EAST Guidelines Review: Issue 2 - Fall 2023
In this issue review of the following EAST Guidelines published in 2022:
(scroll down to see summaries)
Guideline 1 reviewed by Christina Regelsberger-Alvarez, DO
Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 2 reviewed by EAST Guidelines Committee
EAST evidence-based statement on Stand Your Ground laws
Guideline 3 reviewed by Asanthi M. Ratnasekera, DO, FACS
Full-face motorcycle helmets to reduce injury and death
Guideline 4 reviewed by Sarah-Ashley E. Ferencz, MD
Emergency Department Thoracotomy in Children: A PTS, WTA, and EAST Systemic Review and Practice Management Guidelines
Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma
Freeman JJ, Yorkgitis BK, Haines K, Koganti D, Patel N, Maine R, Chiu W, Tran TL, Como JJ, Kasotakis G. Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma. Injury. 2022 Nov; 53(11): 3569-3574. doi: 10.1016/j.injury.2022.08.006. Epub 2022 Aug 4. PMID: 36038390.
Relevant Background:
Angioembolization of the spleen has become a mainstay of treatment for blunt abdominal trauma patients with the following: splenic injury > AAST grade III, hemoperitoneum, blush or active bleeding. Due to compromised immune function, risk of OPSI and associated mortality, vaccination has been mandated for patients who have been treated with splenectomy. This has prompted an assessment of immune function after angioembolization.
PICOs:
In adult trauma patients with splenic injury who undergo angioembolization, are splenic function, OPSI and mortality superior to patients undergoing splenectomy?
Recommendations:
Guideline recommends against routine post-splenectomy vaccinations in adult trauma patients who have undergone angioembolization for splenic injury.
Clinical Application:
Vaccination after splenic angioembolization for blunt trauma is not suggested as current data suggests there is preserved immune function of the spleen with no increase in OPSI or mortality after splenic angioembolization (both proximal and distal).
Additional Thoughts or Information:
More data is slowly emerging which supports the EAST PMG thus far. However, there is still a general paucity of literature on this topic. Only a few new papers have been published since the literature review for the PMG was generated. This guideline warrants re-review in the next 5-10 years when more long-term data is available. If more and higher quality data is available in the future, perhaps a stronger recommendation can be made.
EAST evidence-based statement on Stand Your Ground laws
Kaufman, Elinore J. MD, MSHP; Zakrison, Tanya L. MD, MPH; Hoofnagle, Mark H. MD, PhD; Tatebe, Leah C. MD; Rattan, Rishi MD; Murphy, Patrick B. MD, MPH; Smith, Randi N. MD, MPH; Joseph, DAndrea K. MD; Yeh, D. Dante MD; Haut, Elliott R. MD, PhD; Como, John J. MD, MPH; Christmas, A. Britton MD; Claridge, Jeffrey A. MD; Stein, Deborah M. MD MPH; Jung, Hee Soo MD. EAST evidence-based statement on Stand Your Ground laws. Journal of Trauma and Acute Care Surgery 93(3):p e123-e124, September 2022.
Relevant Background:
Firearm related legislation has important implications for population health. Efforts by trauma surgeons to prevent injury must address not just individual risk factors, but also social and structural factors. Stand your ground laws allow the use of deadly force, without criminal liability, to a perceived threat as opposed a duty to retreat first. A version of these laws is in place in 42 states. While Utah adopted this legislation in 1998, Florida launched the national trend in 2006. A series of studies, including a systematic review, demonstrated that these laws do not provide a reduction in violent crime. Rather, increases in firearm homicide and total homicides have been demonstrated in several states, including Florida.
Recommendations:
Stand Your Ground Laws do not prevent violent crime but rather are associated with increased mortality and inequity. Various populations are disproportionately adversely affected by these laws in self-defense claims under these laws, namely Blacks and women, and thereby contribute to structural racism and sexism.
Additional Thoughts or Information:
This is an important statement from the EAST on the effects of Stand Your Ground Laws. The findings should encourage trauma practitioners to become involved in societal legislative issues, as a part of injury prevention efforts.
Full-face motorcycle helmets to reduce injury and death
Urréchaga EM, Kodadek LM, Bugaev N, Bauman ZM, Shah KH, Abdel Aziz H, Beckman MA, Reynolds JM, Soe-Lin H, Crandall ML, Rattan R. Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg. 2022 Jul 7:S0002-9610(22)00438-X. doi: 10.1016/j.amjsurg.2022.06.018. Epub ahead of print. PMID: 35821175.
Relevant Background:
Although helmets are proven to improve mortality and head injury, no guidelines exist on the type of helmet that should be utilized. Prio systematic reviews have limitations in addressing the ideal type of helmet that is required for injury prevention.
PICOs:
Should non-professional motorcycle riders (P) wear full-face helmets (I) versus helmets that are not full-face (C) to reduce the risk of mortality; injury severity (of the head, face, and neck); traumatic brain injury (TBI); cervical spinal cord injury (SCI); cervical spine fracture; blunt cerebrovascular injury; or facial fracture (O)?
Recommendations:
We conditionally recommend that motorcycle riders wear full-face helmets to reduce traumatic brain injury, facial fracture, and head, face, and neck injury severity.
Clinical Application:
Clinicians should encourage the use of full-face helmets while understanding that the role of the clinician in the face of a conditional recommendation should be to help their patient arrive at a management decision consistent with [patient] values and preferences.
Additional Thoughts or Information:
Overall quality of evidence was low due to the presence of mostly non randomized retrospective cohort studies. On the other hand, 2 of 7 outcomes demonstrated a large effect size of intervention, upgrading their quality of evidence to low. The study further discusses patient preferences, culture, availability of full face helmets. While full face helmets does not limit cognitive performance as commonly described, other factors such as tropical or subtropical climates, female or child users and poor fitting can limit use of full face helmets.
Emergency Department Thoracotomy in Children: A PTS, WTA, and EAST Systemic Review and Practice Management Guidelines
Selesner L, Yorkgitis B, Martin M, et al. Emergency department thoracotomy in children: A PTS, WTA, and EAST systematic review and practice management guideline. J Trauma, published ahead of print.
Relevant Background:
Trauma is the leading cause of mortality and morbidity in the pediatric population in the United States. The decision to perform lifesaving maneuvers, such as Emergency Department Thoracotomy (EDT), is controversial and while there are guidelines in the adult population, recommendations are lacking for children. The following Evidence Based Guideline provides recommendations on performing EDT versus resuscitation without EDT in pediatric trauma patients (<19 years old) both with an without signs of life (SOL) in penetrating or blunt trauma.
PICOs:
PICO 1: In pediatric patients presenting pulseless to the ED with SOL after penetrating thoracic injury, should EDT be performed, versus resuscitation without EDT, to improve hospital survival (HS) and neurologically intact hospital survival (NIS)?
PICO 2: In pediatric patients presenting pulseless to the ED without SOL after penetrating thoracic injury, should EDT be performed, versus resuscitation without EDT, to improve HS and NIS?
PICO 3: In pediatric patients presenting pulseless to the ED with SOL after penetrating abdominopelvic injury, should EDT be performed, versus resuscitation without EDT, to improve HS and NIS?
PICO 4: In pediatric patients presenting pulseless to the ED without SOL after penetrating abdominopelvic injury, should EDT be performed, versus resuscitation without EDT, to improve HS and NIS?
PICO 5: In pediatric patients presenting pulseless to the ED with SOL after blunt injury, should EDT be performed, versus resuscitation without EDT, to improve HS and NIS?
PICO 6: In pediatric patients presenting pulseless to the ED without SOL after blunt injury, should EDT be performed, versus resuscitation without EDT, to improve HS and NIS?
Recommendations:
PICO 1: Conditional recommendation for EDT in pediatric patient presenting pulseless to the ED following a penetrating thoracic injury with SOL.
PICO 2: Conditional recommendation against EDT in a child presenting pulseless to the ED following penetrating thoracic injury without SOL.
PICO 3: Conditional recommendation for EDT in pediatric patient presenting pulseless to the ED following a penetrating abdominopelvic injury with SOL.
PICO 4: Conditionally recommend against EDT following a penetrating abdominopelvic injury without SOL.
PICO 5: Conditional recommendation for EDT in pediatric patient presenting pulseless to the ED following a blunt injury with SOL.
PICO 6: Strong recommendation against EDT in pediatric patient presenting pulseless to ED following a blunt injury without SOL.
Clinical Application:
The decision to perform EDT in children varies from recommendations in adult trauma patients. In an oversimplified summary, a child presenting with any traumatic injury and without signs of life EDT is recommended against; a child presenting with any traumatic injury with signs of life EDT is recommended. One reason for the difference in management between children and adults is because children can hemodynamically compensate for acute blood loss until late in the clinical course. By the time a child presents in extremis, the survival rate of intervention is thought to be lower. Unlike the available literature for adults, length of time without signs of life was unable to be specified, and the treating providers discretion remains of upmost importance. Overall survival for any child undergoing EDT remains low, at 7.2% (13.4% for penetrating, 2.3% for blunt).
Additional Thoughts or Information:
While many providers know the adult literature well, a visual treatment algorithm of the recommendations for pediatric versus adult trauma patients may come in handy during critical decision making.
Below summarizes the recommendations for pediatric and adult patients according to their respective EAST PMGs, with emphasis on the differing recommendation:
-SOL with any type of injury: EDT for children & adults
-*No SOL with any type of penetrating injury: No EDT for children; Yes EDT for adults*
-No SOL with blunt injury: No EDT for children or adults