Trauma EAST and AAST Trauma guidelines

Question 1

In patients with suspected BTAI (P), should CT of the chest with intravenous contrast (I) be used versus conventional catheter-based angiography (C) for the identification of clinically significant injury (O)?

Answer 1

In patients with suspected BTAI, we strongly recommend the use of CT scan of the chest with intravenous contrast for diagnosis of clinically significant BTAI.

Question 2

In patients with BTAI (P), should endovascular (I) repair be performed versus open repair (C) to minimize mortality, stroke, paraplegia, and renal failure (O)?

Answer 2

In patients diagnosed with BTAI, we strongly recommend the use of endovascular repair in patients who do not have contraindications to endovascular repair.

Question 3

In patients with BTAI (P), should timing of repair be delayed (I) or immediate (C) to minimize mortality, stroke, paraplegia, and renal failure (O)?

Answer 3

The patients who benefit the most from delayed repair are those who have major associated injuries. These patients require resuscitation and treatment of immediately life-threatening injuries before aortic repair. For patients without associated injuries who have no reason to undergo delayed repair. The panel does not advocate delaying repair of BTAI (e.g., until the following weekday morning) merely for surgeon convenience.

Question 4

When do you screen for blunt cardiac injury? How?

Answer 4

Significant trauma to the anterior chest (not necessarily sternal fracture though). ECG. Negative ECG and troponin rules out BCI.

Question 5

In trauma patient with severe anterior chest injury, instability, and new arrhythmia, what further test should be done to detect BCI?

Answer 5

echocardiogram; TTE can be attempted first, but do TEE if optimal eval cannot be obtained

Question 6

What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of blunt cerebrovascular injury (BCVI)?

Answer 6

1. any neuro abnormality unexplained
2. arterial epistaxis
3. fractures at petrous bone, high c-spine through foramen transversarium or with sublux or rotation, lefort II/III

Question 7

What is the appropriate modality for the screening and diagnosis of BCVI?

Answer 7

Diagnostic four-vessel cerebral angiography (FVCA) remains the gold standard for the diagnosis of BCVI. Multislice (eight or greater) multidetector CTA has a similar rate of detection for BCVI when compared with historic control rates of diagnosis with FVCA.

Question 8

What is the grading for BCVI?

Answer 8

Grade I—intimal irregularity with <25% narrowing;
Grade II—dissection or intramural hematoma with >25% narrowing;
Grade III—pseudoaneurysm;
Grade IV—occlusion; and
Grade V—transection with extravasation.

Question 9

How do you manage grades I and II BCVI?

Answer 9

Barring contraindications, grades I and II injuries should be treated with antithrombotic agents such as aspirin or heparin (without bolus).

Question 10

How do you manage grade III BCVI (pseudoaneurysm)?

Answer 10

Rarely resolve with observation or heparinization, and invasive therapy (surgery or angiointerventional) should be considered.

Question 11

How do you manage BCVI of the distal common carotid or proximal internal carotid with an associated early neurologic deficit?

Answer 11

operative or interventional repair should be considered to restore flow

Question 12

How should one monitor the response to therapy for BCVI?

Answer 12

Follow-up angiography is recommended in grades I to III injuries. To reduce the incidence of angiography-related complications, this should be performed 7 days postinjury.

Question 13

In patients with blunt abdominal/pelvic trauma (P), should retrograde computed tomography (CT) cystography (I) versus no imaging study be used to diagnose bladder injuries (O)?

Answer 13

1A: In low-risk patients (microscopic hematuria only), we conditionally recommend no radiography versus routine retrograde CT cystography to diagnose bladder rupture.
1B: In moderate-risk patients (gross hematuria), we recommend CT cystography versus no radiography to diagnose bladder rupture.
1C: In high-risk patients (gross hematuria and pelvic fracture), we recommend CT cystography versus no radiography to diagnose bladder rupture.

Question 14

In patients sustaining blunt abdominopelvic trauma with intraperitoneal bladder rupture (P), should operative repair (I) versus nonoperative management (C) be used to decrease complications from the bladder injury (O)?

Answer 14

In patients sustaining blunt abdominopelvic trauma with intraperitoneal bladder rupture, we recommend operative management over nonoperative management to decrease complications from the bladder injury.

Question 15

In patients sustaining blunt abdominopelvic trauma with extraperitoneal bladder rupture (P), should operative repair (I) versus nonoperative management (C) be used to decrease complications from the bladder injury (O)?

Answer 15

In patients sustaining blunt abdominopelvic trauma with simple extraperitoneal bladder ruptures, we conditionally recommend nonoperative management versus operative management to decrease complications from the bladder injury.
In patients with complex extraperitoneal injuries, we conditionally recommend operative repair over nonoperative management to decrease complications from the bladder injury.

Question 16

In patients who have undergone operative or nonoperative management of bladder rupture (P), should cystography (I) versus no imaging study (C) be used to evaluate for bladder closure (O)?

Answer 16

In low-risk patients (operative repair of simple intraperitoneal or extraperitoneal bladder ruptures), we conditionally recommend against routine follow-up cystography in the absence of clinical signs or symptoms concerning for urinary leakage.
In patients at moderate risk of urine leak on follow-up cystography (operative repair of complex intraperitoneal bladder ruptures), we recommend follow-up cystography versus no follow-up cystography to evaluate for successful bladder closure.
In patients at high risk for urine leak on follow-up cystography (nonoperative management of simple extraperitoneal bladder ruptures), we recommend follow-up cystography to evaluate for successful bladder closure.

Question 17

How do you clear a c-spine in a trauma patient?

Answer 17

Negative C-spine CT scan alone. No need for physical exam or adjunct imaging. C-collars should be removed as soon as possible.

Question 18

In patients with penetrating trauma to the brain, are c-collars necessary?

Answer 18

Not unless trajectory suggests direct injury to C-spine.

Question 19

In awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion of the C-spine, what imaging or precautions are needed?

Answer 19

CS imaging is not necessary and the cervical collar may be removed.

Question 20

Patients with c-spine pain or tenderness, neurologic deficit, altered mental status, or distracting injury should have what?

Answer 20

CT C-spine: axial from the occiput to T1 with sagittal and coronal reconstructions. Plain XR contributes no additional information.

Question 21

If CT C-spine is positive for injury, what should be done next?

Answer 21

1) spine consult.

2) MRI.

Question 22

What should be done if CT C-spine is negative in a patient with neck pain?

Answer 22

Options: continue c-collar or obtain MRI

Question 23

In penetrating trauma, how do you manage nondestructive
(involvement of < 50% of the bowel wall without devascularization) colon wounds in the absence of
peritonitis?

Answer 23

standard is primary repair

Question 24

Patients with penetrating intraperitoneal colon wounds which are destructive (involvement of > 50% of the bowel wall or devascularization of a bowel segment) can be managed how?

Answer 24

resection and primary anastomosis IF: Hemodynamically stable without evidence of shock (sustained pre- or intraoperative hypotension as defined by SBP < 90 mm Hg),
Have no significant underlying disease,
Have minimal associated injuries (PATI < 25, ISS < 25, Flint grade < 11),
Have no peritonitis.

Question 25

Patients with penetrating colon injuries and shock, underlying disease, significant associated injuries, or peritonitis should have destructive colon wounds managed how?

Answer 25

resection and colostomy

Question 26

Colostomies performed following colon and rectal trauma can be closed when? How do you know when you can? Can this be done for everyone?

Answer 26

Within two weeks if contrast enema is performed to confirm distal colon healing. Only for patients who do not have non-healing bowel injury, unresolved wound sepsis, or are unstable.

Question 27

In adult patients with severe trauma, should an MT/DCR protocol versus no MT/DCR protocol be used to decrease mortality or total blood products used?

Answer 27

The risks of applying an MT/DCR protocol seem to be low, and use of an MT/DCR protocol is associated with a significant survival benefit.

Question 28

In adult patients with severe trauma, should a high ratio of PLAS:RBC and PLT:RBC versus a low ratio be administered to decrease mortality or total blood products used?

Answer 28

Most patients would value a high-ratio DCR strategy, if not whole blood. Preparing MT packs or pre-positioning blood products in the trauma resuscitation bay in a 1:1:1 ratio (e.g., 6 units PLAS, 1 unit apheresis PLT, and 6 units RBC) can help avoid a significant ratio imbalance during the early empiric resuscitation phase.

Question 29

If MTP is activated, what should be given first?

Answer 29

Leading with hemostatic PLAS and PLT early and then catching up with RBC in short order seems to be a safe guiding principle, although further data are needed in this area.

Question 30

In adult patients with severe trauma, should the hemostatic adjunct rVIIa versus no rVIIa be administered to decrease mortality, total blood products used, or MT? Does use of rVIIa increase rates of VTE?

Answer 30

For most bleeding trauma patients, there does not seem to be a clear, significant mortality benefit from rVIIa. If given early in the resuscitation, rVIIa may decrease the need for a MT. Although there is also no evidence that rVIIa leads to more VTEs, this end point has not been well evaluated in the trauma population.

Question 31

In adult patients with severe trauma, should the hemostatic adjunct TXA versus no TXA be administered to decrease mortality, total blood products used, or MT? Does use of TXA increase rates of VTE?

Answer 31

There is no clear universal mortality benefit to TXA; however, the safety profile of this medication seems to be favorable when used early after injury (i.e., within 3 hours).

Question 32

Results for Laparoscopy Versus Computed Tomography for LEFT-Sided Thoracoabdominal Stab Wounds?

Answer 32

In left thoracoabdominal stab wound patients who are hemodynamically stable and without peritonitis (P), we conditionally recommend laparoscopy (I) rather that computed tomography (C) to decrease the incidence missed diaphragmatic injury (O).

Question 33

In penetrating thoracoabdominal trauma patients in whom a RIGHT diaphragm injury is confirmed or suspected, and who are hemodynamically stable without peritonitis (P), what is recommended?

Answer 33

conditionally recommend Recommend nonoperative (I) over operative (O) management in weighing the risks of delayed herniation, missed thoracoabdominal organ injury, and surgical morbidity (procedural complications, LOS, surgical site infection, and empyema) (O).

Question 34

Results for Repair of Hemodynamically Stable, Acute Diaphragmatic Injuries by an Abdominal or Thoracic Approach?

Answer 34

In hemodynamically stable trauma patients with acute diaphragm injuries, we conditionally recommend (P) the abdominal (I) rather than the thoracic (C) approach to repair the diaphragm to decrease mortality, delayed herniation, missed thoracoabdominal organ injury, and surgical approach-associated morbidity (procedural complications, LOS, surgical site infection, and empyema) (O).

Question 35

Results for Open Versus Laparoscopic Approach for Acute, Penetrating Diaphragmatic Injuries?

Answer 35

In patients with acute penetrating diaphragmatic injuries without concern for other intraabdominal injuries (P) we conditionally recommend laparoscopic (I) over open (C) repair in weighing the risks of mortality, delayed herniation, missed thoracoabdominal organ, and surgical approach-associated morbidity (procedural complications, LOS, surgical site infection, and empyema) (O).

Question 36

In patients presenting pulseless to the emergency department with signs of life after penetrating thoracic injury (P), does EDT (ED thoracotomy) versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Answer 36

EDT in this clinical scenario because of the substantial improvements in both survival and neurologically intact survival over patients resuscitated without EDT.

Question 37

In patients presenting pulseless to the emergency department without signs of life after penetrating thoracic injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Answer 37

EDT in this clinical scenario because of the improvements in both survival and neurologically intact survival over patients resuscitated without EDT.

Question 38

In patients presenting pulseless to the emergency department with signs of life after penetrating extrathoracic injury (P), does EDT versus resuscitation without EDT (C) improve hospital survival and neurologically intact hospital survival (O)?

Answer 38

In patients presenting pulseless to the emergency department with signs of life after penetrating extrathoracic injury, we conditionally recommend that patients undergo EDT. This recommendation does not pertain to patients with isolated cranial injuries.

Question 39

When is endotracheal intubation indicated in trauma?

Answer 39

airway obstruction, hypoventilation, persistent hypoxia, GCS = 8, hemorrhagic shock, cardiac arrest, smoke inhalation w/ >40% burn, impending airway obstruction following facial burn (damage to oropharynx, airway injury on endoscopy)

Question 40

Orotracheal intubation should be guided by what in trauma patients?

Answer 40

direct laryngoscopy

Question 41

What should be used to facilitate endotracheal intubation in truama patients?

Answer 41

RSI

Question 42

To enhance safe and effective ETI in trauma, need to do what?

Answer 42

Have experienced personnel, have pulse-ox monitoring, maintain cervical neutrality, confirm ETT placement (BL breath sounds and ET CO2), continuous ET CO2 monitoring.

Question 43

In obese patients, difficult airways and those w/ c-spine held in line, what tool can be used to increase success?

Answer 43

video laryngoscopy

Question 44

When should ORIF be done for femur fractures (open or closed)? What is the effect as far as outcomes?

Answer 44

internal fixation of femur fractures in less than 24 hours after injury may be associated with a reduction in mortality, infection, and VTE

Question 45

Gross hematuria, pelvic fluid, pelvic fractures (other than acetabular fractures) on CT should prompt what workup?

Answer 45

Conventional cystography or CT cystography. Drainage films and adequate distension of the bladder with contrast medium increases the sensitivity of cystography in the detection of bladder injuries.

Question 46

With what fracture should urethral injury be suspected? What should be done to work it up?

Answer 46

Urethral injury should be suspected when a pubic arch fracture exists and an urethrogram performed.

Question 47

What is the next imaging step in patients with persistent opacity on CXR after tube thoracostomy? Why?

Answer 47

CT of the chest is indicated in patients with persistent opacity on chest radiograph after tube thoracostomy to determine whether significant undrained fluid exists (Level 2).

Question 48

What intervention can be done for stable penetrating thoracoabdominal wounds to diagnose and manage select diaphragm/pulmonary injuries?

Answer 48

Primary VATS of stable penetrating thoracoabdominal wounds is safe and effective for the diagnosis and man­agement of selected diaphragm and pulmonary injuries (Level 2).

Question 49

What amount of chest tube output (over 24 hrs) in a trauma patient should prompt exploration?

Answer 49

1500 mL via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II).

Question 50

Persistent retained hemothorax, seen on plain films, after placement of a thoracostomy tube should be treated with what?

Answer 50

early VATS, not a second chest tube (Level 1).

Question 51

Discuss the timing of VATS in the trauma setting for retained hemothorax.

Answer 51

VATS should be done in the first 3 days to 7 days of hospitalization to decrease the risk of infection and con­version to thoracotomy (Level 2).

Question 52

If a high-risk patient who may not tolerate a thoracotomy has subacute loculated or exudative pleural collections, what is an option to improve drainage?

Answer 52

Intrapleural thrombolytic may be used to improve drain­age of subacute (6-day to 13-day duration) loculated or exudative collections, particularly patients where risks of thoracotomy are significant (Level 3).

Question 53

What do you do for an asymptomatic pneumothorax not seen on CXR but found on CT?

Answer 53

Occult pneumothorax, those not seen on chest radiograph, may be observed in a stable patient regardless of positive pressure ventilation (Level 3).

Question 54

How do you manage persistent air leaks on post-injury day 3 after trauma?

Answer 54

A persistent air leak on postinjury day 3 should prompt a VATS evaluation (Level 2).

Question 55

Do you need to do laparotomy on HD stable pts w/o peritonitis found to have isolated blunt hepatic injury?

Answer 55

A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury.

Question 56

What can be considered as an adjunct to operative intervention in a transient responder to resuscitation in a patient with isolated blunt hepatic injury?

Answer 56

Angiography with embolization may be considered as a first-line intervention for a patient who is a transient responder to resuscitation as an adjunct to potential operative intervention.

Question 57

What should be considered in a hemodynamically stable blunt trauma patient with evidence of active extravasation (a contrast blush) in the liver on abdominal CT scan?

Answer 57

Angiography with embolization

Question 58

After hepatic injury, clinical factors such as a persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in hemoglobin should prompt reevaluation with what?

Answer 58

CT scan

Question 59

The initial diagnostic study of choice for neck trauma when there is suspicion for vascular injury is what?

Answer 59

High resolution CT angiography offers appropriate diagnostic accuracy with minimal risk, making this the initial diagnostic study of choice when available. Duplex US can also be used in lieu of arteriography to rule out an arterial injury in penetrating injuries to zone II of the neck.

Question 60

Is operation necessary in Zone II neck trauma?

Answer 60

Selective operative management and mandatory exploration of penetrating injuries to zone II of the neck have equivalent diagnostic accuracy. Therefore, selective management is recommended to minimize unnecessary operations.

Question 61

How do you rule out esophageal perforation in neck trauma?

Answer 61

Either contrast esophagography or esophagoscopy can be used to rule out an esophageal perforation that requires operative repair. Diagnostic workup should be expeditious because morbidity increases if repair is delayed by more than 24 hours. A strategy of rigid esophagoscopy after equivocal esophagography may lead to better sensitivity of injury.

Question 62

A patient with documented abdominal compartment syndrome should undergo what?

Answer 62

A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy.

Question 63

How do you define abdominal compartment syndrome?

Answer 63

Intra-abdominal pressure (IAP) >20 mm Hg (with or without an abdominal perfusion pressure (APP) ≤60 mm Hg—World Congress of ACS [WCASC] definition), manifested as organ dysfunction (abdominal distension, decompensating cardiac, pulmonary, and renal dysfunction).

Question 64

An acute increase of intra-abdominal pressures to ≥25 mm Hg makes what diagnosis likely prompting consideration for what treatment?

Answer 64

ACS, laparotomy

Question 65

Damage control laparotomy with open abdomen should be considered with what parameters?

Answer 65

acidosis (pH ≤7.2), hypothermia (temperature ≤35°C), and clinical coagulopathy and or if the patient is receiving massive transfusion (≥10 units packed RBCs [PRBCs]) (level III).

Question 66

When should the abdomen be closed following damage control laparotomy with an open abdomen?

Answer 66

On-demand laparotomy is associated with a reduction in relaparotomies and negative laparotomies that may reduce healthcare utilization and medical costs (level II).

Question 67

For type III open fractures (large, devitalized, high-energy, comminuted), describe abx management.

Answer 67

Start abx ASAP after injury. Cover gram negatives as well. Continue for 72 hrs or not >24 hrs after soft tissue coverage has been achieved.

Question 68

For adult patients with grade I/II injuries to the pancreas identified by CT scan, should operative intervention or nonoperative management be performed?

Answer 68

We conditionally recommend nonoperative management for grade I/II pancreatic injuries diagnosed by CT scan. Nonoperative management appears to have low morbidity. If the pancreatic duct is not definitively intact, it seems reasonable to further evaluate the duct with additional tests, such as ERCP or MRCP, because this may change the grade of the injury and therefore the recommended treatment plan.

Question 69

For adult patients with grade III/IV injuries to the pancreas identified on CT scan, should operative intervention or nonoperative management be performed?

Answer 69

We conditionally recommend operative management for grade III/IV pancreatic injuries diagnosed by CT scan. Although there was no statistically significant difference between groups for any single outcome, our group feels that there is a cumulative trend toward increased morbidity after nonoperative management. Treatment failures after nonoperative management occur regularly, and treatment delays likely contribute to morbid complications and death.

Question 70

How do you grade pancreatic traumatic injury?

Answer 70

Grade I – minor contusion or laceration with no duct injury, grade II – major contusion or laceration with no duct injury, grade III – transection or major laceration with duct disruption in distal pancreas, grade IV – transection of proximal pancreas or major laceration with associated injury to the ampulla, grade V – Massive disruption of the pancreatic head

Question 71

For adults undergoing an operation who are intraoperatively found to have a grade I/II pancreas injury, should resectional or nonresectional management be performed?

Answer 71

We conditionally recommend nonresectional management for operative management of grade I/II pancreatic injuries. Our pooled data analysis suggests that mortality from pancreas-related causes are generally low in this population and that there were significantly more intra-abdominal abscesses in the resection group.

Question 72

For adults already undergoing an operation who are intraoperatively found to have a grade III/IV pancreas injury, should resection or nonresection be performed?

Answer 72

We conditionally recommend resection for operative management of grade III/IV pancreatic injuries. Complications are frequent in both groups. In our pooled analysis, fistula development was associated with nonresection strategies. Pancreas-related mortality was higher in the nonresection group, but this finding was potentially confounded by incomplete mortality reporting and bias. Due to the very low quality of available data, this is a conditional recommendation.

Question 73

For adult patients who have undergone an operation for pancreatic trauma, should routine octreotide prophylaxis or no octreotide be used?

Answer 73

We conditionally recommend against the routine use of octreotide for postoperative prophylaxis related to traumatic pancreatic injuries to prevent fistula. Data are limited, but pooled data show no difference in outcomes between groups. The subcommittee concluded that the less invasive (no medication) strategy would be preferable with no difference in outcomes.

Question 74

Patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should be considered for...

Answer 74

pelvic angiography/embolization.

Question 75

Patients with evidence of arterial intravenous contrast extravasation (ICE) in the pelvis by CT may require what? (regardless of hemodynamic status)

Answer 75

pelvic angiography and embolization

Question 76

Patients with pelvic fractures who have undergone pelvic angiography with or without embolization, who have signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out, should be considered for...

Answer 76

repeat pelvic angiography and possible embolization

Question 77

Patients older than 60 years with major pelvic fracture (open book, butterfly segment, or vertical shear) should be considered for what? (without regard for hemodynamic status)

Answer 77

pelvic angiography

Question 78

Does bilateral angiographic embolization lead to gluteal necrosis?

Answer 78

Pelvic angiography with bilateral embolization seems to be safe with few major complications. Gluteal muscle ischemia/necrosis has been reported in patients with hemodynamic instability and prolonged immobilization or primary trauma to the gluteal region as the possible cause, rather than a direct complication of angioembolization.

Question 79

Does bilateral angiographic embolization impair male sexual function?

Answer 79

Sexual function in males does not seem to be impaired after bilateral internal iliac arterial embolization.

Question 80

Can trauma FAST exam exclude intra-abdominal bleeding in pelvic fracture trauma?

Answer 80

Focused Assessment with Sonography for Trauma (FAST) is not sensitive enough to exclude intraperitoneal bleeding in the presence of pelvic fracture.

Question 81

Does FAST have adequate specificity when positive to recommend laparotomy in an unstable pelvic trauma patient?

Answer 81

FAST has adequate specificity in patients with unstable vital signs and pelvis fracture to recommend laparotomy to control hemorrhage.

Question 82

In the hemodynamically stable patient with a pelvic fracture, what is recommended to evaluate for intra-abdominal bleeding regardless of FAST results?

Answer 82

CT of the abdomen and pelvis with intravenous contrast

Question 83

What is the best test to exclude intra-abdominal bleeding in the hemodynamically unstable patient?

Answer 83

Diagnostic peritoneal tap (DP)/Diagnostic peritoneal lavage (DPL) is the best test to exclude intra-abdominal bleeding in the hemodynamically unstable patient.

Question 84

What is an excellent screening tool in the trauma setting to exclude pelvic hemorrhage?

Answer 84

CT of the pelvis is an excellent screening tool to exclude pelvic hemorrhage.

Question 85

Pelvic hematoma >500 cm[3] in size has an increased incidence of what?

Answer 85

arterial injury and need for angiography.

Question 86

What is the role for retroperitoneal packing in bleeding pelvic trauma patients?

Answer 86

Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as a salvage technique after angiographic embolization.

Question 87

Is there a role for prophylactic antibiotics in patients sustaining penetrating abdominal wounds?

Answer 87

A single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage should be administered to all patients sustaining penetrating abdominal wounds.

Question 88

When is selectiev nonoperative management ok for penetrating abdominal injury?

Answer 88

Routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs. Abdominopelvic computed tomography should be considered in patients selected for initial nonoperative management to facilitate initial management decisions. The vast majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after twenty-four hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations as well as peritoneal penetration in an effort to avoid unnecessary laparotomy.

Question 89

In extremity trauma with skeletal and arterial injury, what should the time to reperfusion be to maximize limb salvage?

Answer 89

6 hrs. 4 hrs w/o perfusion may require fasciotomy.

Question 90

In combined skeletal and arterial injury in a trauma patient, which injury takes precedence?

Answer 90

Restoration of blood flow should always take priority over skeletal injury management, either by temporary shunting to allow stabilization of unstable fractures and/or dislocations prior to definitive arterial repair, or by immediate definitive arterial repair when the skeletal injury is stable and not significantly displaced.

Question 91

What test should be done at the end of a revascularization procedure?

Answer 91

Completion angiogram.

Question 92

For low-risk adult civilian patients with penetrating abdominal trauma, should colon repair/R&A be performed versus colostomy to improve survival and reduce infectious complications?

Answer 92

in adult civilian patients with penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention, we recommend that colon repair or R&A be performed rather than colostomy

Question 93

For high-risk adult civilian patients with penetrating colon injury, should colon repair/R&A be performed versus colostomy to improve survival and reduce infectious complications?

Answer 93

In adult, high-risk (delay >12 hours, shock, associated injury, transfusion >6 units of blood, contamination, or left side colon injuries) trauma patients with penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than mandatory colostomy. Colostomy may have a limited role in select patients.

Question 94

For high-risk adult civilian patients requiring DCL, should repair/R&A of penetrating/blunt colon injuries be performed versus colostomy to improve survival and reduce infectious complications?

Answer 94

In adult trauma patients with penetrating colon injury who had DCL, we conditionally recommend that mandatory colostomy not be performed; instead, definitive repair, delayed R&A, or anastomosis (if resection already took place in the setting of DCL) may be performed rather than colostomy. Clinical judgment in these situations is paramount.

Question 95

Is spine immobilization necessary in patients with penetrating trauma?

Answer 95

We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma, as it is associated with increased mortality and has no benefit in preventing neurologic deterioration.

Question 96

In patients with nondestructive penetrating extraperitoneal injuries (P), should proximal diversion (I) be performed versus primary repair (if feasible) without proximal diversion (C) to decrease the incidence of infectious complications (O) (Table 2)?

Answer 96

The committee concludes that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects. Thus, in patients with nondestructive penetrating extraperitoneal rectal injuries, we conditionally recommend proximal diversion (vs. nondiversion).

Question 97

In patients with nondestructive penetrating extraperitoneal rectal injuries (P), should presacral drainage (I) versus no presacral drainage (C) be performed to decrease incidence of infectious complications (O) (Table 3)?

Answer 97

In patients with nondestructive extraperitoneal rectal injuries, we conditionally recommend against the routine use of presacral drains.

Question 98

In patients with nondestructive penetrating extraperitoneal rectal injuries (P), should distal rectal washout be performed (I) versus no distal rectal washout (C) to decrease the incidence of infectious complications (O) (Table 4)?

Answer 98

In patients with nondestructive penetrating extraperitoneal rectal injuries, we conditionally recommend not performing distal rectal washout (vs. performance of distal rectal washout).

Question 99

In adult patients with flail chest after blunt trauma, should rib ORIF be performed (versus nonoperative management) to decrease mortality; DMV, ICU LOS, and hospital LOS; incidence of pneumonia and need for tracheostomy; and improve pain control?

Answer 99

In adult patients with flail chest after blunt trauma, we conditionally recommend operative rib ORIF compared to nonoperative management, to decrease mortality; shorten DMV, ICU LOS, and hospital LOS; incidence of pneumonia, and need for tracheostomy.

Question 100

In adult patients with nonflail rib fractures after blunt trauma, should rib ORIF be performed (versus nonoperative management) to decrease mortality and incidence of pneumonia; shorten DMV, hospital LOS; improve pain control; and decrease need for tracheostomy if applicable?

Answer 100

In adult patients with nonflail pattern rib fractures, we cannot offer a recommendation regarding rib ORIF, compared to conservative management, to decrease mortality; DMV, ICU LOS, and hospital LOS; incidence of pneumonia and need for tracheostomy; and improve pain control, with currently available evidence.

Question 101

Is routine laparotomy is indicated in the hemodynamically stable patient without peritonitis presenting with an isolated splenic injury?

Answer 101

No

Question 102

Is the severity of splenic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age >55 and/or the presence of assd injuries a contraindication to a trial of nonoperative management in a hemodynamically stable patient?

Answer 102

No

Question 103

In the hemodynamically normal blunt abdominal trauma patient without peritonitis, what should be performed to identify and assess the severity of injury to the spleen?

Answer 103

an abdominal CT scan with intravenous contrast

Question 104

What should be considered for patients with American Association for the Surgery of Trauma (AAST) grade of greater than III injuries, presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding?

Answer 104

IR for angiography

Question 105

What is the role of chemical DVT ppx in a patient with blunt splenic injuries?

Answer 105

Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt splenic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.

Question 106

Is routine correction of therapeutic INR necessary in blunt trauma patients?

Answer 106

Unless indicated for other injuries, correction of therapeutic INR’s in the face of a normal head CT is probably not necessary. Consideration should be given to correction of supratherapeutic INR’s.

Question 107

Is repeat head CT in blunt trauma patients taking anticoagulants necessary if initial head CT is negative?

Answer 107

Repeat head CT is not indicated without changes in neurological exam.

Question 108

In patients with significant chest trauma, how would one screen for blunt cardiac injury?

Answer 108

EKG. Nuclear medicine and CPK should not be ordered.

Question 109

What would prompt admission and further workup on EKG in patient with suspected blunt cardiac injury?

Answer 109

New arrhythmias, ST changes, heart block, ischemia, and any unexplained EKG changes

Question 110

What is the next test for workup in patients with a positive EKG who is suspected to have blunt cardiac injury?

Answer 110

Echo