Abstract
ObjectiveTo develop French guidelines on the management of patients with severe abdominal trauma. DesignA consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d’anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d’urgence, SFMU), the French Society of Urology (Société française d’urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. MethodsThe guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a “damage control surgery” strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. ResultsThe SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. ConclusionsSubstantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.
Highlights
Severe abdominal trauma is diagnosed in up to 20% of severe trauma patients and is associated with a high mortality rate of around 20% [1]
Despite numerous guidelines on severe trauma management, no specific guideline on abdominal trauma is available for the French context
No recommendation: After studying the available literature, the experts are not in the position to provide a recommendation in favour or against the use of prehospital FAST to guide the prehospital triage of patients with suspected severe abdominal trauma
Summary
Severe abdominal trauma is diagnosed in up to 20% of severe trauma patients and is associated with a high mortality rate of around 20% [1]. Management of abdominal trauma requires, in particular, a trans-professional and multidisciplinary approach, ranging from the prehospital setting to the intensive care unit (ICU). Over the last ten years, the non-operative management including angio-embolisation has greatly changed the management and outcome of these patients. This circumstance required specific attention in the present guideline. 3 on the abbreviated injury scale (AIS) [4] The aim of these guidelines is to provide a decision-making framework for physicians practicing in a non-specialised setting, managing patients with suspected abdominal trauma. The basic rules of universal good medical practice in intensive care, emergency medicine and emergency surgery were assumed to be known and were not included in the guidelines
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