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The objective of this study was to determine the profile (credentials, training, and type of practice) of female academic general surgeons and factors that influenced their career choice. A survey was sent to female academic surgeons identified through general surgery residency programs and American medical schools. The women had to be Board eligible/certified by the American Board of Surgery or equivalent Board and have an academic appointment in a Department of Surgery. Data were analyzed using the SPSS program. Two hundred seventy women (age range, 32-70 years) completed the survey (98.9% response rate). Fellowships were completed by 82.3 per cent (223/270), most commonly in surgical critical care. There were 134 (50.2%, 134/367) who had two or more Board certificates, most frequently (46%, 61/134) in surgical critical care. Full-time academic appointments were held by 86.7 per cent of women, most as assistant professors, clinical track; only 12.4 per cent were tenured professors. The majority of women described their practice as "general surgery" or "general surgery with emphasis on breast." The most frequent administrative title was "Director." Only three women stated that they were "chair" of the department. The top reason for choosing surgery was "gut feeling," whereas "intellectual challenge" was the reason they pursued academic surgery. When asked "Would you do it again?", 77 per cent responded in the affirmative. We conclude that female academic surgeons are well trained, with slightly more than half having two or more Board certificates; that most female academic surgeons are clinically active assistant or associate professors whose practice is "general surgery," often with an emphasis on breast disease; that true leadership positions remain elusive for women in academic general surgery; and that 77 per cent would choose the same career again. [ABSTRACT FROM AUTHOR]

Background: Firearm-related injury is the leading cause of death among children and adolescents. There is a need to clarify the association of neighborhood environment with gun violence affecting children. We evaluated the relative contribution of specific social determinants to observed rates of firearm-related injury in children of different ages., Methods: This was a population-based study of firearm injury in children (age <18 years) that occurred in Philadelphia census tracts (2015-2021). The exposure was neighborhood Social Deprivation Index (SDI) quintile. The outcome was the rate of pediatric firearm injury due to interpersonal violence stratified by age, sex, race, and year. Hierarchical negative binomial regression measured the risk-adjusted association between SDI quintile and pediatric firearm injury rate. The relative contribution of specific components of the SDI to neighborhood risk of pediatric firearm injury was estimated. Effect modification and the role of specific social determinants were evaluated in younger (<15 years old) versus older children., Results: 927 children were injured due to gun violence during the study period. Firearm-injured children were predominantly male (87%), of black race (89%), with a median age of 16 (IQR 15-17). Nearly one-half of all pediatric shootings (47%) occurred in the quintile of highest SDI (Q5). Younger children represented a larger proportion of children shot in neighborhoods within the highest (Q5), compared with the lowest (Q1), SDI quintile (25% vs 5%; p<0.007). After risk adjustment, pediatric firearm-related injury was strongly associated with increasing SDI (Q5 vs Q1; aRR 14; 95% CI 6 to 32). Specific measures of social deprivation (poverty, incomplete schooling, single-parent homes, and rented housing) were associated with significantly greater increases in firearm injury risk for younger, compared with older, children. Component measures of the SDI explained 58% of observed differences between neighborhoods., Conclusions: Neighborhood measures of social deprivation are strongly associated with firearm-related injury in children. Younger children appear to be disproportionately affected by specific adverse social determinants compared with older children. Root cause evaluation is required to clarify the interaction with other factors such as the availability of firearms and interpersonal conflict that place children at risk in neighborhoods where gun violence is common., Level of Evidence: Level III - Observational Study., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Motor vehicle crashes (MVCs) are a leading cause of preventable trauma death in the United States. Access to trauma center care is highly variable nationwide. The objective of this study was to measure the association between geospatial access to trauma center care and MVC mortality., Methods: This was a population-based study of MVC-related deaths that occurred in 3,141 US counties (2017-2020). American College of Surgeons and state-verified Level I to III trauma centers were mapped. Geospatial network analysis estimated the ground transport time to the nearest trauma center from the population-weighted centroid for each county. In this way, the exposure was the predicted access time to trauma center care for each county population. Hierarchical negative binomial regression measured the risk-adjusted association between predicted access time and MVC mortality, adjusting for population demographics, rurality, access to trauma resources, and state traffic safety laws., Results: We identified 92,398 crash fatalities over the 4-year study period. Trauma centers mapped included 217 Level I, 343 Level II, and 495 Level III trauma centers. The median county predicted access time was 47 minutes (interquartile range, 26-71 minutes). Median county MVC mortality was 12.5 deaths/100,000 person-years (interquartile range, 7.4-20.3 deaths/100,000 person-years). After risk-adjustment, longer predicted access times were significantly associated with higher rates of MVC mortality (>60 minutes vs. <15 minutes; mortality rate ratio 1.36; 95% confidence interval, 1.31-1.40). This relationship was significantly more pronounced in urban/suburban vs. rural/wilderness counties ( p for interaction, <0.001). County access to trauma center care explained 16% of observed state-level variation in MVC mortality., Conclusion: Geospatial access to trauma center care is significantly associated with MVC mortality and contributes meaningfully to between-state differences in road traffic deaths. Efforts to improve trauma system organization should prioritize access to trauma center care to minimize crash fatalities., Level of Evidence: Prognostic and Epidemiological, Level III., (Copyright © 2023 American Association for the Surgery of Trauma.)

Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications., Background: Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance., Methods: Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort., Results: There were 274 patients included (71.2% male). Mean age was 50.56  ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001)., Conclusions: There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Background: Physiologic changes in the elderly lead to higher morbidity and mortality after injury. Increasing level of trauma activation has been proposed to improve geriatric outcomes, but the increased cost to the patient and stress to the hospital system are significant downsides. The purpose of this study was to identify the age at which an increase in activation status is beneficial., Methods: A retrospective review of trauma patients 70 years or older from October 1, 2011, to October 1, 2016, was performed. On October 1, 2013, a policy change increased the activation criteria to the highest level for patients 70 years or older with a significant mechanism of injury. Patients who presented prior to (PRE) were compared with those after the change (POST). Data collected included age, Injury Severity Score (ISS), length of stay (LOS), complications, and mortality. Primary outcome was mortality, and secondary outcome was LOS. Multivariable regressions controlled for age, ISS, injury mechanism, and number of complications., Results: A total of 4,341 patients met the inclusion criteria, 1,919 in PRE and 2,422 in POST. Mean age was 80.4 and 81 years in PRE and POST groups, respectively (p = 0.0155). Mean ISS values were 11.6 and 12.4 (p < 0.0001) for the PRE and POST groups. POST had more Level 1 activations (696 vs. 220, p < 0.0001). After controlling for age, ISS, mechanism of injury, and number of complications, mortality was significantly reduced in the POST group 77 years or older (odds ratio, 0.53; 95% confidence interval, 0.3-0.87) (Fig. 1). Hospital LOS was significantly reduced in the POST group age 78 years or older (regression coefficient, -0.55; 95% confidence interval, -1.09 to -0.01) (Fig. 2)., Conclusions: This study suggests geriatric trauma patients 77 years or older benefit from the highest level of trauma activation with shorter LOS and lower mortality. A focused approach to increasing activation level for elderly patients may decrease patient cost., Level of Evidence: Therapeutic/Care Management, level IV.

Background: Leadership has emerged as a crucial component of professional development for physicians in academic medicine. Most leadership skills can be learned and therefore best practices of delivering leadership development are in high demand. For practicing surgeons, specific strategies to teach leadership have been lacking., Objective: The purpose of this paper is to describe the structure of a tier-based leadership development program called Leaders Growing Leaders, to identify the major curricular components to each tier including measures and outcomes, and to share lessons learned for those who may want to begin a similar leadership development program., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Traditional practices in the delivery of nutrition to the surgical patient include reliance on nonspecific laboratory markers to define malnutrition, prolonged periods of nil per os, early and liberal initiation of parenteral nutrition, withholding enteral feedings based on gastric residual volume measurements, and pursuing feeding tube access for most patients unable to take oral nutrition. However, recent studies call into question all of these practices. This review aims to provide evidenced-based support to abandon these myths regarding nutrition delivery and offer practical up-to-date advice for best practices in patient care.

Background: The American Association for the Surgery of Trauma (AAST) has developed a new grading system for uniform description of anatomic severity of emergency general surgery (EGS) diseases, ranging from Grade I (mild) to Grade V (severe). The purpose of this study was to determine the relationship of AAST grades for acute colonic diverticulitis with patient outcomes. A secondary purpose was to propose an EGS quality improvement program using risk-adjusted center outcomes, similar to National Surgical Quality Improvement Program and Trauma Quality Improvement Program methodologies., Methods: This was a retrospective study of 1,105 patients (one death) from 13 centers. At each center, two reviewers (blinded to each other's assignments) assigned AAST grades. Interrater reliability was measured using κ coefficient. Relationship between AAST grade and clinical events (complications, intensive care unit use, surgical intervention, and 30-day readmission) as well as length of stay was measured using regression analyses to control for age, comorbidities, and physiologic status at the time of admission. Final model was also used to calculate observed-to-expected (O-E) ratios for adverse outcomes (death, complications, readmissions) for each center., Results: Median age was 54 years, 52% were males, 43% were minorities, and 22% required a surgical intervention. Almost two thirds had Grade I or II disease. There was a high level of agreement for grades between reviewers (κ = 0.81). Adverse events increased from 13% for Grade I, to 18% for Grade II, 28% for Grade III, 44% for Grade IV, and 50% for Grade V. Regression analysis showed that higher disease grades were independently associated with all clinical events and length of stay, after adjusting for age, comorbidities, and physiology. O-E ratios showed statistically insignificant variations in risk of death, complications, or readmissions., Conclusion: AAST grades for acute colonic diverticulitis are independently associated with clinical outcomes and resource use. EGS quality improvement program methodology that incorporates AAST grade, age, comorbidities, and physiologic status may be used for measuring quality of EGS care. High-quality EGS registries are essential for developing meaningful quality metrics., Level of Evidence: Prognostic study, level V.

Object: Hypothermia has been extensively evaluated in the management of traumatic brain injury (TBI), but no consensus as to its effectiveness has yet been reached. Explanatory hypotheses include a possible confounding effect of the neuroprotective benefits by adverse systemic effects. To minimize the systemic effects, the authors evaluated a selective cerebral cooling system, the CoolSystem Discrete Cerebral Hypothermia System (a "cooling cap"), in the management of TBI., Methods: A prospective randomized controlled clinical trial was conducted at Grady Memorial Hospital, a Level I trauma center. Adults admitted with severe TBI (Glasgow Coma Scale [GCS] score < or = 8) were eligible. Patients assigned to the treatment group received the cooling cap, while those in the control group did not. Patients in the treatment group were treated with selective cerebral hypothermia for 24 hours, then rewarmed over 24 hours. Their intracranial and bladder temperatures, cranial-bladder temperature gradient, Glasgow Outcome Scale (GOS) and Functional Independence Measure (FIM) scores, and mortality rates were evaluated. The primary outcome was to establish a cranial-bladder temperature gradient in those patients with the cooling cap. The secondary outcomes were mortality and morbidity per GOS and FIM scores., Results: The cohort comprised 25 patients (12 in the treatment group, 13 controls). There was no significant intergroup difference in demographic data or median GCS score at enrollment (treatment group 3.0, controls 3.0; p = 0.7). After the third hour of the study, the mean intracranial temperature of the treatment group was significantly lower than that of the controls at all time points except Hours 4 (p = 0.08) and 6 (p = 0.08). However, the target intracranial temperature of 33 degrees C was achieved in only 2 patients in the treatment group. The mean intracranial-bladder temperature gradient was not significant for the treatment group (p = 0.07) or the controls (p = 0.67). Six (50.0%) of 12 patients in the treatment group and 4 (30.8%) of 13 in the control group died (p = 0.43). The medians of the maximum change in GOS and FIM scores during the study period (28 days) for both groups were 0. There was no significant difference in complications between the groups (p value range 0.20-1.0)., Conclusions: The cooling cap was not effective in establishing a statistically significant cranial-bladder temperature gradient or in reaching the target intracranial temperature in the majority of patients. No significant difference was achieved in mortality or morbidity between the 2 groups. As the technology currently stands, the Discrete Cerebral Hypothermia System cooling cap is not beneficial for the management of TBI. Further refinement of the equipment available for the delivery of selective cranial cooling will be needed before any definite conclusions regarding the efficacy of discrete cerebral hypothermia can be reached.

Background: Although both human immunodeficiency virus (HIV) infection and diarrhea are considerable problems in Cambodia, there have not been any studies to determine the history, clinical presentation, and etiology of chronic diarrhea in patients with HIV infection in Cambodia. In this article, we present a case-control study involving 40 HIV-infected patients with chronic diarrhea and 40 HIV-infected patients without diarrhea., Methods: Clinical, demographic, and laboratory data were collected. Stool samples were examined for parasites, including Cryptosporidium species (by partial acid-fast stain), bacterial pathogens, and rotavirus. Samples from 10 case patients and 10 control subjects were also analyzed for Cryptosporidium species by polymerase chain reaction-restriction fragment-length polymorphism., Results: The median CD4(+) cell count was 11.5 cells/mm(3). A potential pathogen was found in 30 case patients (75%) and 29 control subjects (72.5%). Cryptosporidium was the most common pathogen, present in 16 case patients (40%) and 20 control subjects (53.3%). The presence of Cryptosporidium was confirmed by polymerase chain reaction-restriction fragment-length polymorphism, with a prevalence of 40% in each of the 2 groups of 10 subjects who were enrolled for Cryptosporidium evaluation., Conclusions: Subjects in this cohort had severe immunosuppression. The prevalence of pathogens, including Cryptosporidium, was extremely high but did not differ significantly between the case patients with diarrhea and the control subjects without diarrhea. Further studies are needed to examine factors associated with Cryptosporidium carriage and the natural history of asymptomatic infection.

This is a report of a 10-year experience (1989-1998) with 300 consecutive patients found to have an injury to a named abdominal vessel at the time of an exploratory laparotomy for trauma. An abdominal gunshot wound was the mechanism of injury in 78 per cent of patients, and injury to more than one named abdominal vessel was present in 42 per cent. The abdominal aorta, inferior vena cava, and external iliac artery and vein were the most commonly injured vessels. When management for the five most commonly injured arteries was grouped, exsanguination before attempts at repair occurred in 11 to 15 per cent of patients and the mean survival in the remainder was 46 per cent. When management for the five most commonly injured veins was grouped, exsanguination before attempts at repair occurred in 5 per cent of patients and the mean survival in the remainder was 64 per cent. A number of administrative and medical changes in the management of patients with abdominal trauma occurred from 1992 through 1994. Despite significantly increased Injury Severity Scores for patients treated from 1993 through 1998 as compared with those treated from 1989 through 1992 survival rates for patients with injuries to the abdominal aorta and inferior vena cava were unchanged. Survival rates for injuries to the external iliac artery and vein increased significantly. The local changes in management should be considered for prospective studies in other urban trauma centers.

Background: Critically ill surgical patients are often difficult to assess for complications because of their altered sensorium, multiple monitoring devices, and immobility. Surgeon-performed ultrasound may enhance the physical examination of these patients and provide for an early detection of select complications. We hypothesized that a focused thoracic ultrasound examination could reliably detect a pleural effusion and the results could be used in the decision matrix for patient care., Methods: Serial focused thoracic ultrasound examinations were performed by a surgeon and a medical student on critically ill patients. The medical student learned select facets of the physical examination and then demonstrated how ultrasound imaging could enhance these findings. Ultrasound images were recorded on hard copy and videotape, with the results available to the surgical intensive care unit and surgery teams. The images were reviewed and compared with the chest radiograph readings., Results: Forty-seven patients underwent 140 ultrasound examinations. There were 85 true-negative, 46 true-positive, 9 false-negative, and zero false-positive examination results, yielding an 83.6% sensitivity, 100% specificity, and 94% accuracy. Of the 46 true-positive results, thoracentesis was performed or a thoracostomy tube was placed in 5 patients. Nine false-negative ultrasound examinations occurred in six patients, five of whom had their effusions detected on computed tomographic scans., Conclusion: A focused thoracic ultrasound examination reliably detects pleural effusions in critically ill patients, and the results can be used successfully in the decision matrix for patient care.

As the role of the general surgeon continues to evolve, the surgeon's use of ultrasound imaging will surely influence practice patterns, particularly for the evaluation of patients in the acute setting. With the use of real-time imaging, the surgeon receives "instantaneous" information to augment the physical examination, to narrow the differential diagnosis, or to initiate an intervention. With select ultrasound examinations, the surgeon can rapidly evaluate adult and pediatric patients with an acute abdomen, especially those patients who are hypotensive. In the hands of the surgeon, this noninvasive, bedside tool can assess more accurately the presence, depth, and extent of an abscess, confirm complete aspiration, or diagnose wound dehiscence before it is apparent on physical examination. Ultrasound imaging is so accurate for the diagnosis of pyloric stenosis that it has essentially replaced the upper gastrointestinal series in most institutions. The surgeon's use of ultrasound imaging to detect a pleural effusion has virtually supplanted the lateral decubitus radiograph. Furthermore, an ultrasound-guided thoracentesis not only facilitates the procedure but improves its safety. As surgeons become more facile with ultrasound imaging, it is anticipated that other uses will develop to further enhance its value for the assessment of patients in the acute setting.

Objective: To evaluate admission systolic blood pressure (SBP) in the emergency center (EC) as a means by which patients with transmediastinal gunshot wounds (TM-GSWs) can be triaged to the operating room versus further diagnostic evaluation., Methods: A prospective case series presenting concurrent data collected for 68 consecutive patients with TM-GSWs admitted to one urban trauma center over a 4.5-year period. For purposes of analysis, patients were assigned to the following groups based on SBP in the EC: group I, SBP > 100 mm Hg; group II, SBP from 60 to 100 mm Hg; group III, SBP < 60 mm Hg., Results: The management and outcomes of 68 patients with a mean age of 29 years were evaluated. For patients in group I (n = 20), TM-GSW was diagnosed by findings on x-ray film for 15 patients (75%), at physical examination for 4 patients (20%), and at operation for 1 patient (5%). Indications for immediate operation were found in five patients (25%), whereas further diagnostic evaluation prompted operation for three additional patients. Only one patient developed persistent hypotension from neurogenic shock. There were two deaths from late complications. In patients in group II (n = 16), TM-GSW was diagnosed by findings on x-ray film for 9 patients (56%), at physical examination for 5 patients (31%), and at operation for 2 patients (13%). Six patients with persistent hypotension had indications for immediate operation, whereas further diagnostic evaluation in the remaining patients, who became hemodynamically normal during resuscitation, prompted operation in an additional two patients. There were two intraoperative deaths. For the patients in group III (n = 32), six patients with signs of life underwent immediate operation with one intraoperative death, seventeen patients required EC thoracotomy with 100% mortality, and nine patients were pronounced dead in the EC without an attempt at operation., Conclusion: The diagnosis of TM-GSW for patients in groups I and II is confirmed by finding at physical examination and on chest x-ray films in 90% of cases. In the absence of obvious bleeding, patients with TM-GSWs and SBP > 100 mm Hg may safely undergo further diagnostic evaluation. Sixty percent of such patients did not require an operation. All patients with TM-GSWs and SBP < 60 mm Hg (group III) require immediate operation. For patients with TM-GSWs, SBP from 60 to 100 mm Hg (group II), and without obvious bleeding, it is the response to resuscitation and the results of further diagnostic evaluation that determine the need for operation. Fifty percent of such patients did not require operation.

With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade or hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using beta-blocker-induced relative hypotension, is rapidly becoming the standard of care throughout the United States.

In all its forms and applications, sonography plays a significant role in the management of injured patients, from the emergency department to beyond hospital discharge. The use of new and existing sonographic technology will increase because sonographic imaging and measurements are generally less invasive; are inexpensive; use no ionizing radiation; and are portable, repeatable, and, in many instances, as accurate as the so-called "contemporary gold standards." The training and credentialing of physicians in sonography is in evolution and will be an increasingly important issue with more widespread use and broader applications. The future of sonography in trauma care in the next millennium is bright, and surgeons and surgical residents are encouraged to gain proficiency and learn about this new surgical frontier as it evolves.

Hypothesis: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile., Design: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996., Main Outcome Measure: Fetal survival., Results: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery., Conclusions: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

Background: The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected., Study Design: An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification., Results: One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery., Conclusions: Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.

Objective: This is a report of 50 consecutive patients with juxtapyloric perforations after smoking "crack" cocaine (cocaine base) at one urban public hospital., Summary Background Data: Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been defined, surgical services in urban public hospitals now treat significant numbers of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role for Helicobacter pylori in contributing to these perforations., Methods: A retrospective chart review was performed, supplemented by data from the patient log in the department of surgery., Results: From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of chronic smoking of crack as well as chronic alcohol abuse was noted in all patients; four had a prior history of presumed ulcer disease in the upper gastrointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxtapyloric perforation, usually in the prepyloric area, was found in all patients. Omental patch closure was used in 49 patients and falciform ligament closure in 1. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed through the juxtapyloric perforation in five patients. Urease testing was positive for infection with H. pyonri in four, and these patients were prescribed appropriate antimicrobial drugs., Conclusions: Juxtapyloric perforations after the smoking of crack cocaine occur in a largely male population of drug addicts who are 8 to 10 years younger than the patient group that historically has perforations in the pyloroduodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental patch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.

Background: Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium., Methods: Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded., Results: Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes., Conclusion: Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.

The use of ultrasound for the investigation of urgent diagnostic dilemmas is by no means new. Although it has been widely used for almost 40 years, during the past two decades ultrasound has achieved a primary role in the investigation of emergent conditions, notably in the trauma setting. This is further underscored by the American College of Surgeons (ACS) training initiatives. In addition to the basic ultrasound course sponsored by the ACS at the Clinical Congress meetings, the ACS will offer a specialty module course, "Ultrasound in the Acute Setting," that covers ultrasound as used in trauma, critical care, and acute general surgical problems. This initiative underscores the surgeons' interest in having ultrasound as an integral part of their trauma practice. Having the ability to perform and interpret the ultrasound examination gives the surgeon the advantage of obtaining immediate information about the patient. Considering the pace of the trauma setting, ultrasound is an ideal modality for assessment of these patients. It should be the initial diagnostic test for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate, and it augments the surgeon's diagnostic capabilities.

Background: The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured., Methods: Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant., Results: The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries., Conclusion: Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.