Orlando Regional Medical Center Research Articles

Comprehensive molecular testing prior to first treatment among patient with metastatic non-small cell lung cancer.

431 Background: Nearly 60% of patients with non-small cell lung cancer will have actionable mutations identified via molecular testing. Of these patients, those treated with targeted therapy had longer overall survival than those who did not. Therefore, it is imperative molecular testing is both sent and resulted at time of first treatment. Despite this, multiple barriers remain with reported community rates of <50% with comprehensive molecular testing. We sought to understand testing practices at our institution. Methods: In this retrospective chart review, patients with stage IV, non-small cell, non-squamous cell lung cancer treated at Orlando Regional Medical Center between 1/2021-5/31/2022 were identified. Primary endpoints included rate of comprehensive molecular testing (EGFR, ALK, ROS1, RET, MET, BRAF, KRAS, ErbB2 and NTRK, either tissue or plasma) available prior to first line treatment. Results: Of the 73 patients who were included, 69 patients (94.8%) had comprehensive molecular testing results available prior to first line treatment. 48 (65.8%) patients had tissue testing results prior to first treatment. 44 (60.2%) patients had plasma testing results prior to first treatment. 14 (19.2%) patients had tissue testing sent, without results at time of first treatment. Conclusions: The comprehensive molecular testing rate at a large tertiary hospital is 94.8%, substantially higher than the rates reported in the literature. Despite this, 19.2% of patients had tissue testing sent but not resulted at time of first treatment. Future studies are needed to improve turnaround time of tissue based molecular testing results and evaluate concurrent versus sequential tissue and plasma testing.

Impact of tissue biomarker testing by in-house platform on result times in metastatic non-small cell lung cancer.

49 Background: Biomarker testing for actionable mutations is standard of care for patients diagnosed with metastatic non-small cell, non-squamous cell lung cancer. However, testing via third-party laboratories can take weeks to result, leading to treatment decision delays identified at our own institution. Methods: We conducted a retrospective chart review of metastatic non-small cell, non-squamous cell lung cancer patients treated at Orlando Regional Medical Center before (6/1/2021-5/31/2022) as well as after (1/1/2023-5/31/2023) the initiation of in-house next generation sequencing (NGS) tissue testing using Genexus. Endpoints included average and median time to result of plasma and tissue NGS both before and after initiation of in-house molecular testing. An independent two sample t-test was conducted with p<0.05 considered significant. Results: A total of 49 and 18 patients were included pre and post initiation of in house NGS, respectively. For patients with tissue testing, the average time from collection to result was 31.3 versus 13.9 days (p<0.01), median 29 versus 7 days. For patients who underwent plasma testing (n=49, n=10), average time from collection to result was 13.3 versus 9.6 days (p=0.38), median 9 versus 9 days. Conclusions: Time to comprehensive tissue testing result significantly decreased after the commencement of in-house NGS. Rapid turnaround time allows clinicians to select appropriate first-line treatment without delay in care. Further efforts are needed to expedite molecular testing in all stages of non-small cell lung cancer and evaluate sequential versus concurrent plasma and tissue testing.

Robotic surgery: financial impact of surgical trays optimization in bariatric and thoracic surgery.

The incorporation of new technologies in the surgical field, such as the robotic da Vinci System, has made it possible to offer a series of advantages to the patient and the surgeon, with important benefits for both. However, cost continues to be a limiting factor to the adoption of this technology. The development of strategies to maximize the measures that can lead to reduced expenses is a key factor to improve cost-benefit ratio. According to some studies, more than 50% of the costs of a surgical procedure are related to materials and medical supplies, which is why any measure aimed at optimizing their use is pertinent. Our institution, the Orlando Regional Medical Center (ORMC), created a working group whose main purpose is to optimize the Robotic OR process. Their first step was to optimize the surgical trays, and this was carried out in four stages: observation, modification, trial period, and cost analysis. The specialties involved in this initiative were Bariatric and Thoracic Surgeries. Once the optimization process ended, the number of laparoscopic/thoracoscopy instruments in the trays decreased by 63 and 87% for bariatric and thoracic surgery, respectively; and the number of conventional surgery instruments was also reduced by 47 and 64%, for the same specialties, respectively. The financial analysis concluded that implementing this measure will lead to an estimated six-figure savings per year.

Assessment of pharmacologic prophylaxis use against stress ulcer in the medical wards of University of Gondar Hospital.

Background:Critically ill patients with moderate-to-severe physiologically stressful event are at high risk of developing stress ulcers. The use of pharmacological prophylaxis significantly reduces the incidence of stress ulcer in high-risk patients.Objective:The aim of this study was to assess the use of pharmacological prophylaxis for stress ulcer in the medical wards of University of Gondar Hospital.Methods:A cross-sectional study design was used. In total, 234 patients were selected through simple random sampling technique. The risk of stress ulcer development was assessed using Evidence-Based Medicine Guideline for stress ulcer prepared by Orlando Regional Medical Center. SPSS version 21 was used for data analysis.Result:The most common acute risk factor to stress ulcer was coagulopathy (18.4%), followed by hypoperfusion (9.8%). The concomitant non-steroidal anti-inflammatory drug use (16.7%), mild-to-moderate brain or spinal cord injury (11.1%), and concomitant or recent corticosteroid use (9.4%) were frequently seen risk factors that necessitate administration of a prophylaxis. In total, 82 (35%) study participants were given stress ulcer prophylaxis, among which 52 (63.4%) were given without indication. The most commonly used drug class in the prevention of stress ulcer was proton pump inhibitors (76/82, 92.7%). In total, 43 (18.4%) study subjects were not given stress ulcer prophylaxis while there was clear indication. Patients with a long hospital stay and a diagnosis of central nervous system disorders had significant risk for inappropriate stress ulcer prophylaxis use.Conclusion:In this study, inappropriate use of prophylaxis for stress ulcer was common. The higher proportion of inappropriateness was due to the use of stress ulcer prophylaxis while there was no enough indication. We recommend future researchers to assess the cost and impact of inappropriate stress ulcer prophylaxis use, and the physicians should be adherent to the standard guidelines.

Florida One Step Closer

It is an exciting time in the state of Florida for advanced practice nurses (APNs) because House Bill 1337/Senate Bill 1594 was passed and signed and becomes law on October 1, 2018. This bill changes the current title of Advanced Registered Nurse Practitioner (ARNP) to Advanced Practice Registered Nurse (APRN). Thus, for the first time, all 4 categories of APNs in Florida will be recognized! In celebration of this giant step forward, we took a look back to see how far we have come and to use this accomplishment to motivate ourselves as we continue to work toward our final goal of allowing APRNs to have full practice authority based on their education and training. Cindy D. Kumar, Member, Texas ENA, is Nurse Practitioner in Emergency Services, CEA of TeamHealth, St David’s South Austin Medical Center and St David’s Children’s Hospital, Austin, TX. Darleen A. Williams, Member, Florida ENA, is Clinical Nurse Specialist for Emergency Services, Orlando Regional Medical Center, Orlando, FL.

Saliva Biomarkers May Predict How Long Concussion Symptoms Will Last in Youth

Saliva Biomarkers May Predict How Long Concussion Symptoms Will Last in Youth

Orlando Health Nurse Leaders Reflect on the Pulse Tragedy

In the predawn hours of Sunday, June 12, 2016, dozens of people hit by gunfire poured into Orlando Regional Medical Center's (ORMC) emergency department (ED) in Orlando, Florida. The largest mass-casualty shooting in American history happened just a few blocks from ORMC, Orlando Health's flagship hospital and the region's only level one trauma center. The gunman had opened fire at Pulse, a popular gay nightclub, during a crowded Latin night. Due to the close proximity of the nightclub to ORMC, first responders loaded victims into police cars and the backs of trucks, and transported them to the ED. The shooting resulted in the treatment of 44 total victims in just a few hours’ time, testing the effectiveness of the disaster planning preparedness and the resiliency of team members. Nurse leaders played an important coordinating role during the unfolding disaster, and interprofessional collaboration became crucial to ensure that patients received optimal care. In the time that has elapsed since the 2016 tragedy, the Orlando Health team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork, and a culture of resiliency. In the predawn hours of Sunday, June 12, 2016, dozens of people hit by gunfire poured into Orlando Regional Medical Center's (ORMC) emergency department (ED) in Orlando, Florida. The largest mass-casualty shooting in American history happened just a few blocks from ORMC, Orlando Health's flagship hospital and the region's only level one trauma center. The gunman had opened fire at Pulse, a popular gay nightclub, during a crowded Latin night. Due to the close proximity of the nightclub to ORMC, first responders loaded victims into police cars and the backs of trucks, and transported them to the ED. The shooting resulted in the treatment of 44 total victims in just a few hours’ time, testing the effectiveness of the disaster planning preparedness and the resiliency of team members. Nurse leaders played an important coordinating role during the unfolding disaster, and interprofessional collaboration became crucial to ensure that patients received optimal care. In the time that has elapsed since the 2016 tragedy, the Orlando Health team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork, and a culture of resiliency.

Improving Donor Conversion Rates at a Level One Trauma Center: Impact of Best Practice Guidelines

BackgroundOrgan availability is a consistently limiting factor in transplant surgery. A primary driver of this limitation is donor conversion rate, which is defined as the percentage of eligible donors for whom procurement is actually performed. An alternative way to increase organ availability is through improved utilization of organs from donors after cardiac death (DCD). Recently, a concerted, multidisciplinary effort has been made within our system to improve conversion rates and DCD utilization, thus increasing organ availability.Study designRetrospective analysis of a prospectively collected database from TransLife, our local organ procurement organization (OPO), as well as the Orlando Regional Medical Center (ORMC) trauma registry, from 2009-2012 (up to 2013 for DCD). During which time, this organization implemented best practice guidelines to improve conversions and DCD utilization. We analyzed yearly conversion rates, DCD donations and population demographics before and after implementation of these policies.ResultsDuring the study period, donor conversion rates significantly improved from 58% in 2009 to 82% percent in 2012 hospital-wide (P<0.05); and from 50% in 2009 to 81% in 2012 among trauma patients alone (P<0.05). In addition, total organs transplanted increased from 13 to 31 organs (P<0.05) after implementation of best practice guidelines. No significant differences in trauma population demographics were noted during the study period.ConclusionsBased on our experience, the establishment of best practice policies for referral of potential donors, coupled with programs to educate hospital staff on the existence and importance of these policies, leads to significant improvement in donor conversion rates and increased utilization of DCD donors.

Expanding the Health Care Response to Mass Violence.

For Joseph Ibrahim, MD, the first wake-up call came last year at an Orlando Magic basketball game. The trauma medical director of Orlando Regional Medical Center (ORMC) was sitting in the stands at the Amway Center when he looked around at the crowd of thousands and imagined a mass casualty incident. “Being the only level I [Trauma] Center in this area, we’re responsible for every single person in here,” he recalled thinking to himself. It later struck him that Orlando—with its proximity to Disney World—was a prime target for a mass shooting or bombing. Ibrahim’s fears were realized when the deadliest mass shooting in modern US history unfolded in the early morning hours of June 12 at Orlando’s Pulse nightclub, located 2 blocks from ORMC. But by then, the hospital’s trauma and emergency staff were prepared. Three months before this real-life tragedy, ORMC staged its annual community-wide mass casualty drill. In prior years, the drills have simulated scenarios including a bombing, a rally that became violent, and an airplane crash. This year’s mock disaster—an active shooter incident at a local school with 500 injuries—included all of central Florida’s 15 hospitals, the Federal Bureau of Investigation (FBI), local law enforcement, emergency medical services (EMS), fire personnel, and ORMC’s Air Care Team, which provides transportation and in-flight stabilization for trauma patients. Ibrahim recently pushed to add trauma simulations on a more regular basis, and these smaller drills have been taking place 3 times a month. As 44 injured patients streamed in during 2 waves on the night of the Pulse nightclub shooting, these and other preparations undertaken by the hospital for mass casualties paid off, Ibrahim said: “For the most part, the big needs—anesthesia, operating rooms [and other] space, blood, and people to care for [patients]—were taken care of, and I think it was in large part due to the drills that we had performed.” Jay Kaplan, MD, vice chair of emergency services for Ochsner Health System in New Orleans and president of the American College of Emergency Physicians (ACEP), called the hospital’s response “amazing.” “Within a very short period of time they had 6 trauma surgeons [and] 8 emergency physicians caring for patients,” he said. Surgeons performed 28 operations on Sunday alone. Thirty-five patients survived and, as reported in the media, the 9 patients who did not survive died soon after reaching the hospital, indicating that they had arrived with fatal wounds. Ibrahim said that local EMS reached out to express gratitude for being included in the hospital’s drills. “I’ve had a lot of feedback saying they’re really happy that we did those drills because they knew how to step in and how to best help,” he said. By all accounts, ORMC is an example of how trauma centers and communities should prepare for mass shootings and other intentional mass casualty events. The 2013 Boston Marathon bombing, after which only 3 of 264 patients died, has been cited as another well-coordinated and highly successful response.... Language: en

Family Caregiver Knowledge, Patient Illness Characteristics, and Unplanned Hospital Admissions in Older Adults With Cancer.

To explore factors related to unplanned hospital admissions and determine if one or more factors are predictive of unplanned hospital admissions for older adults with cancer. . A prospective longitudinal design and a retrospective chart review. . Adult oncology outpatient infusion centers and inpatient units at Orlando Regional Medical Center in Florida. . A convenience sample of 129 dyads of older adults with cancer and their family caregivers. . Family caregiver demographic and side effect knowledge data were collected prospectively during interviews with family caregivers using a newly developed tool, the Nurse Assessment of Family Caregiver Knowledge and Action Tool. Patient demographic and clinical data were obtained through a retrospective chart review. Descriptive statistics and logistic regression analyses were used to evaluate data and examine relationships among variables. . Patient illness characteristics; impaired function; side effects, such as infection, fever, vomiting, and diarrhea; family caregiver knowledge; and unplanned hospital admissions. . Unplanned hospital admissions were more likely to occur when older adults had impaired function and side effects, such as infection, fever, vomiting, and diarrhea. Impaired function and family caregiver knowledge did not moderate the effects of these side effects on unplanned hospital admissions. . Findings suggest that the presence of impaired function and side effects, such as infection, fever, vomiting, and diarrhea, predict unplanned hospital admissions in older adults with cancer during the active treatment phase. Side effects may or may not be related to chemotherapy and may be related to preexisting comorbidities. . Nurses can conduct targeted assessments to identify older adults and their family caregivers who will need additional follow-up and support during the cancer treatment trajectory. Information gained from these assessments will assist nurses to provide practical and tailored strategies to reduce the risk for unplanned admissions.

Blood Test May Detect Concussions Days Later

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessBlood Test May Detect Concussions Days LaterNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:20 May 2016https://doi.org/10.1176/appi.pn.2016.5a18AbstractThe levels of two proteins activated after a head injury—GFAP and UCHL—may be predictive of whether an individual had a concussive event.Following a concussion, it can take days for symptoms to arise that would lead a patient to seek help; by then, the underlying lesions of the impact may have healed enough to make it difficult to confirm the concussion with a brain scan. A study published March 28 in JAMA Neurology suggests a blood test may be able to detect evidence of a concussion up to one week after the injury occurred.“Not only could this simple test greatly expand the window for diagnosing concussions, it could make CT scans unnecessary for many people, which reduces their exposure to radiation,” said Linda Papa, M.D., a physician at the Department of Emergency Medicine at the Orlando Regional Medical Center and lead author of the study. Pediatric patients could especially benefit, she told Psychiatric News, as they are particularly vulnerable to radiation damage. Papa added that minimizing computed tomography (CT) scans would save time and money and keep these machines available for people who really need them.Previous studies by Papa and her team found that changes in two proteins—glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1)—following head trauma injury can help to differentiate the patients in need of a neurosurgical intervention from others. (Both of these proteins are known to become elevated in the brain after a head injury, and both can also pass the blood-brain barrier.) In the current study, her group set out to better quantify the presence of these proteins over time, while also testing whether their diagnostic value could extend to predicting the presence of a concussion. They took periodic blood samples from 584 adult patients who had been admitted to the Orlando Health trauma center from 2010 to 2014 (325 of whom were diagnosed with a mild to moderate traumatic brain injury) over a week-long period (the first samples were taken within four hours of the injury). Almost all the patients with mild to moderate TBI had a CT scan to confirm the concussion.They found that both proteins became elevated in the blood within the first hour, though their time courses differed after that; UCH-L1 peaked at eight hours after injury and then declined rapidly over 48 hours, while GFAP levels peaked at 20 hours post-injury and then declined steadily over 72 hours.“And we generally saw that the more severe the injury, the higher the levels of these markers, which makes them very objective measures of trauma severity,” Papa said.In terms of predictive value, GFAP proved better at identifying mild to moderate TBI, with accuracy values ranging from 80 to 97 percent over the seven-day screening period (the test was most accurate 36 to 60 hours after injury). UCH-L1 was not as accurate, ranging from 31 percent to 77 percent over the seven-day period (the test was most accurate in the first eight hours). These protein signatures may also offer clues about long-term outcomes. “After we diagnose concussion patients and send them home, about 70 percent or so will be fine in the long term, but the rest will have recurring problems like headaches and irritability,” she said. “It would be great if we could anticipate potential problems and those patients could come back more regularly, but at this point, however, we can’t tell which patients are which.” Her team is continuing to monitor the outcomes of the study patients to see how they recover and if their previous GFAP and/or UCH-L1 readings correlate with how they feel six months after the injury.This study was funded by a grant from the National Institute of Neurological Disorders and Stroke. ■An abstract of “Time Course and Diagnostic Accuracy of Glial and Neuronal Blood Biomarkers GFAP and UCH-L1 in a Large Cohort of Trauma Patients With and Without Mild Traumatic Brain Injury” can be accessed here. ISSUES NewArchived

Repeated Elevation of the Anterolateral Thigh Flap for Lower Extremity Orthopedic Trauma Does Not Affect Flap Viability.

The anterolateral thigh (ALT) flap has a key role regarding limb salvage and has facilitated the preservation of function and esthetics in lower extremity reconstruction. The purpose of this study is to review the advantages of the ALT flap when used early in the reconstruction of the trauma patient; specifically, its long-term viability when ALT flap reconstruction is followed by recurrent flap elevation performed to allow a variety of sequential orthopedic operations including washout, antimicrobial disc placement, and reinstrumentation. A retrospective analysis was performed to review all ALT flaps performed by the authors from January 2009 to October 2012 at the Orlando Regional Medical Center. A total of 69 patients with an average age of 38 years were included in the study leading to a total of 69 ALT flaps indicated for traumatic orthopedic wounds. Out of these, 29 flaps were elevated at least once leading to a total of 49 flap elevations. The median number of days to flap elevation was 117 with a minimum of 1 day and a maximum of 540 days. A total of 42% flaps were elevated at least once after initial placement for reinstrumentation, washout, or antibiotic disk placement. Overall, 52% of the flaps were lifted once, 34% were lifted twice, and 14% were lifted more than thrice. There is no statistically significant difference in the complication rate between elevating the flap compared with primary ALT placement. We conclude, therefore, there is no elevated risk to long-term viability by elevating the ALT flap. This combined with the ease of elevation makes it a safe procedure to be performed as needed for access to the deep tissues.

Intra-Abdominal Pressure

Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL * See also p. 378. Dr. Cheatham consulted and lectured for Kinetic Concepts Incorporated, provided expert testimony for various law firms, and received support for manuscript preparation from Kinetic Concepts Incorporated.

Designing a Process for Simulation-Based Annual Nurse Competency Assessment

The education council at Orlando Regional Medical Center identified a need to improve the annual nurse competency assessment. A revision process was implemented to improve the method and efficiency of assessing nurse competency. This process included evaluating population-specific competencies using simulation-based scenarios that were developed by a multidisciplinary team. The results showed high participant satisfaction scores and cost savings because of an individualized, efficient approach and bundling of resources.

Are children really just small adults?*

Surgical Intensive Care Units, Orlando Regional Medical Center, Orlando, Florida The author has not disclosed any potential conflicts of interest. For information regarding this article, E-mail: [email protected]

Is the canary still singing?*

Surgical Intensive Care Unit, Orlando Regional Medical Center, Orlando, FL The author has not disclosed any potential conflicts of interest.

Intramuscular Myxomas: A Clinicopathologic Study with Emphasis on Surgical Management

Intramuscular myxomas (IMs) are rare myxoid tumors named for their abundance of noncollagenous mucinous stroma. IMs are benign tumors characterized by a paucity of cells, diminished vascularity, and minimal mitotic figures. The objectives of this study were to examine clinicopathologic features of IM and to discuss clinical management of these unusual soft tissue tumors. A 10-year retrospective study at Orlando Regional Medical Center was conducted from May 1993 to May 2003. A case report of a 48-year-old male with a right gluteal mass is presented. Four cases with histologically confirmed diagnosis of intramuscular myxoma were reported. Three patients presented with lesions of the lower extremity and one with an extrafascial IM of the eighth rib. One of the lower extremity cases was shown to be cellular myxoma, a recently characterized subtype of IM. All cases were treated with at least marginal excision of the mass. There have been no known recurrences. Our findings are consistent with described characteristics for IM with respect to anatomic location and gross and microscopic appearance. As it may be unreliable to differentiate IM from malignant myxoid tumors preoperatively, we favor excision with wide margins in the surgical management of these tumors.

Is Hyperbaric Oxygen a Useful Adjunct in the Management of Problem Lower Extremity Wounds?

Hyperbaric oxygen (HBO) is currently being used in the treatment of nonhealing or "problem" wounds of the lower extremities. In an attempt to evaluate the efficacy of HBO in problem wounds, a retrospective study of the HBO experience at Orlando Regional Medical Center was conducted. From 1989 to 1994, fifty-four patients with nonhealing lower extremity wounds resulting from underlying peripheral vascular disease and/or diabetes mellitus were treated with HBO. Wounds were grouped into the following five categories: (1) diabetic ulcers (n = 17 [31%]); (2) arterial insufficiency (n = 8 [15%]); (3) gangrenous lesions (n = 6 [11%]); (4) nonhealing amputation stumps (n = 13 [24%]); and (5) nonhealing operative wounds (n = 10 [19%]). Each patient received an average of 30 treatments. Outcomes for all 54 patients treated with HBO in this study were dismal. None of the patients experienced complete healing, six (11%) showed some improvement, 43 (80%) showed no improvement, and in five cases (9%) results were inconclusive because these patients underwent concomitant revascularization or amputation. Thirty-eight of the 43 patients who showed no improvement (88%) ultimately required at least one surgical procedure to treat their wounds. Thirty-four patients (63%) developed complications, most commonly barotrauma to the ears, which occurred in 23 patients (43%). The average cost of 30 HBO treatments was $14,000 excluding daily inpatient charges. Based on the experience with HBO therapy at Orlando Regional Medical Center and the paucity of good supporting literature, it is difficult to justify such an expensive, ineffective complication-prone treatment modality for problem extremity wounds.

Malunited Forearm Fractures in Children

From 1971 to 1986, 80 skeletally immature patients with severe diaphyseal both-bone forearm fractures were treated at Orlando Regional Medical Center. Greenstick, Monteggia, and Galeazzi fractures were excluded. Seventy-nine fractures were managed by closed means. When anatomic reduction could not be obtained, the best position was accepted. There were 47 patients with malunions of whom 39 returned for follow-up evaluation greater than 2 years after injury. They form the basis of this study. There were no delayed unions or nonunions in the entire group. Average follow-up in the group reported was 5 years 9 months (range 2 years to 13 years 10 months). All patients were satisfied with their functional and cosmetic results regardless of age, angulation, complete displacement, or loss of radial bow at time of union. Only nine patients had loss of motion. By our criteria, 36 patients (92%) had good or excellent results, with 32 excellent and four good results. Three patients (8%) had fair results, and there were no poor results. Age at time of injury did not correlate with recovery of motion. Distal fractures were found to have a better prognosis than proximal fractures. Based on the results of this study, closed reduction is the treatment of choice for skeletally immature patients with diaphyseal fractures of the radius and ulna.

Blunt Laryngeal Trauma

Ten patients with the diagnosis of blunt laryngotracheal trauma were admitted to Orlando Regional Medical Center from March 1, 1987 through September 30, 1988. These patients have been studied retrospectively with attention to type of injury, management, treatment, and outcome. The use of a flexible nasopharyngoscope in the Emergency Department, significance of a patient's inability to tolerate the supine position, and tracheotomy as the airway of choice are key points in the laryngotracheal injury classification and management protocol presented herein.