Ultrasonographic (US) Two-Dimensional Measurement of Spleen Is Superior to Traditional Length Measurement Alone in Diagnosing Cirrhosis.

BACKGROUND: Splenomegaly measured by spleen length has been an imaging evidence for cirrhosis. However, data remains lacking on the value of other US findings for diagnosing cirrhosis. This study evaluated the value of spleen two-dimensional measurements (2D, i.e., length × thickness) in diagnosing cirrhosis by comparing with other US parameters. METHODS: A retrospective study on 297 cohort 1 patients with clinical/imaging diagnosis of cirrhosis was conducted. Spleen length and thickness were measured via US imaging and compared with other US parameters using statistical analysis to assess their value in diagnosing cirrhosis. A separate 161 cohort 2 patients with histological fibrosis staging was used to validate the findings from the cohort 1. RESULTS: Using 297 cohort 1 patients, US findings of spleen length > 12 cm (50.6% vs. 9.6%, p < 0.001); spleen thickness > 4 cm (78.2% vs. 21%, p < 0.001); and spleen 2D > 46 cm2 (81.6% vs. 15.3%, p < 0.001) were significantly associated with, but only spleen 2D > 46 cm2 (95% CI 7.9-92.8, p < 0.001) was independently associated with clinical/imaging evidence of cirrhosis on multivariate analysis. We further analyzed 161 cohort 2 patients and validated that US finding of spleen 2D > 46 cm2 carried the best sensitivity and specificity (93.5% and 95.3%) and was the only US parameter independently associated with histological stage 3-4 fibrosis, i.e., cirrhosis (95% CI 3.1-87, p = 0.006). CONCLUSION: Using both testing and validation cohorts, we demonstrated that spleen 2D > 46 cm2 carries 93.5% sensitivity and 95.3% specificity and is superior to other US parameters in diagnosing cirrhosis.

Continuing Medical Education Questions: May 2021.

Article Title: ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

Surgeon as Double Agent: Perception of Conflicting Expectations of Patient Care and Stewardship of Resources.

BACKGROUND: Physicians must satisfy 2 competing expectations: advocate for patients and serve as stewards of resources. No guidelines exist for surgeons on resolving this conflict. We surveyed surgeons' perceptions about these dual obligations. STUDY DESIGN: We conducted our study at 2 large university hospitals in 3 distinct steps, each built on the previous one. First, we surveyed 40 surgery residents and medical students using a 10-question assessment tool as the quantitative portion of our analysis. Next, a focus group of attending surgeons was surveyed to identify themes for the qualitative part of our study. Based on these, 5 attending surgeons from varying specialties were interviewed in a semi-structured format. We used the Wilcoxon signed rank test for quantitative analysis and content analysis to report our qualitative findings. RESULTS: Students and residents did not think that they faced resource allocation decisions; however, they observed attending surgeons face them regularly (p = 0.0003). Attending surgeons from various specialties agreed that they thought they were obligated to both provide excellent care and serve as a steward of resources. All surgeons agreed these obligations can conflict. Individual practices varied with all erring on the side of patient care. Concern about being an outlier in one's section was a greater motivator to alter practice than was fear of litigation. No surgeon thought that patients had an adequate understanding of surgeons' dual agency. CONCLUSIONS: Surgeons balance the responsibilities of patient care and stewardship of resources with great variability. Diverse practices likely add to inequalities in healthcare delivery and increase mistrust. Surgeons' social contract with patients calls for transparent strategies to address their dual agency.

Decreased risk of hepatocellular carcinoma recurrence with direct-acting antivirals compared with no treatment for hepatitis C: a meta-analysis.

BACKGROUND: Studies investigating the association between direct-acting antivirals (DAAs) and the recurrence of hepatocellular carcinoma (HCC) related to hepatitis C (HCV) have yielded conflicting results. The objective of this meta-analysis was to define the short- and long-term recurrence rates of HCC after DAA treatment. METHODS: A search of multiple databases was performed, including Scopus, Cochrane, MEDLINE/PubMed and abstracts from gastroenterology meetings. Only studies reporting the recurrence of HCC in patients receiving DAA treatment, compared to HCV controls without DAA treatment, were evaluated. A meta-analysis was completed using the Mantel-Haenszel model. RESULTS: A comprehensive literature search resulted in 32 abstracts and papers. Six papers met our inclusion criteria and were included in the analysis. Follow up ranged from 1.25-4 years. Analysis of these 6 studies found a >60% lower risk of HCC recurrence in patients exposed to DAA compared to controls (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.27-0.47; P<0.001; I 2=88%). A sensitivity analysis, which excluded studies showing the lowest recurrence rate to reduce heterogeneity, showed that patients receiving DAA still had a 60% lower risk of developing HCC (OR 0.4, 95%CI 0.26-0.61; P<0.0001; I 2=39%) and a 66% lower risk of developing HCC beyond 1 year (OR 0.34, 95%CI 0.22-0.54; P<0.00001; I 2=0%) compared to controls. CONCLUSIONS: The use of DAA is associated with a significantly lower risk of HCC development compared to DAA-untreated patients, both overall and beyond 1 year of treatment. Further studies are needed to assess the impact of DAAs on early recurrence.

Resident Education in End-of-Life Communication and Management: Assessing Comfort Level to Enhance Competence and Confidence.

OBJECTIVES: Our primary objective was to understand residents' baseline comfort with end-of-life (EOL) communication and management and to compare this with their comfort after completion of their surgical intensive care unit (SICU) rotation. We also evaluated the association between prior training with perceived level of comfort with EOL issues, and whether the resident believed in the concept of a "better death." DESIGN, SETTING, PARTICIPANTS: As a quality improvement initiative, we conducted surveys of trainees before and after their rotation in the Yale New Haven Hospital SICU. Prerotation and postrotation surveys were administered to all residents who rotated during the 2016-2017 academic year and the first half of 2017-2018. The survey consisted of 34 questions querying residents on their level of training in EOL care, their comfort with management and discussions in different EOL domains, and their beliefs about what measures would have improved their ability to provide EOL care. Residents surveyed were from general surgery, emergency medicine, or anesthesia departments. RESULTS AND CONCLUSIONS: Our study demonstrates that there is a significant correlation between resident comfort with EOL communication and experience providing EOL care. However, concepts in medicolegal aspects of palliative care could be taught through formal didactics, and structured training may allow residents the opportunity to reflect on the importance of a "better death."

Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. METHODS: Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. RESULTS: Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. CONCLUSION: Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. LEVEL OF EVIDENCE: IV. PROSPERO REGISTRATION NUMBER: #42016043019.

Ethnic disparities in gastric cancer incidence and survival in the USA: an updated analysis of 1992-2009 SEER data.

BACKGROUND: Gastric cancer (GC) is the second-leading cause of cancer-related deaths worldwide, with overall 5-year survival less than 20%. However, limited data exist investigating ethnic disparities in stage-specific GC incidence and survival in the USA. AIM: To evaluate ethnicity-specific differences in GC incidence and survival in the USA. METHODS: Using data from the surveillance, epidemiology, and end results 1992-2009 population-based cancer registry, we evaluated ethnic disparities in GC incidence stratified by year of diagnosis, cancer stage at presentation, and geographical distribution of disease. Ethnic disparities in survival were evaluated using Kaplan-Meier and multivariate Cox proportional hazards models. RESULTS: Among men and women combined and among all cancer stages, Asians had the highest incidence of GC, more than double that among Whites (15.6 vs. 7.4 per 100,000/year, p < 0.005). In addition, Asians had the highest survival of all race groups (3-year survival: 26.6%, p < 0.001). Compared with Whites, Blacks (12.8 vs. 7.4 per 100,000/year, p < 0.005) and Hispanics (12.9 vs. 7.4 per 100,000/year, p < 0.005) also had significantly higher incidence of GC. Multivariate Cox models (adjusted for age, year of diagnosis, sex, race/ethnicity, stage of disease, and treatment received) demonstrated significantly higher survival in Asians compared with Whites (HR 0.82, 95% CI 0.80-0.85, p < 0.04). CONCLUSIONS: Racial/ethnic disparities in GC incidence and survival exist in the USA Asians have the highest incidence of GC and the highest overall survival. Outlining high-risk groups may inform potential screening practices and physician awareness for GC.

Using the Rothman index to predict early unplanned surgical intensive care unit readmissions.

BACKGROUND: The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. METHODS: This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. RESULTS: A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Δ, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. CONCLUSION: An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

The use of magnetic resonance imaging in the diagnosis of suspected appendicitis in pregnancy: shortened length of stay without increase in hospital charges.

IMPORTANCE: Making an accurate diagnosis of appendicitis in pregnancy is critical for maternal and fetal outcomes. OBJECTIVE: To determine whether magnetic resonance (MR) imaging in pregnant patients with suspected appendicitis improves outcomes, minimizes length of stay (LOS), and lowers hospital charges. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review at a university tertiary referral center of all pregnant patients seen with abdominal pain and suspected appendicitis who were followed up through delivery during an 11-year period. MAIN OUTCOMES AND MEASURES: Time to operation, LOS, complications, nontherapeutic exploration, fetal outcomes, and hospital charges. RESULTS: Seventy-nine patients were included in this study, 34 of whom had pathology-confirmed appendicitis. Thirty-one patients underwent MR imaging. A trend toward fewer operations (odds ratio [OR], 0.45; 95% CI, 0.18-1.16; P = .07) was observed in the MR imaging group. Seven nontherapeutic explorations were performed in the non-MR imaging group and 1 nontherapeutic exploration in the MR imaging group (OR, 0.44; 95% CI, 0.08-2.32; P = .13). Patients in the MR imaging group were more frequently discharged from the emergency department (OR, 0.35; 95% CI, 0.13-0.94; P = .04) and had shorter LOS (33.7 vs 64.8 hours, P < .001). Gestational age, time to operation, and the presence of perforated appendicitis were similar between groups. No patient discharged without operation returned with appendicitis in either group. On multivariable analysis, the receipt of MR imaging (P < .001) and the absence of operative intervention (P = .001) were associated with shorter LOS. The mean hospital charges were similar in those with vs without appendicitis. One fetal loss occurred in the non-MR imaging group. CONCLUSIONS AND RELEVANCE: Magnetic resonance imaging in pregnant patients with suspected appendicitis does not affect clinical outcomes or hospital charges. It allows safe discharge from the emergency department and improves resource use.

Low dietary vitamin D in mid-life predicts total mortality in men with hypertension: the Honolulu heart program.

BACKGROUND: Vitamin D deficiency was associated with total mortality in previous epidemiological studies. Little is known about the effects of dietary vitamin D intake on mortality. We examined the association between mid-life dietary vitamin D intake and 45-year total mortality. METHODS: The Honolulu Heart Program is a longitudinal cohort study of 8006 Japanese American men in Hawaii aged 45 to 68 at baseline (1965-1968). Mid-life dietary vitamin D intake was calculated from 24-hour dietary recall using Nutritionist IV v3 software. We divided subjects into quartiles of dietary vitamin D. Total mortality data were available over 45 years through 2010. RESULTS: Age-adjusted total mortality rates were higher in the lower quartiles of dietary vitamin D intake compared to the highest (p for trend = 0.011). Using Cox regression, low dietary vitamin D was significantly associated with total mortality; quartile (Q) 1 hazard ratio (HR) = 1.14, 95% confidence interval (95% CI) = 1.07-1.22, p < 0.001; Q2 HR = 1.11, 95% CI = 1.04-1.18, p = 0.002; and Q3 HR = 1.08, 95% CI = 1.01-1.15, p = 0.027; Q4 = reference. After adjusting for age, kilocalories, cardiovascular risk factors, and prevalent chronic diseases, only Q2 remained significant (HR = 1.08, 95% CI = 1.00-1.15, p = 0.037). Among hypertensive subjects only, those in the lower 2 quartiles had higher total mortality; Q1 HR = 1.12, 95% CI = 1.01-1.25, p = 0.039, and Q2 HR = 1.13, 95% CI = 1.02-1.26, p = 0.025, compared to Q4. There was no significant relationship in subjects without hypertension. CONCLUSIONS: Low dietary vitamin D intake in mid-life was a weak predictor of total mortality over 45 years of follow-up. We found a significant association between low dietary vitamin D intake and higher total mortality only among hypertensive subjects. Vitamin D may have cardioprotective effects.

Appendiceal endometriosis in a pregnant woman presenting with acute perforated appendicitis.

Endometriosis is a common disease in women of childbearing age and is defined as the presence of endometrial glands and stroma in organs outside of the uterine cavity. Appendiceal endometriosis is very uncommon and accounts for a small fraction of all cases of extrapelvic endometriosis. Cases of that which occur during pregnancy are extremely rare with an incidence that ranges between 3 and 8 deliveries per 10 000. This makes the diagnosis extremely difficult and represents a challenge in the management of the patient. In this report we describe the case of a pregnant woman who underwent ileocecectomy for perforated appendicitis stemming from endometriosis and subsequent pre-term delivery of a 31-week-old fetus.

Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Diagnosing blunt cardiac injury (BCI) can be difficult. Many patients with mechanism for BCI are admitted to the critical care setting based on associated injuries; however, debate surrounds those patients who are hemodynamically stable and do not otherwise require a higher level of care. To allow safe discharge home or admission to a nonmonitored setting, BCI should be definitively ruled out in those at risk. METHODS: This Eastern Association for the Surgery of Trauma (EAST) practice management guideline (PMG) updates the original from 1998. English-language citations were queried for BCI from March 1997 through December 2011, using the PubMed Entrez interface. Of 599 articles identified, prospective or retrospective studies examining BCI were selected. Each article was reviewed by two members of the EAST BCI PMG workgroup. Data were collated, and a consensus was obtained for the recommendations. RESULTS: We identified 35 institutional studies evaluating the diagnosis of adult patients with suspected BCI. This PMG has 10 total recommendations, including two Level 2 updates, two upgrades from Level 3 to Level 2, and three new recommendations. CONCLUSION: Electrocardiogram (ECG) alone is not sufficient to rule out BCI. Based on four studies showing that the addition of troponin I to ECG improved the negative predictive value to 100%, we recommend obtaining an admission ECG and troponin I from all patients in whom BCI is suspected. BCI can be ruled out only if both ECG result and troponin I level are normal, a significant change from the previous guideline. Patients with new ECG changes and/or elevated troponin I should be admitted for monitoring. Echocardiogram is not beneficial as a screening tool for BCI and should be reserved for patients with hypotension and/or arrhythmias. The presence of a sternal fracture alone does not predict BCI. Cardiac computed tomography or magnetic resonance imaging can be used to differentiate acute myocardial infarction from BCI in trauma patients.

Compared to conventional ventilation, airway pressure release ventilation may increase ventilator days in trauma patients.

BACKGROUND: Airway pressure release ventilation (APRV) is used both as a rescue therapy for patients with acute lung injury and as a primary mode of ventilation. Unlike assist-control volume (ACV) ventilation that uses spontaneous breathing trials, APRV weaning consists of gradual decreases in supporting pressure. We hypothesized that the APRV weaning process increases total ventilator days compared with those of spontaneous breathing trials-based weaning. METHODS: A retrospective review of a Level I trauma center's database identified trauma admissions from January 1, 2007, to December 31, 2010, which required mechanical ventilation for more than 24 hours and survived. Demographics, injuries, in-hospital complications, ventilation mode(s), and total ventilator days were abstracted. RESULTS: A total of 362 patients fulfilled study entry criteria; 53 patients with more than one ventilator mode change were excluded. Seventy-five patients were successfully liberated from mechanical ventilation on APRV and 234 on ACV. The APRV and ACV groups, respectively, were similar in age (46.1 vs. 44.6 years) and sex (72% vs. 73% male) but differed in Injury Severity Score (20.8 vs. 17.5; p = 0.03). Patients on APRV had higher rates of abdominal compartment syndrome (6.7% vs. 0.8%, p = 0.003) and were more likely to have a higher chest Abbreviated Injury Scale (AIS) score ≥3 (57.3% vs. 30.8%, p < 0.001). Ventilator days were significantly greater in the APRV group (19.6 vs. 10.7 days, p < 0.001). Multiple regression was performed to adjust for the clinical differences between the two groups, identifying APRV as an independent predictor for increased number of ventilator days (B = 6.2 ± 1.5, p < 0.001) in addition to male sex, abdomen AIS score of 3 or higher, spine AIS score of 3 or higher, acute renal failure, and sepsis. CONCLUSION: APRV is frequently used for patients who are more severely injured or who develop in-hospital complications such as pneumonia. However, after controlling for potential confounding factors in a multiple regression model, the APRV mode itself seems to increase ventilator days.

Development of a computed tomography-based scoring system for necrotizing soft-tissue infections.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) are associated with significant morbidity and mortality, but a definitive nonsurgical diagnostic test remains elusive. Despite the widespread use of computed tomography (CT) as a diagnostic adjunct, there is little data that definitively correlate CT findings with the presence of NSTI. Our goal was the development of a CT-based scoring system to discriminate non-NSTI from NSTI. METHODS: Patients older than 17 years undergoing CT for evaluation of soft-tissue infection at a tertiary care medical center over a 10-year period (2000-2009) were included. Abstracted data included comorbidities and social history, physical examination, laboratory findings, and operative and pathologic findings. NSTI was defined as soft-tissue necrosis in the dictated operative note or the accompanying pathology report. CT scans were reviewed by a radiologist blinded to clinical and laboratory data. A scoring system was developed and the area under the receiver operating characteristic curve was calculated. RESULTS: During the study period, 305 patients underwent CT scanning (57% men; mean age, 47.4 years). Forty-four patients (14.4%) evaluated had an NSTI. A scoring system was retrospectively developed (table). A score >6 points was 86.3% sensitive and 91.5% specific for the diagnosis of NSTI (positive predictive value, 63.3%; negative predictive value, 85.5%). The area under the receiver operating characteristic curve was 0.928 (95% confidence interval, 0.893-0.964). The mean score of the non-NSTI group was 2.74. CONCLUSIONS: We have developed a CT scoring system that is both sensitive and specific for the diagnosis of NSTIs. This system may allow clinicians to more accurately diagnose NSTIs. Prospective validation of this scoring system is planned.

The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion?

BACKGROUND: Massive transfusion protocol (MTP) utilization and makeup is unknown. STUDY DESIGN AND METHODS: A Web-based survey was sent to members of the Eastern Association for the Surgery of Trauma and published in the American Association for the Surgery of Trauma newsletter. Comparisons were made with chi-square and logistic regression. RESULTS: A total of 186 surgeons and 59 center directors responded. To avoid bias, directors' responses are reported. Sixty percent annually admit more than 1500 patients. Sixty-seven percent had in-house attending coverage and 85% had a MTP. Presence of a MTP was not predicted by institution size, level, residency status, or admissions. Sixty-five percent of MTPs had been in place less than 5 years with 18% less than 1 year. Designs varied: 23% had one batch of components, 25% had two or three, 41% had more than three, and 11% did not use batches. Only 62% of first batches contained fresh-frozen plasma (FFP). In the second batch 98% had FFP. All third boxes had FFP. A ratio of FFP : red blood cells (RBCs) of less than 1 in the first batch predicted a ratio less than 1 in the second batch (p = 0.013). Twenty-seven percent had blood stored in the emergency department and 14% in the operating room. Twenty-four percent of MTPs autoactivate and 80% are trauma surgeon activated, 66% by the anesthesia staff, 32% by other surgeons, and 17% by the blood bank. Trauma surgeons activate the MTP most. CONCLUSION: Most centers have a MTP. Protocols are variable and new, and half have a 1:1 FFP : RBC ratio. Protocols with fewer initial units of FFP compared to RBCs maintain this.

Contrast-induced nephropathy in elderly trauma patients.

BACKGROUND: Computed tomography (CT) is the gold standard for the identification of occult injuries, but the intravenous (IV) contrast used in CT scans is potentially nephrotoxic. Because elderly patients have decreased renal function secondary to aging and chronic disease, we sought to determine the rate of acute kidney injury (AKI) in elderly trauma patients exposed to IV contrast. METHODS: Medical records of patients older than 55 years evaluated at a level-one trauma center between January 2003 and July 2008 were reviewed. Contrast was nonionic, isosmolar, and administered in standard volumes. Groups were based on administration of contrast. AKI was defined as a 25% relative or 0.5 mg/dL absolute increase in serum creatinine within 72 hours of presentation [corrected]. RESULTS: During the study period 1,371 patients older than 55 years were evaluated, and 1,152 met the inclusion criteria. CT was performed on 1,071 patients (96%); 71% of this group received IV contrast. There was no significant difference between the contrast and noncontrast groups in terms of baseline characteristics. Criteria for AKI were satisfied in 2.1% of all patients, including 1.9% the contrast group versus 2.4% in the noncontrast group. AKI diagnosed within 72 hours of patient presentation was an independent risk factor for in-hospital mortality and prolonged length of stay. CONCLUSIONS: IV contrast media in elderly trauma patients is not associated with an increased risk of AKI. Development of AKI within 72 hours of admission is associated with mortality and increased length of stay.

Pulseless electrical activity, focused abdominal sonography for trauma, and cardiac contractile activity as predictors of survival after trauma.

BACKGROUND: Pulseless electrical activity (PEA) secondary to both blunt and penetrating trauma is associated with minimal survival. The pericardial view of the focused abdominal sonography for trauma (p-FAST) can differentiate between patients with and without organized cardiac activity and may assist in the decision to terminate ongoing resuscitation. METHODS: A retrospective review was performed for all patients presenting to a level I trauma center from January 2006 through January/2009 who had PEA on arrival or developed PEA in the emergency department. Additional data abstracted included outcome, the p-FAST findings, and mechanism of injury. Recorded FAST examinations were reviewed by a blinded ultrasound trained physician. RESULTS: During the study period 25 patients presented with PEA and three developed PEA during initial resuscitation. Contractile cardiac activity was present in nine patients with PEA on presentation and immediately after deterioration to PEA in the three patients developing PEA. Four patients had a penetrating mechanism and 24 were blunt. Two pericardial effusions were present on examination, both after blunt trauma. Three patients survived beyond the emergency department (89% early mortality). The survivors had presented in PEA with organized cardiac contractile activity on ultrasound and had tension pneumothorax, tension hemothorax, and hypovolemia treated. Two patients died in the operating room of uncontrolled hemorrhage and one patient died 6 days after admission because of closed head injury. CONCLUSIONS: The presence of PEA at any time during initial resuscitation is a grave prognostic indicator. p-FAST is a useful test to identify contractile cardiac activity. p-FAST may identify those patients with potential for survival.