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Timing is crucial when caring for an injured patient, and the evaluation requires a systematic, rapid, and thorough assessment to identify and treat immediate life-threatening injuries. An integral component of this assessment is the Focused Assessment with Sonography for Trauma (FAST) and the extended FAST (eFAST). These assessments allow for a rapid, noninvasive, portable, accurate, repeatable, and inexpensive means of diagnosing internal injury to the abdomen, chest, and pelvis. Understanding the basic principles of ultrasonography, having a thorough familiarity with the equipment, and being knowledgeable in anatomy allow the bedside practitioner to use this tool to rapidly assess injured patients. This article reviews the basic tenets that underpin the FAST and eFAST evaluations. Practical interventions and tips are provided to assist novice operators-all with the goal of decreasing the learning curve., (©2023 American Association of Critical-Care Nurses.)

Recent increases in firearm violence in U.S. cities are well-documented, however dynamic changes in the people, places and intensity of this public health threat during the COVID-19 pandemic are relatively unexplored. This descriptive epidemiologic study spanning from January 1, 2015 - March 31, 2021 utilizes the Philadelphia Police Department's registry of shooting victims, a database which includes all individuals shot and/or killed due to interpersonal firearm violence in the city of Philadelphia. We compared victim and event characteristics prior to the pandemic with those following implementation of pandemic containment measures. In this study, containment began on March 16, 2020, when non-essential businesses were ordered to close in Philadelphia. There were 331 (SE = 13.9) individuals shot/quarter pre-containment vs. 545 (SE = 66.4) individuals shot/quarter post-containment (p = 0.031). Post-containment, the proportion of women shot increased by 39% (95% CI: 1.21, 1.59), and the proportion of children shot increased by 17% (95% CI: 1.00, 1.35). Black women and children were more likely to be shot post-containment (RR 1.11, 95% CI: 1.02, 1.20 and RR 1.08, 95% CI: 1.03, 1.14, respectively). The proportion of mass shootings (≥4 individuals shot within 100 m within 1 h) increased by 53% post-containment (95% CI: 1.25, 1.88). Geographic analysis revealed relative increases in all shootings and mass shootings in specific city locations post-containment. The observed changes in firearm injury epidemiology following COVID-19 containment in Philadelphia demonstrate an intensification in firearm violence, which is increasingly impacting people who are likely made more vulnerable by existing social and structural disadvantage. These findings support existing knowledge about structural causes of interpersonal firearm violence and suggest structural solutions are required to address this public health threat., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Police transport (PT) of penetrating trauma patients decreases the time between injury and trauma center arrival. Our study objective was to characterize trends in the rate of PT and its impact on mortality. We hypothesized that PT is increasing and that these patients are more injured., Methods: We conducted a single-center, retrospective cohort study of adult (≥18 years) patients presenting with gunshot wounds (GSWs) to a level 1 center from 2012 to 2018. Patients transported by police or ambulance (emergency medical service [EMS]) were included. The association between mode of transport (PT vs. EMS) and mortality was evaluated using χ2, t tests, Mann-Whitney U tests, and logistic regression., Results: Of 2,007 patients, there were 1,357 PT patients and 650 EMS patients. Overall in-hospital mortality was 23.7%. The rate of GSW patients arriving by PT increased from 48.9% to 78.5% over the study period (p < 0.001). Compared with EMS patients, PT patients were sicker on presentation with lower initial systolic blood pressure (98 vs. 110, p < 0.001), higher Injury Severity Score (median [interquartile range], 10 [2-75] vs. 9 [1-17]; p < 0.001) and more bullet wounds (3.5 vs. 2.9, p < 0.001). Police-transported patients more frequently underwent resuscitative thoracotomy (19.2% vs. 10.0%, p < 0.001) and immediate surgical exploration (31.3% vs. 22.6%, p < 0.001). There was no difference in adjusted in-hospital mortality between transport groups. Of patients surviving to discharge, PT patients had higher Injury Severity Score (9.6 vs. 8.3, p = 0.004) and lower systolic blood pressure on arrival (126 vs. 130, p = 0.013) than EMS patients., Conclusion: Police transport of GSW patients is increasing at our urban level 1 center. Compared with EMS patients, PT patients are more severely injured but have similar in-hospital mortality. Further study is necessary to understand the impact of PT on outcomes in specific subsets in penetrating trauma patients., Level of Evidence: Epidemiological, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

As left ventricular assist devices (LVADs) are increasingly used for patients with end-stage heart failure, the need for noncardiac surgical procedures (NCSs) in these patients will continue to rise. We examined the various types of NCS required and its outcomes in LVAD patients requiring NCS. The National Inpatient Sample Database was examined for all patients implanted with an LVAD from 2007 to 2010. Patients requiring NCS after LVAD implantation were compared to all other patients receiving an LVAD. There were 1,397 patients undergoing LVAD implantation. Of these, 298 (21.3%) required 459 NCS after LVAD implantation. There were 153 (33.3%) general surgery procedures, with abdominal/bowel procedures (n = 76, 16.6%) being most common. Thoracic (n = 141, 30.7%) and vascular (n = 140, 30.5%) procedures were also common. Patients requiring NCS developed more wound infections (9.1 vs. 4.6%, p = 0.004), greater bleeding complications (44.0 vs. 24.8%, p < 0.001) and were more likely to develop any complication (87.2 vs. 82.0%, p = 0.001). On multivariate analysis, the requirement of NCSs (odds ratio: 1.45, 95% confidence interval: 0.95-2.20, p = 0.08) was not associated with mortality. Noncardiac surgical procedures are commonly required after LVAD implantation, and the incidence of complications after NCS is high. This suggests that patients undergoing even low-risk NCS should be cared at centers with treating surgeons and LVAD specialists.

Background: Controversy remains over the ideal way to transport penetrating trauma victims in an urban environment. Both advance life support (ALS) and basic life support (BLS) transports are used in most urban centers., Methods: A retrospective cohort study was conducted at an urban Level I trauma center. Victims of penetrating trauma transported by ALS, BLS, or police from January 1, 2008, to November 31, 2013, were identified. Patient survival by mode of transport and by level of care received was analyzed using logistic regression., Results: During the study period, 1,490 penetrating trauma patients were transported by ALS (44.8%), BLS (15.6%), or police (39.6%) personnel. The majority of injuries were gunshot wounds (72.9% for ALS, 66.8% for BLS, 90% for police). Median transport minutes were significantly longer for ALS (16 minutes) than for BLS (14.5 minutes) transports (p = 0.012). After adjusting for transport time and Injury Severity Score (ISS), among victims with an ISS of 0 to 30, there was a 2.4-fold increased odds of death (95% confidence interval [CI], 1.3-4.4) if transported by ALS as compared with BLS. With an ISS of greater than 30, this relationship did not exist (odds ratio, 0.9; 95% CI, 0.3-2.7). When examined by type of care provided, patients with an ISS of 0 to 30 given ALS support were 3.7 times more likely to die than those who received BLS support (95% CI, 2.0-6.8). Among those with an ISS of greater than 30, no relationship was evident (odds ratio, 0.9; 95% CI, 0.3-2.7)., Conclusion: Among penetrating trauma victims with an ISS of 30 or lower, an increased odds of death was identified for those treated and/or transported by ALS personnel. For those with an ISS of greater than 30, no survival advantage was identified with ALS transport or care. Results suggest that rapid transport may be more important than increased interventions., Level of Evidence: Therapeutic study, level IV.

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.

This study examined outcomes in patients with left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO) requiring noncardiac surgical procedures and identified factors that influence outcomes. All patients with mechanical circulatory support (MCS) devices at our institution from 2002 to 2013 undergoing noncardiac surgical procedures were reviewed. There were 148 patients requiring MCS during the study period, with 40 (27.0%) requiring 62 noncardiac surgical procedures. Of these, 29 (72.5%) had implantable LVAD and 11 (27.5%) were supported with ECMO. The two groups were evenly matched with regard to age (53.6 vs. 54.5 years, p = 0.87), male sex (71.4 vs. 45.5%, p = 0.16), and baseline creatinine (1.55 vs. 1.43 mg/dl, p = 0.76). Patients on ECMO had greater demand for postoperative blood products (0.8 vs. 2.8 units of packed red blood cells, p = 0.002) and greater postoperative increase in creatinine (0.07 vs. 0.44 mg/dl, p = 0.047). Median survival was markedly worse in ECMO patients. Factors associated with mortality included ECMO support, history of biventricular assist device, and postoperative blood transfusion. Preoperative aspirin was associated with survival. These findings demonstrate the importance of careful surgical hemostasis and minimizing perioperative blood transfusions in patients on MCS undergoing noncardiac surgical procedures. In addition, low-dose antiplatelet therapy should be continued perioperatively.

Background: Many penetrating trauma patients in severe hemorrhagic shock receive positive pressure ventilation (PPV) upon transport to definitive care, either by intubation (INT) or bag-valve mask (BVM). Using a swine hemorrhagic shock model that simulates penetrating trauma, we proposed that severely injured patients may have better outcomes with "permissive hypoventilation," where manual breaths are not given and oxygen is administrated passively via face mask (FM). We hypothesized that PPV has harmful physiologic effects in severe low-flow states and that permissive hypoventilation would result in better outcomes., Methods: The carotid arteries of Yorkshire pigs were cannulated with a 14-gauge catheter. One group of animals (n = 6) was intubated and manually ventilated, a second received PPV via BVM (n = 7), and a third group received 100% oxygen via FM (n = 6). After placement of a Swan-Ganz catheter, the carotid catheters were opened, and the animals were exsanguinated. The primary end point was time until death. Secondary end points included central venous pressure, cardiac output, lactate levels, serum creatinine, CO2 levels, and pH measured in 10-minute intervals., Results: Average survival time in the FM group (50.0 minutes) was not different from the INT (51.1 minutes) and BVM groups (48.5 minutes) (p = 0.84). Central venous pressure was higher in the FM group as compared with the INT 10 minutes into the shock phase (8.3 mm Hg vs. 5.2 mm Hg, p = 0.04). Drop in cardiac output (p < 0.001) and increase in lactate (p < 0.05) was worse in both PPV groups throughout the shock phase. Creatinine levels were higher in both PPV groups (p = 0.04). The FM group was more hypercarbic and acidotic than the two PPV groups during the shock phase (p < 0.001)., Conclusion: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

Intubation in the prehospital setting does not result in a survival benefit in penetrating trauma. However, the effect of prehospital intubation (PHI) on the development of in-hospital complications has yet to be determined. The goal of this study was to determine if PHI in patients with penetrating trauma results in reduced mortality and in-hospital complications. Patient records for all Category 1 trauma activations as a result of penetrating injury admitted to our institution from 2006 to 2010 were reviewed. There were 1615 Category 1 trauma activations with 152 (9.8%) intubated in the field. A total of 1311 survived initial resuscitative efforts to permit hospital admission with 55 (4.2%) being intubated in the field. For patients surviving to admission, prehospital intubation was associated with increased mortality (hazard ratio, 8.266; 95% confidence interval [CI, 4.336 to 15.758; P < 0.001). After correcting for Injury Severity Score, PHI was not protective against pulmonary complications (odds ratio [OR], 0.724; 95% CI, 0.229 to 2.289; P = 0.582), deep vein thrombosis/pulmonary embolus (OR, 0.838; 95% CI, 0.281 to 2.494; P = 0.750), sepsis (OR, 0.572; 95% CI, 0.201 to 1.633; P = 0.297), wound infections (OR, 1.739; 95% CI, 0.630 to 4.782; P = 0.286), or complications of any kind (OR, 1.020; 95% CI, 0.480 to 2.166; P = 0.959). For victims of penetrating trauma, immediate transportation by emergency medical personnel may result in improved outcomes.

Objectives: We evaluated dobutamine stress echocardiography as an initial screening test for a cardiac evaluation before a liver transplant., Materials and Methods: We retrospectively examined 111 liver transplant candidates who had undergone previous cardiac evaluation; 30 of whom had undergone a liver transplant., Results: Eighty patients (72.1%) completed a dobutamine stress echocardiography (41 chronotropically competent, 39 incompetent), while 31 patients (27.9%) required us to terminate early. Overall, 68 patients (61%) were on β-blockers (21 required early dobutamine stress echocardiography termination, 30 chronotropically incompetent, and 17 competent). Patient results were normal. Thirty patients underwent a liver transplant. Among candidates requiring termination of early dobutamine stress echocardiography, posttransplant cardiac events included 1 fatal acute myocardial infarction, 1 nonfatal acute myocardial infarction, and 1 idiopathic cardiomyopathy. Among chronotropically incompetent patients, 2 patients had transient bradycardia, and among those who were chronotropically competent, 1 had refractory atrial fibrillation, and 1 had transient bradycardia., Conclusions: Nearly 50% of patients with end-stage liver disease may not reach the target heart rate. Early termination of dobutamine stress echocardiography because of cardiac symptoms or significant echocardiographic changes have more effect in predicting postoperative cardiac events, but further evaluation is required even if their target heart rate is close to that desired. Lower target heart rate may be acceptable in chronotropically incompetent individuals provided they are asymptomatic, have no echocardiographic changes, or cardiovascular risk factors, especially if they are on β-blockers.

Background: Prehospital intubation does not result in a survival advantage in patients experiencing penetrating trauma, yet resistance to immediate transportation to facilitate access to definitive care remains. An animal model was developed to determine whether intubation provides a survival advantage during severe hemorrhagic shock. We hypothesized that intubation would not provide a survival advantage in potentially lethal hemorrhage., Methods: After starting a propofol drip, Yorkshire pigs were intubated (n = 6) or given bag-valve mask ventilation (n = 7) using 100% oxygen. The carotid artery was cannulated with a 14-gauge catheter, and a Swan-Ganz catheter was placed under fluoroscopy using a central venous introducer. After obtaining baseline hemodynamic and laboratory data, the animals were exsanguinated through the carotid line until death. The primary end point was time until death, while secondary end points included volume of blood shed, temperature, cardiac index, mean arterial pressure, lactic acid, base excess, and creatinine levels measured in 10-minute intervals., Results: There was no difference in time until death between the two groups (51.1 [2.5] minutes vs. 48.5 [2.4] minutes, p = 0.52). Intubated animals had greater volume of blood shed at 30 minutes (33.6 [4.4] mL/kg vs. 28.5 [4.3] mL/kg, p = 0.03), 40 minutes (41.7 [4.7] mL/kg vs. 34.9 [3.8] mL/kg, p = 0.04), and 50 minutes (49.2 [8.6] mL/kg vs. 40.2 [1.0] mL/kg, p = 0.001). In addition, the intubated animals were more hypothermic at 40 minutes (35.5°C [0.4°C] vs. 36.7°C [0.2°C], p = 0.01) and had higher lactate levels (2.4 [0.1] mmol/L vs. 1.8 [0.4] mmol/L, p = 0.04) at 10 minutes. Cardiac index (p = 0.66), mean arterial pressure (p = 0.69), base excess (p = 0.14), and creatinine levels (p = 0.37) were not different throughout the shock phase., Conclusion: Intubation does not convey a survival advantage in this model of severe hemorrhagic shock. Furthermore, intubation in the setting of severe hemorrhagic shock may result in a more profuse hemorrhage, worse hypothermia, and higher lactate when compared with bag-valve mask ventilation.

Background: Predictors of hospital survival after emergency department thoracotomy (EDT) are well established, but little is known of long-term outcomes after hospital survival. Our primary study objective was to analyze the long-term social, cognitive, functional, and psychological outcomes in EDT survivors., Methods: Review of our Level I trauma center registry (2000-2010) revealed that 37 of 448 patients survived hospitalization after EDT. Demographics and clinical characteristics were analyzed. After attempts to contact survivors, 21 patients or caretakers were invited to an outpatient study evaluation; 16 were unreachable (none of whom were present in the Social Security Death Index). Study evaluation included demographic and social data and an outpatient multidisciplinary assessment with validated scoring instruments (Mini-Mental Status Exam, Glasgow Outcome Scores, Timed Get-Up and Go Test, Functional Independence Measure Scoring, SF-36 Health Survey, and civilian posttraumatic stress disorder checklist)., Results: After extended hospitalization (43 ± 41 days), disposition varied (home, 62%; rehabilitation, 32%; skilled nursing facility, 6%), but readmission was common (33%) in the 37 EDT hospital survivors. Of the 21 contacted, 16 completed the study evaluation, 2 had died, 1 remained in a comatose state, and 2 were available by telephone only. While unemployment (75%), daily alcohol (50%), and drug use (38%) were common, of the 16 patients who underwent the comprehensive, multidisciplinary outpatient assessment after a median of 59 months following EDT, 75% had normal cognition and returned to normal activities, 81% were freely mobile and functional, and 75% had no evidence of posttraumatic stress disorder upon outpatient screening., Conclusion: Despite the common belief that EDT survivors often live with severe neurologic or functional impairment, we have found that most of our sampled EDT survivors had no evidence of long-term impairment. It is our hope that these results are considered by physicians making life or death decisions regarding the "futility" of EDT in our most severely injured patients.

Background: Advanced Life Support (ALS) providers may perform more invasive prehospital procedures, while Basic Life Support (BLS) providers offer stabilisation care and often "scoop and run". We hypothesised that prehospital interventions by urban ALS providers prolong prehospital time and decrease survival in penetrating trauma victims., Study Design: We prospectively analysed 236 consecutive ambulance-transported, penetrating trauma patients an our urban Level-1 trauma centre (6/2008-12/2009). Inclusion criteria included ICU admission, length of stay >/=2 days, or in-hospital death. Demographics, clinical characteristics, and outcomes were compared between ALS and BLS patients. Single and multiple variable logistic regression analysis determined predictors of hospital survival., Results: Of 236 patients, 71% were transported by ALS and 29% by BLS. When ALS and BLS patients were compared, no differences in age, penetrating mechanism, scene GCS score, Injury Severity Score, or need for emergency surgery were detected (p>0.05). Patients transported by ALS units more often underwent prehospital interventions (97% vs. 17%; p<0.01), including endotracheal intubation, needle thoracostomy, cervical collar, IV placement, and crystalloid resuscitation. While ALS ambulance on-scene time was significantly longer than that of BLS (p<0.01), total prehospital time was not (p=0.98) despite these prehospital interventions (1.8 ± 1.0 per ALS patient vs. 0.2 ± 0.5 per BLS patient; p<0.01). Overall, 69.5% ALS patients and 88.4% of BLS patients (p<0.01) survived to hospital discharge., Conclusion: Prehospital resuscitative interventions by ALS units performed on penetrating trauma patients may lengthen on-scene time but do not significantly increase total prehospital time. Regardless, these interventions did not appear to benefit our rapidly transported, urban penetrating trauma patients., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Prehospital intubation does not appear to result in a survival advantage for patients experiencing penetrating trauma; yet, there is still resistance to the practice of "scoop and run" to speed access to advanced care. An animal model was used to determine whether intubation provides a survival advantage during potentially lethal hemorrhage., Methods: The carotid arteries of Sprague-Dawley rats were cannulated, and mean arterial pressure (MAP) was measured. One group of animals (n = 10) was intubated and placed on a ventilator, whereas the other (n = 9) was administered with 100% oxygen via nose cone. Rats were exsanguinated to a MAP of 40 mm Hg and then bled periodically to maintain a MAP between 40 mm Hg and 45 mm Hg. The primary end-point was time until death. Secondary end-points included lactic acid and base excess levels measured in blood collected at 30-minute intervals after inducing shock., Results: There was no significant difference in time until death between the intubated and nose cone groups (85.5 vs. 93.3 minutes, p = 0.60). Intubated animals had higher lactic acid levels at 90 minutes (6.1 vs. 3.5 mmol/L; p = 0.02) and 120 minutes (7.7 vs. 2.6 mmol/L, p = 0.03) after the initiation of shock. In addition, intubated animals had worse base excess at 90 minutes (-13.5 vs. -7.9 mmol/L, p = 0.04)., Conclusion: Intubation does not result in a survival advantage in this rat model of hemorrhagic shock. Positive pressure ventilation may cause decreased venous return and accentuate end-organ hypoperfusion. Large animal studies are needed to further investigate these findings.

Background: Few data exist regarding payer status as a predictor of outcomes in penetrating trauma. This study determined whether insurance status impacts in-hospital complications and mortality in gunshot and stab wound patients at our inner-city, level I trauma center., Methods: Penetrating trauma admissions from 2005 to 2009 were reviewed for patient demographics, insurance, Injury Severity Score, complications, duration of stay, and mortality., Results: A total of 1,347 penetrating trauma patients were admitted with 652 (48.4%) uninsured. Although uninsured patients were more likely to be male (93.3% vs 89.8%, P = .030), there was no difference in age, ISS, or number of radiologic, operative, or interventional procedures. Uninsured patients had lesser intensive care unit (4.4 vs 3.3 days; P = .049) and total hospital length of stay (10.2 vs 8.3; P = .049). No uninsured patients were placed into a rehabilitation facility at the time of discharge (0.0% vs 1.6%, P < .001). There was no difference in frequency of pulmonary complications, thromboembolic complications, sepsis, urinary tract infection, or wound infections. On multivariate analysis, being uninsured was not an independent predictor of in-hospital complications (1.010, 95% confidence interval 0.703-1.450, P = .959) or mortality (odds ratio 0.905, 95% confidence interval 0.523-1.566, P = .722)., Conclusion: This is the first study to show that penetrating trauma patients who are uninsured have lesser duration of stay and decreased placement into a rehabilitation facility. Being uninsured added no additional risk of in-hospital complications or mortality., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Despite limited prospective data, it is commonly believed that human immunodeficiency virus (HIV) and hepatitis infections are widespread in the penetrating trauma population, placing healthcare workers at risk for occupational exposure. Our primary study objective was to measure the prevalence of HIV (anti-HIV), hepatitis B (HB surface antigen [HBsAg]), and hepatitis C virus (anti-HCV) in our penetrating trauma population., Methods: We prospectively analyzed penetrating trauma patients admitted to Temple University Hospital between August 2008 and February 2010. Patients (n = 341) were tested with an oral swab for anti-HIV and serum evaluated for HBsAg and anti-HCV. Positives were confirmed with western blot, neutralization immunoassay, and reverse transcription polymerase chain reaction, respectively. Demographics, risk factors, and clinical characteristics were analyzed., Results: Of 341 patients, 4 patients (1.2%) tested positive for anti-HIV and 2 had a positive HBsAg (0.6%). Hepatitis C was the most prevalent measured infection as anti-HCV was detected in 26 (7.6%) patients. Overall, 32 (9.4%) patients were tested positive for anti-HIV, HBsAg, or anti-HCV. Twenty-eight (75%) of these patients who tested positive were undiagnosed before study enrollment. When potential risk factors were analyzed, age (odds ratio, 1.07, p = 0.031) and intravenous drug use (odds ratio 14.4, p < 0.001) independently increased the likelihood of anti-HIV, HBsAg, or anti-HCV-positive markers., Conclusions: Greater than 9% of our penetrating trauma study population tested positive for anti-HIV, HBsAg, or anti-HCV although patients were infrequently aware of their seropositive status. As penetrating trauma victims frequently require expedient, invasive procedures, universal precautions are essential. The prevalence of undiagnosed HIV and hepatitis in penetrating trauma victims provides an important opportunity for education, screening, and earlier treatment of this high-risk population.

Background: Although the Child-Turcotte-Pugh (CTP) score is an established outcome prediction tool for patients with liver disease, the Model for End-Stage Liver Disease (MELD) score has recently supplanted CTP for patients awaiting transplantation. Currently, data regarding the use of CTP in trauma is limited, whereas MELD remains unstudied. We compared MELD and CTP to determine which scoring system is a better clinical outcome predictor after trauma., Methods: A review of trauma admissions during 2003-2008 revealed 68 patients with chronic liver disease. Single and multiple variable analyses determined predictors of hepatic complications and survival. MELD and CTP were compared using odds ratios and area under the receiver operating curve (AUC) analyses. A p value ≤0.05 was significant., Results: The mean MELD and CTP scores of the population were 13.1 ± 6.0 and 8.3 ± 1.8, respectively (mean ± SD). Overall, 73.5% had one or more complications and 29.4% died. When survivors were compared with nonsurvivors, no difference in mean MELD scores was found, although mean CTP score (survivors, 7.7 ± 1.5; nonsurvivors, 9.4 ± 1.9; p = 0.001) and class ("C" survivors, 12.1%; "C" nonsurvivors, 56.3%; p = 0.002) were different, with survival relating to liver disease severity. Odds ratios and AUC determined that MELD was not predictive of hepatic complications or hospital survival (p > 0.05), although both CTP score and class were predictive (p < 0.05; AUC > 0.70)., Conclusion: Trauma patients suffering from cirrhosis can be expected to have poorer than predicted outcomes using traditional trauma scoring systems, regardless of injury severity. Scoring systems for chronic liver disease offer a more effective alternative. We compared two scoring systems, MELD and CTP, and determined that CTP was the better predictor of hepatic complications and survival in our study population.

Background: Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage., Methods: A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival., Results: The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days)., Conclusions: Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Objectives: We sought to determine whether the performance of pyloric exclusion during repair of penetrating advanced duodenal injuries prevents postoperative duodenal fistulas and improves clinical outcome., Methods: A retrospective chart review of patients from 1995 to 2004 with penetrating duodenal injuries >or=grade II and all combined pancreaticoduodenal injuries was performed. Patients managed either without or with pyloric exclusion were compared on the basis of age, sex, mechanism, injury grade, Injury Severity Score (ISS), hemodynamic stability, the presence of vascular injury or associated injuries, postoperative complications, length of hospital stay, and mortality., Results: Fifteen of 29 patients were managed without pyloric exclusion and 14 with exclusion. Both groups were similar with respect to age, sex, mechanism, injury grade, ISS, hemodynamic stability, the presence of vascular injury, associated abdominal injuries, and mortality rates. A trend toward a higher overall complication rate (71% vs. 33%), pancreatic fistula rate (40% vs. 0%), and length of hospital stay (24.3 days vs. 13.5 days) was evident in the pyloric exclusion group. No duodenal fistula was detected in either patient group., Conclusion: In our study population, the performance of pyloric exclusion for penetrating advanced duodenal injury and combined pancreatic and duodenal injuries did not improve clinical outcome. The trend toward a greater overall complication rate, pancreatic fistula rate, and increased length of hospital stay in the pyloric exclusion group suggests that simple repair without pyloric exclusion is both adequate and safe for most penetrating duodenal injuries.

Trauma care during a disaster may require unusual or unique approaches. The Medical College of Pennsylvania Hospital has developed a physician field response team designed to respond to mass casualty incidents. The team has been mobilized on multiple occasions and its approach refined with each experience. The process of developing a team is presented along with "lessons learned" during the 15 years the team has been in use.

TraumAID is a computer-based decision aid that uses decision rules and logical deduction to generate management plans for the initial definitive management of injured patients; its use is currently confined to assessing penetrating thoracoabdominal injuries in nonpregnant adults. These management plans were compared to trauma center care in an American urban medical school hospital. The TraumAID program was available to trauma chief residents for patient care during the "golden hour." Resulting changes in plans were documented by the residents. For 15 months the management plans for all applicable patients were documented serially, as were computer plans and outcomes. The sequential care and computer-generated care plans were then blinded and judged by three other trauma surgeons as to acceptability and preference. A consecutive series of 97 patients was evaluated. The residents used the computer for 40 cases during patient care. In 5 of the 40 cases, they altered their evaluation, diagnosis, or treatment; in none of these 5 was the alteration judged an error. Of the 97 patients, 10 had adverse outcomes, 2 of which were judged potentially avoidable, with unacceptable errors in management. TraumAID's plans were acceptable for both. In 31 cases previously managed by the judges themselves, the TraumAID plans were preferred by the judge to the care he or she had provided, by a ratio of 25:6 (p < 0.01). In a preliminary assessment, computer-generated, patient-specific protocols for the acute management of injuries were preferred to actual care previously given by the judges themselves and were associated with improved care and potential improvement in outcome.

Objective: To determine whether physical examination alone or in combination with biochemical markers can accurately diagnose hypoperfusion., Methods: Data from 264 consecutive surgical intensive care unit patients were collected by two intensivists and included extremity temperature, vital signs, arterial lactate, arterial blood gases, hemoglobin, and pulmonary artery catheter values with derived indices. Days of data were divided into data collected from patients with cool extremities (cool skin temperature [CST] group) versus warm extremities (warm skin temperature [WST] group). Values are means +/- SD. Comparisons between groups were made by two-tailed unpaired t test; significance was assumed for p < or = 0.05., Results: There were 328 days of observations in the CST group versus 439 in the WST group. There were no differences (p > 0.05) between CST and WST data with regard to heart rate (107 +/- 14 vs. 99 +/- 19 beats/min), systolic blood pressure (118 +/- 24 vs. 127 +/- 28 mm Hg), diastolic blood pressure (57 +/- 14 vs. 62 +/- 15 mm Hg), pulmonary artery occlusion pressure (14 +/- 6 vs. 16 +/- 5 mm Hg), Fio2 (0.48 +/- 0.7 vs. 0.45 +/- 0.2), hemoglobin (8.8 +/- 1.6 vs. 9.3 +/- 1.3 g/dL), Pco2 (44.3 +/- 11.8 vs. 40.7 +/- 9.2 mm Hg), or Po2 (96.4 +/- 12.6 vs. 103.8 +/- 22.2 mm Hg). However, cardiac output (5.3 +/- 2.2 vs. 8.2 +/- 2.6 L/min), cardiac index (2.9 +/- 1.2 vs. 4.3 +/- 1.2 L/min/m2), pH (7.32 +/- 0.2 vs. 7.39 +/- 0.07), TCO2 (19.5 +/- 3.1 vs. 25.1 +/- 4.8 mEq/L), and Svo2 (60.2 +/- 4.4% vs. 68.2 +/- 7.8%) were all significantly lower (p < 0.05) in CST patients compared with WST patients. By comparison, lactate (4.7 +/- 1.5 vs. 2.2 +/- 1.6 mmol/L, p < 0.05) was significantly elevated in patients with cool extremities., Conclusion: Combining physical examination with serum bicarbonate and arterial lactate identifies patients with hypoperfusion as defined by low Svo2 and cardiac index. Hypoperfusion may occur despite supranormal cardiac indices. Patients with cool extremities and elevated lactate levels may benefit from a pulmonary artery catheter to guide but not initiate therapy.

Objective: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome., Methods: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection., Results: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning., Conclusions: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

Aortoesophageal fistula (AEF) is an uncommon cause of upper gastrointestinal hemorrhage. Usually, but not always, patients present with a small sentinel bleed followed by a variable interval of apparent resolution, and then they experience a massive exsanguinating hemorrhage. The variable interval of time after the sentinel bleed is the period in which most AEFs resulting from thoracic aortic aneurysm have been successfully treated. Although only a few successful cases have been reported in the literature, most describe an in situ repair. We describe treatment of a late-presenting AEF due to a thoracic aneurysm with an extra-anatomic bypass graft for the aortic repair.

This pilot study was carried out to determine whether converting from a two-tier to a three-tier in-hospital trauma triage system improves the efficiency of emergency department (ED) care and minimizes inappropriate triage. Patients at an urban, Level 1 trauma centre were triaged using either a two-tier (months 1-3; n = 197) or three-tier (months 4-6; n = 240) trauma response system. Patients were assessed for triage type, age, sex, injury severity score, Glasgow coma score, post-ED disposition, total ED time, survival, complication rate, probability of survival and unexpected death. Comparisons were made by ANOVA table analysis; significance was assumed for p < 0.05. Two-tier (n = 197) and three-tier patients (n = 240) were matched with respect to mean age, sex, mean injury severity score, mean Glasgow coma score, post-ED disposition, survival and probability of survival. Two-tier patients were triaged to give 20% alerts [criteria = physiological derangement (PD) and/or injury mechanism (MOI)] and 80% consults; three-tier patients were triaged as 20% category I (criteria = PD), 18% category II (criteria = MOI) and 62% consults. Total ED time decreased from two-tier (3.98 +/- 2.81 h) to three-tier triage (3.53 +/- 2.14 h, p = 0.001). There was no difference between two-tier alert and three-tier category I times (2.09 +/- 1.64 vs. 1.95 +/- 1.75 h; p = 0.72). Category II patients (3.28 +/- 1.98 h; p = 0.009) spent less time in the ED than did two-tier consults (4.36 +/- 2.65 h). The mean ED three-tier consult time significantly decreased as well (3.95 +/- 2.42 h, p = 0.008 vs. two-tier consult). Complications per patient were unchanged from two-tier to three-tier triage (0.17 +/- 0.52 vs. 0.12 +/- 0.48; p = 0.15). Under-triage (5%) and over-triage (7.5%) were minimal under three-tier triage. It is concluded that using a three-tier triage system results in an increase in the early involvement of the trauma service while decreasing emergency department time and minimizing over-triage.

Purpose: To establish computed tomographic (CT) criteria for the diagnosis of necrotizing fasciitis., Materials and Methods: Twenty CT scans in 20 patients with pathologically proved necrotizing fasciitis were reviewed retrospectively for fascial thickening, fat infiltration, focal fluid collection, soft-tissue gas, muscle involvement, and intra-abdominal extension; the findings were correlated with clinical factors, including associated illnesses, disease site, treatment, and outcome., Results: Average patient age was 57.8 years; there were 13 men and seven women. Four patients (20%) died. Asymmetric fascial thickening and fat stranding were seen in 16 patients (80%). Gas tracking along fascial planes was present in 11 patients (55%), and abscesses were found in seven patients (35%). Infection sites were scrotum (n = 6), a lower extremity (n = 4), perineum (n = 4), neck (n = 2), back (n = 2), arm (n = 1), and abdomen (n = 1). Underlying illness (n = 17) was diabetes in 10 patients (50%), alcoholism in three (15%), chronic renal failure in two (10%), and drug abuse in two (10%)., Conclusion: CT criteria of asymmetric fascial thickening and gas are valuable in assessing suspected necrotizing fasciitis. CT also can provide information on coexistent deep collections.

The TraumAID system has been designed to provide on-line decision support throughout the initial definitive management of injured patients. Here we describe its retrospective evaluation and the use we subsequently made of judges comments on the validation data to evaluate TraumaTIQ, a new critiquing interface for TraumAID, investigating the question of whether, with timely recording of information, a system could produce commentary in line with that of human experts. Our results show that (1) comparable commentary can be produced, and (2) validation studies, which take great time and effort to conduct, can produce useful data beyond their original design goals.

Thoracic trauma victims commonly sustain visceral pleural injury with resultant pneumothorax. These injuries usually respond to standard tube thoracostomy decompression and drainage. However, a subset of these patients develop recurrent and/or loculated pneumothoraces or pneumatoceles that are not readily accessible by tube thoracostomy. Percutaneous catheter drainage of these collections provides a safe and reliable method of management in critically ill patients.

A novel strategy using videotape recordings of initial trauma resuscitations was incorporated into the quality assurance program at a level 1 trauma center. Described are the process of taping the resuscitations, the multidisciplinary nature of the resuscitation team, the security measures taken to assure patient confidentiality, and the review process involved. The videotape review process was incorporated into a multidisciplinary educational trauma conference. The videotapes were used to evaluate the adherence to Advanced Trauma Life Support (ATLS) resuscitation protocols. Resident performance in six aspects of the ATLS resuscitation process were specifically highlighted on each videotape and graded for adherence to preestablished standards. The videotape process allowed an unblased, indisputable accurate documentation of the sequential application of the protocols of evaluation and resuscitation espoused in the ATLS course. We found 23% overall deviation from ATLS resuscitation principles, with at least one aspect of the resuscitation deviating from expected ATLS performance in 64% of the patients. In addition to documenting adherence to ATLS principles, this study illustrated the impact of the videotape review process on the education of eight senior residents in surgery.

After sacrectomy, a hernial defect may develop through the pelvic floor at the reconstructed sacral bed. This complication has not previously been described. We describe a technique for repair of such a defect using a prosthetic patch. Accurate and safe repair of this hernia requires correct preoperative diagnosis and planning, including a thorough knowledge of pelvic floor anatomy.

Background: Thirty-two percent dextran-70 in 10% dextrose is a useful distention medium for hysteroscopic surgery. However, the side effects profile is considerable., Case Report: A young woman underwent hysteroscopic evaluation for menorrhagia. Postoperatively, she suffered severe noncardiogenic pulmonary edema, disseminated intravascular coagulopathy and acute anuric renal failure., Conclusion: Precautions must be taken when using 32% dextran-70 in 10% dextrose to avoid its potentially life-threatening complications.

Presented is a case of a thoracic gunshot wound resulting in descending thoracic aortic and biventricular cardiac injuries. Successful management of these wounds allowed the development of an unusual and previously undescribed complication of thoracic trauma--thoracic compartment syndrome. The clinical features, therapy, and potential sequelae of thoracic compartment syndrome are presented with a review of the literature.

We present a patient who developed a gastric bezoar following extensive penetrating abdominal trauma. Bezoar pathogenesis, diagnosis, and endoscopic therapy are highlighted. Additionally, alternative therapeutic modalities are explored with a review of the literature. Combination endoscopic lavage fragmentation/extraction presents a safe method of bezoar resolution.

An aspirated gold crown could not be removed with standard instruments. The crown was successfully grasped and removed with a large biopsy forceps commonly used in the performance of laparoscopic cholecystectomy.

The case of a 38-year-old woman who was struck by an automobile is presented. The workup for lower extremity injuries revealed stationary arterial waves. Recognition of this arteriographic finding may avoid unnecessary confusion or exploration.

Injuries among the elderly are a common occurrence and, as the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly sustain the same injuries that younger people do; however, because of a variety of age-related processes, the elderly suffer more severe consequences from these injuries. Epidemiologic factors and physiologic processes are used to explain the "susceptibility" of the elderly population to traumatic injuries. Recommendations for initial resuscitation and management of specific injuries are presented along with general principles of injury prevention and rehabilitation. The socioeconomic cost of trauma in the elderly is discussed in terms of physical disabilities and financial burdens.

Incisional hernias are a relatively common occurrence after abdominal operations, having been reported to occur in 2% to 11% of all patients undergoing such procedures. Although many hernias become manifest early, others may not be noted until many years after the index procedure. Predisposing factors for incisional hernia have been well described, and several of these can be altered by the surgeon, including the technique employed for repair. For many years, the repair of incisional hernia was associated with a high recurrence rate. In more recent years, the introduction of synthetic prosthetic materials has provided the opportunity to perform a tension-free repair, thereby reducing the rate of recurrence.

Sinusitis is an important cause of sepsis in the critically ill patient and may be difficult to diagnose. Four patients admitted to the surgical intensive care unit with closed head trauma were found to have sinusitis as the cause of persistent bacteremia. All patients received pharmacologic doses of corticosteroids for treatment of head injury and had prolonged nasotracheal and/or nasogastric intubation. A bedside procedure was used for diagnosis and management. Under local anesthesia, a 16-gauge angiocatheter was inserted under the inferior turbinate and into the maxillary sinus. After purulent fluid was aspirated, the sinuses were irrigated with normal saline. All four patients defervesced within 24 to 48 hours of this procedure, and facial x rays demonstrated clearing of the maxillary sinus. It was concluded that: 1) Sinusitis is a complication of closed head trauma in critically ill patients and should be included in the differential diagnosis when persistent bacteremia occurs; 2) The use of corticosteroids in the treatment of head injury may increase the risk of sinus infection; 3) Facial x rays showing air-fluid levels and/or opacification are a valuable screening test for paranasal sinusitis; and 4) bedside aspiration of the maxillary sinus is an effective diagnostic and therapeutic technique for management of sinusitis in the critically ill.