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

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INTRODUCTION: "Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma. METHODS: We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018. RESULTS: Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively. CONCLUSIONS: Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

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

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

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BACKGROUND: The relationship between behavioral health disorders (BHDs) and outcomes after traumatic injury is not well understood. The objective of this study was to evaluate the association between BHDs and outcomes in the trauma patient population. MATERIALS AND METHODS: We performed a review of the Trauma Quality Improvement Program database from 2013 to 2016 comparing patients with and without a BHD, which was defined as a psychiatric disorder, alcohol or drug use disorders, dementia, or attention deficit hyperactivity disorder. Outcomes of interest were mortality, length of stay (LOS), and inpatient complications. RESULTS: In the study population, 254,882 patients (25%) had a BHD. Of these, psychiatric disorders comprised 38.3% (n = 97,668) followed by alcohol (33.3%, n = 84,845) and drug (26.4%, n = 67,199) use disorders, dementia (20.2%, n = 51,553), and attention deficit hyperactivity disorder (1.7%, n = 4301). On multivariable analysis, overall mortality was lower in the BHD group (odds ratio [OR] 0.83, confidence interval [CI] 0.79-0.83; P < 0.001). Patients with dementia had higher mortality when controlling for other risk factors (OR 1.62, CI 1.56-1.69; P < 0.001). LOS was 8.5 d (s = 0.02) for patients with a BHD versus 7.4 d (s = 0.01) for patients without a BHD (P < 0.001). Comorbid BHD was associated with any inpatient complication (OR 1.19, CI 1.18-1.20; P < 0.001). CONCLUSIONS: Trauma patients with a BHD had lower overall mortality compared with those without a BHD. However, on subgroup analysis, those with dementia had increased mortality. BHDs increased risk for any inpatient complication and prolonged LOS. Trauma patients with BHDs represent a vulnerable population and warrant special attention to minimize harm and improve outcomes.

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BACKGROUND: There is great variation in practice regarding the assessment of trauma patients who present with syncope. The purpose of this study was to determine the yield of screening studies (electrocardiogram, echocardiogram, and carotid duplex) and define characteristics to identify groups that may benefit from these investigations. METHODS: We conducted a retrospective cohort study of all trauma patients from 2003 to 2015 who received a carotid duplex as part of a syncope evaluation at our urban Level 1 Trauma Center. Demographics, clinical findings as well as interventions undertaken (ie: placement of defibrillators/pacemakers) as a result of the syncope evaluation were collected. Data analysis was performed with STATA 14 and relationships between comorbidities, positive findings and interventions were assessed. Significance was assumed for p < 0.05. RESULTS: 736 trauma patients were included in the study. The most common mechanism of injury was fall (592, 82%). A history of congestive heart failure (CHF) and/or coronary artery disease (CAD) and age ≥ 65 were significantly associated with abnormal ECG and ECHO findings, but not with severe carotid stenosis. Elevated Injury Severity Scale (ISS) was significantly associated with an abnormal ECHO on both univariate and multivariate analysis. An abnormal ECG was predictive of an abnormal ECHO (p = 0.02). Ten patients (1.4%) underwent placement of a defibrillator and/or pacemaker, all of whom reported having CHF. Only 11 patients (1.7%) had severe carotid stenosis (>70%) requiring intervention. CONCLUSION: The screening studies used in a syncope evaluation have low yield in the general trauma population. Carotid duplex should not be routinely performed. Cardiac evaluation should be tailored to individuals with cardiac comorbidities, older age and elevated ISS. An ECG should be used as initial screening in this patient cohort.

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BACKGROUND: Hemorrhagic shock and pneumonectomy causes an acute increase in pulmonary vascular resistance (PVR). The increase in PVR and right ventricular (RV) afterload leads to acute RV failure, thus reducing left ventricular (LV) preload and output. Inhaled nitric oxide (iNO) lowers PVR by relaxing pulmonary arterial smooth muscle without remarkable systemic vascular effects. We hypothesized that with hemorrhagic shock and pneumonectomy, iNO can be used to decrease PVR and mitigate right heart failure. METHODS: A hemorrhagic shock and pneumonectomy model was developed using sheep. Sheep received lung protective ventilatory support and were instrumented to serially obtain measurements of hemodynamics, gas exchange, and blood chemistry. Heart function was assessed with echocardiography. After randomization to study gas of iNO 20 ppm (n = 9) or nitrogen as placebo (n = 9), baseline measurements were obtained. Hemorrhagic shock was initiated by exsanguination to a target of 50% of the baseline mean arterial pressure. The resuscitation phase was initiated, consisting of simultaneous left pulmonary hilum ligation, via median sternotomy, infusion of autologous blood and initiation of study gas. Animals were monitored for 4 hours. RESULTS: All animals had an initial increase in PVR. PVR remained elevated with placebo; with iNO, PVR decreased to baseline. Echo showed improved RV function in the iNO group while it remained impaired in the placebo group. After an initial increase in shunt and lactate and decrease in SvO2, all returned toward baseline in the iNO group but remained abnormal in the placebo group. CONCLUSION: These data indicate that by decreasing PVR, iNO decreased RV afterload, preserved RV and LV function, and tissue oxygenation in this hemorrhagic shock and pneumonectomy model. This suggests that iNO may be a useful clinical adjunct to mitigate right heart failure and improve survival when trauma pneumonectomy is required.

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BACKGROUND: This study was performed to evaluate the effect of socioeconomic status (SES) on outcomes after cholecystectomy. METHODS: The National Inpatient Sample (NIS) database (2005 to 2011) was queried for patients undergoing cholecystectomy. Clinically relevant variables were used to examine clinical characteristics, postoperative complications, and mortality. SES was investigated by examining income quartile. RESULTS: More than 2 million patients underwent cholecystectomy during this period. They were divided into quartiles by SES. The lowest cohort was younger (50 years, P < .001) and had the lowest Charlson Comorbidity Index (2.08, P < .001). This cohort was more likely African American (15.8%, P < .001) and more likely to have Medicaid (19.2%, P < .001). Using split-sample validation and multivariate analysis, lower SES, Charlson comorbidity Index, and Medicaid recipients were associated with increased mortality. CONCLUSIONS: Patients with Medicaid and lower SES had poorer outcomes after cholecystectomy.

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BACKGROUND: From 2002 to 2011, there were more than 17,000 shootings in Philadelphia. "Turning Point," Temple University Hospital's inpatient violence intervention program, takes advantage of the teachable moment that occurs after violent injury. In addition to receiving traditional social work services, Turning Point patients watch their trauma bay resuscitation video and a movie about violence, meet with a gunshot wound survivor and an outpatient case manager, and also undergo psychiatric assessment. The purpose of this study was to determine the efficacy of Turning Point in changing attitudes toward guns and violence among victims of penetrating trauma. METHODS: This prospective randomized study was conducted from January 2012 to January 2014. Patients who sustained a gunshot or stab wound were randomized to standard of care, which involved traditional social work services only, or Turning Point. The Attitudes Toward Guns and Violence Questionnaire was administered to assess attitude change. Analysis was performed with repeated-measures analysis of variance. A p < 0.05 was significant. RESULTS: A total of 80 of a potential 829 patients completed the study (40 standard of care, 40 Turning Point). The most common reason for exclusion was anticipated length of stay being less than 48 hours. The two groups were similar with respect to most demographics. Unlike the standard-of-care group, the Turning Point group demonstrated a 50% reduction in aggressive response to shame, a 29% reduction in comfort with aggression, and a 19% reduction in overall proclivity toward violence. CONCLUSIONS: Turning Point is effective in changing attitudes toward guns and violence among victims of penetrating trauma. Longer follow-up is necessary to determine if this program can truly be a turning point in patients' lives. LEVEL OF EVIDENCE: Therapeutic/care management study, level II.

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INTRODUCTION: Impaired wound healing due to immunosuppression has led some surgeons to preferentially use open gastrostomy tube (OGT) over percutaneous gastrostomy tube (PEG) in heart transplant patients when long-term enteral access is deemed necessary. METHODS: The National Inpatient Sample (NIS) database (2005-2010) was queried for all heart transplant patients. Those receiving OGT were compared to those treated with PEG tube. RESULTS: There were 498 patients requiring long-term enteral access treated with a gastrostomy tube, with 424 (85.2%) receiving a PEG and 74 (14.8%) an OGT. The PEG cohort had higher Charlson comorbidity Index (4.1 vs. 2.0, p = 0.002) and a higher incidence of post-operative acute renal failure (31.5 vs. 12.7%, p = 0.001). Post-operative mortality was not different when comparing the two groups (13.8 vs. 6.1%, p = 0.06). On multivariate analysis, while both PEG (OR: 7.87, 95%C.I: 5.88-10.52, p < 0.001) and OGT (OR 5.87, 95%CI: 2.19-15.75, p < 0.001) were independently associated with mortality, PEG conferred a higher mortality risk. CONCLUSIONS: This is the largest reported study to date comparing outcomes between PEG and OGT in heart transplant patients. PEG does not confer any advantage over OGT in this patient population with respect to morbidity, mortality, and length of stay.

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

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INTRODUCTION: Lung transplant patients require a high degree of immunosuppression, which can impair wound healing when surgical procedures are required. We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with open gastrostomy tube (OGT) as compared to percutaneous endoscopic gastrostomy tube (PEG). METHODS: The National Inpatient Sample (NIS) Database (2005-2010) was queried for all lung transplant recipients requiring OGT or PEG. RESULTS: There were 215 patients requiring gastrostomy tube, with 44 OGT and 171 PEG. The two groups were not different with respect to age (52.0 vs. 56.9 years, p = 0.40) and Charlson Comorbidity Index (3.3 vs. 3.5, p = 0.75). Incidence of acute renal failure was higher in the PEG group (35.2 vs. 11.8%, p = 0.003). Post-operative pneumonia, myocardial infarction, surgical site infection, DVT/PE, and urinary tract infection were not different. Post-operative mortality was higher in the PEG group (11.2 vs. 0.0%, p = 0.02). Using multiple variable analysis, PEG tube was independently associated with mortality (HR: 1.94, 95%C.I: 1.45-2.58). Variables associated with survival included age, female gender, white race, and larger hospital bed capacity. DISCUSSION: OGT may be the preferred method of gastric access for lung transplant recipients. CONCLUSIONS: In lung transplant recipients, OGT results in decreased morbidity and mortality when compared to PEG.

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

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

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INTRODUCTION: There is a paucity of data on outcomes for lung transplant (LT) recipients requiring general surgery procedures. This study examined outcomes after cholecystectomy in LT recipients using a large database. METHODS: The National Inpatient Sample Database (2005-2010) was queried for all LT patients requiring laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). RESULTS: There were a total of 377 cholecystectomies performed in LT patients. The majority were done for acute cholecystitis (n = 218; 57%) and were done urgently/emergently (n = 258; 68%). There were a total of 304 (81%) laparoscopic cholecystectomies and 73 (19%) OC. There was no difference in age when comparing the laparoscopic and open groups (53.6 vs 55.5 years; P = .39). In addition, the Charlson Comorbidity Index was similar in the 2 groups (P = .07). Patients undergoing OC were more likely to have perioperative myocardial infarction, pulmonary embolus, or any complication compared with the laparoscopic group. Total hospital charges ($59,137.00 vs $106,329.80; P = .03) and median duration of stay (4.0 vs 8.0 days; P = .02) were both greater with open compared with LC. CONCLUSION: Cholecystectomy can be performed safely in the LT population with minimal morbidity and mortality.

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

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

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

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

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