Trauma Association Critical Decisions Research Articles

Western Trauma Association critical decisions in trauma: airway management in adult trauma patients

This is a recommended evaluation and management algorithm from the Western Trauma Association (WTA) Algorithms Committee addressing the prehospital and in-hospital airway management of adult trauma patients. Because there is...

Western Trauma Association critical decisions in trauma: Management of intracranial hypertension in patients with severe traumatic brain injuries.

Western Trauma Association critical decisions in trauma: Management of intracranial hypertension in patients with severe traumatic brain injuries.

Western Trauma Association critical decisions in trauma: Cervical spine clearance in trauma patients.

Western Trauma Association critical decisions in trauma: Cervical spine clearance in trauma patients.

Western Trauma Association critical decisions in trauma: Management of the open abdomen after damage control surgery.

Sava, Jack MD; Alam, Hasan B. MD; Vercruysse, Gary MD; Martin, Matthew MD; Brown, Carlos V. R. MD; Brasel, Karen MD, MPH; Moore, Ernest E. Jr MD; Ciesla, David MD; Inaba, Kenji MD; for the Western Trauma Association Critical Decisions in Trauma Committee Author Information

Western Trauma Association critical decisions in trauma: Preferred triage and initial management of the burned patient.

This is a recommended management algorithm from the Western Trauma Association addressing the management of victims of burn injury. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published retrospective studies, clinical guidelines, and the expert opinion of members of the Western Trauma Association in conjunction with partner members of the American Burn Association. The algorithm and accompanying comments represent one safe and sensible approach that can be followed at most trauma centers. We recognize that there may be patient or institutional factors that warrant deviation from the published algorithm. We would encourage institutions to use this document as a starting point toward a dialog with local burn centers to collaboratively create a patient-centered care experience for the victims of minor burn injuries arriving at local trauma centers.

Western Trauma Association Critical Decisions in Trauma: Management of renal trauma.

Western Trauma Association Critical Decisions in Trauma: Management of renal trauma.

Western Trauma Association Critical Decisions in Trauma: Management of adult blunt splenic trauma-2016 updates.

This is an updated position article from members of the Western Trauma Association (WTA). It includes recommendations for the management of blunt splenic injury in adult trauma patients based on literature available since the last WTA position article in 2008.1 There remain no prospective randomized

Western Trauma Association Critical Decisions in Trauma: Management of rib fractures.

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with rib fractures. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can 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 as a guideline to develop their own local protocols.

Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability-2016 updates.

Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability-2016 updates.

Western Trauma Association Critical Decisions in Trauma: Management of abdominal vascular trauma.

Western Trauma Association Critical Decisions in Trauma: Management of abdominal vascular trauma.

Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of esophageal injuries.

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can 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 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 esophageal injuries.

Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of duodenal injuries.

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of esophageal injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithms and accompanying comments represent a safe and sensible approach that can 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 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 esophageal injuries.

Western Trauma Association critical decisions in trauma: penetrating chest trauma.

This is a recommended algorithm of the Western Trauma Association for the management of penetrating neck trauma that has penetrated the platysma muscle of the neck. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating neck injury, the current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Fig. 1.) and accompanying text represents a safe and reasonable approach to this difficult injury type and attempts to incorporate the advent of recent advances in radiographic screening and selective or expectant management practice. We recognize that there will be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. The algorithm contains letters A through J, which correspond to the lettered text. Their

Western Trauma Association Critical Decisions in Trauma

This is a recommended algorithm of the Western Trauma Association for the management of penetrating neck trauma that has penetrated the platysma muscle of the neck. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating neck injury, the current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Fig. 1.) and accompanying text represents a safe and reasonable approach to this difficult injury type and attempts to incorporate the advent of recent advances in radiographic screening and selective or expectant management practice. We recognize that there will be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. The algorithm contains letters A through J, which correspond to the lettered text. Their

Western Trauma Association Critical Decisions in Trauma

Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the American Association for the Surgery of Trauma. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Category 1 Creditsi The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Crediti. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Of theAMAPRACategory 1 Crediti listed above, a maximum of 1 credit meets the requirements for self-assessment.

Western Trauma Association Critical Decisions in Trauma

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on the evaluation and management of peripheral vascular trauma, the algorithm is based on the expert opinion of the WTA members and published observational studies. It may not be applicable at all hospitals caring for injured patients. The algorithm contains letters that correspond to lettered text that is intentionally concise. This Part II algorithm focuses on operative techniques, while the Part I algorithm (J Trauma 2011;70: 1551-1556) emphasized evaluation, diagnosis, and need for operation versus a therapeutic procedure performed in an interventional suite.

Featured Articles for CME Credit December 2012 Western Trauma Association Critical Decisions in Trauma

Journal of Trauma and Acute Care Surgery: December 2012 - Volume 73 - Issue 6 - p 1632-1633 doi: 10.1097/TA.0b013e31827ce49e

Western Trauma Association Critical Decisions in Trauma

Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the American Association for the Surgery of Trauma. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Category 1 Creditsi The American College of Surgeons designates this Journal-based CME activity for a maximum of 1 AMA PRACategory 1 Crediti for each article. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Western Trauma Association Critical Decisions in Trauma

In the past three decades, there has been a significant clinical shift in the performance of resuscitative thoracotomy (RT), from a nearly obligatory procedure before declaring any trauma patient deceased to a more selective application of RT. We have sought to formulate an evidence-based guideline for the current indications for RT after injury in the patient. The Western Trauma Association Critical Decisions Committee queried the literature for studies defining the appropriate role of RT in the trauma patient. When good data were not available, the Committee relied on expert opinion. There are no published PRCT and it is not likely that there will be; recommendations are based on published prospective observational and retrospective studies, as well as expert opinion of Western Trauma Association members. Patients undergoing cardiopulmonary resuscitation (CPR) on arrival to the hospital should be stratified based on injury and transport time. Indications for RT include the following: blunt trauma patients with less than 10 minutes of prehospital CPR, penetrating torso trauma patients with less than 15 minutes of CPR, patients with penetrating trauma to the neck or extremity with less than 5 minutes of prehospital CPR, and patients in profound refractory shock. After RT, the patient's intrinsic cardiac activity is evaluated; patients in asystole without cardiac tamponade are declared dead. Patients with a cardiac wound, tamponade, and associated asystole are aggressively treated. Patients with an intrinsic rhythm following RT should be treated according to underlying primary pathology. Following several minutes of such treatment as well as generalized resuscitation, salvageability is reassessed; we define this as the patient's ability to generate a systolic blood pressure of greater than 70 mm Hg with an aortic cross-clamp if necessary. The success of RT approximates 35% for the patient arriving in shock with a penetrating cardiac wound and 15% for all patients with penetrating wounds. Conversely, patient outcome is relatively poor when RT is performed for blunt trauma, 2% survival for patients in shock and less than 1% survival for patients with no vital signs. Patients undergoing CPR on arrival to the hospital should be stratified based on injury and transport time to determine the utility of RT. This algorithm represents a rational approach that could be followed at trauma centers with the appropriate resources; it may not be applicable at all hospitals caring for the injured. There will be patient, personnel, institutional, and situational factors that may warrant deviation from the recommended guideline. The annotated algorithm is intended to serve as a quick bedside reference for clinicians.

Western Trauma Association Critical Decisions in Trauma

P leural infection associated with pneumonia is a potentially lethal disease afflicting more than 60,000 patients annually in the United States. The incidence continues to rise, and the mortality rate exceeds that of myocardial infarction. Five thousand years ago, the Egyptian physician Imhotep first described pleural space disease,4 and Hippocrates in 400 BC was credited for recognizing that prompt drainage of the infected pleural space is essential.5 When these infections become loculated, they are no longer amenable to tube thoracostomy and operative decortication is required. To understand the pathophysiology of a complicated parapneumonic effusion, it is instructive to review the anatomy of the pleural and cytologic players maintaining homeostasis in this unique space. The pleural cavity arises from the coelom that also forms the pericardium and peritoneum. The pleural cavity is lined by mesothelial cells surrounded by a layer of connective tissue, macula cribiformis, which is then encased in two layers of elastic tissue. Visceral mesothelium is intricately connected to the lung parenchyma, whereas the parietal layer is more loosely connected to the thoracic structures separated by a variable fatty layer. The parietal pleura has specialized areas known as stoma, and an extensive lymphatic network exists below which is the predominant route of fluid resorption. Under normal conditions, it is estimated that each pleural cavity generates 0.2 to 0.4 mL/kg per hour. The fluid originates predominantly from the parietal capillaries because of hydrostatic pressure, augmented by the negative pressure of the pleural space. Less fluid is produced by the visceral pleura because the hydrostatic pressure is attenuated by pulmonary venous drainage. However, the visceral surface will add more pleural fluid with increased pulmonary interstitial pressure. The capacity for pleural fluid absorption is thought to exceed 500 mL of fluid from each cavity with an intact lymphatic system. Thus, the net accumulation of pleural fluid is the result of a dynamic system of fluid production and absorption. Recent ultrasound studies of healthy individuals suggest that less than 4 mm of dependent pleural fluid should be considered normal. Complicated parapneumonic effusions, and ultimately empyemas, develop in three conceptual phases. The early phase is a sterile effusion caused by parenchymal inflammation that activates mesothelial cells and enhances capillary permeability, termed exudative (days 2Y5). This is thought to be driven by proinflammatory cytokines, including interleukin 8 and tumor necrosis factor->.8 Ultimately, the volume of fluid traversing into the pleural cavity exceeds the capacity to reabsorb the fluid and an effusion develops. The second phase is termed fibropurulent, which is initiated by bacterial infection (days 5Y10). At this point, the immune system is activated and the once hypocoagulable environment is changed dramatically. Bacterial and neutrophil activity acidify the fluid, consume glucose, increase protein content, and release lactate dehydrogenase (LDH) from cellular apoptosis and necrosis. The environment now becomes hypercoagulable because of the integrated responses of the innate immune and coagulation systems. These findings are directly relevant to the evolution of complicated effusions because the exuberant fibrin deposition is a concerted effort to control progressive infection. The final state of a complicated effusion is referred to as the organization phase (days 10Y21). Fibroblasts migrate into the pleural space and create a dense fibrotic lining of the visceral and parietal surfaces. This phase is thought to be driven by regenerative cytokines, for example, transforming growth factor-A and platelet-derived growth factor released primarily from activated mesothelial cells. The net result is a progressive rind that encases the lung, reducing ventilatory capacity and sequestering bacteria. The objective of this management algorithm for parapneumonic fluid collections (Fig. 1) is to outline cost-effective diagnostic and therapeutic interventions in the surgical intensive care unit (SICU) based on the pathologic state of the pleural cavity. These guidelines are derived from the published experience with adult populations, but conceptually, the same principles apply to the pediatric age group.17Y20