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Background The combination of traumatic simultaneous diaphragmatic rupture and chest wall herniation remains rare, with 42 cases of traumatic transdiaphragmatic intercostal hernia (TDIH) reported in the literature since 1946. An accurate count of cases is difficult to obtain, as TDIH nomenclature has been variable. 1 - 5 Risk factors for traumatic TDIH are not well established. As these injuries are uncommon, best management techniques have yet to be established. Reported repair techniques include primary closure, closure with mesh, and implantation of prosthetic or autologous material. We present our single-center series of 7 patients, the largest reported to our knowledge, and discuss the challenges of repairing these difficult injuries. Methods After obtaining institutional review board approval, data were abstracted from the electronic medical record on all adults who underwent evaluation and treatment for traumatic TDIH between July 2014 and January 2019. Results Of the 7 cases of traumatic TDIH, 6 patients developed TDIH secondary to cough; the seventh patient presented with chronic chest wall pain after an episode of heavy lifting. All patients were obese or overweight. Pain and a “popping sensation” were the most common presenting symptoms. All patients underwent operative intervention with primary repair of the diaphragm and suture approximation of the ribs. 3 patients had onlay mesh repair of the chest wall and/or abdominal wall. 1 patient had plating of his rib fracture. 3 patients had a recurrence of the intercostal portion of the hernia No patients have undergone reoperation thus far. Discussion While previously thought to more commonly occur on the left side due to the protective effects of the diaphragm, 2 the majority in this series had right-sided injuries. Herniation through the ninth-10th interspace remains the most common location. 4 Computed tomography imaging should be used for diagnosis and operative planning. It is best to manage these hernias acutely to re-establish normal anatomy. Mesh may be required in delayed reconstructions of if the chest wall cannot be re-approximated. Rib plating should be considered in cases of instability or flail. High rates of complications are not unexpected given the complicated and rare nature of the injury. Given the high rate of intercostal hernia recurrence, it is likely that mesh repair or should be more often used in the treatment of this injury.

Background School violence continues to afflict our educational institutions. In response, an institutional initiative was launched to train educators and school support staff in life-saving skills aimed at hemorrhage control. Methods The American College of Surgeons Committee on Trauma “Stop the Bleed” (STB) Program was promoted as a quality improvement initiative to schools within the geographic catchment area of this Level I Trauma Center. Participants were given the opportunity to take precourse, and postcourse confidence inventories using a Likert Scale. Statistical analysis of the 324 precourse to postcourse evaluations measuring change in confidence was used to evaluate improvement in readiness of school systems to respond in mass casualty incidents. Results Students enrolled in the STB Program were offered the opportunity to assess their confidence precourse and postcourse in reference to 7 questions. Precourse and postcourse Likert Scale inventories were compared and analyzed to assess the strength of the improvement in confidence using Student’s t-test, where P < .05 is statistically significant. Students demonstrated improvement ( P < .006) that was statistically significant across all 7-question relating to enhance confidence postcourse compared with the precourse. Discussion This STB quality initiative has demonstrated a statistically significant improvement in the confidence of teachers and school personnel to render lifesaving care in the event of a mass casualty or isolated incident of life-threatening hemorrhage. These results support the validity of the training in making a difference in this subpopulation of responders.

Management of craniofacial injuries typically defaults to plastic, ophthalmology, and oral maxillofacial surgeons which can challenge these surgical subspecialists’ capacity to care for both trauma victims and non-trauma patients. Evaluating the need to transfer patients to a higher level of trauma care for isolated craniofacial injuries warrants investigation. Our 5-year retrospective study measured the frequency of craniofacial injuries and subsequent surgical interventions in elderly trauma patients’ ≥65 years old. Eighty-one percent of patients consulted with plastic surgeons and 28% with ophthalmology. Twenty percent had craniofacial surgery with the majority of surgical interventions were in soft tissue (97%), mandible (48%), and Le Fort III (29%) injuries. A patient’s ISS, GCS, head and face AIS, and presents of spinal or brain injury had no statistically significant impact on injury repair. Elderly patients with isolated craniofacial trauma may be better served by pretransfer consultation with a surgical subspecialist to determine the necessity.

Background In rural state trauma systems, management of the obstetrical trauma patient often defaults to transfer to level I trauma centers. We evaluate the necessity of transferring obstetrical trauma patients without severe maternal injury. Materials and Methods A retrospective 5-year review of obstetrical trauma patients admitted to a rural state-level I trauma center was conducted. Injury severity measures such as abdominal AIS, ISS, and GCS were correlated with outcomes. Furthermore, the impact of maternal and gestational age on uterine compromise, uterine irritability, and the need for cesarean section intervention are presented. Results Twenty-one percent of patients were transferred from outside facilities with a median age of 29 years, average ISS of 3.9 ± 5.6, GCS of 13.8 ± 3.6, and abdominal AIS of 1.6 ± .8. Outcomes included maternal fatality of 2%, fetal demise of 4%, 6% experienced premature rupture of membranes, 9% experienced fetal placental compromise, 15% had uterine contractions, 15% of cesarean deliveries, and fetal decelerations occurred in 4%. Predictors of fetal compromise are strongly associated with high maternal ISS and low GCS. Discussion The frequency of traumatic injury in this unique population of patients is fortunately limited. The best predictor for fetal demise and uterine irritability is maternal injury severity, measured by ISS and GCS. Therefore, without severe maternal trauma, obstetrical trauma patients with minor injuries can safely be managed at non-tertiary care facilities with obstetrical capabilities.

BackgroundMuch has been written from the social science perspective surrounding surgeons’ stress and burn out. The literature is sparse in reference to scientific investigations of the hemodynamic effect of that stress. This prospective clinical study quantifies the physiologic impact of performing surgery upon the acute care surgeon.MethodsOver 2.5 years, monitoring devices were affixed to surgeons prior to entering the operating room, and physiologic variables were documented every 30 minutes. Qualifying cases were projected as being greater than 2 hours with a baseline preoperative measurement obtained. Variables recorded included blood pressure (BP), heart rate (HR), rate pressure product (RPP), oxygen saturation (O2sat), and end-tidal carbon dioxide (ET CO2).ResultsStatistically significant differences ( P < .05) were found between baseline data to the maximum recording during the surgical operation for: BP (min 101 ± 6.6 (mmHg)-max 117 ± 5.1 (mmHg)), HR (min 70.5 ± 6.2 (bpm)-max 83.7 ± 9.0 (bpm)), O2sat (min 97 ± 2.0 (%)-max 100 ± 0.22(%)), and ET CO2(min 34.1 ± 1.15 mmHg-max 38 ± 1.7 mmHg) ( P < .0001). The RPP ranged from 10.49 mmHg/min to 15.88 mmHg/min with a mean of 14.00 mmHg/min.DiscussionThe practice of surgery is considered demanding in training and lifestyle in comparison to other medical specialties. This data is among the first to demonstrate the negative physiological impact of surgery upon the metabolic demand of the surgeon. The longitudinal implications of increased physiologic demand over time may have cardiovascular and cerebrovascular consequences.

The aim of the study was to quantify nutritional losses related to pre- and postoperative fasts in critically ill intubated patients and to explore whether shorter fasts are safe and appropriate in this population. A retrospective review of mechanically ventilated adults undergoing surgery more than 24 hours after admission to a Level I trauma center over 15 months was done, which yielded 132 procedures and 81 unique patients. Ninety per cent of preoperative periods and 43 per cent of postoperative periods were affected by nonmedical barriers to feeding. Eighty-two per cent of gastrically fed nonemergent cases were fasted for longer than the 6-hour American Society of Anesthesiologists guideline, whereas 91 per cent of emergent cases had shorter fasts. There were no anesthetic complications, placing an upper limit of 6 per cent on the rate of aspiration for fasts shorter than six hours (95% confidence). Forty-three per cent of cases did not resume tube feeds within 90 minutes postoperatively, and only 37 per cent had a documented justification for delay. Intubated patients were frequently fasted preoperatively for longer than recommended and postoperatively for longer than medically indicated. No complications were observed with shorter-than-guideline fasts. This strengthens the evidence that “standard” preoperative fasting is unnecessary and deleterious in many critically ill intubated patients. New protocols and national guidelines are needed to ensure adequate nutrition.

Background Clavicle fractures historically have been managed without internal fixation. Current literature is raising questions regarding this management as opposed to offering operative fixation in some instances. This study addresses the use of the Disabilities of the Arm, Shoulder and Hand (DASH) outcomes measure to identify those that have the least satisfaction with nonoperative care of the clavicle fracture based upon clavicular deformity and variation in fracture location based upon Allman Classification. Methods Patients having suffered clavicle fractures were mailed the DASH Outcomes Questionnaire to be completed and returned. A total of 113 surveys were returned completed with 92 being of value for evaluation. Patient chest or clavicle radiographs were evaluated, and measurements were made of the clavicle fractures for amount of separation or shortening and grade according to Allman Classification. Statistical evaluation compared DASH Scores (patient satisfaction as outcome measure) to the Allman Classification and the degree of separation or shortening. Comparison of categorical variables was performed using Fisher's exact test. Comparison of continuous variables was preformed using Student's t test. Statistical significance was demonstrated by a p value of less than 0.05. Results Patients with clavicular shortening of greater than 2 cm were found to have the highest DASH score indicating dissatisfaction and disability with their outcome postinjury (p = 0.0001). Separation or lengthening seemed to be associated with lower DASH Scores. Patients with Allmen Classification I (midshaft clavicle) fractures had higher DASH score than other fracture locations (p = 0.0001). Conclusions Patients with midshaft clavicle fractures with shortening of greater than 2 cm may be good candidates for operative repair given the degree of dissatisfaction with nonoperative management of these fractures as assessed by long-term outcome measures of disability.

Terrorists' use of explosive, biologic, chemical, and nuclear agents constitutes the potential for catastrophic events. Understanding the unique aspects of these agents can help in preparing for such disasters with the intent of mitigating injury and loss of life. Explosive agents continue to be the most common weapons of terrorists and the most prevalent cause of injuries and fatalities. Knowledge of blast pathomechanics and patterns of injury allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents, their attendant clinical symptoms, and recommended management strategies is an important prerequisite for optimal preparation and response to these less frequently used agents of mass casualty. Orthopaedic surgeons should be aware of the principles of management of catastrophic events. Stress is less an issue when one is adequately prepared. Decontamination is essential both to manage victims and prevent further spread of toxic agents to first responders and medical personnel. It is important to assess the risk of potential threats, thereby allowing disaster planning and preparation to be proportional and aligned with the actual casualty event.

The Accreditation Council for Graduate Medical Education imposed 80-hour work week constraints on residency programs in July 2003. Certain programs were granted an additional 10 per cent for specific educational purposes, bringing restrictions to 88 hours per week. The increased demand for residents to leave the hospital has placed teaching institutions in exhaustive situations to provide comprehensive patient care. In response to the work hour constraints among residents and emergency room staff, a unique group of registered nurses, trauma nurse specialists (TNSs), were credentialed with advanced practice skill sets. Governed by practice guidelines and overseen by a medical director, TNSs perform invasive procedures that are normally the responsibility of the surgical resident. The purpose of this study was to evaluate work hours saved for surgery residents using credentialed nurses (TNSs). Procedure logs were maintained by the TNSs over a 6-month period, and surgical house staff (postgraduate year 1–3) over a 4-month period. A total of 423 procedures were recorded, reflecting time taken for attempted/completed procedures and complications. Resident procedures numbered 98; TNS procedures numbered 325. TNSs spent an average of 42 hours per month (10.6 hours per week) completing advanced procedures with no statistical difference in time or complications compared with surgical residents. By using the TNSs, work hours for surgery residents were saved while maintaining a safe and reliable work atmosphere for patients.

Objective: The goal of this survey was to establish a benchmark for trauma surgeons' level of operational understanding of the command structure for a prehospital incident, a mass casualty incident (MCI), and weapons of mass destruction (WMD). The survey was distributed before the World Trade Center destruction on September 11, 2001. Methods: The survey was developed by the authors and reviewed by a statistician for clarity and performance. The survey was sent to the membership of the 2000 Eastern Association for the Surgery of Trauma spring mailing, with two subsequent mailings and a final sampling at the Eastern Association for the Surgery of Trauma 2001 meeting. Of 723 surveys mailed, 243 were returned and statistically analyzed (significance indicated by p < 0.05). Results: No statistical difference existed between level of designation of a trauma center (state or American College of Surgeons) and a facility's level of preparedness for MCIs or WMD. Physicians in communities with chemical plants, railways, and waterway traffic were statistically more likely to work at facilities with internal disaster plans addressing chemical and biological threats. Across all variables, physicians with military training were significantly better prepared for response to catastrophic events. With the exception of cyanide (50%), less than 30% of the membership was prepared to manage exposure to a nerve agent, less than 50% was prepared to manage illness from intentional biological exposure, and only 73% understood and were prepared to manage blast injury. Mobile medical response teams were present in 46% of the respondents' facilities, but only 30% of those teams deployed a trauma surgeon. Approximately 70% of the membership had been involved in an MCI, although only 60% understood the command structure for a prehospital incident. Only 33% of the membership had training regarding hazardous materials. Of interest, 76% and 65%, respectively, felt that education about MCIs and WMD should be included in residency training. Conclusion: A facility's level of preparedness for MCIs or WMD was not related to level of designation as a trauma center, but may be positively influenced by local physicians with prior military background. Benchmark information from this survey will provide the architecture for the development and implementation of further training in these areas for trauma surgeons.

Lower extremity fractures (LEFx) and pelvic fractures (PFx) are believed to increase the risk of lower extremity deep vein thrombosis (LEDVT). We studied trauma patients at high risk for LEDVT to determine whether an increased incidence of LEDVT was associated with LEFx and/or PFx. From January 1995 through December 1997 4163 trauma patients were admitted to our Level I trauma center. One thousand ninety-three patients at high risk for LEDVT were screened with serial lower extremity venous duplex ultrasound. Their medical records were retrospectively reviewed for demographics, mechanism of injury, and fracture data. The occurrence of LEDVT, pulmonary embolus, and LEDVT prophylaxis and treatment were noted. The incidence of LEDVT in the fracture group (Fx) was compared with that in the nonfracture group (NFx) using chi-square analysis and logistic regression. Statistical significance was set at ≤0.05. Complete data were available for 1059 of 1093 patients. Five hundred sixty-nine (53.73%) patients had PFx and/or LEFx, 151 (14.26%) patients had PFx only, 317 (29.3%) patients had LEFx only, and 101 (9.54%) patients had both PFx and LEFx. Four hundred ninety (46.27%) patients had NFx. In 1059 patients LEDVT was detected in 125 (11.8%). Sixty-three patients in the Fx groups developed LEDVT (50.4%): 19 (15.2%) PFx patients, 15 (12.0%) PFx/LEFx patients, and 29 (23.2%) LEFx patients. Sixty-two (49.6%) NFx patients developed LEDVT. LEDVT incidence was not significantly different between the Fx and NFx groups or among the PFx, LEFx, and PFx/LEFx groups ( P = 0.317). Nine patients developed pulmonary embolism: four NFx patients, two LEFx patients, two PFx patients, and one PFx/LEFx patient. Significant predictors of LEDVT were age and hospital length of stay. Mean age in patients with LEDVT was 47.58 years and in patients without LEDVT it was 40.89 years ( P < 0.001). Mean hospital length of stay in patients with LEDVT was 29.81 days and in patients without LEDVT it was 16.84 days. The power of this study to detect differences representing medium effect sizes was greater than 90 per cent. We conclude that LEFx and/or PFx was not associated with an increased incidence of LEDVT in trauma patients at high risk for LEDVT. Lower extremity venous duplex ultrasound needs to be performed in both Fx and NFx groups to detect LEDVTs.

Background: Acute spinal cord injury (SCI) is a devastating problem, with over 10,000 new cases annually. Pulmonary embolism (PE) is a well-recognized risk in SCI patients, although no clear recommendations for prophylaxis exist. We therefore evaluated whether routine placement of prophylactic inferior vena cava filters is indicated in SCI patients. Methods: The trauma registry of a regional trauma center was used to identify patients sustaining acute SCI resulting in tetraplegia or paraplegia after blunt or penetrating trauma for a 5-year period beginning in January 1995. Patients were analyzed for demographics, mechanism of injury, Injury Severity Score, associated long bone or pelvic fracture, severe closed-head injury, type of deep venous thrombosis (DVT) prophylaxis, level of SCI, and incidence of DVT and PE. DVT prophylaxis was performed in all patients with sequential compression devices (SCDs) when extremity fracture status permitted. Data are expressed as mean ± SD and analyzed using Fisher's exact test. Results: There were 8,269 admissions during the study period, with an overall incidence of DVT and PE of 11.8 % and 0.9 %, respectively. There were 111 (1.3%) patients who sustained SCI, with an incidence of DVT and PE of 9.0 % and 1.8%, respectively, and no deaths. Of these 111 patients, 41.4% were paraplegics and 58.6% were tetraplegics, and 17.1 % of patients had severe closed-head injury. Mean hospital length of stay was 23 ± 20 days for SCI patients. Surveillance duplex ultrasound was performed an average of 2.3 ± 2.1 times during each hospitalization. Mean Injury Severity Score was 30.0 ± 12.2. The incidence of DVT and PE in those patients with SCDs alone was 7.1 % and 2.3%; for SCDs plus subcutaneous heparin, the incidence was 11.1 % and 2.8%; and for SCDs plus low-molecular-weight heparin, the incidence was 7.4% and 0%, respectively, with no statistical difference between groups. The incidence of DVT in SCI patients with long bone fractures was 37.5 %, which was significantly greater than the total SCI population (p < 0.02). Conclusion: The incidence of DVT and PE in SCI patients was similar to that of the overall trauma population when appropriate DVT prophylaxis was used. Subgroup analysis demonstrated that SCI associated with long bone fracture significantly increases the incidence of DVT. On the basis of the low incidence of PE in the present study, routine placement of prophylactic caval filters does not appear warranted in all SCI patients. However, SCI patients with long bone fractures, patients with DVT formation despite prophylactic anticoagulation, or patients with contraindications to anticoagulation may be appropriate candidates for prophylactic caval filtration.

OBJECTIVE: With contemporary interest of Trauma Systems and injury prevention strategists focusing upon boating safety, a prospective study was designed to survey practices of commercial and recreational boaters' compliance with United States Coast Guard (USCG) regulations. Data were collected by interview survey. Information was obtained from 24 commercial and 57 recreational boaters. Prevalence rates were calculated for compliance with USCG regulations. An analysis for statistical difference was conducted using the Wilcoxon rank sum test. Data analysis revealed that commercial boaters statistically spend more days on the water per year and have more years of boating experience than do recreational boaters ( P < 0.05). No statistical difference was demonstrated between commercial and recreational boaters for life jacket-to-crew member ratio, swimming competency, or compliance with USCG safety equipment, with exception to flotation suits. The prevalence of alcohol use by the operators of commercial and recreational boats was found to be 8 and 12 per cent ( P < 0.60) respectively, and for crew members 8 and 35 per cent ( P < 0.01), respectively. Boating practices in these sample populations conform to USCG regulations. Swimming competency exhibited by these boaters is complementary to safe boating behaviors. The consumption of alcohol while boating, although comparable to reported statistics, is still of concern to injury prevention strategists.

Background: Intolerance of enteral nutrition interrupts caloric balance and increases hospital costs. This study proposes that enteral feeding by percutaneous endoscopic gastrojejunostomy (PEGJ) provides continuous uninterrupted nutrition with greater consistency than percutaneous endoscopic gastrostomy (PEG). Methods: This prospective nonrandomly assigned study was conducted at a Level I trauma center from December of 1997 through October of 1998. All feeding tubes were placed by trauma/critical care surgeons for nutritional support. Feeding course was monitored for 14 days from time of tube placement. Demographic data and outcome variables compared were age, sex, Injury Severity Score, Abbreviated Injury Score, hospital length of stay, number of days to reach nutritional goal feedings, caloric goal, protein goal, cc/hr at goal, total parenteral nutrition usage, complications, and hospital charges. Statistical analyses used the independent samples t test, Cox regression, and Pearson X 2 with significance level set at 0.05. Results: Patients receiving enteral nutrition by PEGJ reached nutritional goal sooner than patients who received enteral nutrition by PEG (p = 0.02). Thirty-seven of 46 PEGJ patients (80%) were at goal rate at day 3, whereas 28 of 43 PEG patients (65%) were at goal on day 3. Nine of 43 PEG patients (21%) and 3 of 46 PEGJ patients (7%) failed to reach goal within 14 days. Conclusion: This study suggests that enteral nutrition delivered by means of PEGJ is better tolerated than enteral nutrition delivered by means of PEG in trauma patients with no abdominal conditions that preclude percutaneous feeding tube placement.

Background: Temporary abdominal wound closure after celiotomy for trauma is often desirable. The ideal method of temporary closure should allow rapid closure, easy maintenance, and allow reexploration and wound repair with minimal tissue damage. Over the past 7 years, we have successfully used a vacuum closure system (the vacuum pack) for temporary management of the open abdomen. Methods: Medical records of trauma patients undergoing exploratory celiotomy from April of 1992 to February of 1999 were reviewed. Demographic data as well as indications for open-abdominal management and complications of open-abdominal management were collected. Results: Two hundred sixteen vacuum packs were performed in 112 trauma patients. Of the 216 vacuum packs placed, 2.8% were placed for increased intra-abdominal pressure, 5.3% for inability to achieve tension-free fascial closure, 20% for damage control, 55% for reexploration, and 16.7% for a combination of factors. Sixty-two patients (55.4%) went on to primary closure and 25 patients (22.3%) underwent polyglactin mesh repair of the defect followed by wound granulation and eventual skin grafting. Twenty-two patients (19.6%) died before abdominal closure was attempted. Five patients (4.5%) developed enterocutaneous fistulae. Five patients (4.5%) developed intra-abdominal abscesses. There were no eviscerations. Three patients (2.7%) required further explorations after abdominal closure. Overall mortality rate was 25.9%, none related to the vacuum pack. Conclusions: The vacuum pack is the temporary abdominal wound closure of choice in patients undergoing open abdominal management at our institution. Primary closure is achieved in the majority of patients with a low rate of complication. The technique is simple and easily mastered. Technical complications are rare and easily repaired.

Hyoid bone fractures secondary to blunt trauma other than strangulation are rare (ML Bagnoli et al., J Oral Maxillofac Surg 1988; 46: 326–8), accounting for only 0.002 per cent of all fractures. The world literature reports only 21 cases. Surgical intervention involves airway management, treatment of associated pharyngeal perforations, and management of painful symptomatology. The importance of hyoid fracture, however, rests not with the rarity of it, but with the lethal potential of missed diagnosis. We submit three cases with varying presentations and management strategies. All three of our cases incurred injury by blunt trauma to the anterior neck. Two patients required emergent surgical airway after unsuccessful attempts at endotracheal intubation. One patient presented without respiratory distress and was managed conservatively. After fracture, the occult compressive forces of hematoma formation and soft tissue swelling may compromise airway patency. It is our clinical observation that hypoxia develops rapidly and without warning, leading to cardiorespiratory collapse. With endotracheal intubation prohibited by obstruction, a surgical airway must be established and maintained. Recognition of subtle clinical and physical findings are critical to the diagnosis of laryngotracheal complex injuries and may be life-saving in many instances. To ensure a positive outcome, a strong degree of suspicion based on mechanism of injury is mandated.

Objective: To increase awareness and understanding of post-traumatic carotid cavernous fistula (PTCCF) with the intent to expedite diagnosis and treatment of this disabling injury, a 14-year retrospective review of patients with angiographically identified PTCCF was conducted at this Level I trauma center. A frequency analysis of signs, symptoms, and disability was performed. The impact on disability of demographics, number of embolization attempts required for closure of the PTCCF, and time from injury to diagnosis was assessed by t test for independent samples. Results: Nine patients were diagnosed with 10 PTCCFs. Mean patient age was 41.5 years. All patients with PTCCF had basilar skull fracture, loss of consciousness, bruit, and chemosis; 90% had exophthalmos; 70% had visual changes; 50% complained of headache; and 80% had some lasting disability. Mean age of patients with partial to total disability was 47 years, while the mean age of patients without lasting disability was 19.5 years (p = 0.013). No statistical correlation could be found between disability and sex, blunt versus penetrating injury, days to diagnosis, or number of embolization attempts. Conclusion: Patients sustaining head trauma with basilar skull fractures and presenting with the described signs and symptoms should be evaluated for PTCCF. Risk of disability does not appear to be influenced by number of attempts at embolization or time to diagnosis. However, age may have a significant impact on outcome.

Background: The 24-hour observation critical pathway for trauma is a clinical tool developed to expedite health care delivery to minimally injured patients. The use of patient care, BS, guidelines and physician-approved standing orders was implemented in a Level I trauma center. Methods: A retrospective chart review was performed of 122 patients admitted via the emergency department between December 1, 1993, and May 31, 1994. All patients were evaluated in the emergency department by emergency medicine and trauma physicians and deemed appropriate for 24-hour observation. The information collected included patient demographics, hospital charges, injuries, length of stay, diagnostic tests, consultations, and variances from the critical pathway. Results: During the 6-month study period, there were 600 trauma admissions. Of those admissions, 122 patients (20%) were evaluated in the emergency department and deemed appropriate for enrollment in the 24-hour observation pathway. The charts of these patients were reviewed. Fourteen admissions were determined inappropriate for the critical pathway because of the severity of injuries or discharge against medical advice. One hundred eight charts were evaluated further. Eighty-nine patients (80%) completed the critical pathway with a length of stay of 24 hours. Conclusion: The 24-hour observation critical pathway was designed and used appropriately as exemplified by an overall 80% completion rate. The critical pathway offers a mechanism to streamline care of the minimally injured trauma patient. It also serves as a quality-improvement tool for increasing efficiency, decreasing utilization of resources, and decreasing length of stay.

Negative-pressure wound therapy (NPWT) has been used for to treat wounds for more than 15 years and, more recently, has been used to secure split-thickness skin grafts. There are some data to support this use of NPWT, but the actual mechanism by which NPWT speeds healing or improves skin graft take is not entirely known. The purpose of this project was to assess whether NPWT improved angiogenesis, wound healing, or graft survival when compared with traditional bolster dressings securing split-thickness skin grafts in a porcine model.We performed two split-thickness skin grafts on each of eight 30 kg Yorkshire pigs. We took graft biopsies on postoperative days 2, 4, 6, 8, and 10 and submitted the samples for immunohistochemical staining, as well as standard hematoxylin and eosin staining. We measured the degree of vascular ingrowth via immunohistochemical staining for von Willenbrand's factor to better identify blood vessel epithelium. We determined the mean cross-sectional area of blood vessels present for each representative specimen, and then compared the bolster and NPWT samples. We also assessed each graft for incorporation and survival at postoperative day 10.Our analysis of the data revealed that there was no statistically significant difference in the degree of vascular ingrowth as measured by mean cross-sectional capillary area (p = 0.23). We did not note any difference in graft survival or apparent incorporation on a macroscopic level, although standard hematoxylin and eosin staining indicated that microscopically, there seemed to be better subjective graft incorporation in the NPWT samples and a nonsignificant trend toward improved graft survival in the NPWT group.We were unable to demonstrate a significant difference in vessel ingrowth when comparing NPWT and traditional bolster methods for split-thickness skin graft fixation. More studies are needed to elucidate the manner by which NPWT exerts its effects and the true clinical magnitude of these effects.

Disaster planning and response to a mass casualty incident pose unique demands on the medical community. Because they would be required to confront many casualties with bodily injury and surgical problems, surgeons in particular must become better educated in disaster management. Compared with routine practice, triage principles in disasters require an entirely different approach to evaluation and care and often run counter to training and ethical values. An effective response to disaster and mass casualty events should focus on an "all hazards" approach, defined as the ability to adapt and apply fundamental disaster management principles universally to any mass casualty incident, whether caused by people or nature. Organizational tools such as the Incident Command System and the Hospital Incident Command System help to effect a rapid and coordinated response to specific situations. The United States federal government, through the National Response Plan, has the responsibility to respond quickly and efficiently to catastrophic incidents and to ensure critical life-saving assistance. International medical surgical response teams are capable of providing medical, surgical, and intensive care services in austere environments anywhere in the world.

his quote reflects America’s commitment to freedom nd the implied sacrifices necessary to preserve those reedoms. Recently, much time has been spent on trying o appreciate the threat of terrorism that challenges those reedoms in today’s world. As defined by the Federal ureau of Investigation, terrorism is “the unlawful use of orce and violence against persons or property to intimdate or coerce a government, the civilian population, or ny segment thereof, in furtherance of political or social bjectives.” The two major goals of terrorists, which est serve their ends of destroying the most fundamental alues and infrastructure of societies, are the maximizing f casualty generation and maximizing the lethality of hose casualties. Pivotal to all terrorist activities, as defined by Paul R illar in his book entitled Terrorism and US Foreign Polcy, are the strong political motivations of the individual erpetrators. Arnold complements Pillar’s assumpions in the reference to “racial tribalism,” which decribes the banding together of single ethnic and cultural roups to replace existing political structures with one ased on their own cultural groups and ethical and culural homogeneity. Terrorist activities are best distinguished from those of ecognized engagements of war by the blatant lack of ompliance with the laws that are codified in the Geneva onvention, specifically, by targeting noncombatants in ivilian clothes, and taking, mistreating, and killing hos

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

The Accreditation Council for Graduate Medical Education imposed 80-hour work week constraints on residency programs in July 2003. Certain programs were granted an additional 10 per cent for specific educational purposes, bringing restrictions to 88 hours per week. The increased demand for residents to leave the hospital has placed teaching institutions in exhaustive situations to provide comprehensive patient care. In response to the work hour constraints among residents and emergency room staff, a unique group of registered nurses, trauma nurse specialists (TNSs), were credentialed with advanced practice skill sets. Governed by practice guidelines and overseen by a medical director, TNSs perform invasive procedures that are normally the responsibility of the surgical resident. The purpose of this study was to evaluate work hours saved for surgery residents using credentialed nurses (TNSs). Procedure logs were maintained by the TNSs over a 6-month period, and surgical house staff (postgraduate year 1-3) over a 4-month period. A total of 423 procedures were recorded, reflecting time taken for attempted/completed procedures and complications. Resident procedures numbered 98; TNS procedures numbered 325. TNSs spent an average of 42 hours per month (10.6 hours per week) completing advanced procedures with no statistical difference in time or complications compared with surgical residents. By using the TNSs, work hours for surgery residents were saved while maintaining a safe and reliable work atmosphere for patients.

Acute renal failure (ARF) occurs in 10 per cent to 23 per cent of intensive care unit patients with mortality ranging from 50 per cent to 90 per cent. ARF is characterized by an acute decline in renal function as measured by urine output (UOP), serum creatinine, and blood urea nitrogen (BUN). Causes may be prerenal, intrarenal, or postrenal. Treatment consists of renal replacement therapy (RRT), either intermittent (ID) or continuous (CRRT). Indications for initiation of dialysis include oliguria, acidemia, azotemia, hyperkalemia, uremic complications, or significant edema. Overall, the literature comparing CRRT to ID is poor. No studies of only surgical/trauma patients have been published. We hypothesize that renal function and hemodynamic stability in trauma/ surgical critical care patients are better preserved by CRRT than by ID. We performed a retrospective review of trauma/surgical critical care patients requiring renal supportive therapy. Thirty patients received CRRT and 27 patients received ID. The study was controlled for severity of illness and demographics. Outcomes assessed were survival, renal function, acid-base balance, hemodynamic stability, and oxygenation/ventilation parameters. Populations were similar across demographics and severity of illness. Renal function, measured by creatinine clearance, was statistically greater with CRRT (P = 0.035). There was better control of azotemia with CRRT: BUN was lower (P = 0.000) and creatinine was lower (P = 0.000). Mean arterial blood pressure was greater (P = 0.021) with CRRT. No difference in oxygenation/ventilation parameters or pH was found between groups. CRRT results in an enhancement of renal function with improved creatinine clearance at the time of dialysis discontinuation. CRRT provides better control of azotemia while preserving hemodynamic stability in patients undergoing renal replacement therapy. Prospective randomized controlled studies and larger sample sizes are needed to further evaluate these modalities.

Acute renal failure (ARF) occurs in 10 per cent to 23 per cent of intensive care unit patients with mortality ranging from 50 per cent to 90 per cent. ARF is characterized by an acute decline in renal function as measured by urine output (UOP), serum creatinine, and blood urea nitrogen (BUN). Causes may be prerenal, intrarenal, or postrenal. Treatment consists of renal replacement therapy (RRT), either intermittent (ID) or continuous (CRRT). Indications for initiation of dialysis include oliguria, acidemia, azotemia, hyperkalemia, uremic complications, or significant edema. Overall, the literature comparing CRRT to ID is poor. No studies of only surgical/trauma patients have been published. We hypothesize that renal function and hemodynamic stability in trauma/surgical critical care patients are better preserved by CRRT than by ID. We performed a retrospective review of trauma/surgical critical care patients requiring renal supportive therapy. Thirty patients received CRRT and 27 patients received ID. The study was controlled for severity of illness and demographics. Outcomes assessed were survival, renal function, acid-base balance, hemodynamic stability, and oxygenation/ventilation parameters. Populations were similar across demographics and severity of illness. Renal function, measured by creatinine clearance, was statistically greater with CRRT ( P = 0.035). There was better control of azotemia with CRRT: BUN was lower ( P = 0.000) and creatinine was lower ( P = 0.000). Mean arterial blood pressure was greater ( P = 0.021) with CRRT. No difference in oxygenation/ventilation parameters or pH was found between groups. CRRT results in an enhancement of renal function with improved creatinine clearance at the time of dialysis discontinuation. CRRT provides better control of azotemia while preserving hemodynamic stability in patients undergoing renal replacement therapy. Prospective randomized controlled studies and larger sample sizes are needed to further evaluate these modalities.

Background: Little attention has been focused on destructive injuries of the bowel in patients requiring open abdominal management. We therefore reviewed our institutional experience for destructive bowel injury requiring open abdominal management with the vacuum pack technique (vac). Methods: The trauma registry at a Level I trauma center was used to identify patients sustaining destructive bowel injury for an 11-year period beginning in May 1990. Patients were assessed for pertinent clinical and demographic information, and individuals requiring open abdominal management were compared with those who did not. Results: One hundred four patients required bowel resection and constitute the study population. Twenty-nine patients had vacs placed, with 22 (75.9%) of the total eventually obtaining delayed fascial closure. Nineteen (18.3%) patients had resection and primary repair (PR) of large and/or small bowel in conjunction with a vac, 10 (9.6%) patients had stoma formation in conjunction with a vac, 62 (59.6%) patients had resection and PR of small and/or large bowel in conjunction with primary fascial closure, and 13 (12.5%) patients had stoma formation and primary fascial closure. There were no differences in abdominal abscess or leak rates between groups. There were four deaths, none of which was secondary to failure of an anastomosis. Conclusion: Bowel resection with PR appears to be a safe alternative after destructive bowel injury and results in acceptable morbidity when performed in conjunction with open abdominal management.

During this study we investigated the yearly risk of radiation exposure for surgical residents (group 1, n = 8), emergency department (ED) physicians (group 2, n = 6) and nurses (group 3, n = 97) participating in the resuscitation of trauma victims in the emergency department of a 500-bed teaching hospital. Dosimeter readings of the three study groups were recorded monthly over the 1-year study period. During the study interval, 758 patients underwent resuscitation following trauma; 2098 portable radiographs (758 chest films, 758 lateral cervical spine films, and 582 radiographs of the pelvis) were obtained during the resuscitation phase of these patients. The total radiation exposure for group 3 was significantly greater than that for groups 1 and 2 (340 +/- 50 vs. 160 +/- 112 and 20 +/- 14 mrem, respectively, p < 0.01). Individual residents received a significantly greater amount of radiation than ED physicians and nurses (20 +/- 28 vs. 3.3 +/- 2.0 and 3.5 +/- 2.0 mrem, respectively, p < 0.05). However, despite repeated exposure to radiation, individuals in the three groups did not exceed the safety limits of 0.05 Gy/year set by the National Council on Radiation Protection and Measurements. Based on the results of this study, we conclude that trauma resuscitation teams can provide quality care to their patients without concern over the detrimental effects of radiation exposure, provided that the basic principles of radiation protection are followed.

Differences in prehospital resuscitation measures and outcomes of trauma patients transported by two air medical programs were assessed comparing the prehospital administration of crystalloid only (Group A) with the administration of 2 liters of crystalloid followed by blood (Group B).A 1-year retrospective review of flight and hospital records of patients taken to Level I trauma centers by two separate air medical programs was completed. Physiologic variables, total fluids infused, and flight times were compared.Thirty-one patients (Group A) received crystalloids in flight, and 17 patients received in-flight blood (Group B). No statistical differences were found between the two groups when comparing age, ISS, PS, RTS, GCS, survival, and total fluid volume. Group B had statistically greater mean flight times compared with Group A (P.05). A difference was demonstrated between groups A and B in pH and HCO3 measurements (P.05), with Group B presenting in a more acidotic state on admission to the hospital.Patients with lengthy flight times, despite the administration of blood products, presented to the trauma center more acidotic than trauma patients receiving only crystalloid. The true impact of blood products on outcome could not be demonstrated because of statistical differences in flight times between the groups. A multicenter study matching flight times, head injury status, and flight type of assess benefit of prehospital utilization of blood products is warranted.

Objective: To define those physiologic and clinical variables that have a positive or negative predictive value in discriminating survivors from nonsurvivors with traumatic injuries and a Trauma Score of 5 or less. Methods: A retrospective review of 2,622 trauma patients transported by an air medical service from the scene of injury to a Level I trauma center was performed. Demographic, physiologic, and clinical variables were evaluated. Results: One hundred thirty-six patients were studied; 14 patients survived trauma resuscitation. Survivors had statistically significant improvement in the Glasgow Coma Scale from the field to arrival in the emergency room. Revised Trauma Score, probability of survival, pulse, respiratory rate, cardiac rhythm, central nervous system activity, and signs of life were statistically more favorable in survivors. Conclusion: In patients who survived to discharge, signs of central nervous system activity in the field was a positive predictor of survival, and severe head injury served as a negative predictor of survival.

Background: Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation. Methods: Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study population's demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality. Results: No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization. Conclusion: Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Objectives : Nonoperative management of hemodynamically stable blunt hepatic injury has emerged as an acceptable and safe treatment. Surveillance of this population's injuries is costly. As a prelude to establishing practice guidelines, the utility of repeat computed tomographic (CT) scans was investigated. Methods : A retrospective study was conducted on 243 hepatic injuries. The CT scans of 95 patients managed nonoperatively who did not have ongoing transfusion requirements were reviewed and graded according to the American Association for the Surgery of Trauma (AAST) hepatic injury scale. Patients were grouped according to injury grade, assigned to two subgroups (patients with one CT scan versus more than one CT scan) and compared with respect to several physiologic and clinical variables. Results : Statistical analysis revealed no significant difference between subgroups with the same grade of injury. No significant difference was demonstrated between subgroups' length of stay. Conclusions : No patients failed nonoperative treatment or succumbed to their injuries. Findings on repeat CT scan have not altered the decision to discharge the clinically stable patient having suffered a grade III or lower liver injury.