Trauma Association Critical Decisions Research Articles

Western Trauma Association Critical Decisions in Trauma

The operative management of mangled extremities after trauma remains controversial. We have sought to develop an evidence-based algorithm to help guide practitioners when faced with these relatively infrequent but very challenging clinical dilemmas. The Western Trauma Association Critical Decisions Committee queried the literature to identify high-quality managements that would help guide the care of mangled extremities. When good data were not available, the Committee relied on expert opinions, either from the literature or from our senior members. Virtually, all the scoring systems used to guide therapy have not been proven to be valid. Hemodynamically unstable patients who failed to respond to initial resuscitation should be taken to the operating room for exploration and vascular control. Those who are stable should undergo a stepwise vascular and neurologic evaluation process. A comprehensive evaluation of factors that may help predict the appropriateness of limb salvage should be done in the operating room. Patients who are not candidates for salvage should undergo primary amputation. Those who are should undergo attempts at limb salvage. Patients with mangled extremities remain a significant management challenge. This algorithm represents a guideline based on the best evidence available in the literature and expert opinion. It does not establish a standard of care. It should provide a framework for treating physicians and other healthcare professionals to guide therapy, considering individual patients' clinical status and institutional resources.

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability

Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability

Western Trauma Association (WTA) Critical Decisions in Trauma: Management of Adult Blunt Splenic Trauma

Western Trauma Association (WTA) Critical Decisions in Trauma: Management of Adult Blunt Splenic Trauma

Western Trauma Association Critical Decisions in Trauma: Screening for and Treatment of Blunt Cerebrovascular Injuries

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of blunt cerebrovascular injuries (BCVI) in adult patients. Because there are no published prospective randomized clinical trials that have generated class I data, the recommendations herein are based on published observational studies and expert opinion of Western Trauma Association members. The algorithm (Fig. 1) and accompanying comments represent a safe and sensible approach that could be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols. The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite the pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with BCVI.

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture with Hemodynamic Instability

Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture with Hemodynamic Instability

Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability

SUMMARY Patients with hemodynamic instability and pelvic frac-ture remain a significant challenge in management. A mul-tidisciplinary approach has been shown to have the bestoutcomes. The algorithm outlined above represents the ef-forts of the Western Trauma Association Critical Decisions inTrauma Ad Hoc Committee based on the best evidence avail-able and expert opinion. Prospective validation of this algo-rithm is recommended. REFERENCES 1. Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhageassociated with major pelvic fracture: a multispecialty challenge. J Trauma. 1986;26:987–994.2. Smith W, Williams A, Agudelo J, et al. Early predictors of mortalityin hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21:31–37.3. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, SmithWR. Preperitonal pelvic packing for hemodynamically unstablepelvic fractures: a paradigm shift. J Trauma. 2007;62:834–839;discussion 839–842.4. Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH. Factorsaffecting mortality in pelvic fractures.

Western Trauma Association Critical Decisions in Trauma: Foreword

In this issue of the Journal, The Western Trauma Association (WTA) Critical Decisions in Trauma ad hoc committee presents the first two annotated algorithms focusing on adult spleen injury and pelvic fracture. This effort was born out of a call for evidence-based care by our Past Presidents to aid the clinician at the point of care with a tool that could be easily accessed and implemented. An algorithm is an illustration of a series of medical decisions that address certain patient-specific conditions outlining appropriate responses intended to lead to an outcome. The goals of an algorithm are to identify diagnostic alternatives, treatment options, and outcomes by weighing decision benefits against risks and costs. A primary benefit of a well-developed algorithm is that it focuses the reader on the critical decision points in any clinical scenario and specifically lists the input data that leads to a decision. Algorithms can be applied to specific problems, processes, or diseases. They allow for evolution of a disease-related topic with new information or clinical conditions that may affect decision-making later in the time course of a situation. They can convey the scope of a clinical condition from presentation, through testing and assessment, followed by a clinical judgment and action leading to an eventual outcome. Annotations are added to appropriate points on the algorithm and are necessary for all decision nodes. The purpose of the annotation is to explain all critical factors affecting decisions in as concise a manner as possible. The primary advantage of an algorithm is that it can summarize an evidence-based guideline into an easily and quickly available practice protocol for use in the clinical care setting. The WTA has played a significant role in guiding the practice of trauma surgery based on sound scientific evidence through publication of its multicenter trials. High-quality practice algorithms will further serve the trauma community by an efficient review of current recommendations in trauma decision making. The President of the WTA appointed an ad hoc committee to oversee the development of these algorithms. For the purpose of the first set of algorithms the ad hoc committee also served as the writing committee. After a thorough literature review, which included review of currently published guidelines, a draft document was distributed to the committee. Critical review by the committee members was used to develop a second draft. The algorithm was reviewed and revised at a meeting of the committee. The algorithms were presented to the WTA membership at the 38th Annual Meeting (February 24– March 1, 2008). Membership discussion resulted in further refinement before final submission to the Journal. We anticipate that implementation of the algorithms will require consideration of institution-specific capability. An additional benefit of algorithm development is to reveal areas of uncertainty thereby defining the “gray areas”. These areas are perfect questions to be developed into clinical research projects. Algorithms will be forwarded to the WTA Multi-institutional Trials Committee for consideration of study development to test application of the algorithm. Further, a study group may be formed to perform decision analysis if appropriate for the given question. Each algorithm will be reviewed on a cycle of every 3 years by the steering committee. If substantial revision is necessary the algorithm may be directed back to the expert panel for revision. The algorithms in the current issue will be the first in a series to follow and we look forward to the trauma community testing the algorithms and further refining care by eliminating the “gray areas” in decision making.