A whole bunch of trauma guidelines

The Eastern Association for the Surgery of Trauma has published a number of helpful evidence-based guidelines for trauma management, and many of them are included in this month’s Journal of Trauma and Acute Care Surgery
Here are brief snippets from some of them. All the guidelines can be viewed or downloaded in full for free here.
Nonoperative management of blunt hepatic injury

  • Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age.
  • Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention.
  • Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries.

Selective nonoperative management of blunt splenic injury

  • Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries.
  • Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention.
  • Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries.

Screening for blunt cardiac injury

  • Electrocardiogram (ECG) alone is not sufficient to rule out BCI.
  • BCI can be ruled out only if both ECG result and troponin I level are normal, a significant change from the previous guideline.
  • Patients with new ECG changes and/or elevated troponin I should be admitted for monitoring.
  • Echocardiogram is not beneficial as a screening tool for BCI and should be reserved for patients with hypotension and/or arrhythmias.
  • The presence of a sternal fracture alone does not predict BCI.
  • Cardiac computed tomography or magnetic resonance imaging can be used to differentiate acute myocardial infarction from BCI in trauma patients.

Evaluation and management of penetrating lower extremity arterial trauma

  • Expedited triage of patients is possible with physical examination and/or the measurement of ankle-brachial indices.
  • Computed tomographic angiography has become the diagnostic study of choice when imaging is required.
  • Tourniquets and intravascular shunts have emerged as adjuncts in the treatment of penetrating lower extremity arterial trauma.

Prophylactic antibiotic use in penetrating abdominal trauma

  • There is evidence to support a Level I recommendation that prophylactic antibiotics should only be administered for 24 hours in the presence of a hollow viscus injury.
  • There are no data to support continuing prophylactic antibiotics longer than 24 hours in damage control laparotomy.

Screening for thoracolumbar spinal injuries in blunt trauma

  • Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries.
  • Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging.
  • Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted

Emergency tracheal intubation immediately following traumatic injury

  • The decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease.
  • Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations.
  • There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation.

Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax

  • Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

Evaluation and management of geriatric trauma

  • Effective evidence-based care of aging patients necessitates aggressive triage, correction of coagulopathy, and limitation of care when clinical evidence points toward an overwhelming likelihood of poor long-term prognosis

Management of pulmonary contusion and flail chest

  • Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion.
  • Obligatory mechanical ventilation in the absence of respiratory failure should be avoided.
  • The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure.
  • Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury.
  • Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.
  • A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status.
  • Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time.
  • Positive end-expiratory pressure or continuous positive airway pressure should be provided.
  • High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.
  • Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons.
  • Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.
  • Steroids should not be used in the therapy of pulmonary contusion.
  • Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Evaluation and management of small-bowel obstruction

  • Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management.
  • Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration.
  • The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO.
  • Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes.
  • Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

2012 Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Supplement
J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4)

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