Eastern Association for the Surgery of Trauma (EAST) practice management guidelines and the perpetual quest for excellence

Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association

Objectives

Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established.

Methods

Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations.

Results

A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use.

Conclusions

In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.

History of Equity, Diversity, and Inclusion in Trauma Surgery: for Our Patients, for Our Profession, and for Ourselves

Purpose of Review

Disparities exist in outcome after injury, particularly related to race, ethnicity, socioeconomics, geography, and age. The mechanisms for this outcome disparity continue to be investigated. As trauma care providers, we are challenged to be mindful of and mitigate the impact of these disparities so that all patients realize the same opportunities for recovery. As surgeons, we also have varied professional experiences and opportunities for achievement and advancement depending upon our gender, ethnicity, race, religion, and sexual orientation. Even within a profession associated with relative affluence, socioeconomic status conveys different professional opportunities for surgeons.

Recent Findings

Fortunately, the profession of trauma surgery has undergone significant progress in raising awareness of patient and professional inequity among trauma patients and surgeons and has implemented systematic changes to diminish these inequities. Herein we will discuss the history of equity and inclusion in trauma surgery as it has affected our patients, our profession, and our individual selves.

Summary

Our goal is to provide a historical context, a status report, and a list of key initiatives or objectives on which all of us must focus. In doing so, the best possible clinical outcomes can be achieved for patients and the best professional and personal “outcomes” can be achieved for practicing and future trauma surgeons.

Developing a National Trauma Research Action Plan: Results from the geriatric research gap Delphi survey

BACKGROUND

Treating older trauma patients requires a focus on the confluence of age-related physiological changes and the impact of the injury itself. Therefore, the primary way to improve the care of geriatric trauma patients is through the development of universal, systematic multidisciplinary research. To achieve this, the Coalition for National Trauma Research has developed the National Trauma Research Action Plan that has generated a comprehensive research agenda spanning the continuum of geriatric trauma care from prehospital to rehabilitation.

METHODS

Experts in geriatric trauma care and research were recruited to identify current gaps in clinical geriatric research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines ensuring heterogeneity and generalizability. On subsequent surveys, participants were asked to rank the priority of each research question on a nine-point Likert scale, categorized to represent low-, medium-, and high-priority items. The consensus was defined as more than 60% of panelists agreeing on the priority category.

RESULTS

A total of 24 subject matter experts generated questions in 109 key topic areas. After editing for duplication, 514 questions were included in the priority ranking. By round 3, 362 questions (70%) reached 60% consensus. Of these, 161 (44%) were high, 198 (55%) medium, and 3 (1%) low priority.

CONCLUSION

Among the questions prioritized as high priority, questions related to three types of injuries (i.e., rib fracture, traumatic brain injury, and lower extremity injury) occurred with the greatest frequency. Among the 25 highest priority questions, the key topics with the highest frequency were pain management, frailty, and anticoagulation-related interventions. The most common types of research proposed were interventional clinical trials and comparative effectiveness studies, outcome research, and health care systems research.

"A" stands for airway - Which factors guide the need for on-scene airway management in facial fracture patients?

Background

Numerous guidelines highlight the need for early airway management in facial trauma patients since specific fracture patterns may induce airway obstruction. However, the incidence of these hallmark injuries, including flail mandibles and posterior displacement of the maxilla, is contentious. We aim to evaluate specific trauma-related variables in facial fracture patients, which affect the need for on-scene versus in-hospital airway management.

Methods

This retrospective cohort study included all patients with any type of facial fracture, who required early airway management on-scene or in-hospital. The primary outcome variable was the site of airway management (on-scene versus hospital) and the main predictor variable was the presence of a traumatic brain injury (TBI). The association of fracture type, mechanism, and method for early airway management are also reported. Altogether 171 patients fulfilled the inclusion criteria.

Results

Of the 171 patients included in the analysis, 100 (58.5) had combined midfacial fractures or combination fractures of facial thirds. Altogether 118 patients (69.0%) required airway management on-scene and for the remaining 53 patients (31.0%) airway was secured in-hospital. A total of 168 (98.2%) underwent endotracheal intubation, whereas three patients (1.8%) received surgical airway management. TBIs occurred in 138 patients (80.7%), but presence of TBI did not affect the site of airway management. Younger age, Glasgow Coma Scale-score of eight or less, and oro-naso-pharyngeal haemorrhage predicted airway management on-scene, whereas patients who had fallen at ground level and in patients with facial fractures but no associated injuries, the airway was significantly more often managed in-hospital.

Conclusions

Proper preparedness for airway management in facial fracture patients is crucial both on-scene and in-hospital. Facial fracture patients need proper evaluation of airway management even when TBI is not present.

A core outcome set for damage control laparotomy via modified Delphi method

OBJECTIVES

Damage control laparotomy (DCL) remains an important tool in the trauma surgeon's armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias.

METHODS

A modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) 'landmark' DCL papers and EAST ad hoc COS task force consensus.

RESULTS

Of 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus.

CONCLUSIONS

Through an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes.

LEVEL OF EVIDENCE

V, criteria.

A core outcome set for resuscitative endovascular balloon occlusion of the aorta: A consensus based approach using a modified Delphi method

BACKGROUND

The utilization of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma has grown exponentially in recent years. However, inconsistency in reporting of outcome metrics related to this intervention has inhibited the development of evidence-based guidelines for REBOA application. This study sought to attain consensus on a core outcome set (COS) for REBOA.

METHODS

A review of "landmark" REBOA articles was performed, and panelists (first and senior authors) were contacted for participation in a modified Delphi study. In round 1, panelists provided a list of potential core outcomes. In round 2, using a Likert scale (1 [not important] to 9 [very important]), panelists scored the importance of each potential outcome. Consensus for core outcomes was defined a priori as greater than 70% of scores receiving 7 to 9 and less than 15% of scores receiving 1 to 3. Feedback was provided after round 2, and a third round was performed to reevaluate variables not achieving consensus and allow a final "write-in" round by the experts.

RESULTS

From 17 identified panelists, 12 participated. All panelists (12 of 12, 100%) participated in each subsequent round. Panelists initially identified 34 unique outcomes, with two outcomes later added upon write-in request after round 2. From 36 total potential outcomes, 20 achieved consensus as core outcomes, and this was endorsed by 100% of the participants.

CONCLUSION

Panelists successfully achieved consensus on a COS for REBOA-related research. This REBOA-COS is recommended for all clinical trials related to REBOA and should help enable higher-quality study designs, valid aggregation of published data, and development of evidence-based practice management guidelines.

LEVEL OF EVIDENCE

Diagnostic test or criteria, level V.

TRIAL REGISTRATION

Core Outcomes in Trauma Surgery: Development of a Core Outcome Set for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) http://www.comet-initiative.org/Studies/Details/1709.

The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time

BACKGROUND

Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines.

MATERIALS AND METHODS

We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included.

RESULTS

The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001).

CONCLUSIONS

Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.