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Background: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths.Methods: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT.Results: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instability. Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cm catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p < 0.001).Conclusion: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement. [ABSTRACT FROM AUTHOR]

Background: Trauma care benefits from the use of imaging technologies. Trauma patients and trauma team members are exposed to radiation during the continuum of care. Knowledge of exposure amounts and effects are important for trauma team members.Methods: We performed a review of the published literature; keywords included "trauma," "patients," "trauma team members," "wounds," "injuries," "radiation," "exposure," "dose" and "computed tomography" (CT). We also reviewed the Board on Radiation Effects Research (BEIR VII) report, published in 2005 and 2006.Results: We found no randomized controlled trials or studies. Relevant studies demonstrated that CT accounts for the single largest radiation exposure in trauma patients. Exposure to 100 mSv could result in a solid organ cancer or leukemia in 1 of 100 people. Trauma team members do not exceed the acceptable occupation radiation exposure determined by the National Council of Radiation Protection and Management. Modern imaging technologies such as 16- and 64-slice CT scanners may decrease radiation exposure.Conclusion: Multiple injured trauma patients receive a substantial dose of radiation. Radiation exposure is cumulative. The low individual risk of cancer becomes a greater public health issue when multiplied by a large number of examinations. Though CT scans are an invaluable resource and are becoming more easily accessible, they should not replace careful clinical examination and should be used only in appropriate patients. [ABSTRACT FROM AUTHOR]

Background: For decades, trauma registries have been the primary source of data for resource allocation, quality improvement efforts and hypothesis-generating research in trauma care. Surprisingly, the quality and completion of data in these registries has rarely been reported. In preparation for a research program on population-based epidemiology of severe trauma, we evaluated the Calgary component of the Alberta Trauma Registry (ATR). Methods: We identified the ATR records of all adult trauma patients (aged >/= 16 yr) admitted to hospitals in the Calgary Health Region (CRH) between April 1, 2001 and March 31, 2002 with severe injuries (Injury Severity Score >/= 12). From these registry data, we randomly selected 100 patient records, and we compared 14 fields, sampling parameters from prehospital care to discharge, with information from the hospital chart. Results: Only 9 of 100 records were found to be incomplete. Of these, none had more than 1 field incomplete. Of the approximately 1400 data fields assessed, only 9 were missing data, resulting in a 99% (1391/1400) completion rate. Of 100 records, 22 were found to have inaccurate data; of these, 18 had 1 incorrect field, 2 had 2 incorrect fields and 2 had 3 incorrect fields. Overall, the ATR is 98% accurate. Conclusions: The Calgary component of the ATR can be considered accurate and complete. Some of its inaccuracy is attributable to a change in the way time to operating room was recorded. Data from all other fields collected in a standard manner can continue to be used with confidence for administrative and research purposes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Severe trauma arising from electrocution is uncommon, and we wished to study the incidence, risk factors and outcome to identify potential areas of prevention. We therefore studied an active population of adult victims of severe electrical trauma in a large area of Canada (the Calgary Health Region [CHR]). METHODS: From 3 databases, we collected data on all adult (> or = 18 yr) residents of the CHR who suffered electrical injury associated with an Injury Severity Score of 12 or greater or died as a result of electrocution between Apr. 1, 1996, and Mar. 1, 2002. Of particular interest were the incidence, the age and sex of the victims, the mechanism, the type of electrical power and the outcome. RESULTS: Ten cases of severe electrical trauma were identified (2.4 per 1 million population annually). Victims' ages were a mean (and standard deviation) of 38.2 (10.3) years. All 10 victims were male for an annual sex-specific incidence of 4.9 per 1 million people. Men aged 18-49 years were nearly 3 times more likely to be victims of electrocution than older men, although this result was not statistically significant (6.1 v. 2.1 per 1 million annually; relative risk 2.9; 95% confidence interval 0.4-127.5). All episodes of electrocution were unintentional, and 7 were occupationally related. All 10 electrocutions resulted from domestically generated current, and 9 were related to power-line exposure. Overall, 6 patients died for a death rate due to severe electrical trauma of 1.4 per 1 million people annually. CONCLUSION: This population-based study demonstrates that severe electrocution is rare but is associated with death in the majority of cases in this large Canadian region. [ABSTRACT FROM AUTHOR]

Objective: To describe the incidence of non-neurologic organ dysfunction and its association with outcome in patients with severe traumatic brain injury admitted to intensive care.Design: Observational cohort study.Setting: Foothills Medical Centre, which is the only neurosurgical service in southern Alberta (population approximately 1.3 million).Patients: Patients were 209 consecutive patients with severe traumatic brain injury.Interventions: None.Measurements and Main Results: Non-neurologic organ dysfunction was measured by the maximum modified multiple organ dysfunction score. Organ system failure was defined as a component score of >/=3 on any day during the patient's intensive care unit stay. One hundred and eighty-five patients (89%) developed dysfunction of at least one non-neurologic organ system. Ninety-six organ system failures were identified in 74 patients (35%). Respiratory failure was the most common non-neurologic organ system failure, occurring in 23% of patients, whereas cardiovascular failure occurred in 18%. Eight patients (4%) had failure of the coagulation system. One patient had renal failure, whereas no patient developed hepatic failure. In a multivariate model, non-neurologic organ dysfunction was independently associated with hospital mortality (odds ratio for hospital mortality, 1.63; 95% confidence interval, 1.34, 1.98 for one maximum modified multiple organ dysfunction score point). Non-neurologic organ dysfunction was also independently associated with dichotomized Glasgow Outcome Score, as a measure of neurologic outcome (odds ratio for unfavorable neurologic outcome, 1.53; 95% confidence interval, 1.22, 1.98 for one maximum modified multiple organ dysfunction score point). The timing of the organ dysfunction did not appear to be important in the prediction of outcome.Conclusions: Non-neurologic organ dysfunction is common in patients with severe traumatic brain injury and is independently associated with worse outcome. [ABSTRACT FROM AUTHOR]

The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of clinical examination or plain radiography but is ultimately detected with thoracoabdominal computed tomography (CT). This situation is increasingly common in trauma care with the increased use of CT. The rate is approximately 5% in injured people presenting to hospital, with CT revealing at least twice as many pneumothoraces as suspected on plain radiography. Whereas pneumothorax is a common and treatable cause of mortality and morbidity, there is substantial disagreement regarding the appropriate treatment of OP. The greatest controversy is in patients in the critical care unit who require positive-pressure ventilation. There is little current evidence to direct the proper management of ventilated trauma patients with OP, and no studies have focussed specifically on these patients. Future randomized trials will need to consider the potential effects of OP on pulmonary mechanics and potential influences on the known risks of ventilator-induced lung injury associated with mechanical ventilation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Bloodstream infection (BSI) is recognized as an important infectious complication of major trauma. However, its occurrence, the risk factors contributing to its development, and its outcomes have not been well described. DESIGN: Cohort with linkage of regional trauma and microbiology databases. PATIENTS: Adult trauma patients with injury severity score (ISS) > or = 12 admitted to a regional trauma centre during a 33-month period. RESULTS: Of 1797 victims of acute trauma identified (median ISS 20; interquartile range [IQR] 16-25), 71 (4%) had 77 episodes of BSI, for an overall rate of 2.9 per 1000 hospital days. BSI in the majority of patients (37 of 72, or 52%) had onsets within the first week of hospitalization; 7 (10%) patients had community-acquired BSI (onset within 2 d). Independently associated with the development of nosocomial BSI were higher ISSs (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07); requirement for ICU admission (OR 7.06, CI 3.38-14.75); and burns (OR 5.75, CI 2.16-15.30). Although trauma-related BSI was a predictor of increased in-hospital case fatality (15/71 v. 208/1726; relative risk 1.75, CI 1.10-2.78), it was not an independent predictor of death. CONCLUSION: In our series, 1 in 25 major trauma cases was complicated by BSI. The infection occurred within the first week after injury in over half of our cases. Knowledge of the epidemiology of these infections will be important for planning preventive or early therapeutic efforts. [ABSTRACT FROM AUTHOR]

The parasternal intercostal is an obligatory inspiratory muscle working in coordination with the diaphragm, apparently sharing a common pathway of neural response. This similarity has attracted clinical interest, promoting the parasternal as a noninvasive alternative to the diaphragm, to monitor central neural respiratory output. However, this role may be confounded by the distinct and different functions of the costal and crural diaphragm. Given the anatomic location, parasternal activation may significantly impact the chest wall via both mechanical shortening or as a "fixator" for the chest wall. Either mechanical function of the parasternal may also impact differential function of the costal and crural. The objectives of the present study were, during eupnea and hypercapnia, 1 ) to compare the intensity of neural activation of the parasternal with the costal and crural diaphragm and 2 ) to examine parasternal recruitment and changes in mechanical action during progressive hypercapnia, including muscle baseline length and shortening. In 30 spontaneously breathing canines, awake without confounding anesthetic, we directly measured the electrical activity of the parasternal, costal, and crural diaphragm, and the corresponding mechanical shortening of the parasternal, during eupnea and hypercapnia. During eupnea and hypercapnia, the parasternal and costal diaphragm share a similar intensity of neural activation, whereas both differ significantly from crural diaphragm activity. The shortening of the parasternal increases significantly with hypercapnia, without a change in baseline end-expiratory length. In conclusion, the parasternal shares an equivalent intensity of neural activation with the costal, but not crural, diaphragm. The parasternal maintains and increases its active inspiratory shortening during augmented ventilation, despite high levels of diaphragm recruitment. Throughout hypercapnic ventilation, the parasternal contributes mechanically; it is not relegated to chest wall fixation. NEW & NOTEWORTHY This investigation directly compares neural activation of the parasternal intercostal muscle with the two distinct segments of the diaphragm, costal and crural, during room air and hypercapnic ventilation. During eupnea and hypercapnia, the parasternal intercostal muscle and costal diaphragm share a similar neural activation, whereas they both differ significantly from the crural diaphragm. The parasternal intercostal muscle maintains and increases active inspiratory mechanical action with shortening during ventilation, even with high levels of diaphragm recruitment.

Background: The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks., Methods: We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design., Results: From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason., Conclusions: This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.

Introduction: Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the management of acute appendicitis and biliary disease., Methods: A comprehensive systematic review and meta-analysis of outcome studies for emergent appendectomy and cholecystectomy from 1966 to 2017, comparing studies prior to and following ACS implementation, were performed., Results: Of 1,704 studies, 27 were selected for analysis (appendicitis, 16; biliary pathology, 7; both, 4). Following ACS introduction, the complication rate was significantly reduced in both appendectomy and cholecystectomy (risk ratios, 0.70; 95% confidence interval [CI], 0.57-0.85; I = 9.2% and relative risk, 0.62; 95% CI, 0.41-0.94; I = 63.5%) respectively. There was a significant reduction in the time from arrival in emergency until admission and from admission to operation (-1.37 hours: 95% CI, -1.93 to -0.80; -2.51 hours: 95% CI, -4.44 to -0.58) in the appendectomy cohort. Time to operation was shorter in the cholecystectomy group (-6.46 hours; 95% CI, -9.54 to -3.4). Length of hospital stay was reduced in both groups (appendectomy, -0.9 day; cholecystectomy, -1.09 day). There was a reduction in overall cost in cholecystectomy group (-US $854.37; 95% CI, -1,554.1 to -154.05). No statistical significance was detected for wound infection, abscess, conversion of laparoscopy to open technique, rate of negative appendectomy, after hours, readmission, and cost., Conclusion: The implementation of ACS models in general surgery emergency care has significantly improved system and patient outcomes for appendicitis and biliary pathology., Level of Evidence: Systematic review and meta-analysis of a retrospective study, level III.

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown., Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed., Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively., Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada., Competing Interests: Anthony MacLean received a stipend to serve as a faculty member at an Ethicon colorectal surgery bootcamp for the Canadian colorectal surgery fellows. No other competing interests were declared., (© 2020 Joule Inc. or its licensors)

Classic physiology suggests that the two distinct diaphragm segments, costal and crural, are functionally different. It is not known if the two diaphragm muscles share a common neural mechanical activation. We hypothesized that costal and crural diaphragm are recruited differently during hypercapnic stimulated ventilation, and the EMG recordings of the esophageal crural diaphragm segment does not translate to the same level of mechanical shortening for costal and crural segments In 30 spontaneously breathing canines, without confounding anesthetic, we measured directly electrical activity and corresponding mechanical shortening of both the costal and crural diaphragm, at room air and during increasing hypercapnia. During hypercapnic ventilation, the costal diaphragm showed a predominant recruitment over the crural diaphragm. The distinct mechanical contribution of the costal segment was not due to a different level of neural activation between the two muscles as measured by segmental EMG activity. Thus, the two diaphragm segments exhibited a significantly different neural-mechanical relationship., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Surgical competence encompasses both technical and nontechnical skills. This study seeks to evaluate the validity evidence for a comprehensive surgical skills examination and to examine the relationship between technical and nontechnical skills., Methods: Six examination stations assessing both technical and nontechnical skills, conducted yearly for surgical trainees (n = 120) between 2010 and 2014 are included., Results: The assessment tools demonstrated acceptable internal consistency. Interstation reliability for technical skills was low (alpha = .39). Interstation reliability for the nontechnical skills was lower (alpha range -.05 to .31). Nontechnical skills domains were strongly correlated, ranging from r = .65, P < .001 to .86, P < .001. The associations between nontechnical and technical skills were inconsistent, ranging from poor (r = -.06; P = .54) to moderate (r = .45; P < .001)., Conclusions: Multiple samplings of integrated technical and nontechnical skills are necessary to assess overall surgical competency., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: In Advanced Trauma Life Support (ATLS©) courses, multiple choice question (MCQ) tests are used to assess student's post course knowledge. As part of the ninth Edition Revision Process, existing MCQ tests were reviewed and revised by an International MCQ Revision group. The aim of this study was to evaluate the revision procedure and its effects., Methods: Based on psychometric data and evidence based guidelines for adequate MCQ item and test development, a detailed stepwise approach was determined and followed to evaluate the existing MCQs, and to guide test item revision or replacement., Results: The MCQ Revision group composed three new draft test versions comprising of 40 MCQs each. These were beta-tested among ATLS Instructors in various countries involved in ATLS. Psychometric analysis demonstrated that a minority of MCQ items required revision to create three equally balanced tests. After these final adjustments, a new set of three validated MCQ tests was available for use in 9th edition ATLS provider courses. Beta testing was performed using instructors but not students. The failure rate amongst students of ATLS provider courses increased significantly after introduction of the new MCQ tests., Conclusion: ATLS tests were revised and updated using current evidence based guidelines and psychometric analysis. Difficulty of the tests was not initially beta-tested on students. Increasing test item discrimination and quality resulted in lower test scores by students., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation., Background: Animal studies suggest that the pathophysiology and physical signs of tension pneumothorax differ by subject ventilatory status., Methods: We searched electronic databases through to October 15, 2013 for observational studies and case reports/series reporting clinical manifestations of tension pneumothorax. Two physicians independently extracted clinical manifestations reported at diagnosis., Results: We identified 5 cohort studies (n = 310 patients) and 156 case series/reports of 183 cases of tension pneumothorax (n = 86 breathing unassisted, n = 97 receiving assisted ventilation). Hypoxia was reported among 43 (50.0%) cases of tension pneumothorax who were breathing unassisted versus 89 (91.8%) receiving assisted ventilation (P < 0.001). Pulmonary dysfunction progressed to respiratory arrest in 9.3% of cases breathing unassisted. As compared to cases who were breathing unassisted, the adjusted odds of hypotension and cardiac arrest were 12.6 (95% confidence interval, 5.8-27.5) and 17.7 (95% confidence interval, 4.0-78.4) times higher among cases receiving assisted ventilation. One cohort study reported that none of the patients with tension pneumothorax who were breathing unassisted versus 39.6% of those receiving assisted ventilation presented without an arterial pulse. In contrast to cases breathing unassisted, the majority (70.4%) of those receiving assisted ventilation who experienced hypotension or cardiac arrest developed these signs within minutes of clinical presentation., Discussion: The reported clinical presentation of tension pneumothorax depends on the ventilatory status of the patient. This may have implications for improving the diagnosis and treatment of this life-threatening disorder.

Objective: To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province., Background: Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers., Methods: We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models., Results: In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix., Conclusions: In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.

Background: Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high-volume centre changed over time., Methods: We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995-2011)., Results: Of the 12,879 severely injured patients requiring admission, there was a 1.5- fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19)., Conclusion: Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue.

Purpose of Review: Acute kidney injury (AKI) is common after major surgery, and is associated with morbidity, mortality, increased length of hospital stay, and high health care costs. Although recent guidelines for AKI provide recommendations for identification of patients at risk, monitoring, diagnosis, and management of AKI, there is lack of understanding to guide successful implementation of these recommendations into clinical practice., Sources of Information: We held a planning meeting with multidisciplinary stakeholders to identify barriers, facilitators, and strategies to implement recommendations for prevention, early identification, and management of AKI after major surgery. Barriers and facilitators to knowledge use for peri-operative AKI prevention and care were discussed., Findings: Stakeholders identified barriers in knowledge (how to identify high-risk patients, what criteria to use for diagnosis of AKI), attitudes (self-efficacy in preventive care and management of AKI), and behaviors (common use of diuretics, non-steroidal anti-inflammatory drugs, withholding of intravenous fluids, and competing time demands in peri-operative care). Educational, informatics, and organizational interventions were identified by stakeholders as potentially useful elements for future interventions for peri-operative AKI., Limitation: Meeting participants were from a single centre., Implications: The information and recommendations obtained from this stakeholder's meeting will be useful to design interventions to improve prevention and early care for AKI after major surgery.

Background: Injury epidemiology fluctuates with economic activity in many countries. These relationships remain unclear in Canada., Methods: The annual risk of admission for major injury (Injury Severity Score ≥12) to a high-volume, level-1 Canadian trauma center was compared with indicators of economic activity over a 16-year period using linear regression., Results: An increased risk of injured patient admissions was associated with rising mean gross domestic product (GDP [millions of chained 2002 dollars]) (.36 person increase per 100,000 population/$1,000 increase in GDP; P = .001) and annual gasoline prices (.47 person increase per 100,000 population/cent increase in gasoline price; P = .001). Recreation-related vehicle injuries were also associated with economic affluence. The risk of trauma patient mortality with increasing mean annual GDP (P = .72) and gasoline prices (P = .32) remained unchanged., Conclusion: Hospital admissions for major injury, but not trauma patient mortality, were associated with economic activity in a large Canadian health care region., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to develop a surgical skills program for first-year surgical residents by integrating the Canadian Medical Education Direction for Specialists (CanMEDS) roles., Methods: A 9-week course combining basic surgical skills and CanMEDS roles was developed and provided to 24 residents from the Departments of Surgery and Obstetrics and Gynecology at the University of Calgary. Sessions consisted of a pretest/posttest, teaching the surgical skills, supervised practice, posttest, and teaching CanMEDS roles., Results: The pretest scores indicated the residents' preparation and understanding of the session, which improved as the course progressed. The residents' satisfaction surveys graded on a scale from 1 to 5, syllabus content, syllabus effectiveness, teaching expectations, technical demonstrations, practice sessions, confidence gained, and bench model fidelity indicated a mean of 4.09 (standard deviation = 0.81) satisfaction with the new course. Similarly, preceptors' satisfaction surveys graded on a scale from 1 to 5 demonstrated a mean of 4.16 (standard deviation = 0.69) satisfaction., Conclusions: Surgical skills and CanMEDS roles of communication, professionalism, collaborator and manager, can be taught simultaneously proving that this new teaching format can be feasible, effective, and logistically convenient, providing a satisfying experience for both residents and preceptors., (© 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.)

Background: Although health care providers utilize classically described signs and symptoms to diagnose tension pneumothorax, available literature sources differ in their descriptions of its clinical manifestations. Moreover, while the clinical manifestations of tension pneumothorax have been suggested to differ among subjects of varying respiratory status, it remains unknown if these differences are supported by clinical evidence. Thus, the primary objective of this study is to systematically describe and contrast the clinical manifestations of tension pneumothorax among patients receiving positive pressure ventilation versus those who are breathing unassisted., Methods/design: We will search electronic bibliographic databases (MEDLINE, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews) and clinical trial registries from their first available date as well as personal files, identified review articles, and included article bibliographies. Two investigators will independently screen identified article titles and abstracts and select observational (cohort, case-control, and cross-sectional) studies and case reports and series that report original data on clinical manifestations of tension pneumothorax. These investigators will also independently assess risk of bias and extract data. Identified data on the clinical manifestations of tension pneumothorax will be stratified according to whether adult or pediatric study patients were receiving positive pressure ventilation or were breathing unassisted, as well as whether the two investigators independently agreed that the clinical condition of the study patient(s) aligned with a previously published tension pneumothorax working definition. These data will then be summarized using a formal narrative synthesis alongside a meta-analysis of observational studies and then case reports and series where possible. Pooled or combined estimates of the occurrence rate of clinical manifestations will be calculated using random effects models (for observational studies) and generalized estimating equations adjusted for reported potential confounding factors (for case reports and series)., Discussion: This study will compile the world literature on tension pneumothorax and provide the first systematic description of the clinical manifestations of the disorder according to presenting patient respiratory status. It will also demonstrate a series of methods that may be used to address difficulties likely to be encountered during the conduct of a meta-analysis of data contained in published case reports and series. PROSPERO registration number: CRD42013005826.

Background: Traumatic brain injury (TBI) constitutes the leading cause of posttraumatic mortality. Practically, the major interventions required to treat TBI predicate expedited transfer to CT after excluding other immediately life-threatening conditions. At our center, trauma responses variably consist of either full trauma activation (FTA) including an attending trauma surgeon or a non-trauma team response (NTTR). We sought to explore whether FTAs expedited the time to CT head (TTCTH)., Methods: Retrospective review of augmented demographics of 88 serious head injuries identified from a Regional Trauma Registry within one year at a level I trauma center. The inclusion criteria consisted of a diagnosis of head injury recorded as intubated or GCS < 13; and CT-head scanning after arriving the emergency department. Data was analyzed using STATA., Results: There were 58 FTAs and 30 NTTRs; 86% of FTAs and 17% of NTTRs were intubated prehospital out of 101 charts reviewed in detail; 13 were excluded due to missing data. Although FTAs were more seriously injured (median ISS 29, MAIS head 19, GCS score at scene 6.0), NTTRs were also severely injured (median ISS 25, MAIS head 21, GCS at scene 10) and older (median 54 vs. 26 years). Median TTCTH was double without dedicated FTA (median 50 vs. 26 minutes, p < 0.001), despite similar justifiable delays (53% NTTR, 52% FTA). Without FTA, most delays (69%) were for emergency intubation. TTCTH after securing the airway was longer for NTTR group (median 38 vs. 26 minutes, p =0.0013). Even with no requirements for ED interventions, TTCTH for FTA was less than half versus NTTR (25 vs. 61 minutes, p =0.0013). Multivariate regression analysis indicated age and FTA with an attending surgeon as significant predictors of TTCTH, although the majority of variability in TTCTH was not explained by these two variables (R² = 0.33)., Conclusion: Full trauma activations involving attending trauma surgeons were quicker at transferring serious head injury patients to CT. Patients with FTA were younger and more seriously injured. Discerning the reasons for delays to CT should be used to refine protocols aimed at minimizing unnecessary delays and enhancing workforce efficiency and clinical outcome.

Background: Most medical errors are nontechnical and include failures in team communication, situational awareness, resource use, and leadership. Other high-risk industries have adopted team-based crisis resource management (CRM) training strategies to address "nontechnical" skills and to improve human error and safety. Here, we describe the development and evaluation of a national multidisciplinary trauma CRM curriculum., Methods: A needs analysis survey was distributed to general surgery program directors across Canada. With the use of this feedback, a course called STARTT [Standardized Trauma and Resuscitation Team Training] was developed and held in conjunction with the Canadian Surgery Forum. Participants completed a precourse and postcourse evaluation exploring changes in attitudes toward simulation and CRM principles using previously validated instruments., Results: Twenty surgical residents, 6 nurses, 4 respiratory therapists, and 11 instructors (trauma surgeons, emergency physicians, nurses, and intensivists) participated. Of the participants, 100% completed the survey. Satisfaction was very high, with 97.5% of the participants rating the course as "good" or "excellent" and 97.5% recommending it to others. The presurvey and postsurvey showed statistically significant improvement in attitudes toward simulation and overall CRM principles (136.3 vs. 140.3 of 170, p = 0.004) following the course, primarily in the domain of teamwork (69.1 vs. 72.0 of 85, p = 0.002)., Conclusion: Creation of a national multidisciplinary trauma CRM curriculum is feasible, has high satisfaction among participants, and can improve attitudes toward the importance of simulation and CRM principles with the ultimate goal of improving patient safety and care.

Background: Pericardiocentesis (PCC) had been taught as a mandatory skill in the Advanced Trauma Life Support (ATLS®) course as a bridge to definitive surgical therapy for traumatic pericardial tamponade since its inception in 1978. Immediate thoracotomy for penetrating trauma to the heart and chest has resulted in the decreased use of PCC in trauma. PCC is now offered as an optional skill in the ninth edition of the ATLS®. A review of the literature regarding the use and effectiveness of PCC in traumatic pericardial tamponade in the modern era is necessary to better define its current role in trauma care., Methods: Scientific publications from 1970 to 2010 involving PCC after trauma were identified. The Preferred Reporting Items for Systematic reviews and Meta-Analyses was used. Human studies describing acute traumatic tamponade were included. Publications involving nontraumatic or chronic pericardial tamponade from effusions caused by inflammatory, infectious, or neoplastic etiology were excluded. Publications were categorized by level of evidence., Results: Of the 135 publications identified, 27 were included, composing of 2,094 trauma patients with suspected cardiac tamponade. The reported use of PCC decreased from 45.9% of patients in the period 1970 to 1979 down to 6.4% of patients in the period between 2000 and 2010 (p < 0.05). Reported rates describing the use of PCC as the sole intervention decreased from 13.7% in the period 1970 to 1979 to 2.1% in the period 2000 to 2010 (p < 0.05). Survival analysis after PCC was possible for 380 patients. Overall survival following PCC was 83.4% (n = 317) and 91.8% (n = 145) when used as the sole intervention. In patients who received PCC then thoracotomy, survival rate was 79.5% (n = 178)., Conclusion: Studies on the use of PCC for trauma are limited and biased toward survivors. The reported survival rate is high. There remains a limited role for PCC in nontrauma centers where definitive surgical management is not immediately available and transport time to a higher level of care facility supports the use of temporary decompression by PCC., Level of Evidence: Systematic review, level III.

There is pressure for surgical departments to introduce new and innovative health technologies in an evidence-based manner while ensuring that they are safe and effective and can be managed with available resources. A local health technology assessment (HTA) program was developed to systematically integrate research evidence with local operational management information and to make recommendations for subsequent decision by the departmental executive committee about whether and under what conditions the technology will be used. The authors present a retrospective analysis of the outcomes of this program as used by the Department of Surgery & Surgical Services in the Calgary Health Region over a 5-year period from December 2005 to December 2010. Of the 68 technologies requested, 15 applications were incomplete and dropped, 12 were approved, 3 were approved for a single case on an urgent/emergent basis, 21 were approved for "clinical audit" for a restricted number of cases with outcomes review, 14 were approved for research use only, and 3 were referred to additional review bodies. Subsequent outcome reports resulted in at least 5 technologies being dropped for failure to perform. Decisions based on local HTA program recommendations were rarely "yes" or "no." Rather, many technologies were given restricted approval with full approval contingent on satisfying certain conditions such as clinical outcomes review, training protocol development, or funding. Thus, innovation could be supported while ensuring safety and effectiveness. This local HTA program can be adapted to a variety of settings and can help bridge the gap between evidence and practice.

Background: Limited controlled data exist regarding the role of bioprosthetic meshes for hernia repair. Often the only option available in contaminated cases, their high cost calls for an evaluation of their utility and indications for use., Methods: A retrospective review of cases in which human acellular dermal matrix (HADM) was used to reconstruct a thoracoabdominal wall defect at the Foothills Medical Centre of Calgary was conducted. Attention was placed to identify the need for surgical reintervention postoperatively., Results: Over 2 years, 13 patients required the use of HADM for reconstruction of their thoracoabdominal wall; 69.2% of the cases were contaminated or infected. Three patients (23.1%) presented postoperative infectious complications; only 1 required reoperation. No patients required removal of their prosthesis. Two patients presented recurrences (median follow-up = 126 days)., Conclusions: The use of HADM for complex thoracoabdominal wall defects in contaminated or infected settings is a reliable option available for surgeons., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: A common tenet in emergency medical services (EMS) is that faster response equates to better patient outcome, translated by some EMS operations into a goal of a response time of 8 minutes or less for advanced life support (ALS) units responding to life-threatening events., Objective: To explore whether an 8-minute EMS response time was associated with mortality., Methods: This was a one-year retrospective cohort study of adults with a life-threatening event as assessed at the time of the 9-1-1 call (Medical Priority Dispatch System Echo- or Delta-level event). The study setting was an urban all-ALS EMS system serving a population of approximately 1 million. Response time was defined as 9-1-1 call receipt to ALS unit arrival on scene, and outcome was defined as all-cause mortality at hospital discharge. Potential covariates included patient acuity, age, gender, and combined scene and transport interval time. Stratified analysis and logistic regression were used to assess the response time-mortality association., Results: There were 7,760 unit responses that met the inclusion criteria; 1,865 (24%) were ≥8 minutes. The average patient age was 56.7 years (standard deviation = 21.5). For patients with a response time ≥8 minutes, 7.1% died, compared with 6.4% for patients with a response time ≤7 minutes 59 seconds (risk difference 0.7%; 95% confidence interval [CI]: -0.5%, 2.0%). The adjusted odds ratio of mortality for ≥8 minutes was 1.19 (95% CI: 0.97, 1.47). An exploratory analysis suggested there may be a small beneficial effect of response ≤7 minutes 59 seconds for those who survived to become an inpatient (adjusted odds ratio = 1.30; 95% CI: 1.00, 1.69)., Conclusions: These results call into question the clinical effectiveness of a dichotomous 8-minute ALS response time on decreasing mortality for the majority of adult patients identified as having a life-threatening event at the time of the 9-1-1 call. However, this study does not suggest that rapid EMS response is undesirable or unimportant for certain patients. This analysis highlights the need for further research on who may benefit from rapid EMS response, whether these individuals can be identified at the time of the 9-1-1 call, and what the optimum response time is.

Introduction: Screening CT often detects posttraumatic pneumothoraces that were not diagnosed on a preceding supine anteroposterior chest radiograph (occult pneumothoraces (OPTXs)). Because abdominal CT imaging misses OPTXs in the upper thorax, the objective of this study was to evaluate the utility of cervical spine (C-spine) CT screening for diagnosing OPTXs., Methods: A dual-institution (Foothills Medical Centre and Grady Memorial Hospital) retrospective review of consecutive OPTXs was performed. The accuracy of various CT screening protocols in detecting OPTXs was compared., Results: OPTXs were detected in 75 patients. Patient demographics and injury characteristics were similar between centres (65% male; 97% blunt mechanism; 29% hemodynamically unstable; mean ISS=27; mean length of stay=22 days; mortality=9%)(p>0.05). Patients received either abdominal (41%) or thoraco-abdominal (59%) CT imaging. Most patients (89%) also underwent C-spine CT imaging. OPTXs were evident on thoracic CT in 100% (44/44), abdominal CT in 83% (62/75), and C-spine CT in 82% (55/67) of cases. All patients with OPTXs identified solely on thoracic CT (i.e. not abdominal) who also underwent imaging of their C-spine could have had their OTPXs diagnosed by using the pulmonary windows setting of their C-spine CT series. Combining C-spine and abdominal CT screening diagnosed all OPTXs (67/67) detected on thoracic CT, for patients who also underwent these investigations., Conclusions: OPTXs were evident on thoracic (and not abdominal) CT in 17% of severely injured patients. For patients who also underwent C-spine imaging, all OPTXs isolated to thoracic CT could be diagnosed by using the pulmonary windows setting of their C-spine CT imaging protocol. All OPTXs, regardless of intra-thoracic location, could also be detected by combining C-spine and abdominal CT screening., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Managing complex abdominal wall injuries acutely or at the time of reconstruction is challenging. Contaminated surgical fields, devitalized tissue, intestinal fistula and tissues under tension contribute to clinical scenarios where closure is not possible or morbidity is unacceptable. The introduction of an absorbable extracellular matrix derived from porcine small intestinal submucosa (Surgisis) adds a potentially useful tool to the surgeon's armamentarium. A retrospective case series of the initial experience in 5 patients with complex abdominal wall injury following trauma managed with Surgisis is described. A review of the literature describing the use of Surgisis in contaminated fields is also performed., (2010 Elsevier Ltd. All rights reserved.)

Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized.

Background: Airway compromise secondary to isolated injury at the atlas (C1) and axis (C2) without an associated spinal cord injury is a rare, but recognized phenomenon that results in significant morbidity and mortality. No previous study in the literature has reported the incidence of this potentially lethal complication of these relatively common fractures., Methods: The medical records for 625 consecutive patients who presented to a Level I trauma center with C1 and C2 fractures during the years from 1996 to 2005 were reviewed retrospectively. Strict inclusion and exclusion criteria were applied to identify adult patients with isolated fractures and no other injuries. All patients that developed significant airway compromise were identified and correlations were made with the patient's demographic features, clinical presentation, and radiologic findings, to determine potential risk factors., Results: During the 10 years studied, 343 patients with isolated C1 and C2 fractures were identified. Of these, 17 patients developed significant airway compromise. This represents a 4.9% incidence of this potentially life-threatening complication. Older age and male gender were found to be risk factors with a statistically significant association (p value <0.05). The majority of patients also exhibited prevertebral swelling, the presence of significant degenerative changes, and significant fracture displacement. Twelve patients required intubation and admission to Intensive Care Unit (ICU). There were four deaths., Conclusions: Approximately 5% of patients with isolated C1 and C2 fractures developed airway compromise. All patients with these injuries should be assessed for the risk of developing this complication and some will require close monitoring to detect this problem at an early stage.

Background: Non-operative management of blunt hepatic trauma is successful in the majority of hemodynamically stable patients. Due to the risk of recurrent hemorrhage, pharmacologic deep venous thrombosis (DVT) prophylaxis is often delayed. The optimal timing of prophylaxis is unclear. A multi-centre, retrospective review of patients with blunt hepatic injuries presenting between 2000 and 2004 was performed. All patients had an ISS >/= 12 and a CT scan confirming hepatic trauma. Patients were categorized into: (1) early DVT prophylaxis (48 hrs), and (3) no prophylaxis., Methods and Results: Thirty-seven (25%) and 45 (42%) patients received early and delayed DVT prophylaxis respectively. The remainder (32%) received none. Mean hepatic injury grades were lower in the early prophylaxis group (II) compared to the delayed and no prophylaxis cohorts (III)(p = 0.002). The number of patients requiring post-admission blood transfusions was highest in the delayed group (44%) compared to the early (26%) and no prophylaxis (6%) groups (p = 0.03). No patient in the early prophylaxis cohort developed a DVT or required delayed angiographic or operative intervention. Two patients in the delayed group failed non-operative management. Eight (18%) patients in the delayed group developed a clinically significant DVT; 1 (2%) progressed to a PE., Conclusion: Practice patterns indicate that chemical DVT prophylaxis initiated within 48 hours of admission may be safe in patients with significant blunt hepatic trauma. Delays in prevention result in venothromboembolic events, but not in fewer blood transfusions or a decreased need for subsequent angiographic or operative therapies.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Background: A tension pneumothorax requires immediate decompression using a needle thoracostomy. According to advanced trauma life support guidelines this procedure is performed in the second intercostal space (ICS) in the midclavicular line (MCL), using a 4.5-cm (2-inch) catheter (5-cm needle). Previous studies have shown a failure rate of up to 40% using this technique. Case reports have suggested that this high failure rate could be because of insufficient length of the needle., Objectives: To analyze the average chest wall thickness (CWT) at the second ICS in the MCL in a trauma population and to evaluate the length of the needle used in needle thoracostomy for emergency decompression of tension pneumothoraces., Methods: Retrospective review of major trauma admissions (Injury Severity Score >12) at the Foothills Medical Centre in Calgary, Canada, who underwent a computed tomography chest scan admitted in the period from October 2001 until March 2004. Subgroup analysis on men and women, <40 years of age and >/=40 years of age was defined a priori. CWT was measured to the nearest 0.01 cm at the second ICS in the MCL., Results: The mean CWT in the 604 male patients and 170 female patients studied averaged 3.50 cm at the left second ICS MCL and 3.51 cm on the right. The mean CWT was significantly higher for women than men (p < 0.0001). About 9.9% to 19.3% of the men had a CWT >4.5 cm and 24.1% to 35.4% of the women studied., Conclusions: A catheter length of 4.5 cm may not penetrate the chest wall of a substantial amount (9.9%-35.4%) of the population, depending on age and gender. This study demonstrates the need for a variable needle length for relief of a tension pneumothorax in certain population groups to improve effectiveness of needle thoracostomy.

Background: The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF)., Methods: A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve., Results: Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R)., Conclusion: Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.

Background: Post-traumatic splenic pseudocysts are uncommon. The optimal treatment is not well defined., Methods: A retrospective chart review was conducted at the three adult hospitals in the Calgary Health Region., Results: Six cases of splenic pseudocysts were found over a 6-year period. One splenic pseudocyst spontaneously resolved. A second splenic cyst was removed by open splenectomy. The remaining 4 patients were all first treated with percutaneous drainage. However, 3 of the 4 cysts recurred. Two of these 3 recurrent cysts were treated with laparoscopic fenestration, and all subsequently recurred; 1 of these patients later developed a splenic abscess. The third patient had a repeat percutaneous drain with subsequent recurrence. The last patient died of sepsis secondary to an iatrogenic punctured colon., Conclusions: Percutaneous drainage and laparoscopic fenestration have an unacceptably high rate of failure. Partial or complete splenectomy should be considered for young and otherwise healthy patients who have large symptomatic splenic pseudocysts.

Study Objectives: Patients requiring prolonged admission to the ICU consume significant health-care resources and have a high rate of in-hospital death. The long-term mortality outcome of these patients has not been well defined in a nonselected cohort. The objective of this study was to describe the occurrence and factors predictive of prolonged ICU stay at admission, and to define the long-term (>/= 1 year) mortality outcome., Design: Population-based cohort., Setting: All adult multisystem and cardiovascular surgical ICUs in the Calgary Health Region (CHR) from July 1, 1999, to March 31, 2002., Patients: Adult (>/= 18 years old) residents of the CHR admitted to regional ICUs., Interventions: None., Measurements and Results: During the study, 4,845 patients had a median length of stay of 2 days (interquartile range, 1 to 4 days); 2,115 patients (44%) were admitted for < 2 days, 1,496 patients (31%) were admitted for 2 to 3 days; 1,018 patients (21%) were admitted from 4 to 13 days; and 216 patients (4%) had a prolonged (>/= 14 day) admission to the ICU. A higher severity of illness, the presence of shock, and bloodstream infection were independently associated with a prolonged ICU admission, and cardiovascular surgery was associated with a lower risk. Patients with prolonged ICU admissions were nearly twice as likely to die as patients with shorter ICU admissions: 53 of 216 patients (25%) vs 584 of 4,629 patients (13%) [p = 0.0001]. Among the 3,924 survivors to hospital discharge, the rates of mortality during the year following ICU admission were as follows: 59 deaths in 1,758 patients (3%) admitted < 2 days, 74 deaths in 1,267 patients (6%) with 2- to 3-day admissions, 78 deaths in 766 patients (10%) with 4- to 13-day admissions, and 10 deaths in 133 patients (8%) with admissions >/= 14 days., Conclusions: One in 25 critically ill patients will have prolonged ICU admission and higher ICU-related mortality. However, survivors of prolonged ICU admission have good long-term mortality outcome after acute illness.

Background: Nonradiologists typically diagnose pneumothoraces (PTX) based on a visible pleural stripe. PTXs not seen on supine AP chest radiographs (CXR), but appreciated on a computed tomographic (CT) scan, termed occult pneumothoraces (OPTX), are increasingly common. The purpose was to (1) determine whether perceived OPTXs were truly occult or simply missed and (2) address factors that contribute to the poor sensitivity of the supine CXR., Methods: A previous study of severely injured patients (ISS >or =12) identified 44 patients with OPTXs. JPEG images of these CXRs were randomly arranged with images of 11 injured patients without PTXs (CT proven). Three unique groups of radiologists reviewed the images for signs of PTXs, and determined if a thoracic CT was subsequently required., Results: Retrospective review identified only 12 to 24% of the OPTXs depending on radiology group. The kappa inter-observer agreement value was 0.55 to 0.56 (poor agreement). PTXs were most commonly identified via the deep sulcus sign (75-90%). CXRs were considered inadequate in 16 to 25% of OPTX images and in 0 to 18% of images without OPTXs. Thoracic CT scans were recommended in 18 to 33% of patients with inadequate CXRs, but 67 to 82% of patients with adequate CXRs., Conclusions: Less than 24% of all OPTXs might have been inferred from subtle radiologic findings, such as the deep sulcus sign. The majority of OPTX cases (50-64%) did not warrant a CT scan based on other findings. Concern for an OPTX after severe trauma is a valid indication for thoracic CT.