount of hospital resources. In our cost-conscious environment, it becomes necessary to address the overall performance of our ICUs. This study was designed to analyze survival among trauma ICU (TICU) patients with a length of stay (LOS)1 month.We retrospectively reviewed the prospectively collected Trauma Registry Database between January 1, 1995, and January 1, 2005, in an adult TICU from a Level I trauma center. Data on demographics, mechanism of injury, Injury Severity Score (ISS), LOS, and in-hospital survival was collected. Descriptive statistics were calculated and student's t test and comparison of proportions were performed where appropriate. Logistic regression was performed to analyze independent predictors of mortality with significance when p0.05.The initial cohort consisted of 3,556 patients with a mean LOS of 9.8 days (range, 0-274 days). Sixty-nine percent were men, mean age was 44.3 years (range, 0-104 years), and mean ISS was 18 (range, 0-75). The mechanism of injury was blunt trauma in 75%, burns in 15%, and penetrating trauma in 10%. Overall survival was 87%. A total of 339 patients had a LOS1 month. There was no difference in survival between patients with a LOS1 month and those with a LOS1 month (87.1% versus 86.7%). Patients50 years old (n = 1,251) had a longer LOS (12.5 versus 8.4 days; p0.001) and increased mortality (22.1% versus 8.0%; p0.001). Age remained an independent predictor of mortality when controlling for ISS.In our TICU population, extended LOS did not preclude a significant chance of survival. Patients50 years old had longer LOS and increased mortality. This suggests that the utilization of resources in patients with a prolonged LOS is reasonable and justified.

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

Study objective: Annually, 38 million people are evaluated for trauma, the leading cause of death in persons younger than 45 years. The primary objective is to assess whether using a protocol inclusive of point-of-care, limited ultrasonography (PLUS), compared to usual care (control), among patients presenting to the emergency department (ED) with suspected torso trauma decreased time to operative care. Methods: The study was a randomized controlled clinical trial conducted during a 6-month period at 2 Level I trauma centers. The intervention was PLUS conducted by verified clinician sonographers. The primary outcome measure was time from ED arrival to transfer to operative care; secondary outcomes included computed tomography (CT) use, length of stay, complications, and charges. Regression models controlled for confounders and analyzed physician-to-physician variability. All analyses were conducted on an intention-to-treat basis. Results are presented as mean, first-quartile, median, and third-quartile, with multiplicative change and 95% confidence intervals (CIs), or percentage with odds ratio and 95% CIs. Results: Four hundred forty-four patients with suspected torso trauma were eligible; 136 patients lacked consent, and attending physicians refused enrollment of 46 patients. Two hundred sixty-two patients were enrolled: 135 PLUS patients and 127 controls. There were no important differences between groups. Time to operative care was 64% (48, 76) less for PLUS compared to control patients. PLUS patients underwent fewer CTs (odds ratio 0.16) (0.07, 0.32), spent 27% (1, 46) fewer days in hospital, and had fewer complications (odds ratio 0.16) (0.07, 0.32), and charges were 35% (19, 48) less compared to control. Conclusion: A PLUS-inclusive protocol significantly decreased time to operative care in patients with suspected torso trauma, with improved resource use and lower charges. [Ann Emerg Med. 2006;48: 227-235.]

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

Accurate screening of the thoracolumbar spine (TLS) remains problematic in the care of trauma patients. The current standard of care for TLS screening is not clearly defined. In trauma patients undergoing computed tomography (CT) of the chest and or abdomen, compelling supportive evidence for reformatting and reusing this CT data to clear the thoracolumbar spine has accumulated over the last 3 years. The objective of this review was to identify and review all published studies comparing reformatted CT to traditional plain radiography for TLS clearance.A Medline search for all English language articles published on this subject since 1980 identified seven studies. Each was classified according to the levels of evidence classification of the Agency for Health Care Policy and Research. The methodology of each study was reviewed for the CT protocol, utilization of radiologist blinding and whether historical dictated reports or de novo image readings were used for comparison. The sensitivity and specificity of each study and the gold standard utilized in its calculation was noted. Where available, detailed information regarding the missed injuries and their clinical relevance was abstracted for each study.All evaluated studies demonstrated superior sensitivity and interobserver variability for reformatted CT compared with plain radiographic screening. CT was also more accurate in localizing, classifying, and delineating the age, bony intrusion, and soft-tissue damage associated with the fracture. For studies with time-motion components, a protocol utilizing CT clearance was not only more accurate but faster and more economical. Screening with reformatted visceral CT data required no additional scan time or radiation exposure.The evidence to date demonstrates the superior sensitivity of reformatted visceral CT for detecting thoracolumbar spine injury. With no further patient movement, radiation exposure, cost, or time, trauma patients undergoing visceral CT can have their thoracolumbar spine promptly evaluated. Further prospective evaluation of the CT protocols to optimize visualization of both the viscera and the bone is warranted.

Objective The objective of this study was to review the outcome of nonoperative treatment for penetrating internal jugular vein (IJ) injuries in a continuous series of prospectively identified, hemodynamically stable patients. Methods All penetrating neck injuries assessed from February 1, 2004, to August 31, 2004, were prospectively identified. Patients without an indication for urgent neck exploration underwent diagnostic assessment with multislice helical computed tomographic angiography with or without vascular ultrasonography. All IJ injuries with no other indication for surgical exploration were treated nonoperatively. All patients were discharged home and followed up for a minimum of 1 week to document outcomes. Results From 51 neck injuries penetrating the platysma, 7 required urgent neck exploration, during which 2 IJ injuries were ligated. Forty-four patients underwent multislice helical computed tomographic angiography. Eight IJ injuries (two gunshot wounds and six stab wounds) with no other indication for neck exploration were identified and managed nonoperatively. One external wound was in zone 1, five were in zone 2, one was in zone 3, and one traversed all three zones. The average length of stay was 4.5 days. At follow-up, ranging from 1 week to 5 months, all patients were asymptomatic, and no patient required delayed operation for IJ injury. Conclusions In hemodynamically stable patients with no other indication for exploration, the nonoperative management of penetrating jugular vein injuries should be considered as a safe alternative.

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

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

Background: It is possible to quantify the amount of hemoperitoneum seen on focused assessment with sonography for trauma (FAST) using a simple scoring system that had previously been shown to correlate with the need for subsequent laparotomy in adults. A score of 3 or greater was shown to be highly accurate in predicting the need for laparotomy. We hypothesized that this scoring system might also predict the need for laparotomy in pediatric trauma patients. Methods: We retrospectively reviewed all records for patients 15 years and younger who underwent FAST after blunt trauma. A positive ultrasound examination was defined as one containing free intraperitoneal fluid with or without solid organ injury. The ultrasound score (USS) was defined as the depth of the deepest pocket of fluid collection measured in centimeters plus the number of additional spaces where fluid was seen. Results: Thirty-eight (19.6%) of 193 patients who had FAST performed had positive ultrasound examinations. Thirty-seven patients with complete records were analyzed. There were no differences between patients with a USS ≤3.0 and those with a USS > 3.0 in terms of admission pulse, Glasgow Coma Scale score, Injury Severity Score, or the proportion of patients who were initially hypotensive. One of 22 patients with a USS ≤3.0 required therapeutic laparotomy versus 8 of 15 patients with a USS > 3.0 (p = 0.002). For a USS > 3.0, sensitivity, specificity, and accuracy in predicting therapeutic laparotomy were 89%, 75%, and 78%, respectively. CoflclvsloAl Ultrasound quantification of hemoperitoneum by a simple scoring system may serve as a useful adjunct to traditional clinical parameters in predicting the need for subsequent laparotomy in pediatric patients. Prospective validation with a larger study is required.

Background Intra-abdominal hypertension has been recognized as a source of morbidity and mortality in the traumatized patient following laparotomy. Multiple organ dysfunction attributable to intra-abdominal hypertension has been called the abdominal compartment syndrome. The epidemiology and characteristics of these processes remain poorly defined. Methods Intra-abdominal pressure was measured prospectively in all patients admitted to a trauma intensive care unit over 9 months. Data were gathered on all patients with intra-abdominal hypertension. Results Some 706 patients were evaluated. Fifteen (2 per cent) of 706 patients had intra-abdominal hypertension. Six of the 15 patients with intra-abdominal hypertension had abdominal compartment syndrome. Half of the patients with abdominal compartment syndrome died, as did two of the remaining nine patients with intra-abdominal hypertension. Patients with abdominal compartment syndrome had a mean intra-abdominal pressure of 42 mmHg compared with 26 mmHg in patients with intra-abdominal hypertension only (P < 0·05). Conclusion The incidence of intra-abdominal hypertension and abdominal compartment syndrome was 2 and 1 per cent respectively. Intra-abdominal hypertension did not necessarily lead to abdominal compartment syndrome, and often resolved without clinical sequelae. Abdominal compartment syndrome did not occur in the absence of earlier laparotomy. Abdominal compartment syndrome was associated with a marked increase in intra-abdominal pressure (above 40 mmHg).

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan–Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan–Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the abdomen: 0 US, 466 CT, and 176 DPL (see table). This compares to 801 procedures on the 1033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant ( P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 ( P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

To determine the optimal method of wound closure for dirty abdominal wounds.The rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection.Fifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed.Two patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups.A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.

Objective: We sought to identify potential measurable onscene information that would assist clinicians in the identification of patients at risk for thoracic aortic tear (AT) after vehicular trauma. Methods: Data were prospectively collected at the scene of 295 motor vehicle crashes from 1995 to 1999. There were 34 cases (12%) with AT. Scene data consisted of vehicle maximal crush, maximal intrusion into the occupant compartment, change in velocity (Delta V) and principal direction of force. Thoracic aortic injuries were confirmed radiographically or at autopsy. Crash factors were analyzed for correlation with AT by logistic regression. Results: Delta V ≥ 20 mph and near-side impact were the factors having the strongest correlation with thoracic aortic injury. Delta V ≥ 20 mph (n = 32 with AT) had an odds ratio = 6.4, (p < 0.01). Near impact (n = 20 with AT) had an odds ratio = 2.3, (p < 0.05) and intrusion ≥ 15 inches had an odds ratio = 3.2,p < 0.05. The sensitivity, specificity, and accuracy of the presence of near impact, Delta V ≥ 20 mph, or both, were 100%, 34%, and 64%. The positive and negative predictive values were 16% and 100%, respectively. There was no relationship of AT to use of seat belts or airbags. Conclusion: Thoracic aortic injury after vehicular collision can be reliably excluded if near-impact, Delta V ≥ 20 mph, or intrusion ≥ 15 inches are not present. Mechanism of injury in the form of crash scene information may aid clinicians in identifying individuals at risk for thoracic aortic tear after vehicular trauma.

Objective: To determine the utility of near-infrared spectroscopy in the diagnosis of lower extremity compartment syndrome (CS). Methods: Nine patients with CS confirmed by physical examination and elevated compartment pressures (64 ± 17 mm Hg) were evaluated before and after fasciotomy. Control readings were also performed on 33 surgical patients who had no evidence of CS. The deltoid muscle was used as a reference value. Results: The deltoid muscle oxygen saturation (Sto 2 ) readings revealed a mean = 84 ± 17% prefasciotomy and mean = 83 ± 12% postfasciotomy in the CS group. The control group had a mean Sto 2 of 83 ± 11%. In the CS group, the leg compartment with the highest pressure had a Sto 2 mean = 56 ± 27% before fasciotomy. This value was statistically significantly lower (p < 0.05) than either the postfasciotomy mean Sto 2 in that compartment (82 ± 16%) or the values found in matched control patients with no evidence of CS (87 ± 7%). Conclusion: Near-infrared spectroscopy-derived Sto 2 values in the lower extremities of trauma patients with CS were diminished relative to the control patients and usually normalized after fasciotomy. Near-infrared spectroscopy evaluation may offer a rapid, noninvasive method of assessing extremities at risk for CS.

Since West and colleagues showed clear benefits in outcomes for patients treated at specialized trauma centers in the 1970s, patients could no longer be simply transported to the nearest hospital. Scoring systems were initially created for the purposes of field triage. Of necessity these systems must be straightforward and user-friendly for prehospital personnel. Scoring systems should accurately assess severity of injury both anatomically and physiologically. The mechanism of injury is critical. Comorbid factors, age, and clinical judgment also factor into the accuracy of field triage systems. With all these factors incorporated, a scoring system should reliably predict injury severity and patient outcomes. Beside field triage, scoring systems have found a number of other uses. Because large numbers of patients are quantifiable by scoring systems, these data can be used for quality assurance. Review of records may provide details of proper care, possible areas of preventable morbidity and mortality, and treatment center specific deficiencies or strengths. Another area where scoring systems have proved valuable is in evaluating trauma care delivery and trauma research. By providing a quantifiable number for groups of trauma patients, comparisons are possible. Researchers can compare different hospitals, different regions, different practice environments, and different modes of therapy. It has become standard in all forms of trauma research to include an injury severity score in the data collection. Scoring systems can also aid in determining entry criteria for prospective research protocols. Using these systems for research has greatly advanced communication among trauma surgeons, health care workers, and researchers by enabling them to speak in similar terms. Last, trauma scoring systems have the potential to be used in reimbursement assessment. It is generally recognized that trauma and critical care are under-reimbursed. So, although the thought of controlled reimbursement is anathema for most, the era of cost-contained health care delivery is here to stay, and if a quantifiable system proves reliable, it may be that health care regulators should use it. What follows is a discussion of the current trauma severity scoring systems, and their areas of strength, weakness, and applicability.

Background: Although the high cost and inappropriate use of antibiotics have been documented before, we are not aware of any data on nonsurgical site infectious morbidity associated with prolonged courses of prophylactic antibiotics (PA). Study Design: Data regarding antibiotic orders were collected using a custom designed microbiology database in the Surgical Intensive Care Unit of a teaching hospital from October 1, 1995 through April 30, 1997. The database was retrospectively reviewed. The cost of PA in excess of 1 day was calculated. Frequency of bacteremia and line infections were compared in patients receiving 1 day or less of PA versus more than 4 days of PA. Results: Sixty-one percent of PA orders were continued for more than 1 day. Cost of PA beyond 1 day totaled $44,893. Bacteremia and line infection were more frequent in the patients receiving more than 4 days of PA. Conclusions: There was poor compliance with the protocol of stopping PA at 24 hours. The cost of noncompliance was $44,893. There were more bacteremias and line infections in patients with duration of PA of more than 4 days.

The use of sonography for evaluating blunt abdominal trauma is gaining popularity in the United States. Radiologists may begin to play a vital role in the initial evaluation of the critically injured patient. With the rapid identification of free intraperitoneal fluid, unstable patients may be sent to the operating room without delay. Effective utilization of trauma sonography requires use of a targeted examination. Understanding the anatomic relationships of the various peritoneal reflections and awareness of the potential pitfalls that may be encountered will minimize examination time while permitting accurate interpretation.

Background The increased popularity of personal watercraft (PWC) has resulted in an increase in PWC-related injuries. In an effort to better understand the problem, a retrospective review of 37 victims of such injuries seen at a Level I trauma center and fatalities examined by the medical examiner were analyzed. Results Fourteen percent of the victims were passengers, two of whom were struck from behind, resulting in severe injuries. Twelve patients died of their injuries. For six victims, the cause of death was drowning; only one of these victims was wearing a personal flotation device. Two patients sustained transected aortas, 20% had brain injuries, 20% had spinal fractures, and 48% had skeletal and skull fractures. Abdominal organ injuries were present in only 13.5% of the victims, but they were significant, with liver, spleen, and kidney lacerations and aortic and renal artery injuries. Conclusion In this population of victims of PWC crashes meeting preestablished trauma criteria or on-scene deaths, injuries were significant. Many of the drowning deaths may have been prevented with the use of personal flotation devices. The potential for serious intra-abdominal injury must be recognized and dealt with appropriately.

Ultrasound (US) provides a rapid, portable, and noninvasive method for evaluating the blunt trauma patient. In 1993, US was introduced into the workup of blunt abdominal trauma (BAT) at our institution and has rapidly become the modality of choice over computed tomography (CT) and diagnostic peritoneal lavage (DPL). In this study, the cost effectiveness of utilizing US in BAT was evaluated. We compared the number of DPLs and CTs performed during the 6-month period in 1993 preceding the incorporation of US with the number of CTs, DPLs, and USs performed during the last 6 months of 1994. Costs were determined by the finance department based on actual expenditures by the hospital, excluding physician fees, in 1994 U.S. dollars. Six hundred twenty-six patients were evaluated for BAT during the 6-month period in 1993. In this group, 450 patients had CT examinations, 160 had DPL, and 16 had both. This resulted in a cost of $254,316. During the last 6 months in 1994,564 patients were evaluated for BAT, including 470 USs, 175 CTs, and 11 DPLs. The cost for this group was $133,077, with a decrease in hospital expenditure of $170 per patient. We conclude that utilizing US in the evaluation of BAt leads to a significant cost reduction. Extrapolated over 1 year, with 1100 blunt abdominal trauma patients, the cost savings would be over $187,000.

The purpose of this study was to review all positive trauma abdominal ultrasound examinations, to determine a standard imaging protocol that would provide rapid patient evaluation, and to assess the ability of ultrasound to predict the need for emergent laparotomy.

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.

Objective The authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time. Methods Adult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire. Results There was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically different (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was $6077 and for an open appendectomy $7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique. Conclusion Laparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

We present a series in which videothoracoscopy was used to evaluate and manage patients after thoracic trauma. We used this technique in 11 patients with thoracic injuries. We describe 5 representative cases. It was used successfully in 10 of 11 patients. Indications included evaluation of ongoing hemothorax, evacuation of clotted hemothorax and empyema, and decortication for persistent airleak. Etiologies included blunt trauma, stab wounds, and gunshot wounds.

PURPOSE: The aim of the study was to review our experience with colostomy closure after Hartmann's procedure and the possible impact of laparoscopic colostomy closure. METHODS: A retrospective review of hospital stay after colostomy closure by laparotomy in the last four years was conducted. A chart review of patients undergoing laparoscopic colostomy closure after Hartmann's procedure since the introduction of operative laparoscopy at our institution was also done. RESULTS: One hundred twenty patients had colostomy closure carried out by the trauma service at the University of Miami/Jackson Memorial Hospital. In thirty-seven patients, colostomy closure was associated with other surgical procedures such as ventral herniorrhaphy, delayed closure of the open abdomen, ureteroneocystostomy, and so forth, or they underwent loop colostomy closure. These patients were excluded from further review. Sixty-five patients underwent reversal of Hartmann's procedure by laparotomy. They had an average hospital stay of 9.5 days (range, 6 to 34 days). This group of patients had colostomy closure prior to the introduction of operative laparoscopy in our institution. With increased laparoscopy experience, laparoscopically assisted Hartmann's reversal has been attempted in 18 patients and completed in 14 patients. The average hospital stay in the laparoscopically completed group was 6.3 days (range, 4 to 10 days). This group had a 0 percent mortality and a 14.3 percent morbidity. This compares favorably to recently reported series of colostomy closure by laparotomy. CONCLUSION: Laparoscopically assisted Hartmann's reversal results in comparable morbidity, but may be associated with shorter hospital stay when compared with laparotomy.

Differences in handgun bullet diameter, expansion, and penetration (no exit) versus perforation (with exit) may be the cause of variable blood pressure effects after thoracopulmonary injury. Forty nonlethal isolated gunshot wounds of the thorax were evaluated excluding wounds of the heart, great vessels, and spinal cord. Chest radiographs were assessed for bullet base diameter, bullet expansion, and wound length. Large bullets were defined as having radiographic base images of 9 mm or more in diameter. Systolic blood pressures were compared between penetrating large and small bullet groups and with perforating wounds. Response times and demographics were compared. Wounds caused by large bullet penetration resulted in lower initial systolic blood pressures than wounds caused by small bullet penetration (98 vs 125 mm Hg, P < 0.05). The average age, transport time, and wound length were similar among the bullet groups. We conclude that penetrating thoracopulmonary wounds caused by large bullets resulted in lower initial systolic blood pressure.

A critical aspect of enhancing patient safety is modifying the healthcare safety culture. We hypothesize that students who participate in safety curricula are knowledgeable regarding patient safety and likely to intervene to avoid patient errors.A two-part patient safety curriculum was taught: introductory theories (first year) and a clinically oriented course during surgery rotations (third year). All students participated in the first year introduction and a random cohort of students (62.6%, N = 67) participated in the third year program. Multiple choice tests and web-based surveys were administered. Statistical analysis was carried out using Student's t-test for comparisons of test mean scores and z-test for comparison of the survey data.Students who participated in both years' curricula scored higher on didactic test than those who participated in only the first year course (82.9% versus 75.5%, P0.001). More students participating in both portions of the curricula intervened during at least one clinical encounter to avoid a patient error (77% versus 61%, P0.05). Students rated junior house-staff more receptive to patient safety suggestions than surgical fellows and faculty (84% versus 66%, P0.05); 75% of students rated their surgical clerkship exposure to patient safety somewhat/extremely valuable compared with 54% students who rated the first year exposure as somewhat/extremely valuable (P0.05).Medical students who have practical applications of patient safety education reinforced during surgery rotations are knowledgeable and willing to intervene in patient safety concerns. Teaching clinically relevant patient safety skills influences positive behavioral changes in medical students' performance on surgical teams.

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.

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 objective of this study was to compare the utility of plain radiographs to multislice computed tomography (MCT) for cervical spine (c-spine) evaluation. We hypothesized that plain radiographs add no clinically relevant diagnostic information to MCT in the screening evaluation of the c-spine of trauma patients.This was a prospective, unblinded, consecutive series of injured patients requiring c-spine evaluation that were imaged with three-view plain films and MCT (occiput to T1 with 3-dimensional reconstruction). The final discharge diagnosis based on all prospectively collected clinical data, MCT, and plain films was utilized as the gold standard for the sensitivity calculation.From October 2004 to February 2005, 667 trauma patients requiring c-spine evaluation were enrolled. Average age was 35.4 years and 70% were male. The mechanism of injury was blunt in 99% and 48.7% occurred as a result of motor vehicle collision. Sixty of 667 (9%) sustained acute c-spine injuries. MCT had a sensitivity of 100% and specificity of 99.5%. Plain films had a sensitivity of 45% and specificity of 97.4%. Plain radiography missed 15 of 27 (55.5%) clinically significant c-spine injuries.MCT outperformed plain radiography as a screening modality for the identification of acute c-spine injury in trauma patients. All clinically significant injuries were detected by MCT. Plain films failed to identify 55.5% of clinically significant fractures identified by MCT and added no clinically relevant information.

Severe atraumatic intraperitoneal hemorrhage is uncommon during the third trimester of pregnancy. Within this small population of patients, ruptured hepatic adenoma, ruptured splenic artery aneurysm, and uterine rupture represent three common causes of antepartum third trimester intraperitoneal bleeding. Other less common causes include spontaneous bleeding because of the HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) and intraperitoneal rupture of a placentia previa with percreta, among others. This case report describes the use of the Modified Rapid Deployment Hemostat (MRDH, Marine Polymer Technologies, Inc., Danvers, Mass.) to control exsanguniating hemorrhage in a patient with severe pre-eclampsia that was found to have a large spontaneous liver injury. With the scope of trauma surgery evolving into a more generalized trauma and emergency general surgery specialty, this report is also intended to provide insight into an uncommon but life-threatening cause of hemorrhage that may confront the emergency general surgeon.

Background: The optimal management strategy for patients sustaining penetrating neck injury without an urgent indication for operative exploration remains controversial. The objective of this study was to prospectively assess multislice helical computed tomography angiography (MCTA) as a stand alone screening modality for the initial evaluation of hemodynamically stable patients with penetrating neck injuries. Our hypothesis was that MCTA is a sensitive diagnostic screening test that could noninvasively evaluate the vascular and aerodigestive structures of the neck. Methods: After Institutional Review Board approval, all penetrating neck injuries assessed during a 16-month period were prospectively evaluated at a Level I trauma center. Patients without an indication for urgent neck exploration underwent MCTA screening. MCTA accuracy was tested against an aggregate gold standard of final diagnosis encompassing all imaging, surgical procedures and clinical follow-up obtained. Results: In all, 106 injuries penetrated the platysma; 15 required urgent exploration and 91 underwent MCTA (34 gunshot wounds/57 stab wounds). Nineteen external wounds were in zone 1, 39 were in zone 2, 10 in zone 3, and 23 traversed multiple zones. MCTA was nondiagnostic in 2.2% secondary to artifact from retained missile fragments. Follow-up was achieved in 84.5% of patients for a mean of 33.3 days (range: 2-150). MCTA achieved 100% sensitivity and 93.5% specificity in detecting all vascular and aerodigestive injuries sustained. MCTA correctly identified two tracheal and two carotid artery injuries requiring operative or endovascular repair in asymptomatic patients. No injuries requiring intervention were missed by MCTA. Conclusion: In the initial evaluation of stable penetrating neck injuries, MCTA appears to be a sensitive and safe screening modality. Further investigation is warranted.

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.

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

Surgeons in the United States first began performing their own ultrasound examinations as part of the initial evaluation of trauma patients [1]. Increasing experience with this diagnostic modality brought about the recognition that the learning curve was reasonable [2], and that ultrasonography had several distinct advantages that could be applied to patient care. Surgeon-performed ultrasonography has since found use in the office, intraoperative, and critical care settings. Evaluation of critically ill patients often proves to be challenging. The combination of altered sensorium, underlying disease, and presence of multiple drains/monitoring devices often hampers a thorough physical examination [3]. Ultrasonography may, in such circumstances, serve as a useful adjunct, as both a diagnostic and a therapeutic modality. With increasing experience, the list of potential applications continues to grow. The current indications for ultrasonography in the critical care setting are enumerated in Box 1. This review will focus on the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients in the intensive care setting.