Eastern Association For The Surgery Of Trauma Guidelines Research Articles

Eastern Association for the Surgery of Trauma (EAST) vs Western Trauma Association (WTA): How a Level 1 Trauma Center Splits the Difference in Resuscitative Thoracotomy.

Background Resuscitative thoracotomy (RT) is performed in severe trauma cases as a final lifesaving effort. Prominent, yet differing, practice management guidelines exist from Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA). This study evaluates all RTs performed from 2012 to 2019 at an urban Level 1 trauma center for management guideline indication and subsequent outcomes. Methods Our trauma registry was queried to identify RT cases from 2012 to 2019. Data was collected on patient demographics, prehospital presentation, cardiopulmonary resuscitation (CPR) requirements, and resuscitation provided. Survival to the operating room, intensive care unit, and overall were recorded. Information was compared with regard to EAST and WTA criteria. Results Eighty-seven patients who underwent RTs were included. WTA guidelines were met in 78/87 (89.7%) of cases, comparatively EAST guidelines were met in every case. Within the EAST criteria, conditional and strong recommendations were met in 70/87 (80.4%) and 17/87 (19.5%) of cases, respectively. In nine cases (10.3%) indications were discordant, each meeting conditional indication by EAST and no indication by WTA. All patients that survived to the operating room (OR), ICU admission, and overall met EAST criteria. Conclusion All RTs performed at our Level 1 trauma center met indications provided by EAST criteria. WTA guidelines were not applicable in nine salvaging encounters due to the protracted duration of CPR before proceeding to RT. Furthermore, more patients that survived to OR and ICU admission met EAST guidelines suggesting an improved potential for patient survivability. As increased data is derived, management guidelines will likely be re-established for optimized patient outcomes.

Uncovering gaps in GRADE reporting of Eastern Association for the Surgery of Trauma (EAST) guidelines

ObjectivesTo formally evaluate the uptake and reporting of the Grading of Recommendation Assessments, Development and Evaluation (GRADE) approach in clinical practice guidelines (CPGs) developed by the Eastern Association for the Surgery of Trauma (EAST). Study Design and SettingBased on an a priori, written protocol, we developed a dedicated data abstraction form that included the six suggested criteria for using and applying GRADE. By searching the EAST website, we identified all EAST guidelines that referenced the use of GRADE. All steps of the data abstraction process were completed independently and in duplicate by two members of the research team. ResultsWe identified a total of 48 CPGs that used GRADE. Trauma and violence prevention (n = 11; 23.9%) was the most common topic. The median number of patient/population, intervention, comparison, and outcomes (PICO) questions addressed was 3 (interquartile range: 2; 4) with a median of 2.5 (interquartile range: 1; 4) critical outcomes. A conditional/weak recommendation was provided for n = 79 (51.4%) PICOs, whereas a strong recommendation was provided for 33 PICOs (23.9%). For 22 PICOs (15.9%), no recommendation was made. Nearly all guideline documents provided search dates (n = 44; 95.7%) and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram (n = 44; 95.7%). Most described categories for rating down (n = 35; 76.1%). GRADE decision-making domains related to the ratio of benefits to harms, values and preferences, and resource utilization were referenced by 43.5% (n = 20), 43.5% (n = 20), and 30.4% (n = 14) of CPGs, respectively. For nearly half of PICO questions (n = 59; 44.2%) authors did not provide an evidence profile or summary of findings table. Comparing time periods from 2014–2018 to 2019–2022, the proportion of recommendations with an overall certainty of evidence increased (52.4% vs 83.9%; P < 0.001). ConclusionEAST has successfully adopted GRADE to develop many trauma-related guidelines, each addressing a finite number of focused clinical questions based on systematic reviews conducted in-house. Overall reporting improved over time. There is for improvement when it comes to consistent provision of an overall certainty of evidence, the reporting of the evidence to decision-making process, and the justification of strong recommendations based on low/very low certainty evidence.

Plate of ribs: single institution’s matched comparison of patients managed operatively and non-operatively for rib fractures

BackgroundRib fractures are associated with significant morbidity and mortality in polytraumatized patients. There is considerable variability in the management (operative vs. non-operative) and timing of operative intervention. Although Eastern Association for the Surgery of Trauma (EAST) guidelines recommend early operative intervention in patients with flail chest, there are no strong recommendations regarding operative fixation in patients with a non-flail chest rib fracture pattern.MethodsWe reviewed our Trauma Quality Improvement Program database for patients aged 18 to 99 who underwent operative intervention of ribs from January 2016 to July 2019. We examined hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, Injury Severity Score, age, discharge disposition and packed red blood cell transfusions. Similarly, we collected data from patients aged 18 to 99 who had one or more rib fractures in this time frame. We compared results in a 4:1 ratio of patients managed non-operatively to patients managed operatively. The patient groups were matched based on age, number of rib fractures and presence of bilateral rib fractures.ResultsBetween January 2016 and July 2019, 33 of 4189 total patients diagnosed with rib fractures underwent operative fixation; the matched non-operative group consisted of 132 patients. The statistically significant differences included presence of bilateral rib fractures, displaced rib fractures and flail chest segments. The median ICU days were longer in the operative group (6.0 vs. 3.5 days). A subgroup analysis of patients without flail segments demonstrated a significant presence of displaced rib fractures.Our single-institution matched comparison of outcomes in operative intervention versus Non-operative Management (NOM) of rib fractures found an increased median number of ICU days. Patients who underwent operative intervention often stayed in the ICU preoperatively and postoperatively for aggressive pulmonary hygiene and pain control, suggesting observer bias. The increased incidence of displaced rib fractures and the presence of a flail segment in the operative group demonstrate congruence with EAST guidelines. A subgroup analysis of patients without flail segment did not demonstrate differences in outcomes nor shoulder girdle injury characteristics.Level of evidenceThis article presents level III evidence that can be used by other clinicians to analyze eligibility for patients to undergo surgical stabilization of rib fracture (SSRF) and to provide counterarguments for performing SSRF in a heterogenous group of patients.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were &filig;rst addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. Sixty articles were identi&filig;ed. Of these, 51 articles were selected to construct the guidelines. There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically signi&filig;cant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

A retrospective analysis of cervical spine radiography in a specialist trauma unit for head injury

ObjectivesThe performance of an adequate and complete series of cervical radiographs in the trauma patient is essential in order to ensure safe trauma management. Eastern Association for the Surgery of...

Eastern Association for the Surgery of Trauma Practice Management Guidelines for Hemorrhage in Pelvic Fracture—Update and Systematic Review

Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

012 Retrospective analysis of cervical spine radiography in a tertiary head injury centre

Objectives and BackgroundsThe EAST (Eastern Association for the Surgery of Trauma) guidelines define adequate radiography of the cervical spine. Previous studies looking at emergency department cervical spine radiographs have found...

Cost-effectiveness of guidelines for insertion of inferior vena cava filters in high-risk trauma patients

Inferior vena cava filters (IVCFs) can prevent pulmonary embolism (PE); however, indications for use vary. The Eastern Association for the Surgery of Trauma (EAST) 2002 guidelines suggest prophylactic IVCF use in high-risk patients, but the American College of Chest Physicians (ACCP) 2008 guidelines do not. This analysis compares cost-effectiveness of prophylactic vs therapeutic retrievable IVCF placement in high-risk trauma patients. Markov modeling was used to determine incremental cost-effectiveness of these guidelines in dollars per quality-adjusted life-years (QALYs) during hospitalization and long-term follow-up. Our population was 46-year-old trauma patients at high risk for venous thromboembolism (VTE) by EAST criteria to whom either the EAST (prophylactic IVCF) or ACCP (no prophylactic IVCF) guidelines were applied. The analysis assumed the societal perspective over a lifetime. For base case and sensitivity analyses, probabilities and utilities were obtained from published literature and costs calculated from Centers for Medicare & Medicaid Services fee schedules, the Healthcare Cost & Utilization Project database, and Red Book wholesale drug prices for 2007. For data unavailable from the literature, similarities to other populations were used to make assumptions. In base case analysis, prophylactic IVCFs were more costly ($37,700 vs $37,300) and less effective (by 0.139 QALYs) than therapeutic IVCFs. In sensitivity analysis, the EAST strategy of prophylactic filter placement would become the preferred strategy in individuals never having a filter, with either an annual probability of VTE of ≥ 9.6% (base case, 5.9%), or a very high annual probability of anticoagulation complications of ≥ 24.3% (base case, 2.5%). The EAST strategy would also be favored if the annual probability of venous insufficiency was <7.69% (base case, 13.9%) after filter removal or <1.90% with a retained filter (base case, 14.1%). In initial hospitalization only, EAST guidelines were more costly by $2988 and slightly more effective by .0008 QALY, resulting in an incremental cost-effectiveness ratio of $383,638/QALY. Analysis suggests prophylactic IVC filters are not cost-effective in high-risk trauma patients. The magnitude of this result is primarily dependent on probabilities of long-term sequelae (venous thromboembolism, bleeding complications). Even in the initial hospitalization, however, prophylactic IVCF costs for the additional quality-adjusted life years gained did not justify use.

Cost-Effectiveness of Guidelines for Insertion of Inferior Vena Cava Filters in High-Risk Trauma Patients

Inferior vena cava filters (IVCF) can prevent pulmonary embolism (PE); however, indications for use vary. While the Eastern Association for the Surgery of Trauma (EAST) 2002 guidelines suggest prophylactic IVCF use in high-risk patients, the American College of Chest Physicians (ACCP) 2008 guidelines do not. This analysis compared the cost-effectiveness of prophylactic vs therapeutic retrievable IVCF placement in high-risk trauma patients. A Markov model was created to determine incremental cost-effectiveness of these guidelines in dollars per quality-adjusted life-years (QALYs) by accounting for costs and utilities of events occurring during hospitalization and long-term follow-up. Our population was 46-year-old trauma patients at high risk for venous thromboembolism (VTE) by EAST criteria to whom either the EAST (prophylactic IVCF) or ACCP (no prophylactic IVCF) guidelines were applied. The analysis assumed the societal perspective over the patient's lifetime, using a 1-day cycle length. For base case and sensitivity analyses, event probabilities and utilities were obtained from published literature, and costs calculated from the Center for Medicare and Medicaid Services (CMS) fee schedules, the Healthcare Cost and Utilization Project database, and Redbook wholesale drug prices for 2007; for data not available from the literature, assumptions were set forth based on similarities to other populations. In base case analysis, prophylactic IVCFs were not cost-effective, being both more costly ($37,700 vs $37,300) and less effective (by 0.139 QALYs) than therapeutic IVCFs. Results were sensitive to several probabilities; the cost-effectiveness of prophylactic IVCFs varied significantly with probabilities of late venous thromboembolism (VTE) and complications related to anticoagulation. Prophylactic IVCFs were less effective, but less costly when the probability of late VTE was <4.3% per year (base case, 4.6%) among those with a removed filter, or <5.1% per year (base case, 6.1%) among those with a retained filter. The probability of anticoagulation complications, primarily gastrointestinal bleeding, was assumed to be the same in individuals with removed filters and individuals who never had a filter. Prophylactic filters were less effective, but less costly when the probability of anticoagulation complications among those with a removed filter or who never had a filter was >3.9% per year (base case, 2.5%). Prophylactic filters were less effective and more costly over the range of probabilities in the literature of anticoagulation complications for individuals with a retained filter (base case, 2.1%/y). Our analysis suggests prophylactic IVC filters are not cost-effective. This result is dependent on probabilities of long-term sequelae (VTE, bleeding complications) that are poorly characterized in the literature due to the recent advent of retrievable filters and lack of long-term follow-up in patients with retained and removed filters.

Clinical Examination and its Reliability in Identifying Cervical Spine Fractures

The Eastern Association for the Surgery of Trauma (EAST) guidelines recommend that cervical spine (c-spine) radiographic evaluation is unnecessary in the awake, alert blunt trauma patient who is not intoxicated, has no distracting injuries, and demonstrates no tenderness over the c-spine or neurologic deficits. The purpose of this study was to compare the reliability of the clinical examination (CE) with that of computed tomography in identifying the presence of c-spine fractures. We prospectively evaluated 534 blunt trauma patients between February 2004 and January 2005. Positive CE was defined as complaints of neck pain, external trauma of the c-spine or neurologic deficit, tenderness or abnormalities to palpation over the cervical spine. Computed tomography was used to define the accuracy of CE. There were 52 patients with, and 482 patients without, c-spine fractures. Forty of the 52 patients with fractures were accurately identified by CE for a sensitivity of 76.9% and a negative predictive value (NPV) of 95.7%. In the group with an initial Glasgow Coma Score of 15, 16 of 24 patients with fractures were accurately identified for a sensitivity of 66.7% and an NPV of 96.5%. In the subset of patients who by EAST guidelines would not require any radiographic evaluation, there were 17 fractures and 10 were accurately identified by clinical examination. The sensitivity in this group was 58.8% with an NPV of 96.4%. Four of the seven missed injuries required intervention. This trial suggests that with a normal Glasgow Coma Score, CE cannot be relied upon to rule out c-spine fracture. CE is unreliable to diagnose or exclude a cervical spine fracture.

The Inefficiency of Plain Radiography to Evaluate the Cervical Spine After Blunt Trauma

Controversy persists regarding the most efficient and effective method of cervical spine evaluation after blunt trauma. Historic guidelines for patients undergoing computed tomography (CT) of the head advocate imaging the occiput-C2 as part of that study. For the remaining cervical spine, plain cervical spine radiographs (CSR) with supplemental CT are recommended. Many patients who require head CT also undergo supplemental cervical spine CT after plain CSR, which leads to separate, discontinuous cervical spine CT scans. We sought to determine the incidence of this in our population. We hypothesized that plain CSR alone often proves inadequate to evaluate the cervical spine in patients who require head CT. The Eastern Association for the Surgery of Trauma (EAST) guidelines for cervical spine evaluation after blunt trauma were previously adopted and followed during the study period from December 1, 2002 to July 1, 2003. Our protocol included cross-table lateral and anteroposterior CSR with the occiput-C2 imaged with the head CT. We used segmental cervical spine CT to supplement those regions inadequately visualized by plain films. The electronic charts of 848 consecutive blunt trauma victims were retrospectively reviewed. The data abstracted included demographics, injury severity score, and the use and results of head CT and radiographic evaluation of the cervical spine. Of 848 consecutive blunt trauma patients, 716 (84.4%) underwent head CT. Average age was 44 years old, and average Injury Severity Score was 9. Seventy-six patients (11.6%) had clinical cervical spine examination alone, whereas 640 (89.4%) underwent plain CSR. In 178 patients (27.8%), plain two-view CSR visualized the entire cervical spine. Plain CSR were inadequate to visualize the complete cervical spine in 462 patients (72.2%). Of these patients, segmental CT was performed in 400 (87.6%). The remaining 62 (13.4%) patients did not have radiologic completion of their cervical spine evaluation before clinical examination. Nineteen patients (3.0%) had cervical spine fractures diagnosed on CT, of which only 6 (31.6%) were seen on plain CSR. The sensitivity and specificity of CSR to detect fractures was 31.6 and 99.2%, respectively. Plain CSR are inadequate to fully evaluate the cervical spine after blunt trauma, and supplemental CT is commonly required. Complete cervical spine CT is available, efficient, and accurate. Our findings support a growing body of literature that suggests that this modality should be used for blunt trauma patients who require radiographic evaluation of the cervical spine. Plain cervical spine radiographs need not be obtained. The EAST guidelines for cervical spine evaluation after blunt trauma should be updated to reflect this evolving practice pattern.