Comparison of Outcomes in Below-Knee Amputation Between Vascular, General, and Orthopedic Surgeons.

INTRODUCTION: General surgeons (GS), orthopedic surgeons (OS), and vascular surgeons (VS) can perform below-knee amputation (BKA) operations. We compared the outcomes of BKA patients among the three specialties. METHODS: Adult patients who underwent a BKA were identified from the 2016-2018 National Surgical Quality Improvement Project database. Statistical data for orthopedic and vascular BKA cases were then compared with GS cases using logistic regression analysis. Outcomes included mortality, length of hospital stay, and complications. RESULTS: There were 9619 BKA cases. VS had the highest volume of BKA with 58.9% of the cases, compared to GS at 22.9% and OS at 18.1%. 4.4% of general surgery patients had severe frailty compared to OS (3.3%) and VS (3.4%, P < 0.001). VS has the lowest rates of emergency cases (11.9% versus 16.1 for GS versus 15.8% versus OS) and the most favorable wound classification (38.3%, versus 48.7% for GS and VS). Peripheral vascular disease was notably highest in VS (34.0% versus. 20.6% for GS and 9.9% for OS, P < 0.001). Compared to GS, VS was more likely to have a prolonged length of stay (odds ratio) (OR)(1.409), 95% CI 1.265-1.570) while OS was less likely (OR 0.650, 95% CI 0.561-0.754). OS had a lower risk of complications (OR 0.781, 95% CI 0.674-0.904). Mortality was not significantly different among the three specialties. CONCLUSIONS: The National Surgical Quality Improvement Project retrospective analysis of BKA cases suggested that mortality was not statistically different when performed by VS, GS, and OS. There were fewer overall complications when OS performed a BKA, but this is more likely a result of operating upon a generally healthier patient population with lower incidence of preoperative comorbid conditions.

An Evaluation of Diagnostic Tests for Aerodigestive Injuries in Penetrating Neck Trauma.

Assessment of aerodigestive injuries in penetrating neck trauma (PNT) is currently left up to the discretion of physicians which can result in a lot of confusion and unnecessary testing. This study was performed at a level 1 trauma center to assess the role of computed tomography arteriogram (CTA) in evaluating for aerodigestive injury in PNT. A total of 242 patients met criteria, with ages ranging from 7 to 86 years. Computed tomography arteriogram, EGD, esophagography, and bronchoscopy were classified into positive, negative, and indeterminate results. Computed tomography arteriogram was then further analyzed for violation of the carotid sheath, investing, pretracheal, and deep cervical fascias. Results showed a high sensitivity and NPV (100%) of CTA in assessing aerodigestive injury. Computed tomography arteriogram is a reliable first-line screening tool for aerodigestive injury. EGD appears more useful than esophagography at identifying esophageal injuries. Esophagography and bronchoscopy should be reserved to aid in injury management decision-making rather than as screening studies.

The American Association for the Surgery of Trauma Organ Injury Scale for Spleen Does Not Equally Predict Interventions in Penetrating and Blunt Trauma.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the spleen (and other organs) was created in 1989. It has been validated to predict mortality, need for operation, length of stay (LOS), and intensive care unit (ICU) LOS. PURPOSE: We aimed to determine if the Spleen OIS is applied equally to blunt and penetrating trauma. RESEARCH DESIGN/STUDY SAMPLE: We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017-2019, including patients with spleen injuries. DATA COLLECTION: Outcomes included the rates of mortality, operation, spleen-specific operation, splenectomy, and splenic embolization. RESULTS: 60900 patients had a spleen injury with an OIS grade. Mortality rates increased in Grades IV and V for both blunt and penetrating trauma. In blunt trauma, the odds for any operation, spleen-specific operation, and splenectomy increased, for each increase in grade. Penetrating trauma showed similar trends in grades up to grade IV, but were statistically similar between grade IV and V. Splenectomy was higher in penetrating trauma for all grades. Splenic embolization peaked at 25% of grade IV trauma before decreasing in grade V. Rates in penetrating trauma were significantly lower in all grades, peaking at 2.5% of Grade III injuries. CONCLUSIONS: The mechanism of trauma is a significant factor for all outcomes, independent of AAST-OIS. Hemostasis is predominantly surgical in penetrating trauma, achieved with angioembolization more frequently in blunt trauma. Penetrating trauma management is influenced by the potential for injury to peri-splenic organs.

Validating the American Association for the Surgery of Trauma Pancreas Injury Grade Using Trauma Quality Improvement Program Data.

The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the pancreas was created in 1990. Our aim was to validate the ability of the AAST-OIS pancreas grade to predict adjuncts to operative management, including endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drain placement. We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019, including all patients with a pancreas injury. Outcomes included the rates of mortality, laparotomy, ERCP, and peri-pancreatic or hepatobiliary percutaneous drain placement. Outcomes were analyzed by AAST-OIS, and odds ratios (ORs) and 95 confidence intervals (CIs) were calculated for each. 3571 patients were included in the analysis. The AAST grade was associated with increased rates of mortality and laparotomy at every level (P < .05). Endoscopic retrograde cholangiopancreatography rates increased from grade 2 to 3 (OR 4.685, 95% CI 3.254-6.745), were similar between grades 3 and 4 (P > .05), and decreased from grades 4 to 5 (OR .443, CI .250-.788). Likewise, rates of percutaneous drain placement increased from grade 2 to 3 (OR 1.999, CI 1.192-3.353), were similar between grades 3 and 4 (P > .05), and decreased from grades 4 to 5 (OR .266, .076-.934). Increasing pancreatic injury grade is associated with increased mortality and laparotomy rates at all levels. Endoscopic retrograde cholangiopancreatography and percutaneous drainage procedures are used most in mid-grade (3-4) pancreatic trauma. The decrease in nonsurgical procedures in grade 5 pancreatic trauma is likely secondary to increased rates of surgical management (resection and/or wide drainage). The AAST-OIS for pancreatic injury is associated with mortality and interventions.

The American Association for the Surgery of Trauma Organ Injury Scale is Associated With Cystoscopic and Percutaneous Urologic Procedures in Renal Injuries.

BACKGROUND: The American Association for the Surgery of Trauma Organ Injury Scale for the kidney was created in 1989. It has been validated to various outcomes including operations. It was updated in 2018 to better predict endourologic interventions, but this change has not been validated. In addition, the AAST-OIS does not consider mechanism of trauma in its interpretation. METHODS: We analyzed 3 years of the Trauma Quality Improvement Program database including all patients with a kidney injury. We recorded rates of mortality, operation, renal operation, nephrectomy, renal embolization, cystoscopic intervention, and percutaneous urologic procedures. RESULTS: 26294 patients were included. In penetrating trauma, mortality, operation, renal-specific operation, and nephrectomy rates increased at every grade. Renal embolization and cystoscopy rates peaked in grade IV. Percutaneous interventions were rare across all grades. In blunt trauma, mortality and nephrectomy rates increased only in grades IV and V. Operation, renal operation, and renal embolization rates increased at every grade level. Cystoscopy rates peaked in grade IV. Percutaneous procedure rates only increased between grades III and IV. Penetrating injuries are more likely to require nephrectomy in grades III-V, cystoscopic procedures in grade III, and percutaneous procedures in grades I-III. DISCUSSION: Endourologic procedures are most utilized in grade IV injuries, which are in part defined by injuries with damage to the central collecting system. Despite penetrating injuries more frequently requiring nephrectomy, they also more frequently require nonsurgical procedures. Mechanism of trauma should be considered when interpreting the AAST-OIS for kidney injuries.

Effect of Age Alone on Outcome of Acute Surgical Conditions Among Healthy Patients (Non-smokers, Non-obese, and No Comorbid Conditions).

BACKGROUND: The impact of age alone in relation to postoperative outcomes needs to be further elucidated. This study investigated whether increasing age was associated with increased morbidity and mortality for patients with no comorbidities undergoing acute care surgery (ACS). METHODS: The 2016-2018 National Surgical Quality Improvement Project database was used to identify adult patients who underwent ACS performed on an urgent/emergent basis. Patients overweight or with pre-existing medical comorbidities were excluded. Patients were divided into age groups in decades. The association between outcomes and the different age groups, other patient characteristics, and perioperative factors was examined by multivariate logistic regression. RESULTS: 22,770 patients were identified, of which 73.5% were appendectomies, and 21.6% were open procedures. Increasing age correlated with higher unadjusted complication rates and mortality. Multivariate analyses revealed that compared to patients ≤ 30 years old, mortality was not different for patients 31-60 years old, but it was higher for the age groups > 61 years old. Patients aged 51-60 and from 71 and above were associated with higher risks of complications. Subset analysis on octogenarians revealed a 1.14-fold higher odds of mortality for every year of increasing age. Preoperative risk factors including open procedure, wound class, and American Society of Anesthesiology (ASA) class were also associated with greater risks of mortality in octogenarians. CONCLUSION: Patients older than age 50 were at higher risk for postoperative complications, and mortality significantly increased for each decade past 60 years old in healthy individuals.

Can the 5-item Modified Frailty Index Predict Outcomes in Geriatric Trauma? A National Database Study.

BACKGROUND: Frailty results in increased vulnerability to adverse outcomes following trauma. We investigated the association between the 5-item modified frailty index (mFI-5) and outcomes in geriatric trauma patients. METHODS: The 2011-2016 Trauma Quality Improvement Program database was used to study outcomes in patients ≥ 65 years old. The mFI-5 was measured and categorized into no frailty (mFI-5 = 0), moderate frailty (mFI-5 = 0.2), and severe frailty (mFI-5 ≥ 0.4). Multivariable logistic regression analyses were performed to identify independent factors of mortality and complications. RESULTS: 26,963 cases met the inclusion criteria, of whom 25.5% were not frail, 38% were moderately frail, and 36.6% were severely frail. Mean age (± SD) was 76 ± 7 years, 61.5% were male, and 97.8% sustained blunt injuries. Median Injury Severity Score (ISS) was 17 (IQR = 10-26), and the median Glasgow Coma Scale was 15 (IQR = 12-15). Overall mortality was 30.6%. Factors independently associated with mortality were age (OR = 1.07 per year, 95%CI 1.06-1.07), blunt trauma (OR = 1.44, 95%CI 1.19 -1.75), ISS (OR = 1.04 per unit increase in ISS, 95%CI 1.03-1.04), and severe frailty (OR = 1.23, 95%CI 1.15-1.32). Interestingly, male sex and GCS appeared to be protective factors with OR of 0.88 (95%CI 0.83 - 0.93) and 0.89 per point change in GCS (95%CI 0.88-0.9), respectively. Moderate (OR = 1.27, 95%CI 1.19-1.25) and severe frailty (OR = 1.49, 95%CI 1.-1.59) were significantly associated with in-hospital complications. CONCLUSION: Moderate and severe frailty were significant predictors of complications. Only severe frailty was associated with short-term mortality. The mFI-5 can be used as an objective measure to stratify risks in geriatric trauma.

The American Association for the Surgery of Trauma (AAST) Liver Injury Grade Does Not Equally Predict Interventions in Blunt and Penetrating Trauma.

INTRODUCTION: The AAST liver injury grade has a validated association with mortality and need for operation. AAST liver injury grade is the same regardless of the mechanism of trauma. METHODS: A 5-year retrospective review of all liver injuries at an urban, level-one trauma center was performed. RESULTS: Totally, 315 patients were included (29% blunt, 71% penetrating). In blunt trauma, AAST grade was associated with need for laparotomy (0%, 7%, 5%, 33%, 29%, Grade 1-5, p = 0.01), angiography (0%, 7%, 25%, 40%, 57%, p < 0.001), embolization (0%, 7%, 15%, 33%, 43%, p = 0.01), and percutaneous drainage procedures (13% use in Grade 4, otherwise 0%, p = 0.04), but not ERCP (0% for all grades). In penetrating trauma, AAST grade was associated with need for angiography (7%, 4%, 15%, 24%, 30%, p < 0.01) and percutaneous drainage (7%, 2%, 14%, 18%, 26%, p = 0.03) and had a marginal association with embolization (0%, 4%, 11%, 13%, 22%, p = 0.06). Laparotomy, ERCP, sphincterotomy, and stenting rates increased with AAST grade, but this was not statistically significant. CONCLUSION: AAST grade is associated with the need for surgical hemostasis, angioembolization, and percutaneous drainage in both penetrating and blunt trauma. Operative, endoscopic, and percutaneous procedures are utilized more in penetrating trauma. Angioembolization was used more in blunt trauma. Mechanism should be considered when using AAST grade to guide management of liver injuries.

"HYPER-EARLY" Tracheostomy within 48 hours has less Complications and Better Prognosis Compared to Traditional Tracheostomy.

INTRODUCTION: Tracheostomies may be performed "early" or "late." There is no agreement on the best timing for tracheostomy. This study compares tracheostomies and complications when performed within 48 hours with those performed from 48 hours to 21 days. METHODS: Patients who underwent tracheostomy in the 2017-2018 National Trauma Data Bank (NTDB) were categorized into 2 groups: early tracheostomy (≤48 hours) and late tracheostomy (>48 hours to 21 days). Primary outcome measured was mortality. Chi square models, Mann-Whitney U Test, and multivariate logistics were used for data analysis. RESULTS: 843 patients had tracheostomy performed, of which 16% underwent early tracheostomy. Majority were male in both early (84%) and late (74%) tracheostomy groups. Mortality was not statically significant in early (13%) or late (9%) (P = .151). Total duration of ventilation in early tracheostomy group was less (5 days) compared to late tracheostomy group (16 days, P < .001). Patients with late tracheostomy had almost 18% cases of ventilator-associated pneumonia (VAP) when compared to early tracheostomy patients (7%, P < .001). Early tracheostomy patients also had shorter hospital length of stay (HLOS) (13 vs 27 days) and intensive care unit (ICU) length of stay (LOS) (7 vs 20 days) than late tracheostomy patients (P<.001). Early tracheostomy patients also had shorter hospital length of stay (HLOS) (13 vs 27 days) and intensive care unit (ICU) length of stay (LOS) (7 vs 20 days) than late tracheostomy patients (P < .001). CONCLUSION: Tracheostomy performed as early as 48 hours is beneficial as it demonstrates a decrease time on ventilator, decreased HLOS, as well as lower VAP rates. Our data shows "hyper-early" tracheostomies might be more beneficial that the current national practice.

Complications After Inpatient Laparoscopic Cholecystectomy: Effect of Surgeon Experience, Procedure Volume, and Other Surgeon-Based Characteristics.

BACKGROUND: Previous studies have examined how factors such as gender, education, type of training (MD or DO), and experience of the treating surgeon affect patient outcomes. We investigated patient complications after elective laparoscopic cholecystectomy based on surgeon characteristics. METHODS: A Medicare database was used to identify surgeon-specific data. The main outcome measure was the adjusted complication rates (ACR) for individual surgeons as reported by the ProPublica Surgeon Scorecard. Surgeon gender, type of training, medical school rank, years since graduation, procedure volume, and teaching status of the primary hospital affiliation were assessed for any association with increased ACR using logistic regression analysis. We explored the associations among procedure volume, years of experience, and ACR using Spearman correlation. RESULTS: 1107 predominantly male (94.6%) surgeons were included. 94.4% were MDs and 34.5% were affiliated with teaching hospitals. Mean length of practice was 24 ± 9 years, and median surgeon procedure volume was 28 (IQR = 23, 37). Overall median ACR was 4.3%. Multivariate analysis demonstrated that surgeon gender (P = .71), medical school rank, type of training (P = .68), or hospital affiliation (P = .77) did not have a significant impact on ACR. Increased surgeons' years in practice (r = -.028, P = .35) and increased surgeon procedure volume (r = -.021, P = .49) were negatively associated with increased ACR. CONCLUSION: Surgeon gender, type of training, medical school rank, or hospital affiliation had no impact on complications after laparoscopic cholecystectomy. Surgeon experience and procedure volume may have clinical implications for patient outcomes. Further studies to elucidate factors associated with surgeon quality and patient outcomes are necessary.

Maternal Outcomes After Trauma in Pregnancy: A National Database Study.

OBJECTIVES: Trauma is an important non-obstetric cause of mortality in pregnant females. METHODS: The National Trauma Databank (NTDB) was queried between 2017 and 2018. Pregnant women >20 weeks gestation, who underwent trauma, were included. They were categorized into different age groups from 12-18, 18-35, and 36-50 years of age. The primary outcome measure was 30-day mortality. RESULTS: 1,058 pregnant trauma patients were included. Mean age was 26.7 ± 6 years. Of those 94.5% had blunt and 3.8% had penetrating injuries. Median GCS and ISS were 15 (15, 15) and 2 (1, 5), respectively. Penetrating trauma patients required more operative intervention (57.5%) than blunt trauma patients (24.6%). Univariate analysis comparing age groups 12-18, 19-35, and >36 years revealed differences. (P < .05) in ED systolic blood pressure (110.9 ± 19.7 vs 117.3 ± 20.3 vs 129.1 ± 29.3 mmHg, P = .01) and diabetes mellitus (.0 vs 2.7% vs 6.6% P = .03). There was no difference in HLOS (P = .72), complications (P = .279), and mortality (P = .32). Multivariate logistic regression analysis revealed that compared to patients 12-18 years old, patients 19 to 35 (P = .27) or those >36 (P = 1.0) did not show a significant difference in mortality. Patients with high ISS had higher complication rates (OR 1.09; 95% CI 1.04-1.15) and prolonged HLOS (OR 1.00; 95% CI 1.07-1.15). CONCLUSION: On average pregnant women (>20 weeks gestation) who presented to trauma centers had minor injuries and maternal age or mechanism of injury did not affect mortality. Despite a low ISS, a significant number of these patients required operative procedures.

Rapid evolution of a Morgagni hernia with herniation of the left hepatic lobe: case report and review of the literature.

Morgagni hernias are a rare form of congenital diaphragmatic hernia, commonly found on cross-sectional imaging. Repair is generally performed electively for pulmonary or gastrointestinal symptoms. Our case presented acutely with gastric obstruction. Two months prior she had a small bowel obstruction and underwent computed tomography, diagnostic laparoscopy, lysis of adhesions and takedown of the falciform ligament, where a 'groove' to the left of the falciform was noted, but not repaired. We collected the presentation, technique, complications and results of 12 prior cases. A trans-abdominal, robotic-assisted tissue repair of the diaphragm with mesh reinforcement utilizing as few as three ports appears to be safe and effective. The robotic platform offers additional degrees of freedom, making retrosternal operating more ergonomic to the surgeon. The rapid progression of our patient suggests that repair at the time of discovery should be considered so that the serious complications can be avoided.

Protective Effect of Phosphatidylserine Blockade in Hemorrhagic Shock.

BACKGROUND: Phosphatidylserine (PS) is a key cell membrane phospholipid normally maintained on the inner cell surface but externalizes to the outer surface in response to cellular stress. We hypothesized that PS exposure mediates organ dysfunction in hemorrhagic shock. Our aims were to evaluate PS blockade on (1) pulmonary, (2) renal, and (3) gut function, as well as (4) serum lysophosphatidic acid (LPA), an inflammatory mediator generated by PS externalization, as a possible mechanism mediating organ dysfunction. MATERIALS AND METHODS: Rats were either (1) monitored for 130 min (controls, n = 3), (2) hemorrhaged then resuscitated (hemorrhage only group, n = 3), or (3) treated with Diannexin (DA), a PS blocking agent, followed by hemorrhage and resuscitation (DA + hemorrhage group, n = 4). Pulmonary dysfunction was assessed by arterial partial pressure of oxygen, renal dysfunction by serum creatinine, and gut dysfunction by mesenteric endothelial permeability (LP). LPA levels were measured in all groups. RESULTS: Pulmonary: there was no difference in arterial partial pressure of oxygen between groups. Renal: after resuscitation, creatinine levels were lower after PS blockade with DA versus hemorrhage only group (P = 0.01). Gut: LP was decreased after PS blockade with DA versus hemorrhage only group (P < 0.01). Finally, LPA levels were also lower after PS blockade with DA versus the hemorrhage only group but higher than the control group (P < 0.01). CONCLUSIONS: PS blockade with DA decreased renal and gut dysfunction associated with hemorrhagic shock and attenuated the magnitude of LPA generation. Our findings suggest potential for therapeutic targets in the future that could prevent organ dysfunction associated with hemorrhagic shock.

Alcohol in Traumatic Brain Injury: Toxic or Therapeutic?

BACKGROUND: Alcohol (EtOH) poses a challenge in traumatic brain injuries (TBIs) given its metabolic and neurologic impact. Studies have had opposing results regarding mortality and complication rates in the intoxicated TBI patient. We hypothesized that trauma mechanism, brain injury severity, and blood alcohol concentration (BAC) would influence the impact of EtOH on mortality in TBI. METHODS: We performed a single-institution retrospective review of consecutive adult trauma patients tested for EtOH and a diagnosis of TBI. The primary outcome was mortality, and secondary outcomes included infectious complications. The primary analysis included univariate and multivariate regression comparing mortality between intoxicated and sober patients, at different values of BAC, different brain injury severities, and among mechanisms of trauma. RESULTS: Admission EtOH was assessed in 583 patients with TBI, with 256 testing positive for EtOH and 327 testing negative. Overall, EtOH was associated with lower mortality on univariate analysis (4.7% versus 8.9%, P = 0.05) but not on multivariate analysis (P = 0.21). There was no effect of EtOH on mortality when patients were stratified by brain injury severity or among penetrating trauma victims. However, EtOH was associated with lower overall infectious complications on univariate and multivariate regression. Finally, EtOH was predictive of mortality with an area under the receiver operator characteristic curve of 0.83. CONCLUSIONS: We found that EtOH is not associated with mortality in the patient with TBI, suggesting no causative effect. However, EtOH showed some predictability of mortality based on a receiver operator characteristic analysis. Interestingly, EtOH was associated with lower infectious complications, suggesting an immunomodulatory effect of EtOH in TBI.

Protective effect of phosphatidylserine blockade in sepsis induced organ dysfunction.

BACKGROUND: Phosphatidylserine is usually an intracellularly oriented cell membrane phospholipid. Externalized phosphatidylserine on activated cells is a signal for phagocytosis. In sepsis, persistent phosphatidylserine exposure is also a signal for activation of the coagulation and inflammatory cascades. As such, phosphatidylserine may be a key molecule in sepsis induced cellular and organ injury. We hypothesize that phosphatidylserine blockade provides a protective effect in sepsis induced organ dysfunction. METHODS: Sepsis was induced in adult female rats using an endotoxin model. Diannexin, a homodimer of annexin A5, was administered for phosphatidylserine blockade. Rats were allocated to control (n = 5), sepsis (n = 6), or sepsis and phosphatidylserine blockade (n = 9) groups. Gut, pulmonary, renal, and hematologic dysfunctions were evaluated by mesenteric microvascular fluid leak, partial pressure of oxygen, serum creatinine, activated clotting time, and glomerular fibrin deposition, respectively. RESULTS: Rats in the sepsis group demonstrated gut, renal, and hematologic dysfunction. Phosphatidylserine blockade reversed signs of gut dysfunction and mesenteric microvascular leak (P < .01). In addition, phosphatidylserine blockade corrected systemic coagulopathy, as measured by activated clotting time (P = .03) and glomerular fibrin deposition (P = .008). There was no difference in renal dysfunction (P = .1) or pulmonary dysfunction in any of the groups (P = .6). CONCLUSION: In sepsis, phosphatidylserine blockade had a protective effect on gut dysfunction and coagulopathy. Increased phosphatidylserine exposure may be a key mediator of organ dysfunction and coagulopathy during sepsis. These data may provide insights into novel treatment options for septic patients.

Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities.

This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.