EAST Guidelines Review: Issue 5 - Fall 2025
In this issue review of the following Injury Prevention and Mitigation EAST Guidelines published in 2025:
(scroll down to see summaries)
Guideline 1 reviewed by Justin Cirone, MD MS
Systematic review and meta-analysis of efficacy of helmet use and helmet laws to reduce mortality and cervical spine injury in adult motorcycle riders: A practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 2 reviewed by Linda Imen Yala, MD
The effect of ridesharing services on motor vehicle crash outcomes: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 3 reviewed by Joshua A. Marks, MD
Posttraumatic stress disorder mitigation in trauma patients: An evidence-based systematic review from the Eastern Association for the Surgery of Trauma
Guideline 1:
Systematic review and meta-analysis of efficacy of helmet use and helmet laws to reduce mortality and cervical spine injury in adult motorcycle riders: A practice management guideline from the Eastern Association for the Surgery of Trauma
Ratnasekera, A. , Seng, S. , Gardiner, S. , Butler, C. , Goldenberg-Sandau, A. , Lu, N. , Abdel Aziz, H. , Appelbaum, R. , Mashbari, H. , Hafiz, S. , Chowdhury, S. , Soe-Lin, H. , Reynolds, J. , Teichman, A. , Kartiko, S. , Kaufman, E. , Murphy, P. , Kodadek, L. & Rattan, R. (2025). Systematic review and meta-analysis of efficacy of helmet use and helmet laws to reduce mortality and cervical spine injury in adult motorcycle riders: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 99 (4), 650-663. doi: 10.1097/TA.0000000000004607.
Relevant Background:
Almost 6,000 motorcyclists were killed in the United States in 2021 which was the highest motorcycle fatality rate since 1975. Helmet use among motorcyclists has been known to decrease mortality, however, helmet laws have varied over time and between states with only 18 states currently having universal helmet laws. This guideline used the established GRADE methodology and a rigorous search strategy to create a systematic review and meta-analysis of peer-reviewed prospective observational, retrospective, and randomized studies published from January 1, 2010, to October 1, 2024. The authors analyzed 37 of 7,408 studies that met inclusion criteria with over 550,000 patients in the largest analyzed category.
PICOs:
PICO 1: Should adult motorcycle riders wear helmets or not wear helmets to improve mortality, brain injury–related mortality, cervical spine injury, and discharge disposition from the hospital?
PICO 2: Should universal motorcycle helmet laws or no universal motorcycle helmet laws be in place to improve mortality, brain injury–related mortality, cervical spine injury, and discharge disposition from the hospital?
Recommendations:
Motorcyclist Helmet Use: The working group strongly recommends use of helmets in adult motorcycle riders to reduce death and injury. This is based on low-quality evidence, but the literature found helmet use to be protective overall particularly based on the relative risks and benefits. Arguments against helmet use cited limited auditory and visual acuity which has literature to the contrary and the other often-cited argument is that helmet use increases cervical spine injury, but this review found helmet use to be protective against cervical spine injury. The working group also balanced the desire for rider autonomy with the burden on society due to unhelmeted motorcyclist injuries.
Universal Helmet Laws: The working group strongly recommends implementation of universal helmet laws to reduce motorcycle-related death and injury. This is based on low-quality evidence, but the recommendation was augmented by consistent results despite study design variations. The recommendation strength in this study was supported by consistent study findings, the potential for catastrophic harm, cost savings to society, and repeated increases in mortality after helmet laws were repealed. Partial helmet laws, which only apply to younger individuals, had little to not effect and may have worsened outcomes.
Clinical Application:
Additional Thoughts/Input:
The topic of motorcyclist helmet mandates has been an ongoing source of controversy. The authors of this guideline have a unique viewpoint since those involved in clinical trauma care see the results of these devastating injuries firsthand. Those who are against helmet mandates often do not have the same experience. Having done my residency in one of the only three states with no helmet laws, I know the anti-universal helmet law group is not a small cohort. I think it would be worthwhile to have a widely publicized panel on this topic between pro- and anti-helmet law groups with the goal of finding a common ground that goes beyond simply mandating behavior and finds a solution that incorporates and acknowledges the negative effects of unhelmeted motorcyclist injuries.
Guideline 2:
The effect of ridesharing services on motor vehicle crash outcomes: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma
Relevant Background:
In the United States, motor vehicle collisions (MVCs) and specifically MVCs associated with impaired drivers account for a large portion of adult deaths. Interventions have been attempted to prevent impaired driving and, within the past few decades, ridesharing has emerged as a novel means to achieve this reduction. The goal of this paper was therefore to systematically review the literature to inform policy makers and public health practitioners on the use of ridesharing apps in the reduction of crash injuries and deaths.
PICOs:
PICO 1: For the general population, should the presence of ridesharing services compared with no ridesharing be recommended for the following outcomes: total MVCs, MVCs involving alcohol, MVC deaths involving alcohol, MVC injuries, MVC injuries involving alcohol-intoxicated drivers, pedestrians struck by alcohol-intoxicated drivers, MVCs involving other intoxicants, and arrests for driving under the influence?
PICO 2: In the general population, should more versus less use of ridesharing services be recommended for the outcomes listed?
Recommendations:
PICO 1: Conditional recommendation that ridesharing service compared with no ridesharing services reduce MVC-related morbidity at the population level.
PICO2: Conditional recommendation for more use of ridesharing services compared to less use to reduce MVC related harm at the population level.
Clinical Application:
This review provides support for the adoption of accessible transportation alternatives to reduce MVC-related harm.
Additional Thoughts/Input:
As with many population-based systematic reviews, low level of evidence and paucity of studies make clear recommendations difficult. Further, to extrapolate that rideshare alone and not querying whether availability to alternative transportation in general results in less morbidity is hard to conclude. These conditional recommendations for ridesharing services provide the goal to advocate for alternative means of transportation at the policy level.
Guideline 3:
Posttraumatic stress disorder mitigation in trauma patients: An evidence-based systematic review from the Eastern Association for the Surgery of Trauma
Relevant Background:
Advances in trauma care have increased the survival of injured patients; however, less progress has been made to address the psychological disorders associated with traumatic events. Emotional or psychological distress is common and >20% of trauma patients will develop post-traumatic stress disorder (PTSD) and/or depression within the first year of injury. Untreated PTSD and depression are associated with lost productivity, poor quality of life (QOL), and functional impairment. There is a growing awareness of the need to address this problem. Trauma centers have developed programs to
manage patients' mental health needs; however, this is not commonplace nor easy to implement. This EAST practice management guideline offers direction on early identification of individuals at risk for PTSD as well as evidence-based treatment options to assist patients to mitigate PTSD symptoms in the long term.
PICOs:
PICO 1: In adult trauma patients admitted to the hospital, should behavioral health screening be performed compared with no screening to decrease PTSD, re-injury rate, hospital length of stay and improve post-injury QOL?
PICO 2: In adult trauma patients admitted to the hospital, should behavioral health intervention be provided compared with regular care to decrease PTSD, re-injury rate, hospital LOS, and improve post-injury QOL?
PICO 3: In adult trauma patients admitted to the hospital who are screened positive for acute stress disorder (ASD)/PTSD/depression, should behavioral health intervention be provided compared with regular care to decrease PTSD, re-injury rate, hospital LOS, and improve post-injury QOL?
PICO 4: In adult trauma patients admitted to the hospital with preexisting mental health conditions, should in-hospital mental health counseling (psychiatry/psychology) consults be provided compared with outpatient versus no follow-up to decrease PTSD, re-injury rate, hospital LOS, and improve post-injury QOL?
PICO 5: In adult trauma patients admitted to the hospital, will cognitive behavioral therapy (CBT) compared with other therapies decrease PTSD, re-injury rate, hospital LOS, and improve postinjury QOL?
Recommendations:
PICO 1: Conditional recommendation to screen for ASD/PTSD in adult trauma patients admitted to the hospital during their initial hospitalization to identify injured patients at risk for PTSD. There were insufficient data to evaluate re-injury, post-injury QOL, and hospital LOS.
PICO 2: Conditional recommendation for behavioral health intervention for adult trauma patients admitted to the hospital during their initial hospitalization with high risk of ASD/PTSD to decrease PTSD outcome.
PICO 3: Conditional recommendation for the use of behavioral health intervention in patients who are screened to have ASD/PTSD or depression to decrease PTSD outcome.
PICO 4: Insufficient data to evaluate any outcomes.
PICO 5: Strong recommendation for CBT compared with other therapy to decrease the development of PTSD in hospitalized trauma adult patients.
Clinical Application:
We should probably be screening our trauma patients for PTSD as they become medically stable, have a GCS score of =14, are not acutely intoxicated or heavily medicated, and are able to respond to the screening process. Those who screen positive should undergo a behavioral health intervention such as cognitive behavioral therapy (CBT) to mitigate the development of PTSD.
Additional Thoughts/Input:
The EAST PMG on PTSD mitigation is critically important in that it gets us to focus on the mental toll that trauma takes on our patients. Beyond the physical rehabilitation, all too often, we neglect the mental recovery also needed. We need to do better to identify patients at risk and ensure adequate resources are provided to try to provide for a full physical and mental recovery. This further highlights the necessary multidisciplinary team approach to trauma care.