EAST Guidelines Review: Issue 6 - Winter 2025
In this issue review of the following Trauma and Emergency General Surgery EAST Guidelines published in 2025: (scroll down to see summaries)
Guideline 1 reviewed by Christina M. Regelsberger-Alvarez, DO FACSTrauma in pregnancy: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 2 reviewed by Kate Savoie, MD, MS
Surgical management of incarcerated and strangulated inguinal hernias requiring urgent surgical intervention: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 3 reviewed by Julia R. Coleman, MD, MPH
Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma
Guideline 1:
Trauma in pregnancy: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma
Appelbaum RD, Yorkgitis B, Rosen J, et al. Trauma in pregnancy: A systematic review,
meta-analysis and practice management guideline from the Eastern Association for the
Surgery of Trauma. J Trauma Acute Care Surg. 2025; 99(2):298-309.
Relevant Background:
Trauma is the leading cause of non-obstetric, pregnancy-related mortality. Caring for the pregnant trauma patient may be challenging due to altered maternal anatomy and physiology. Additionally, the fetus also requires assessment and care as the fetus experiences a disproportionately high risk of harm ranging from 3:1 to 9:1 fetal mortality/maternal mortality. Current evaluation and management of the pregnant trauma patient is based on Advanced Trauma Life Support (ATLS) protocols. While ATLS provides a basis for care, additional questions remain regarding resuscitative hysterotomy (RH), fetal monitoring, laboratory tests, use of non-ionizing imaging modalities and timing of fetal evaluation.
PICOs:
PICO 1: In pregnant trauma patients (EGA =20 weeks) undergoing resuscitative thoracotomy for traumatic arrest (P), should immediate RH be performed (I) versus resuscitative thoracotomy alone (C) to reduce maternal morbidity, maternal mortality, and fetal death (O)?
PICO 2: In trauma patients with viable pregnancies without injuries requiring hospitalization (P), should a formal observation period of maternal/fetal monitoring be performed (I) versus short maternal/fetal monitoring with discharge (C) to allow for intervention to reduce maternal complication, neonatal/fetal complication, fetal death, and preterm labor (O)?
PICO 3: In trauma patients with viable pregnancies (P), should additional pregnancy-specific laboratory tests be drawn (I) versus only standard trauma laboratory tests (C) to screen for maternal complication or neonatal/fetal complication and to reduce fetal death (O)?
PICO 4: In trauma patients with pregnancies (P), should nonionizing radiation imaging be performed (I) versus traditional trauma CT imaging (C) to reduce maternal complication, issues with neonatal development, neonatal/fetal complication, and missed injury (O)?
PICO 5: In trauma patients with viable pregnancies (P), should fetal assessment be performed at the end of the primary survey (I) versus at the end of the secondary survey when the maternal evaluation has been completed (C) to reduce maternal mortality, maternal complication, neonatal/fetal complication, and fetal death (O)?
Recommendations:
PICO 1: Given the data available, the workgroup conditionally recommends that, in trauma patients with viable pregnancies (EGA =20 weeks) undergoing RT, RH should be performed concomitantly.
PICO 2: In trauma patients with viable pregnancies, we conditionally recommend that a formal observation period of at least 4 to 6 hours of maternal/fetal monitoring be performed to allow for intervention to reduce maternal complication.
PICO 3: In trauma patients with viable pregnancies, we cannot recommend for or against pregnancy-specific laboratory tests being drawn to screen for maternal complication and to reduce fetal death. Kleihauer-Betke testing should be performed in all patients who are Rh negative if abdominal trauma is suspected given the possibility of isoimmunization if an appropriate amount of Rh D immunoglobulin is not administered.
PICO 4: In trauma patients with viable pregnancies, we cannot recommend for or against nonionizing radiation imaging being performed to reduce maternal complication, issues with neonatal development, neonatal/fetal complication, and missed injury. However, the workgroup suggests that, in pregnant trauma patients, the possible effects of high-dose ionizing radiation exposure should not prevent medically indicated diagnostic imaging procedures from being performed. Other imaging procedures not associated with ionizing radiation (US, MRI) should be considered when appropriate based on initial presentation and mechanism of injury.
PICO 5: Given the paucity of data, the workgroup suggests that, in trauma patients with viable pregnancies, fetal assessment should be performed at the end of the primary survey when a rapid initial maternal evaluation and stabilization have been completed.
Clinical Application:
In this field, it will be difficult to obtain high-quality data that can generate strong recommendations as research is limited to retrospective and case-control studies in this population. However, this practice management guideline does address practical clinical questions and provides more specific guidance to the multidisciplinary team than what is currently available through ATLS. Certainly, RH should be strongly considered in patients with EGA > 20 weeks and completed within 4 minutes to maximize maternal benefit. Kleihauer-Betke testing should be performed in all patients who are Rh negative if abdominal trauma is suspected given the possibility of isoimmunization if an appropriate amount of Rh D immunoglobulin is not administered. Practitioners should remember that no clinically indicated imaging should be withheld from the pregnant patient due to fear of ionizing radiation. Treatment of the pregnant individual must remain the priority as this results in the best outcome for the fetus.
Additional Thoughts/Input:This practice management guidelines assists in providing practical recommendations for any providers involved with trauma. This guideline may be particularly helpful in guiding the initial care of the pregnant trauma patient in the community or rural setting where specialists may be unavailable.
Guideline 2:
Surgical management of incarcerated and strangulated inguinal hernias requiring urgent surgical intervention: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma
Farrell MS, Zhang Z, Kirsch J, Bower K, Bower C, Gelbard R, Kent AJ, Khariton K, Perez A, Lo Menzo E, Rabinowitz JB, Ratnasekera A
Relevant Background:
Inguinal hernias (IH) are common operations with approximately 5% of IH requiring urgent surgical intervention. There are currently no guidelines and limited literature on the management of urgent IH surgery.
PICOs:
PICO 1: In adults with acutely incarcerated or strangulated inguinal hernias who are deemed to require surgery (P), should early operative intervention (<6 hours after symptom onset) (I) versus delayed operative intervention (>6 hours after symptom onset) (C) be used to reduce the risk of bowel resection, mortality, SSI, and unplanned return to the operating room?
PICO 2: In adults with acutely incarcerated or strangulated inguinal hernias who require emergency surgery (P), should mesh repair (I) versus primary tissue repair (C) be used to reduce the risk of hernia recurrence, SSI, and unplanned return to the operating room?
PICO 3: In adults with acutely incarcerated or strangulated inguinal hernias who require emergency surgery (P), should laparoscopic repair (I) versus open repair (C) be used to reduce the risk of hernia recurrence, SSI, hospital length of stay (LOS), ileus, postoperative bowel perforation, and unplanned return to the operating room?
PICO 4: In adults with acutely incarcerated or strangulated inguinal hernias who require emergency surgery (P), should postoperative antibiotics (I) be given versus no postoperative antibiotics (C) to decrease mortality, postoperative SSI, and hospital LOS?
Recommendations:
A total of 34 studies were included in the analysis. Earlier intervention (<6 hours) was conditionally recommended for acute incarcerated or strangulated IH due to lower risk of bowel resection (3 non-randomized studies). Additionally, the authors conditionally recommended performing a mesh repair for acute incarcerated or strangulated IH (22 studies: 4 randomized observational, 18 non-randomized). Utilization of mesh lead to a lower rate of recurrence but no difference in SSI. A laparoscopic approach was conditionally recommended as the operative approach due to lower rate of recurrence and shorter hospital LOS. A specific laparoscopic approach was not assessed. No recommendations were made regarding antibiotic usage due to lack of literature (10 non-randomized studies).
Clinical Application:
An approach to early laparoscopic mesh IH repair for strangulated or incarcerated IH will lead to a lower rate of bowel resection, lower recurrence and shorter LOS. Attempts should be made to intervene on incarcerated IH within 6 hours of onset of symptoms.
Guideline 3:
Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma
Harfouche MN, Bugaev N, Como JJ, Fraser DR, McNickle AG, Golani G, Johnson BP, Hojman H, Abdel-Aziz H, Sawhney JS, Cullinane DC, Lorch S, Haut ER, Fox N, Magder LS, Kasotakis G. Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open. 2025 Mar 28;10(1):e001730. doi: 10.1136/tsaco-2024-001730. PMID: 40166770; PMCID: PMC11956280.
Relevant Background:
The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the management of patients with subdiaphragmatic bleeding, as well as its utility in traumatic cardiac arrest (TCA), is unknown.
PICOs:
PICO 1: In hemodynamically unstable trauma patients with suspected subdiaphragmatic bleeding, should REBOA versus no REBOA be performed, prior to definitive hemostatic procedures, to decrease time to definitive intervention, blood transfusion requirements and mortality?
PICO 2: In hemodynamically unstable trauma patients with suspected pelvic fractures, should REBOA versus no REBOA be performed, prior to definitive hemostatic procedures, to decrease time to definitive intervention, blood transfusion requirements and mortality?
PICO 3: In trauma patients with cardiac arrest OR impending cardiac arrest due to suspected subdiaphragmatic bleeding, should REBOA versus resuscitative thoracotomy be utilized to increase the rate of return of spontaneous circulation (ROSC), decrease time to aortic occlusion, and decrease mortality?
PICO 4: In trauma patients with cardiac arrest due to suspected subdiaphragmatic bleeding, should REBOA versus resuscitative thoracotomy be utilized to increase the rate ROSC, decrease time to the aortic occlusion, and decrease mortality?
PICO 5: In hemodynamically unstable patients with subdiaphragmatic bleeding of non-traumatic etiology, should REBOA versus no REBOA be performed, prior to definitive hemostatic procedures, to decrease blood transfusion requirements and mortality?
PICO 6: In hemodynamically stable patients with anticipated subdiaphragmatic bleeding due to placenta accreta syndrome (PAS), should REBOA vs no REBOA be performed prophylactically, prior to definitive hemostatic procedures, to decrease blood
transfusion requirements and blood loss?
Recommendations:
PICO 1: In hemodynamically unstable trauma patients with suspected subdiaphragmatic bleeding, our analysis showed no mortality benefit for REBOA over no REBOA. The committee gave a conditional recommendation against using REBOA in this population.
PICO 2: In hemodynamically unstable trauma patients with suspected subdiaphragmatic bleeding due to blunt pelvic fractures, quantitative analysis demonstrated two times greater odds of mortality for the REBOA population. The committee gave a conditional recommendation against using REBOA in this population.
PICO 3: In trauma patients with cardiac arrest or impending cardiac arrest due to suspected subdiaphragmatic bleeding, quantitative analysis demonstrated nearly four times lower odds of mortality for the REBOA population, however due to poor quality evidence and ambiguity of patient inclusion, the committee could not make a recommendation for or against using REBOA in this population.
PICO 4: In trauma patients with cardiac arrest due to suspected subdiaphragmatic bleeding, quantitative analysis demonstrated lower odds of mortality for REBOA by more than half and slightly longer time from initiation to successful aortic occlusion. The committee made a conditional recommendation for using REBOA in this population.
PICO 5: Lack of research prevented the committee from making a recommendation for or against REBOA in this patient population.
PICO 6: On pooled analysis, prophylactic use of REBOA prior to cesarean section ± hysterectomy in patients with PAS led to a reduction of pRBC transfusion by close to 3 units and EBL by 1L. The committee made a conditional recommendation for the use of REBOA in this patient population.
Clinical Application:
This systematic review highlights the best available evidence pertaining to the use of REBOA in hypotensive trauma and nontrauma patients with suspected subdiaphragmatic bleeding. It identifies a unique patient population with placenta accreta that may benefit from prophylactic use of the REBOA catheter prior to cesarean section. Given limited quality data (majority were retrospective and have a high degree of bias, span a long study period during which practice patterns may have changed, and have heterogenous inclusion criteria), the committee could only provide conditional rather than strong recommendations for the PICO questions. Resuscitative thoracotomy should still be performed as deemed necessary in individuals in extremis with suspected supradiaphragmatic bleeding.
Additional Thoughts/Input:Outside of placenta accreta, the indications for REBOA are unclear, without strong supportive evidence given the significant heterogeneity between studies.