Interhospital transfer of blunt multiply injured patients to a level 1 trauma center does not adversely affect outcome.

BACKGROUND: Stops at nontrauma centers for severely injured patients are thought to increase deaths and costs, potentially because of unnecessary imaging and indecisive/delayed care of traumatic brain injuries (TBIs). METHODS: We studied 754 consecutive blunt trauma patients with an Injury Severity Score greater than 20 with an emphasis on 212 patients who received care at other sites en route to our level 1 trauma center. RESULTS: Referred patients were older, more often women, and had more severe TBI (all P < .05). After correction for age, sex, and injury pattern, there was no difference in the type of TBI, Glasgow Coma Scale (GCS) upon arrival at the trauma center, or overall mortality between referred and directly admitted patients. GCS at the outside institution did not influence promptness of transfer. CONCLUSIONS: Interhospital transfer does not affect the outcome of blunt trauma patients. However, the unnecessarily prolonged stay of low GCS patients in hospitals lacking neurosurgical care is inappropriate.

Use of computed tomography findings and contrast extravasation in predicting the need for embolization with pelvic fractures.

Transarterial embolization (AE) can be a lifesaving procedure for severe hemorrhage associated with pelvic fractures. The purpose of this study was to identify demographic and radiographic findings that predict the need for embolization. We performed a retrospective review of all patients with at least one pelvic fracture and admission to the intensive care unit over a 35-month period. Computed tomography (CT) and pelvic radiographs were reviewed. Patient demographics, outcomes, time to angiography, and whether or not embolization was performed were determined. Statistical analysis was used to determine factors associated with the need for AE. Of the 327 total patients with pelvic fractures, 317 underwent CT scanning. Forty-four patients (13.5%) underwent angiography and 25 (7.6%) required therapeutic embolization. There were 39 total deaths (11.6%) with five deaths related to pelvic hemorrhage (1.5%). Multivariate analysis revealed that age older than 55 years (odds ratio [OR], 1.06; P < 0.001), systolic blood pressure less than 90 mmHg in the emergency department (OR, 11.64; P = 0.0008), and CT extravasation (OR, 147.152; P < 0.0001) were significantly associated with the need for embolization. Contrast extravasation was not present in 25 per cent of patients requiring therapeutic AE. The presence of contrast extravasation is highly associated with the need for pelvic embolization in patients with pelvic fractures, but its absence does not exclude the need for pelvic angiography.

Flail chest injury: are we making any progress?

Flail chest represents a severe injury with mortality historically reported at up to 30 per cent. Although management has changed dramatically over the past several decades, there is a paucity of large recent series. With Institutional Review Board approval, a retrospective review of all patients with flail chest admitted from January 2001 through May 2010 was undertaken. Patient demographics, outcomes, and cause of death were specifically analyzed with univariate and multivariate analysis. There were 164 patients at a median age of 51.4 years. Head injury and pulmonary contusion were present in 67 (40.8%) and 125 (77%), respectively. Pneumonia developed in 72 (43.9%). There were 41 deaths (25%), for which flail chest contributed to 15 (9.1%). Of the patients with flail chest-related death, the majority (n = 10 [66.7%]) died within 48 hours of presentation. There were only five deaths (3.0%) related to flail chest after 48 hours. Multivariate analysis of ventilator dependency revealed requirement for laparotomy (P = 0.019) or tracheostomy (P < 0.0001) and pneumonia (P = 0.0002) as significant. Pneumonia was the most significant independent predictor of overall (P < 0.0001) and intensive care unit length of stay (P < 0.0001). The mortality associated with flail chest has greatly improved; however, the rate of pneumonia remains high. Further efforts at pneumonia prevention are thus warranted.

Statewide experience with Clostridium difficile colitis in academic and non-academic medical centers.

BACKGROUND: Clostridium difficile colitis is a nosocomial infection that can present as minor, readily treated symptoms or as fulminant colitis leading to death. Risk factors for C. difficile colitis have been defined, and certain populations of hospitalized patients appear to be particularly susceptible. However, most information on C. difficile colitis is from large tertiary-care medical centers. Whether the community hospital experience is similar to that of large referral centers is unknown. METHODS: We abstracted all cases of C. difficile colitis (ICD-9-CM 008.45) for 2003-2005 from a state database and divided the hospitals into academic and nonacademic centers. Cases were stratified according to whether the colitis was listed as the primary presenting diagnosis or a secondary diagnosis. Demographic information, associated diagnoses, length of stay, and deaths were analyzed. RESULTS: The incidence of C. difficile colitis increased from 2003 to 2005, and the majority of cases occurred at nonacademic centers. Patients in nonacademic centers more frequently had C. difficile colitis as the primary diagnosis, had a shorter length of stay, were older, and were more frequently women. The mortality rate was higher for secondary (8.5%) than for primary (2.6%; p < 0.05) C. difficile colitis, but there was no difference between academic and nonacademic centers. CONCLUSIONS: The incidence of C. difficile colitis is increasing in this statewide database. Compared with academic medical centers, nonacademic centers deal with a higher rate of primary C. difficile colitis that is associated with a lower mortality rate and shorter stay than secondary colitis.

Impact of withdrawal of care and futile care on trauma mortality.

BACKGROUND: The observed to expected (O:E) mortality based on Injury Severity Scores (ISS) has been used to assess quality of trauma center (TC) care. Injuries in the elderly have increased, and these patients often have advanced directives, on occasion limiting aggressive care even for potentially survivable injuries; unfortunately, there are few data on the impact of these demographic changes on mortality. Additionally, many patients arrive moribund and care provided is likely to be futile. We sought to examine the impact of these situations on TC mortality. METHODS: All trauma deaths for 2008-2009 were assessed for ISS, preventability of mortality, potential for survivability, impact of withdrawal of care (WOC), and timing of deaths. RESULTS: There were 5433 patients with 347 deaths (6.4%). Deaths occurred more frequently in men (70%) who were older (56.3 years) and had head injuries (70%, Glasgow Coma Scale score of 6.9). The average ISS was high (25.5), but 19% of deaths occurred in minimally injured (ISS < 15). One fifth of all patients who died arrived in or rapidly progressed to cardiac arrest with little to no chance to impact survival. Of the nonsurvivors, 147 (42% of deaths) had WOC at a mean of 1.5 days based on advanced directives (18%) or family desires. Combing WOC and futile care, medical treatment could not have been expected to impact survival in 62% of deaths. CONCLUSION: There has been a major shift in the demographics of the injured with a high proportion of elderly and head injured and/or those who have little likelihood of survival. Crude mortality or O:E based on ISS overestimates preventable deaths. Societal factors, presence of advanced directives, and WOC decisions must be considered when assessing TC performance. Although our crude mortality rate was 6.4%, it was only 2.4% in patients we were actually permitted to treat. We suggest a WOC factor should be added to TC data to characterize mortality rates more accurately.

Acute appendicitis--not just for the young.

BACKGROUND: The incidence of appendicitis is highest in young patients, but the number of elderly patients with appendicitis appears to be increasing. The authors evaluated a statewide experience to assess the effect of age on resource utilization and outcomes for this common disease. METHODS: All discharges from Kentucky hospitals for appendicitis were identified. Patients from rehabilitation hospitals, those with inflammatory bowel disease, and those undergoing incidental appendectomy were excluded. RESULTS: Young (aged ≤ 29 years) and middle-aged (aged 30-64 years) patients each constituted 45% of all patients with appendicitis. Length of stay, hospital charges, and frequency of complicated appendicitis all increased with age. Although elderly patients (aged ≥ 80 years) underwent laparoscopic appendectomy as frequently (60%) as younger patients, they were more likely to undergo complicated open procedures. CONCLUSIONS: Older patients represent a substantial population of patients with appendicitis, with more complicated operative procedures, increased lengths of stay, and increased resource utilization.

Catastrophic gastrointestinal injury due to battery acid ingestion.

BACKGROUND: Acids account for 20% of all chemical exposures through various routes. Caustic acids such as hydrochloric and sulfuric acid are common ingredients in many household and industrial products. Due to the corrosive properties of these substances, tissue injury caused by oral exposure can lead to severe esophageal and gastrointestinal burns. CASE REPORT: We report a case of a patient presenting with severe acidosis, who required multiple laparoscopic evaluations to assess various gastrointestinal tract injuries and who ultimately underwent total gastrectomy. The diagnosis was made primarily based on the arterial blood gas and esophagogastroduodenoscopy findings, as well as the pathological examinations of various biopsied and resected tissues showing hemorrhagic necrosis of the esophagus, stomach, and small bowel. This patient eventually admitted to having ingested an unspecified amount of battery acid. CONCLUSIONS: Collaborative efforts by Emergency Medicine, Pathology, and General Surgery services are required for timely diagnosis, treatment, and management of patients after caustic acid exposures.

Decreasing regional neurosurgical workforce-a blueprint for disaster.

BACKGROUND: Traumatic brain injuries are a frequent cause of death and a substantial source of morbidity. Neurosurgeons (NS) are commonly involved in the management of patients with moderate and severe traumatic brain injuries to minimize morbidity from both primary and secondary brain injuries. However, NS willing to care for injured patients have become increasingly scarce. Although many institutions have been individually affected by shortages of NS providing care to injured patients, data on regional changes in NS availability and the effect on patient care are limited. METHODS: We queried a state discharge database for all traumatic intracranial hemorrhages (ICH) and skull fractures from 2004 to 2007 by International Classification of Diseases-9th Rev.-Clinical Modification codes. Institutions were categorized as those that admitted >30 or <30 ICH patients per year. The state medical society provided the number of NS practicing in the state per year. RESULTS: The total number of patients with significant head injuries increased over the study period. The number of NS decreased over the same time period. A greater proportion of patients were managed in centers admitting >30 ICH per year, and the number of facilities admitting <30 ICH per year decreased. CONCLUSION: In this state, increasing numbers of patients with ICH are being concentrated in a small number of centers, while the number of NS available to care for them has decreased. Shortages in neurosurgical workforce for patients with traumatic ICH have the potential for catastrophic consequences on a regional basis if effective solutions to this manpower issue are not created.

Management differences for pediatric solid organ injuries in a rural state.

Pediatric liver and spleen injuries are frequently treated in specialized hospitals. Not all injured children, however, are treated in referral centers. We evaluated the management of pediatric liver and spleen injuries in a rural state without a state trauma system to determine if differences existed between trauma centers and nontrauma centers. A state database was queried for patients < or = 15-years-old who suffered liver and spleen injuries from 2003 to 2005. Iatrogenic injuries were excluded. There were 115 pediatric liver and 183 pediatric spleen injuries. Fifty per cent of liver and 63 per cent of spleen injuries in nontrauma centers were isolated solid organ injuries compared with 18 per cent and 36 per cent, respectively, in trauma centers. The mortality rate for both liver and spleen injuries was similar in trauma and nontrauma centers. Hospital charges were higher in trauma centers but this was due to patients with associated injuries. The nonoperative management rate was similar for liver injuries. Pediatric patients with splenic injuries had a lower rate of nonoperative management in nontrauma centers (75% to 90%, nontrauma vs trauma). In Kentucky, pediatric solid organ injuries are usually managed nonoperatively in both trauma and nontrauma centers, but trauma centers cared for fewer isolated solid organ injuries.

Is splenectomy after trauma an endangered species?

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 +/- 0.9 days, 10.9% mortality) compared with trauma (11.0 +/- 0.5 days, 7.7% mortality) or medical (9.7 +/- 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training.

Morbid obesity impacts mortality in blunt trauma.

Twenty-six per cent of adults in the Unites States are obese and trauma remains a major cause of death. We assessed the impact of morbid obesity on mortality in patients with blunt trauma. We reviewed the records of patients with a body mass index 40 kg/m2 or greater injured by blunt trauma from 1993 to 2003 and compared them with a 4:1 control population with a normal body mass index and matched for sex and constellation of injuries. For comparison, patients were categorized by Injury Severity Score 9 or less or Injury Severity Score 10 or greater. Student t test and chi2 were used for statistical analysis. P < 0.05 was considered significant. One hundred seven morbidly obese patients were identified and compared with 458 control subjects with a normal body mass index and matched for sex and constellation of injuries. Although the morbidly obese patients were found to be significantly younger, those who incurred multiorgan injury experienced a significantly longer hospital length of stay and displayed a greater than fourfold increase in mortality when compared with the control subjects. Furthermore, the number of morbidly obese patients admitted over the 10-year period significantly increased by fourfold (0.4% to 1.5%). Over the last decade, there has been a significant increase in morbidly obese patients cared for in our trauma center. Although these patients were significantly younger with a similar Glasgow Coma Score as that of the control population, morbid obesity significantly increased mortality when the injury from blunt trauma transitioned from a single to a multiorgan injury.

Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries.

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2-18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.

Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy.

BACKGROUND: The justification and preference for operative versus nonoperative management of hepatic injuries caused by blunt trauma remains ambiguous. This review assesses the outcome of operative and nonoperative management of liver injury after blunt trauma. METHODS: We retrospectively reviewed the demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, and outcome of patients with documented hepatic injury from 1993 to 2003. RESULTS: The overall mortality rate was 9.4%, with 3.7% caused by the liver injury itself. Fifty-nine percent (330 of 561) of liver injuries were of low severity (grades I and II), with an overall mortality rate of 6.6% caused by concomitant injuries and liver-related mortality of 0%. Forty-one percent (231 of 561) of liver injuries were high-severity injuries (grades III, IV, and V). Mortality for nonoperative management of high-severity liver injuries was 2.2%. If operative intervention was required because of hemodynamic instability or concomitant injuries then the mortality rate was significantly higher at 30%. Forty-two of the 378 (11%) liver injuries treated nonoperatively required an adjunctive procedure for successful management. CONCLUSIONS: Selective management of liver injuries presented a low liver-related mortality rate. Low-grade injuries can be managed nonoperatively with excellent results. High-grade injuries can be managed nonoperatively, if operative intervention is not required for hemodynamic instability or associated injuries, with a low mortality. In these patients, adjunctive procedures will be required selectively for successful nonoperative management of high-grade liver injuries. High-grade injuries requiring operative management because of hemodynamic instability or concomitant injuries continue to have significantly higher mortality.

Trauma/critical care surgeon: a specialist gasping for air.

BACKGROUND: In the last 10 years, trauma/critical care has become less attractive because of the decreasing surgical caseload, the nocturnal work hours, and the economics of the practice. Nevertheless, during the same period, the number of verified trauma centers has significantly increased. This study assesses the economic drive behind this dichotomy. METHODS: Over a 1-year period, we collected financial data on 1,907 trauma patients for both Level I trauma centers and trauma/critical care surgeons. Financial data, including payor source, cost, reimbursement, margin, and reimbursement-to-charge and reimbursement-to-direct cost ratios, were calculated. RESULTS: For commercial- and government-insured patients, the reimbursement-to-direct cost ratio was 2-and 35-fold greater, respectively, for the trauma centers than for the trauma/critical care surgeons. For uninsured patients, the addition of local government funds allowed the trauma center to cover direct cost with no margin. In contrast, even with the addition of supplemental salary dollars from the institution, for every dollar in direct cost generated by the trauma/critical care surgeons in caring for uninsured patients, they recovered 55 cents, or a loss of 45 cents per direct cost dollar spent. CONCLUSION: The economic dichotomy that exists between trauma centers and trauma/critical surgeons is significant. It drives institutional growth and, at the same time, discourages surgeons from entering the subspecialty. As physician reimbursement decreases and the number of uninsured patients increases, this economic dichotomy will amplify. Over the next decade, without a significant adjustment, the subspecialty is in danger of extinction.

Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery.

BACKGROUND: Trauma surgery as a specialty in the United States is at a crossroads. Currently, less than 100 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. In order for the field to flourish, the training of future trauma surgeons must be modified to compensate for these changes. DATA SOURCES: Recent medical literature regarding the training of trauma surgeons and report of the Future of Trauma Surgery/Trauma Specialization Committee of the American Association for the Surgery of Trauma. CONCLUSIONS: The new post-graduate trauma training fellowship of the future should be built on a foundation of general surgery. The goal of this program will be to train a surgeon with broad expertise in trauma, critical care, and emergency general surgery. This new emphasis on non-trauma emergency surgery required an image change and thus a new name; Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery.

Physician extenders impact trauma systems.

BACKGROUND: The implementation of revised surgical resident work hours has led many teaching hospitals to integrate health care extenders into the trauma service. We undertook this review to assess the effectiveness of these individuals in meeting the goals of the work hour restrictions and whether they impact other hospital and patient outcomes. METHODS: During the year 2002, we integrated two nurse practitioners into the trauma service of a teaching hospital. We prospectively collected data a year before (2001), during (2002), and a year after (2003) the integration that included number of admissions, hospital length of stay, intensive care stay, floor length of stay, mortality, direct cost per case, and weekly resident work hours on 44 residents at all levels. RESULTS: After the incorporation of physician extenders, we observed statistically significant reductions in floor, intensive care unit, and overall hospital lengths of stay. Patient mortality and cost per patient remained unchanged. Furthermore, we were able to obtain compliance with the Accreditation Council for Graduate Medical Education requirements for residency work hour limitations, as the average number of hours worked per resident on the trauma service decreased from 86 hours to 79 hours per week. CONCLUSION: As graduate medical education becomes ever more regulated, physician extenders can be successfully integrated into busy academic Level I trauma centers. This integration positively impacts patient flow and resident work hours without altering patient outcomes or direct hospital cost.

Cirrhosis and trauma: a deadly duo.

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and X2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.

Examination of the role of abdominal computed tomography in the evaluation of victims of trauma with increased aspartate aminotransferase in the era of focused abdominal sonography for trauma.

BACKGROUND: Current evaluation of patients with negative findings on a focused abdominal sonography for trauma scan and an isolated increase of admission hepatic enzymes includes abdominal computed tomography (CT). Many of these patients do not have clinically important hepatic injuries. The purpose of this study was to establish the admission aspartate aminotransferase (AST) level below which patients do not need an abdominal CT for injury evaluation and treatment. METHODS: Patients who were hemodynamically stable, had a focused abdominal sonography for trauma scan with negative findings, and an AST level greater than 200 IU/L were identified over a 1-year period. Medical records were reviewed for demographics, injuries sustained, mechanism, evaluation, interventions, and complications. RESULTS: A total of 67 patients, mostly with blunt trauma, were identified; 42 (63%) had an AST level < 360 IU/L, and 25 (37%) had an AST level > 360 IU/L. Patients with an AST level > 360 IU/L had a 88% chance of having any hepatic injury and a 44% chance of having an injury of grade III or greater (P =.0001). Patients with an AST level of < 360 IU/L only had a 14% chance of having a liver injury and no chance of having an injury of grade III or greater (P =.036). CONCLUSIONS: Clinically important hepatic injuries are not missed if an abdominal CT is only performed for patients with a focused abdominal sonography for trauma scan with negative findings and an AST level of > 360 IU/L. Eliminating unnecessary CT allows for more cost-effective use of resources.

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds.

BACKGROUND: Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies. METHODS: Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures. RESULTS: Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation. CONCLUSION: Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.