Focused Assessment With Sonography In Trauma Research Articles

Fast examination and interventional ultrasound in the diagnosis and treatment of combat abdominal trauma

To improve the diagnosis and surgical treatment of wounded patients with combat abdominal trauma by methods of emergency ultrasound diagnostics and minimally invasive surgery under the control of ultrasound. The purpose of the work is to improve the results of diagnosis and surgical treatment of wounded patients with combat abdominal trauma by emergency ultrasound examination techniques and minimally invasive surgical interventions under ultrasound control. A clinical and statistical analysis of the results of the surgical treatment of 293 wounded patients with combat abdominal trauma treated at the Military Medical Clinical Centre of the Southern Region was conducted. In the main group, additional therapeutic and diagnostic measures were performed — focused assessment with sonography in trauma (FAST), puncture rehabilitation and drainage surgery under the control of ultrasound. In the main group, in contrast to the control group, FAST examination was conducted in all wounded patients. The widespread introduction of the FAST examination and diagnostic punctures under ultrasound control into diagnostics reduces the level of more traumatic diagnostic laparocentesis from 24.7 to 2.2% and unreasonable surgical interventions from 3.2 to 0.7 %. An algorithm of diagnostic and therapeutic measures for wounded patients with combat abdominal trauma based on the results of the FAST examination was developed. The data obtained indicate that the widespread implementation of FAST, percutaneous puncture and sanitation interventions under ultrasound control in the diagnosis and treatment of combat abdominal trauma and its complications helps to reduce the number of invasive and more traumatic (often useless) interventions, which leads to faster recovery and shorter treatment time.

Ultrasound Rounds: Anesthesiologist-Performed Intraoperative Point-of-Care Focused Assessment With Sonography in Trauma Examination Changes Surgical Management.

Focused Assessment with Sonography in Trauma (FAST) examinations have been performed for decades by surgeons during initial patient presentation for emergency care and surgical planning, as well as for guiding resuscitation. This case highlights how use of intraoperative FAST examinations performed by anesthesiologists can dramatically change patient management. Use by anesthesiologists perioperatively is an important skill, although it is not widely practiced.

Using Deep Learning to Detect the Presence and Location of Hemoperitoneum on the Focused Assessment with Sonography in Trauma (FAST) Examination in Adults.

Abdominal ultrasonography has become an integral component of the evaluation of trauma patients. Internal hemorrhage can be rapidly diagnosed by finding free fluid with point-of-care ultrasound (POCUS) and expedite decisions to perform lifesaving interventions. However, the widespread clinical application of ultrasound is limited by the expertise required for image interpretation. This study aimed to develop a deep learning algorithm to identify the presence and location of hemoperitoneum on POCUS to assist novice clinicians in accurate interpretation of the Focused Assessment with Sonography in Trauma (FAST) exam. We analyzed right upper quadrant (RUQ) FAST exams obtained from 94 adult patients (44 confirmed hemoperitoneum) using the YoloV3 object detection algorithm. Exams were partitioned via fivefold stratified sampling for training, validation, and hold-out testing. We assessed each exam image-by-image using YoloV3 and determined hemoperitoneum presence for the exam using the detection with highest confidence score. We determined the detection threshold as the score that maximizes the geometric mean of sensitivity and specificity over the validation set. The algorithm had 95% sensitivity, 94% specificity, 95% accuracy, and 97% AUC over the test set, significantly outperforming three recent methods. The algorithm also exhibited strength in localization, while the detected box sizes varied with a 56% IOU averaged over positive cases. Image processing demonstrated only 57-ms latency, which is adequate for real-time use at the bedside. These results suggest that a deep learning algorithm can rapidly and accurately identify the presence and location of free fluid in the RUQ of the FAST exam in adult patients with hemoperitoneum.

External validation of the ultrasound competency assessment tool

AbstractObjectivePoint‐of‐care ultrasound (POCUS) is a core component of emergency medicine (EM) residency training. No standardized competency‐based tool has gained widespread acceptance. The ultrasound competency assessment tool (UCAT) was recently derived and validated. We sought to externally validate the UCAT in a 3‐year EM residency program.MethodsThis was a convenience sample of PGY‐1 to ‐3 residents. Utilizing the UCAT and an entrustment scale, as described in the original study, six different evaluators split into two groups graded residents in a simulated scenario involving a patient with blunt trauma and hypotension. Residents were asked to perform and interpret a focused assessment with sonography in trauma (FAST) examination and apply the findings to the simulated scenario. Demographics, prior POCUS experience, and self‐assessed competency were collected. Each resident was evaluated simultaneously by three different evaluators with advanced ultrasound training utilizing the UCAT and entrustment scales. Intraclass correlation coefficient (ICC) between evaluators was calculated for each assessment domain; analysis of variance was used to compare UCAT performance and PGY level and prior POCUS experience.ResultsThirty‐two residents (14 PGY‐1, nine PGY‐2, and nine PGY‐3) completed the study. Overall, ICC was 0.9 for preparation, 0.57 for image acquisition, 0.3 for image optimization, and 0.46 for clinical integration. There was moderate correlation between number of FAST examinations performed and entrustment and UCAT composite scores. There was poor correlation between self‐reported confidence and entrustment and UCAT composite scores.ConclusionsWe had mixed results in our attempt to externally validate the UCAT with poor correlation between faculty and moderate to good correlation with faculty to diagnostic sonographer. More work is needed to validate the UCAT before adoption.

Automated detection and localization of pericardial effusion from point-of-care cardiac ultrasound examination.

Focused Assessment with Sonography in Trauma (FAST) exam is the standard of care for pericardial and abdominal free fluid detection in emergency medicine. Despite its life saving potential, FAST is underutilized due to requiring clinicians with appropriate training and practice. To aid ultrasound interpretation, the role of artificial intelligence has been studied, while leaving room for improvement in localization information and computation time. The purpose of this study was to develop and test a deep learning approach to rapidly and accurately identify both the presence and location of pericardial effusion on point-of-care ultrasound (POCUS) exams. Each cardiac POCUS exam is analyzed image-by-image via the state-of-the-art YoloV3 algorithm and pericardial effusion presence is determined from the most confident detection. We evaluate our approach over a dataset of POCUS exams (cardiac component of FAST and ultrasound), comprising 37 cases with pericardial effusion and 39 negative controls. Our algorithm attains 92% specificity and 89% sensitivity in pericardial effusion identification, outperforming existing deep learning approaches, and localizes pericardial effusion by 51% Intersection Over Union with ground-truth annotations. Moreover, image processing demonstrates only 57ms latency. Experimental results demonstrate the feasibility of rapid and accurate pericardial effusion detection from POCUS exams for physician overread.

Artificial intelligence evaluation of focused assessment with sonography in trauma.

The focused assessment with sonography in trauma (FAST) is a widely used imaging modality to identify the location of life-threatening hemorrhage in a hemodynamically unstable trauma patient. This study evaluates the role of artificial intelligence in interpretation of the FAST examination abdominal views, as it pertains to adequacy of the view and accuracy of fluid survey positivity. Focused assessment with sonography for trauma examination images from 2015 to 2022, from trauma activations, were acquired from a quaternary care level 1 trauma center with more than 3,500 adult trauma evaluations, annually. Images pertaining to the right upper quadrant and left upper quadrant views were obtained and read by a surgeon or radiologist. Positivity was defined as fluid present in the hepatorenal or splenorenal fossa, while adequacy was defined by the presence of both the liver and kidney or the spleen and kidney for the right upper quadrant or left upper quadrant views, respectively. Four convolutional neural network architecture models (DenseNet121, InceptionV3, ResNet50, Vgg11bn) were evaluated. A total of 6,608 images, representing 109 cases were included for analysis within the "adequate" and "positive" data sets. The models relayed 88.7% accuracy, 83.3% sensitivity, and 93.6% specificity for the adequate test cohort, while the positive cohort conferred 98.0% accuracy, 89.6% sensitivity, and 100.0% specificity against similar models. Augmentation improved the accuracy and sensitivity of the positive models to 95.1% accurate and 94.0% sensitive. DenseNet121 demonstrated the best accuracy across tasks. Artificial intelligence can detect positivity and adequacy of FAST examinations with 94% and 97% accuracy, aiding in the standardization of care delivery with minimal expert clinician input. Artificial intelligence is a feasible modality to improve patient care imaging interpretation accuracy and should be pursued as a point-of-care clinical decision-making tool. Diagnostic Test/Criteria; Level III.

The Frequency of POCUS in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study.

Background: Point of care ultrasound (POCUS) is ubiquitous in the modern emergency department (ED). POCUS can be helpful in the management of patients with sepsis in many ways including determining the cause of sepsis, assessing fluid status, guiding resuscitation, and performing procedures. However, the frequency and manner in which POCUS is incorporated into the care of septic patients in community emergency medicine remains unclear. Objective: To evaluate POCUS frequency and exam types used in the care of patients with sepsis in two community EDs in Southern California. Methods: We performed a retrospective analysis of 5,264 ED visits with a diagnosis of sepsis at two community emergency departments between January 2014 and December 2018. Patients 18 years or older who were diagnosed with sepsis and had either lactate ≥ 4 mmol, a documented mean arterial pressure (MAP) < 65 mmHg, or a systolic blood pressure (SBP) < 90 mmHg were included. Charts were reviewed to determine if POCUS was used during the ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in POCUS use over the study period, and the types of exams performed. Results: POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR = 1.09; CI 1.04, 1.15; p=0.001). The most common POCUS exam was ultrasound-guided central line placement, with the next most common exams being cardiac, followed by inferior vena cava (IVC). Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography in Trauma (FAST) exams were found to increase significantly over the study period. Conclusions: Total POCUS use increased significantly in this cohort of septic patients over the study period due to more cardiac, IVC, lung and FAST exams being performed.

Anatomical Correlation for Focused Assessment With Sonography in Trauma

When learning the Focused Assessment with Sonography in Trauma (FAST) exam, anatomical orientation can be difficult, especially in the subxiphoid and upper quadrant views. To facilitate understanding in these areas, a novel in-situ cadaver dissection was used to demonstrate anatomy related to the FAST exam. In situ, because the structures remained in normal positions with adjacent organs, layers, and spaces clearly visible from the point of view of the ultrasound probe. These views were then correlated with what was seen on the ultrasound screen. The right upper quadrant and subxiphoid anatomy were viewed in a mirror to match the ultrasound images, and the left upper quadrant was viewed directly from the examiner’s position, also matching the view on the ultrasound screen. The in-situ cadaver dissection was developed as a resource to correlate FAST exam ultrasound images in the upper quadrant and subxiphoid regions with related cadaver anatomy.

Competency Standard Derivation for Point-of-Care Ultrasound Image Interpretation for Emergency Physicians.

Because number-based standards are increasingly controversial, the objective of this study was to derive a performance-based competency standard for the image interpretation task of point-of-care ultrasound (POCUS). This was a prospective study. Operating on a clinically-relevant sample of POCUS images, we adapted the Ebel standard-setting method to derive a performance benchmark in 4 diverse pediatric POCUS applications: soft tissue, lung, cardiac and focused assessment with sonography in trauma (FAST). In Phase I (difficulty calibration), cases were categorized into interpretation difficulty terciles (easy, intermediate, hard) using emergency physician-derived data. In Phase II (significance), a 4-person expert panel categorized cases as low, medium, or high clinical significance. In Phase III (standard setting), a 3x3 matrix was created, categorizing cases by difficulty and significance, and a 6-member panel determined acceptable accuracy for each of the 9 cells. An overall competency standard was derived from the weighted sum. We obtained data from 379 emergency physicians resulting in 67,093 interpretations and a median of 184 (interquartile range, 154, 190) interpretations per case. There were 78 (19.5%) easy, 272 (68.0%) medium, and 50 (12.5%) hard-to-interpret cases, and 237 (59.3%) low, 65 (16.3%) medium, and 98 (24.5%) cases of high clinical significance across the 4 POCUS applications. The panel determined an overall performance-based competency score of 85.0% for lung, 89.5% for cardiac, 90.5% for soft tissue, and 92.7% for FAST. This research provides a transparent chain of evidence that derived clinically relevant competency standards for POCUS image interpretation.

Trends in point-of-care ultrasound use among emergency medicine residency programs over a 10-year period.

Point-of-care ultrasound (POCUS) is increasingly utilized in emergency medicine (EM). While residents are required by the Accreditation Council for General Medical Education to complete a minimum of 150 POCUS examinations before graduation, the distribution of examination types is not well-described. This study sought to assess the number and distribution of POCUS examinations completed during EM residency training and evaluate trends over time. This was a 10-year retrospective review of POCUS examinations across five EM residency programs. The study sites were deliberately selected to represent diversity in program type, program length, and geography. Data from EM residents graduating from 2013 to 2022 were eligible for inclusion. Exclusion criteria were residents in combined training programs, residents who did not complete all training at one institution, and residents who did not have data available. Examination types were identified from the American College of Emergency Physicians guidelines for POCUS. Each site obtained POCUS examination totals for every resident upon graduation. We calculated the mean and 95% confidence interval for each procedure across study years. A total of 535 residents were eligible for inclusion, with 524 (97.9%) meeting all inclusion criteria. The mean number of POCUS examinations per resident increased by 46.9% from 277 in 2013 to 407 in 2022. All examination types had stable or increasing frequency. Focused assessment with sonography in trauma (FAST), cardiac, obstetric/gynecologic, and renal/bladder were performed most frequently. Ocular, deep venous thrombosis, musculoskeletal, skin/soft tissue, thoracic, and cardiac examinations had the largest percentage increase in numbers over the 10-year period, while bowel and testicular POCUS remained rare. There was an overall increase in the number of POCUS examinations performed by EM residents over the past 10 years, with FAST, cardiac, obstetric/gynecologic, and renal/bladder being the most common examination types. Among less common procedures, increased frequency may be needed to ensure competence and avoid skill decay for those examination types. This information can help inform POCUS training in residency and accreditation requirements.

Solid Organ Injury Grading in the Abdomen: A Primer for Emergency Radiology

The American Association for the Surgery of Trauma (AAST) established the Organ Injury Scale (OIS) in 1984, making an initial revision in 1994, and the most recent revision in 2018. This recent revision was made to better predict the need for operative or angiointervention management, considering active hemorrhage or other vascular complications. Diagnosis of hemodynamically stable patients is made by CT; however, hemodynamically unstable patients may be diagnosed via focused assessment with sonography in trauma (FAST) ultrasound or emergency laparotomy.1–3 In this article, we discuss in depth the different OIS gradings for renal, hepatic, and splenic trauma and demonstrate the necessary information that an emergency radiologist must know through a series of cases. This knowledge will allow radiologists to concisely communicate with referring teams and help them make the appropriate management decisions for each patient case.1 , 4

Computed Tomography Findings in Traumatic Pneumorachis: A Case Report

The phenomenon of air entering the spinal canal is rare and termed pneumorachis. Due to its rarity, the evaluation and management of pneumorachis have not been well understood. Here, the authors describe a case of pneumorachis associated with pneumothorax, pneumomediastinum, subcutaneous emphysema, and traumatic pulmonary injuries in a 21-year-old male patient following blunt chest trauma after a motor vehicle accident. The patient presented with chest pain and difficulty breathing immediately after the vehicle accident, along with a deformed left arm. A bedside Focused Assessment with Sonography in Trauma (FAST) scan was performed, followed by a non-contrast CT of the thorax, which revealed intraspinal air and multiple fractures. The patient recovered without any adverse outcomes with conservative management of the intraspinal air. Pneumorachis is usually secondary to trauma and typically follows a benign course with spontaneous resolution after conservative management. It is important to be aware of this condition to identify it early and prevent complications.

Virtual Ultrasound Training in a Multinational Teaching Program.

Before the COVID-19 pandemic, a 1-week in-person Clinical Ultrasound Course was taught in African nations as part of a U.S. Department of State-funded program that supports and trains African peacekeepers serving with the United Nations and African Union. In order to maintain active engagement with host nations despite the travel restrictions due to the COVID-19 pandemic, portions of the course were taught virtually in 2021 to providers in Ghana, Senegal, and Rwanda. An abbreviated course was delivered covering the Focused Assessment with Sonography in Trauma (FAST) trauma exam and vascular access. The goal of this study is to assess the effectiveness of the Clinical Ultrasound Course while taught in a virtual classroom. Thirty-six participants enrolled in the program. Participants completed a pre-course survey before the training. Training consisted of a pre-recorded lecture followed by hands-on ultrasound instruction. After the training, participants completed a post-course survey. Eight participants were excluded from the study because they did not complete both surveys. Survey questions assessed the participants' comfort with ultrasound mechanics and the FAST exam. Participant responses were measured utilizing a visual analog scale. Based on survey results, all participants gained a better understanding of the indications and limitations of the FAST exam from the virtual Clinical Ultrasound Course. All participants also felt more comfortable using ultrasound in clinical practice than they did before the course. Ghanaian and Senegalese participants showed greater improvement in all areas studied than Rwandan participants. This is likely due to the fact that the Rwandan hospital system had prior ultrasound training and a higher baseline understanding than their counterparts. The Rwandan hospital system had previously completed the in-person sessions of the Clinical Ultrasound Course and therefore had some institutional knowledge, while the Ghanaians and Senegalese took the course for the first time during this study. Virtual delivery of the Clinical Ultrasound Course was successful. Participants felt more comfortable in all aspects of ultrasound taught during the course and indicated that they were more likely to use ultrasound in clinical practice. This demonstrates that virtual ultrasound teaching is a viable option for international educational programs in the future.

Point of Care Ultrasound Literature Primer: Key Papers on Focused Assessment With Sonography in Trauma (FAST) and Extended FAST

Objective The objective of this study is to identify the top five most influential papers published on focused assessment with sonography in trauma (FAST) and the top five most influential papers on the extended FAST (E-FAST) in adult patients. Methods An expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. These experts are ultrasound fellowship-trained or equivalent, are involved with point-of-care ultrasound (POCUS) research and scholarship, and are leaders inboth the POCUSprogram at their local site and within the national Canadian POCUS community. This 14-member expert group used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for FAST and E-FAST. Results The expert panel identified 56 relevant papers on FAST and 40 relevant papers on E-FAST. After completing all three rounds of the modified Delphi process, the authors identified the top five most influential papers on FAST and the top five most influential papers on E-FAST. Conclusion We have developed a reading list of the top five influential papers for FAST and E-FAST that will benefit residents, fellows, and clinicians who are interested in using POCUS in an evidence-informed manner.

42 Artificial Intelligence Model to Identify Organ Features for Guiding FAST Ultrasound Exams

The Focused Assessment with Sonography in Trauma (FAST) exam is used to rapidly identify unstable trauma patients with intraperitoneal hemorrhage. Maintaining high diagnostic precision during a point-of-care FAST Exam requires accurate and prompt recognition of relevant anatomical landmarks. In the cranial abdominal views (right upper quadrant – RUQ, and left upper quadrant – LUQ), these landmarks include solid organs (Spleen, Liver, Kidney) and their interfaces with surrounding structures (the Diaphragm and the inferior tips of the Liver/Spleen).

POCUS spotlight: focused assessment with sonography in trauma (FAST) exam

POCUS spotlight: focused assessment with sonography in trauma (FAST) exam

Deep Learning for FAST Quality Assessment.

To determine the feasibility of using a deep learning (DL) algorithm to assess the quality of focused assessment with sonography in trauma (FAST) exams. Our dataset consists of 441 FAST exams, classified as good-quality or poor-quality, with 3161 videos. We first used convolutional neural networks (CNNs), pretrained on the Imagenet dataset and fine-tuned on the FAST dataset. Second, we trained a CNN autoencoder to compress FAST images, with a 20-1 compression ratio. The compressed codes were input to a two-layer classifier network. To train the networks, each video was labeled with the quality of the exam, and the frames were labeled with the quality of the video. For inference, a video was classified as poor-quality if half the frames were classified as poor-quality by the network, and an exam was classified as poor-quality if half the videos were classified as poor-quality. The results with the encoder-classifier networks were much better than the transfer learning results with CNNs. This was primarily because the Imagenet dataset is not a good match for the ultrasound quality assessment problem. The DL models produced video sensitivities and specificities of 99% and 98% on held-out test sets. Using an autoencoder to compress FAST images is a very effective way to obtain features that can be used to predict exam quality. These features are more suitable than those obtained from CNNs pretrained on Imagenet.

Comparing the Ability of FAST and CT scan in Determining Free Fluid in Stable Patients with Blunt Abdominal Trauma

Background: Blunt abdominal trauma (BAT) has a high rate of morbidity and mortality. In the past few years, focused assessment with sonography in trauma (FAST) and computerized tomography (CT) scan have been extensively utilized and studied in management of BAT. The present study aims to compare the diagnostic accuracy of FAST and CT scan in detection of free fluid in BAT patients.&#x0D; Methods: In this cross-sectional study, patients with BAT were evaluated by both FAST and CT scans in Shahid Sadoughi Hospital, Yazd, Iran, from May 2017 to February 2018. The results were compared and the sensitivity, specificity, and accuracy of FAST and CT scan were calculated. In addition, the accuracy of FASTs performed by emergency medicine residents (EMR) was compared with those procedures performed by radiology residents (RR) in detecting abdominal free fluid following blunt trauma.&#x0D; Results: In this study, 175 patients were participated and most of them were males. The commonest cause of trauma was a road traffic accident (RTA). When FAST was performed by EMRs, sensitivity was  96.3%, specificity 75%, 60% positive  and 98.1% negative predictive values and 94.8% accuracy in true evaluating free fluid , and Sensitivity 97.5%, specificity 83.3%, 71.4%  positive and 98.8%  negative predictive values  when FAST was performed by RRs.&#x0D; Conclusion: Based on this study finding, it seems that FAST is highly sensitive, specific and accurate in the initial evaluation of patients with BAT.

Intraosseus administration of an ultrasound contrast agent in a case of pediatric blunt abdominal trauma

Adding an ultrasound contrast agent to the Focused Assessment with Sonography in Trauma (FAST) exam can substantially improve the diagnostic accuracy of identifying solid organ injuries and rapidly identify significant organ lacerations and active intraperitoneal hemorrhage. The standard recommendations are to use a 20g peripheral IV for administration to prevent microbubble breakage associated with high infusion pressures. In time-critical trauma resuscitations however, rapid vascular access often necessitates the use of intraosseous catheters (IO). We describe the first use of IO access to successfully administer an ultrasound contrast agent in a critically injured 16 month-old toddler. The cFAST exam identified a liver laceration and provided superior diagnostic information compared the non-contrast abdominal CT obtained at an outside facility. • Adding an ultrasound contrast agent to the FAST exam can help to rapidly diagnose significant solid abdominal organ injuries. • Ultrasound contrast arrival times and organ opacification appear to be similar to the intravenous route. • A contrast-enhanced FAST exam (cFAST) can provide superior diagnostic information compared to an unenhanced abdominal CT.

Double Jeopardy Injuries: Improved Clinical Outcomes With FAST Imaging and Subxiphoid Pericardial Window for Combined Cardiac and Abdominal Stab Wounds.

This study reviews our experience with combined cardiac and abdominal stab wounds over 12years and reviews how changes in technology and clinical approaches have impacted our management of these patients. A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. Twenty-two cases were identified (100% male, mean age: 27years). Mean values of admission physiology: systolic blood pressure (SBP): 85mmHg, pH: 7.2, base excess: -10.2mmol/L and serum lactate 6.7mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed.