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Background: Tube thoracostomy is a commonly performed procedure in trauma patients. The optimal chest tube size is unknown. This study measures chest tube drainage in a controlled laboratory setting and compares measured flowrates to those predicted by the Hagen-Poiseuille equation., Materials and Methods: A model of massive hemothorax was created, consisting of a basin containing synthetic blood substitute (aqueous Glycerin and Xanthan gum) and a standard pleur-evac setup at -20 cm H 2 O suction. Flow measurements were calculated by measuring the time to drain 2L of blood substitute from the basin. Chest tube sizes tested were 20F, 24F, 28F, 32F, and 36F. Thoracostomy opening was modeled using custom built device that represents two ribs, with the distance between varied 2 to 12 mm. Flowrate increases were compared against predicted increases according to the Hagen-Poiseuille equation. Percent of predicted increase was calculated, both incremental increase and using 20F tube benchmark., Results: All tubes were occluded at a 2 mm thoracostomy opening. At 3 mm, 32F and 36F were occluded while smaller tubes were patent. Tubes 28F and larger exhibited high speed and consistent flowrates, even after decreasing thoracostomy opening down to 7 mm, while flowrates rapidly decreased at opening smaller than 7 mm. Smaller 24F and 20F tubes exhibited highly variable flowrates through the system. Maximum flowrates were 21.7, 36.8, 49.6, 55.6, and 61.0 mL/s for 20F-36F tubes, respectively. The incremental increase in flow ratio for increasing chest tube size was 1.69 (20F to 24F), 1.35 (24F to 28F), 1.12 (28F to 32F), and 1.10 (32F to 36F)., Conclusions: The 28F chest tube exhibited high and consistent velocity, while smaller tubes were slower and more variable. Larger tubes offered only slightly higher flowrates. The 28F is a good balance of reasonable size and high flowrate and is likely the optimal size for most clinical applications., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Timely tourniquet placement may limit ongoing hemorrhage and reduce the need for blood products. This study evaluates if prehospital tourniquet application altered the initial transfusion needs in arterial injuries when compared with a non-tourniquet control group., Methods: Extremity arterial injuries were queried from our level I trauma center registry from 2013 to 2017. The characteristics of the cohort with prehospital tourniquet placement (TQ+) were described in terms of tourniquet use, duration, and frequency over time. These cases were matched 1:1 by the artery injured, demographics, Injury Severity Score, and mechanism of injury to patients arriving without a tourniquet (TQ-). The primary outcome was transfusion within the first 24 hours, with secondary outcomes of morbidity (rhabdomyolysis, renal failure, compartment syndrome), amputation (initial vs. delayed), and length of stay. Statistical tests included t-test and χ 2 for continuous and categorical variables, respectively, with p<0.05 considered as significant., Results: Extremity arterial injuries occurred in 192 patients, with 69 (36%) having prehospital tourniquet placement for an average of 78 minutes. Tourniquet use increased over time from 9% (2013) to 62% (2017). TQ+ patients were predominantly male (81%), with a mean age of 35.0 years. Forty-six (67%) received blood transfusion within the first 24 hours. In the matched comparison (n=69 pairs), TQ+ patients had higher initial heart rate (110 vs. 100, p=0.02), frequency of transfusion (67% vs. 48%, p<0.01), and initial amputations (23% vs. 6%, p<0.01). TQ+ patients had increased frequency of initial amputation regardless of upper (n=43 pairs) versus lower (n=26 pairs) extremity involvement; however, only upper extremity TQ+ patients had increased transfusion frequency and volume. No difference was observed in morbidity, length of stay, and mortality with tourniquet use., Discussion: Tourniquet use has increased over time in patients with extremity arterial injuries. Patients having prehospital tourniquets required a higher frequency of transfusion and initial amputation, without an increase in complications., Level of Evidence: Therapeutic study, level IV., Competing Interests: Competing interests: None declared.

Introduction: Computed tomography (CT) scans are useful in the evaluation of trauma patients, but are costly and pose risks from ionizing radiation in children. Recent literature has demonstrated the use of CT scan guidelines in the management of pediatric trauma. The study objective is to review our treatment of pediatric blunt trauma patients and evaluate CT use before and after CT-guideline implementation., Methods: Our Pediatric Level 2 Trauma Center (TC) implemented a CT scan practice guideline for pediatric trauma patients in March 2014. The guideline recommended for or against CT of the head and abdomen/pelvis using published criteria from the Pediatric Emergency Care and Research Network. There was no chest CT guideline. We reviewed all pediatric trauma patients for CT scans obtained during initial evaluation before and after guideline implementation, excluding inpatient scans. The Trauma Registry Database was queried to include all pediatric (age < 15) trauma patients seen in our TC from 2010 to 2016, excluding penetrating mechanism and deaths in the TC. Scans were considered positive if organ injury was detected. Primary outcome was the proportion of patients undergoing CT and percent positive CTs. Secondary outcomes were hospital length of stay, readmissions, and mortality. Categorical and continuous variables were analyzed with χ and Wilcoxon rank-sum tests, respectively. p < 0.05 was considered significant., Results: We identified 1,934 patients: 1,106 pre- and 828 post-guideline. Absolute reductions in head, chest, and abdomen/pelvis CT scans were 17.7%, 11.5%, and 18.8%, respectively (p < 0.001). Percent positive head CTs were equivalent, but percent positive chest and abdomen CT increased after implementation. Secondary outcomes were unchanged., Conclusions: Implementation of a pediatric CT guideline significantly decreases CT use, reducing the radiation exposure without a difference in outcome. Trauma centers treating pediatric patients should adopt similar guidelines to decrease unnecessary CT scans in children., Level of Evidence: Therapeutic study, level IV.

Background: Penetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to drain hemopericardium and assess for continued bleeding and instability. This study objective is to review patients with PCI managed with sternotomy and PCW and compare outcomes., Methods: All patients with penetrating chest trauma from 2000 to 2016 requiring PCW or sternotomy were reviewed. Data were collected for patients who had PCW for hemopericardium managed with only pericardial drain, or underwent sternotomy for cardiac injuries grade 1-3 according to the American Association for the Surgery of Trauma (AAST) Cardiac Organ Injury Scale (OIS). The PCW+drain group was compared with the Sternotomy group using Fisher's exact and Wilcoxon rank-sum test with P<0.05 considered statistically significant., Results: Sternotomy was performed in 57 patients for suspected PCI, including 7 with AAST OIS grade 1-3 injuries (Sternotomy group). Four patients had pericardial injuries, three had partial thickness cardiac injuries, two of which were suture-repaired. Average blood drained was 285 mL (100-500 mL). PCW was performed in 37 patients, and 21 had hemopericardium; 16 patients proceeded to sternotomy and 5 were treated with pericardial drainage (PCW+drain group). All PCW+drain patients had suction evacuation of hemopericardium, pericardial lavage, and verified bleeding cessation, followed by pericardial drain placement and admission to intensive care unit (ICU). Average blood drained was 240 mL (40-600 mL), and pericardial drains were removed on postoperative day 3.6 (2-5). There was no significant difference in demographics, injury mechanism, Revised Trauma Score exploratory laparotomies, hospital or ICU length of stay, or ventilator days. No in-hospital mortality occurred in either group., Conclusions: Hemodynamically stable patients with penetrating chest trauma and hemopericardium may be safely managed with PCW, lavage and drainage with documented cessation of bleeding, and postoperative ICU monitoring., Level of Evidence: Therapeutic study, level IV., Competing Interests: Competing interests: None declared.

Background: Fellowship trainees in acute care surgery require experience in the management of complex and operative trauma cases. Trauma center staffing usually follows standard 12-hour or 24-hour shifts, with resident and fellow trainees following a similar schedule. Although trauma admissions can be generally unpredictable, we analyzed temporal trends of trauma patient arrival times to determine the best time frame to maximize trainee experience during each day., Methods: We reviewed 10 years (2007-2016) of trauma registry data for blunt and penetrating trauma activations. Hourly volumetric trends were observed, and three specific events were chosen for detailed analysis: (1) trauma activation with Injury Severity Score (ISS) greater than 15, (2) laparotomy for trauma, and (3) thoracotomy for trauma. A retrospective shift log was created, which included day (7:00 AM to 7:00 PM), night (7:00 PM to 7:00 AM), and swing (noon to midnight) shifts. A swing shift was chosen because it captures the peak volume for all three events. Means and 95% confidence intervals were calculated, and comparisons were made between shifts using the Wilcoxon matched-pairs signed rank test with Bonferroni correction, and p less than 0.05 considered significant., Results: During the 10-year study period, 28,287 patients were treated at our trauma center. This included the evaluation and management of 7,874 patients with ISS greater than 15, performance of 1,766 laparotomies, and 392 thoracotomies for trauma. Swing shift was superior to both day and night shifts for ISS greater than 15 (p < 0.001). Both swing and night shifts were superior to day shift for laparotomies (p < 0.001). Swing shift was superior to both day shift (p < 0.001) and night shift (p = 0.031). Shifts with the highest yield of ISS greater than 15, laparotomies, and thoracotomies include night and swing shifts on Fridays and Saturdays., Conclusion: Projected experience of acute care surgery fellows in managing complex trauma patients increases with the integration of swing shifts into the schedule. Daily trauma volume follows a temporal pattern which, when used correctly, can increase trainee exposure to complex and operative trauma cases. We encourage other centers to analyze their volume and adjust trainee schedules accordingly to maximize their educational experience., Level of Evidence: Therapeutic study, level IV.

Background: The use of 5 or more medications is defined as polypharmacy (PPM). The clinical impact of PPM on the isolated severe traumatic brain injury (TBI) patient has not been defined., Methods: A retrospective cohort study was performed at our academic level 1 trauma center examining patients with isolated TBI. Pre-injury medications were reviewed, and inhospital mortality was the primary measured outcome., Results: There were 698 patients with an isolated TBI over the 5-year study period; 177 (25.4%) patients reported pre-injury PPM. There were 18 (10.2%) deaths in the PPM cohort and 24 (4.6%) deaths in the non-PPM cohort (P < .0001). Stepwise logistic regression analysis revealed a 2.3 times greater risk of mortality in the PPM patients (P = .019)., Conclusions: Pre-injury PPM increases mortality in patients with isolated severe TBI. This knowledge may provide opportunities for intervention in this population., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Acute-care surgery (ACS), trauma, and surgical critical care (SCC) fellowships graduate fellows deemed qualified to perform complex cases immediately upon graduation. We hypothesize international fellow rotations can be a resource to supplement operative case exposure., Methods: A survey was sent to all program directors (PDs) of ACS and SCC fellowships via e-mail. Data were captured and analyzed using the REDCap (Research Electronic Data Capture) tool., Results: The survey was sent to 113 PDs, with a response rate of 42%. Most fellows performed less than 150 operative cases (59.5%). The majority of PDs thought the operative exposure either could be improved or was not enough to ensure expertise in trauma and emergent general surgery. Only a minority of the PDs found their case load exceptional (can be improved: 43%, not enough: 30% exceptional: 27%). Most PDs thought an international experience could supplement the breadth of cases, provide research opportunities, and improve understanding of trauma systems (70%). Ten sites offered international rotations (70%). Most fellowships would be willing to provide reciprocity to the host institution (90%)., Conclusions: The majority of PDs for ACS, trauma, and SCC programs perceive a need for increased quality and quantity of operative cases. The majority recognize international fellow rotations as a valuable tool to supplement fellows' education.

Background: Over the past decade, the American Association for the Surgery of Trauma Acute Care Surgery (ACS) fellowship program has matured to 20 verified programs. As part of an ongoing curricular evaluation, we queried the current practice patterns of the graduates of ACS fellowship programs regarding their view on their ACS training. We hypothesized that the majority of ACS fellowship graduates would be practicing ACS in academic Level I trauma centers and that fellowship training was pivotal in their career., Methods: Graduates of American Association for the Surgery of Trauma-certified ACS fellowships completed an online survey that included practice demographics, specific categories of cases delineated by the current ACS curriculum, and perceived impact of training., Results: Surveys were submitted by 56 of 77 graduates for a completion rate of 73%. The majority of respondents were male (68%) aged 40 years or younger (80%). All but four completed ACS fellowship training in last 5 years (93%), and 83% completed fellowship in the last 3 years. Regarding their current practice, broadly defined ACS predominated (96%) with 2% practicing only trauma surgery and 2% only general surgery. Practice settings were 64% urban, 29% suburban, and 7% rural locations, with 84% of graduates practicing in a hospital-based group. The practitioner's hospital was identified as university/university-affiliated in 53%, community in 38%, and military in 9%, with 91% identified as a teaching hospital; trauma designation was identified as Level I (55%), Level II (39%), and other (6%). The graduates' average current practice mix is 10% elective general surgery, 29% emergency general surgery, 32% trauma, 25% surgical critical care, and 4% other (burn, bariatric, vascular, and thoracic). Only 16% of graduates do not perform elective cases. Case specifics demonstrated 92% of graduates perform vascular cases, 88% perform thoracic cases, and 70% perform complex hepatobiliary. Practice elements that were satisfiers included (1) scope of practice, (2) case mix, (3) percentage emergency general surgery, (4) lifestyle, (5) case complexity (with 3 and 4 tied). Graduates agreed the ACS fellowship training prepared them well for practice and was worth the time invested (both 82%), increased their marketability and self-confidence (80%), and prepared them well for academics (71%) and administration (63%). Of those surveyed, 93% would encourage others to do an ACS fellowship., Conclusion: Although 93% of graduates practice in urban/suburban areas, there was a mixture of university, university-affiliated, and community institutions and an almost even division of Levels I and II designation. Graduates demonstrate ongoing use of their acquired advanced operative training, particularly in vascular and thoracic surgery. The majority of ACS fellowship graduates were practicing ACS and felt fellowship training was valuable in their career path and that they would recommend it to others.

A battery-operated active cooling/heating device was developed to maintain thermoregulation of trauma victims in austere environments while awaiting evacuation to a hospital for further treatment. The use of a thermal manikin was adopted for this study in order to simulate load testing and evaluate the performance of this novel portable active cooling/heating device for both continuous (external power source) and battery power. The performance of the portable body temperature conditioner (PBTC) was evaluated through cooling/heating fraction tests to analyze the heat transfer between a thermal manikin and circulating water blanket to show consistent performance while operating under battery power. For the cooling/heating fraction tests, the ambient temperature was set to 15°C ± 1°C (heating) and 30°C ± 1°C (cooling). The PBTC water temperature was set to 37°C for the heating mode tests and 15°C for the cooling mode tests. The results showed consistent performance of the PBTC in terms of cooling/heating capacity while operating under both continuous and battery power. The PBTC functioned as intended and shows promise as a portable warming/cooling device for operation in the field.

Background: Laparoscopic techniques have evolved, allowing increased capabilities within most subspecialties of general surgery, but have failed to gain traction managing injured patients. We hypothesized that laparoscopy is effective in the diagnosis and treatment of penetrating abdominal injuries., Methods: We retrospectively reviewed patients undergoing abdominal exploration following penetrating trauma at our Level 1 trauma center during a 6-year period from January 1, 2008, to December 31, 2013. Demographic and resuscitation data were obtained from our trauma registry. Charts were reviewed for operative details, hospital course, and complications. Hospital length of stay (LOS) and complications were primary end points. Patients were classified as having nontherapeutic diagnostic laparoscopy (DL), nontherapeutic diagnostic celiotomy (DC), therapeutic laparoscopy (TL), or therapeutic celiotomy (TC). TL patients were case-matched 2:1 with TC patients having similar intra-abdominal injuries., Results: A total of 518 patients, including 281 patients (55%) with stab wounds and 237 patients (45%) with gunshot wounds, were identified. Celiotomy was performed in 380 patients (73%), laparoscopy in 138 (27%), with 44 (32%) converted to celiotomy. Nontherapeutic explorations were compared including 70 DLs and 46 DCs with similar injury severity. LOS was shorter in DLs compared with DCs (1 day vs. 4 days, p < 0.001). There were no missed injuries. Therapeutic explorations were compared by matching all TL patients 2:1 to TC patients with similar type and severity of injuries. Twenty-four patients underwent TL compared with 48 TC patients in the case matched group. LOS was shorter in the TL group than in the TC group (4 days vs. 2 days, p < 0.001). Wound infections were more common with open exploration (10.4% vs. 0%, p = 0.002), and more patients developed ileus or small bowel obstruction after open exploration (9.4% vs. 1.1%, p = 0.018)., Conclusion: Laparoscopy is safe and accurate in penetrating abdominal injuries. The use of laparoscopy resulted in shorter hospitalization, fewer postoperative wound infection and ileus complications, as well as no missed injuries., Level of Evidence: Therapeutic study, level IV.

Background: This study was designed to define the gaps in essential and desirable (E/D) case volumes that may prompt reevaluation of the acute care surgery (ACS) curriculum or restructuring of the training provided., Methods: A review of the first 2 years of ACS case log entry (July 2011 to June 2013) was performed. Individual trainee logs were evaluated to determine how often they performed each case on the E/D list. Trainees described cases using current procedural terminology codes, which had been previously mapped to the E/D list., Results: There were 29 trainees from 15 programs (Year 1) and 30 trainees from 13 programs (Year 2) who participated in case log entry, with some overlap between the years. There were a total of 487 fellow-months of data with an average of 14.6 current procedural terminology codes per month and 175.5 per year for cases on the E/D list versus 12 and 143.5 for cases not on the E/D list, respectively. Overall, the most common essential cases were laparotomy for trauma (1,463; 705 in Year 1, 758 in Year 2), tracheostomy (665; 372 in Year 1, 293 in Year 2) and gastrostomy tubes (566; 289 in Year 1, 277 in Year 2). There are a total of 73 types of essential operations and 45 types of desirable operations in the current curriculum. There were 16 distinct codes (13.6%) never used, of which 6 overlapped with other codes. Based on body region, the 10 E/D codes never used by any fellow were as follows: one head/face, lateral canthotomy; five neck; elective neck dissections; one thoracic, vascular trauma to chest; three pediatrics, inguinal hernia repair and small bowel obstruction treatments., Conclusion: The current ACS trainees lack adequate head/neck and pediatric experience as defined by the ACS curriculum. Restructuring rotations at individual institutions and a focus on novel educational modalities may be needed to augment the individual institutional exposure. Reevaluation of the curriculum may be warranted.

Background: A case log was created by the American Association for the Surgery of Trauma Acute Care Surgery (ACS) committee to track trainee operative experiences, allowing them to enter their cases in the form of Current Procedural Terminology (CPT) codes. We hypothesized that the number of cases an ACS trainee performed would be similar to the expectations of a fifth-year general surgery resident and that the current list of essential and desired cases (E/D list) would accurately reflect cases done by ACS trainees., Methods: The database was queried from July 1, 2011, to June 30, 2012. Trainees were classified as those in American Association for the Surgery of Trauma-accredited fellowships (ACC) and those in ACS fellowships not accredited (non-ACC). CPT codes were mapped to the E/D list. Cases entered manually were individually reviewed and assigned a CPT code if possible or listed as "noncodable." To compensate for nonoperative rotations and noncompliance, case numbers were analyzed both annually and monthly to estimate average case numbers for all trainees. In addition, case logs of trainees were compared with the E/D list to assess how well it reflected actual trainee experience., Results: Eighteen ACC ACS and 11 non-ACC ACS trainees performed 16.4 (12.6) cases per month compared with 15.7 (14.2) cases for non-ACC ACS fellows (p = 0.71). When annualized, trainees performed, on average, 195 cases per year. Annual analysis led to similar results. The E/D list captured only approximately 50% of the trainees' operative experience. Only 77 cases were categorized as pediatric., Conclusion: ACS trainees have substantial operative experience averaging nearly 200 major cases during their ACS year. However, high variability exists in the number of essential or desirable cases being performed with approximately 50% of the fellows' operative experience falling outside the E/D list of cases. Modification of the fellows' operative experience and/or the rotation requirements seems to be needed to provide experience in E/D cases.

Background: The American College of Surgeons' Trauma Quality Improvement Program is focused on identifying variations in outcomes across trauma centers for the purposes of performance improvement. In previous analyses, patients who died in the emergency department were excluded. We investigated the effect of inclusion and exclusion of emergency department (ED) deaths (dead on arrival [DOA] and died in ED [DIE]) on analyses of overall risk-adjusted trauma center performance., Methods: Data for patients admitted to 65 Trauma Quality Improvement Program hospitals during the 2009 calendar year was used. A logistic regression model was developed to estimate risk-adjusted mortality. Trauma centers were then ranked based on their observed-to-expected (O/E) mortality ratio with 90% confidence intervals (CIs) and classified by outlier status: low outliers/high performers had a 90% CI for O/E mortality ratio of less than 1, and high outliers/low performers had a 90% CI for O/E mortality ratio of greater than 1. Changes in outlier status, rank, and quartile were examined with and without DOA and DIE patients included in the analyses to discern the impact of such exclusions on overall risk-adjusted center-specific performance., Results: Thirty-one trauma centers (48%) reported no DOA patients in 2009, while 6 centers (9%) reported more than 10. Of 224 patients, 14 (6.2%) had a documented time of death of more than 30 minutes after ED arrival despite being recorded as DOA. Forty-one trauma centers (63%) changed rank by three positions or less. Ten trauma centers changed their quartile ranking by a single quartile, but no centers were found to change quartile rank more than one quartile. Changes in outlier status occurred for 6 trauma centers (9%)., Conclusion: The relative frequency of patients classified as DOA varies greatly between trauma centers. Misclassification of patients as DOA occurs. Inclusion of ED deaths in risk-adjusted analysis of mortality results in a small but insignificant change in predicting the outcome results of a trauma center. This change is less than the rate of finding a center to be a high or low outlier by chance alone using the 90% CI. Inclusion of DOA and DIE patients in risk-adjusted analysis of mortality is appropriate and eliminates the bias introduced by exclusion of ED deaths owing to misuse of the DOA classification., Level of Evidence: Prognostic/epidemiologic study, level III.

Unlabelled: The purpose of this study was to implement a multidisciplinary daily quality checklist in a trauma intensive care setting to determine adherence to infection prevention protocols as well as the impact on infection and complications., Methods: A multidisciplinary team developed a checklist incorporating evidence-based practice guidelines for the prevention of hospital-acquired infections. Infection rates were monitored and correlated with checklist completion., Results: Central line, urinary tract infections, and ventilator-associated pneumonia decreased during the study period by 100%, 26%, and 82%, respectively., Conclusion: Initiation of a multidisciplinary daily quality checklist is correlated with decreased infection rates in a trauma intensive care setting.

Objectives: The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients., Methods: A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Score >or=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests., Results: There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients., Conclusions: CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers.

A 15 year old male was an unrestrained passenger in a high speed motor vehicle crash followed by ejection. The patient was noted to have evidence of bilateral pneumothorax upon arrival in the Emergency Department. Bilateral chest tubes were placed under sterile conditions; however, the left pneumothorax remained, and a second left chest tube was placed. Repeat chest radiographs revealed extensive subcutaneous emphysema, pneumomediastinum, and pneumopericardium. Needle aspiration of the pericardium returned significant quantities of air, an immediate improvement in blood pressures followed. An 18-gauge triple lumen catheter was placed into the pericardial space for additional withdrawal of air via syringe. Mechanisms have been proposed to explain the development of tension pneumopericardium after chest trauma. Early diagnosis is crucial, and may be found on initial chest radiographs. Computed tomography is also an effective method for evaluating the presence of air in the pericardial space and may assist in establishing the diagnosis. Tension pneumopericardium requires immediate recognition and decompression to prevent cardiac tamponade with a fatal circulation collapse, an entity that is as serious as the tamponade resulting from hemopericardium. Traumatic pneumopericardium is rare, but can be a complicated finding associated with high-speed blunt chest trauma. Patients with evidence of pneumopericardium should be closely monitored, particularly those supported by positive pressure ventilation.

Purpose: The National Surgical Quality Improvement Program has improved the quality of surgical care by tracking risk-adjusted patient outcomes. Unlike the National Surgical Quality Improvement Program, the trauma center verification program of the American College of Surgeons (ACS) focuses on availability of optimal resources, not outcomes. We hypothesized that significant variations in outcomes exist across similar level ACS-verified trauma centers despite availability of similar resources., Methods: The National Trauma Data Bank was used to identify adult patients (age 16-99 years) who were treated at ACS-verified Level I trauma centers that submitted at least 1,000 patients during the 5-year study period (264,102 patients from 58 trauma centers, excluding dead upon arrival). Multivariate logistic regression was used to analyze expected survival for each patient, adjusted for age, gender, race, injury mechanism, transfer status, and injury severity. Observed-to-expected survival ratios (O/E ratios with 95% confidence intervals) were used to rank trauma centers as high performers (O/E ratio significantly larger than 1), low performers (O/E ratio significantly less than 1), or average performers (O/E ratio overlapping 1)., Results: Almost half the centers performed significantly different from their risk-adjusted expectation. Fourteen were high performers, 11 were low performers, and 33 were average performers., Conclusions: The trauma center verification process in its present form may not ensure optimal outcome across all verified centers. If further validated, these findings suggest significant room for trauma quality improvement by replicating structures and processes of high performing trauma centers.

Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles., Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006., Results: Through trial and error, we developed a "quick and easy" method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal., Conclusions: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.

Background: To determine which patients need a "one-shot" intravenous pyelogram (IVP) before laparotomy for penetrating abdominal trauma., Study Design: Over a 15-month period, 240 laparotomies were performed for penetrating trauma at our urban level I trauma center. Prospectively collected data included clinical suspicion of genitourinary injury, results of preoperative IVP, intraoperative findings, and operative decisions influenced by the IVP., Results: Preoperative IVP was performed in 175 patients (73%). Of these, 71 (41%) had suspicion of a renal injury based on the presence of a flank wound or gross hematuria. The IVP was believed to influence operative decisions in six patients, all in this group. Each of these six patients had either a shattered kidney or a renovascular injury and had a nephrectomy performed with the knowledge that a normal functioning kidney was present on the contralateral side. No patient without a flank wound or gross hematuria had an IVP that was judged to be helpful intraoperatively. Preoperative IVP was helpful only in patients with flank wounds or gross hematuria. Nephrectomy was performed in two additional patients who did not undergo IVP, both of whom presented in shock., Conclusions: Routine preoperative IVP is not necessary in all patients undergoing laparotomy for penetrating trauma. The number of IVPs can be safely reduced by 60% if the indications are narrowed to include only those stable patients with a flank wound or gross hematuria.

Objective: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable patients with penetrating chest injuries., Methods: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center., Results: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18-100%), 96.6% (95% CI 88-100%), and 96.7% (95% CI 89-100%), respectively., Conclusion: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.

Background: To demonstrate the safety and efficacy of 65 degrees C (149 degrees F) centrally administered intravenous fluid (CIVF) compared to conventional 40 degrees C (104 degrees F) CIVF in the treatment of hypothermia., Method: Ten beagles (9-13 kg) were prospectively randomized to receive 65 degrees C or 40 degrees C CIVF. They were anesthetized and data were collected at baseline, during hypothermia, and after 1 and 2 hours of rewarming. The plasma free/total hemoglobin (PFHb/THb) was measured to detect hemolysis. Each subject was cooled to 30 degrees C (86 degrees F) and then received either 65 degrees C or 40 degrees C CIVF through a specialized catheter in the superior vena cava for 2 hours in addition to conventional rewarming techniques. All subjects survived 7 days, after which they were sacrificed and a complete autopsy was performed., Results: The rewarming rate was 3.7 degrees C/hr in the 65 degrees C CIVF group and 1.75 degrees C/hr in the 40 degrees C CIVF group. Core temperatures were significantly different after 1 hour (33.4 degrees +/- 0.77 degrees versus 31.7 degrees +/- 0.57 degrees, P < 0.01) and 2 hours (37 degrees +/- 1.03 degrees versus 33.4 degrees +/- 0.89 degrees, P < 0.001). PFHb/THb was not different. Two intimal injuries occurred in each group but these were remote from the infusion site. Blinded examination by two pathologists could not differentiate the etiology of these injuries from mechanical trauma., Conclusion: CIVF at 65 degrees C is a safe and effective means of treating hypothermia.

There are circumstances that make abdominal wall closure unsafe and technically impossible after laparotomy for trauma. In these difficult cases, prosthetic materials may be necessary to temporarily close the abdominal wall. To determine the optimal prosthetic in these instances, a retrospective chart review was conducted in our urban Level I trauma center. Twenty-five patients received 31 abdominal wall prostheses over a 4-year period. There were 7, 8, and 10 patients with 7 Marlex, 9 Dexon, and 15 Goretex prostheses, respectively. Each patient had only one type of prosthesis placed. The average age was 30.7 +/- 12.0 years, injury severity score was 20.3 +/- 7.4, and abdominal trauma index was 35.9 +/- 18.0; there was no significant difference in these values between groups. Eight patients died soon after the prosthesis was placed (average, 12.9 days) secondary to ongoing shock or multiple organ failure. Three of the seven surviving Goretex patients (43%) were intentionally left with small hernias. Three of the six Dexon patients (50%) were left with hernias; one of these eviscerated on day 150 and subsequently died, and the others have disabling gigantic hernias. Three of the four Marlex patients (75%) developed fistulae as a result of erosion into the small bowel or colon. One Marlex patient suffered with a chronically draining abdominal wound for 398 days prior to definitive closure. Goretex appears to be the best prosthetic for temporary abdominal wall closure because it causes less inflammatory reaction because of its smooth surface. It is therefore easier to retrieve at the time of definitive closure and carries less risk of fistula formation than other prostheses. Our Dexon patients suffered with gigantic hernias and one died because of complications of evisceration. We have abandoned the use of Marlex in abdominal wall closure because of the high incidence of fistula formation. We advocate the use of Goretex in temporary abdominal wall closure in this challenging group of patients.

Three weeks after a shotgun wound to the chest and abdomen, a patient developed acute ureteral colic caused by a migrating shotgun pellet. The pellet passed spontaneously. A search of the literature revealed 25 similar cases of this unusual complication of missile injuries to the abdomen. These cases are reviewed and analyzed. Ureteral obstruction from migrating retained missiles is an unusual complication of missile injuries to the abdomen. Cases have been described occurring after shotgun, gunshot, and shrapnel wounds. Cases involving bullets and shrapnel fragments usually have had long latent periods after the initial injury and required surgery to remove the obstructing projectile. In contrast, cases of "buckshot colic" from shotgun pellets present earlier and often resolve with spontaneous passage of the pellet. The following report illustrates how conservative management can be successful in cases of "buckshot colic."

A great deal of time and effort is spent attempting to diagnose myocardial contusion in patients with blunt thoracic trauma. Many diagnostic protocols have been proposed in the past. However, there is no test with sufficient specificity to predict which patients will develop complications that will require therapy. Recent studies have raised the question of limiting the cardiac evaluation in certain selected patients with blunt thoracic trauma. We prospectively studied the safety of limiting the cardiac evaluation in patients who were hemodynamically stable, had no history of cardiac disease, had a normal baseline ECG, did not require surgery or neurological observation for associated injuries, and were less than 55 years of age. These patients represent the majority of patients considered at risk for myocardial contusion when mechanism is the sole criterion. These patients were simply admitted for 24 hours of continuous cardiac monitoring. No patient developed any complications of myocardial contusion requiring therapy. We conclude that it is safe to limit the cardiac evaluation in this group of patients.

The objective was to establish the relationship between the aspiration of free blood (+ASP) versus diagnostic peritoneal lavage (DPL), abdominal injury severity, hemodynamic instability, and the need for immediate operative intervention. We prospectively compared the significance of +ASP to +DPL in our level I trauma center. Consecutive patients received sequential needle tap, catheter aspiration (ASP), and DPL. If gross blood was withdrawn during the tap or ASP, it was returned to the peritoneal cavity before completing the DPL. The DPL was considered positive if there were > 100,000 RBCs for blunt injuries or anterior abdominal stab wounds, or > 10,000 RBCs for other penetrating injuries. During a 12-month period, 566 patients fulfilled the study criteria; they were 50 per cent blunt and 50 per cent penetrating trauma. There were 70 patients with both +ASP/+DPL, 30 with -ASP/+DPL and 4 with +ASP but -DPL. Exploratory laparotomy was performed on these 104 patients (18.4%), 22 of which were considered nontherapeutic. The ATI was statistically higher in the +ASP patients (14.9 +/- 12.9 versus 8.5 +/- 8.2, P < 0.05) but was not clinically different. Overall injury severity and hemodynamic stability were not different in the two groups. The sensitivity of DPL at detecting intra-abdominal injury was higher than the ASP group (98% versus 72%), but the specificities were equal (98%). Because +ASP patients are not more critically injured or unstable than +DPL patients, and because DPL is more accurate in detecting the need for operative intervention, aspiration should be abandoned as part of the DPL procedure in patients with abdominal trauma.

The risk of nosocomial human immunodeficiency virus (HIV) infection among hospitalized patients comes almost exclusively from transfusion of fresh blood products. Current estimates of the risk of HIV infection from the transfusion of blood or components vary from 1/40,000 to 1/250,000 (0.0025% to 0.0004%), with the most probable likelihood estimated to be 1/153,000 (0.0007%). The major route of transmitting such HIV infection is via blood collected during the interval between infection of the donor and development of a detectable circulating antibody level to the AIDS virus (i.e., the "window period"). The current risk to hemophiliacs receiving treated coagulation factor concentrates is negligible. The risk to healthcare personnel of acquiring HIV infection from accidental puncture wounds and from handling HIV-infected blood or body fluids is 0.42% per episode. Most reported seroconversions have resulted from penetrating injuries with sharp objects contaminated with HIV-positive blood. The degree of risk to healthcare workers will vary with the community, the patient population served, and the frequency of penetrating injuries.