Trauma, critical care and surgical emergencies


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Trauma, critical care and surgical emergencies

  1. 1. Trauma, Critical Care and Trauma, Critical Frankel • Kirton RabinoviciSurgical EmergenciesA Case and Evidence-Based Textbook Care and Surgical EmergenciesAbout the bookThis book provides a comprehensive and contemporary discussion about thethree key areas of acute care surgery; trauma, surgical critical care, and surgicalemergencies. The 65 chapters, written by prominent surgeons in the field, arearranged by organ, anatomical site and injury type, and each includes a case studywith evidence-based analysis of diagnosis, management, and outcomes. Unless Trauma, Critical Care and Surgical Emergenciesstated otherwise, the authors used the GRADE evidence classification systemestablished by the American College of Chest Physicians.Trauma, Critical Care and Surgical Emergencies is essential reading for all surgeons, A Case andfellows, residents and students, especially those working in trauma, emergency andcritical care environments. Evidence-BasedAbout the editors TextbookReuven Rabinovici MD, Chief, Trauma Division, Tufts Medical Center, Boston,Massachusetts, USA; Professor of Surgery, Tufts University School of Medicine,Boston, Massachusetts, USA.Heidi L Frankel MD, Chief, Division of Trauma and Critical Care and Acute CareSurgery; Director, Shock Trauma Center, Penn State Milton S. Hershey MedicalCenter, Pennsylvania, USA; Charlene J. Smith Endowed Professor of Surgery,The Pennsylvania State University College of Medicine, Pennsylvania, USA.Orlando Kirton MD, Professor of Surgery, Vice Chairman, Department of Surgery,University of Connecticut School of Medicine, Farmington, Connecticut, USA; theLudwig J. Pyrtek, M.D. Chair in Surgery and Director of Surgery, Hartford Hospital,Connecticut, USA.With an introduction on Evidence Based Medicine by Timothy C Fabian MD, WilsonAlumni Professor of Surgery and Chairman of the Department of Surgery, Universityof Tennessee Health Science Center, Memphis, Tennessee, USA. Edited by Reuven Rabinovici Heidi L FrankelTelephone House, 69-77 Paul Street,London EC2A 4LQ, UK52 Vanderbilt Avenue, New York, NY 10017, Orlando Kirton
  2. 2. Trauma, Critical Care and SurgicalEmergencies: A Case and Evidence-BasedTextbookEdited byReuven Rabinovici, MD, FACSChief, Division of Trauma and Acute Care SurgeryTufts Medical CenterProfessor of SurgeryTufts University Medical SchoolBoston, Massachusetts, USAHeidi L Frankel, MD, FACSCharlene J Smith Endowed Professor of SurgeryPenn State UniversityChief, Division of Trauma, Acute Care and Critical Care SurgeryPenn State Hershey Medical CenterMedical Director,Penn State Shock Trauma CenterHershey, Pennsylvania, USAOrlando C Kirton, MD, FACSLudwig J Pyrtek, MD Chair in SurgeryDirector of SurgeryChief Division of General SurgeryHartford Hospital, Hartford, ConnecticutProfessor of SurgeryProgram Director,Integrated General Surgery Residency ProgramVice Chair, Department of SurgeryUniversity of Connecticut School of MedicineFarmington, Connecticut, USA
  3. 3. © 2010 Informa UKFirst published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ. Informa Healthcare is a trading division ofInforma UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales number 1072954.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright,Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham CourtRoad, London W1P 0LP.Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad toacknowledge in subsequent reprints or editions any omissions brought to our attention.A CIP record for this book is available from the British Library.Library of Congress Cataloging-in-Publication DataData available on applicationISBN-13: 9780849398957OrdersInforma HealthcareSheepen PlaceColchesterEssex CO3 3LPUKTelephone: +44 (0)20 7017 5540Email: CSDhealthcarebooks@informa.comTypeset by C&M Digitals (P) Ltd, Chennai, IndiaPrinted and bound in Great Britain by MPG Books Ltd, Bodmin, Cornwall, UK
  4. 4. ContentsList of Contributors viiPreface xvEvidence-Based Medicine xviiTimothy C FabianI. Trauma  1. Fluid resuscitation for the trauma patient 1 Michael M Krausz  2. Complex airway 8 Thomas C Mort and Joseph V Portereiko  3. Major blunt head injury 31 Brian Hood, Leo Harris, and M Ross Bullock  4. Minor blunt head injury in the intoxicated patient 47 Eleanor S Winston and Lisa Patterson  5. Stab wound to the carotid artery 52 Jonathan B Lundy and Stephen M Cohn  6. Cervical spine fracture with quadriplegia 60 Eric B Harris, James Lawrence, Jeffrey Rihn, Li Gang, and Alexander R Vaccaro  7. Blunt thoracic aortic injury 76 David Wisner  8. Transmediastinal penetrating trauma 86 Kevin Schuster and Erik Barquist  9. Diaphragmatic injury following penetrating trauma 91 Anthony Shiflett, Joe DuBose, and Demetrios Demetriades10. Blunt liver injury 97 Leslie Kobayashi, Donald Green, and Peter Rhee11. Blunt splenic injury 107 Amy D Wyrzykowski and David V Feliciano12. Penetrating renal injuries 114 Rao R Ivatury13. Blunt pancreaticoduodenal injury 119 Nasim Ahmed and Jerome J Vernick14. Penetrating colon injury 128 Aaron Winnick and Patricia O’Neill15. Rectal injury with pelvic fracture 142 Kimberly K Nagy16. Abdominal aortic injury 145 Gainosuke Sugiyama and Asher Hirshberg 
  5. 5. contents17. Blunt pelvic fracture with hemoperitoneum 151 John H Adamski II and Thomas M Scalea18. The mangled extremity 164 Samuel C Schecter, Scott L Hansen, and William P Schecter19 Damage control laparotomy 174 Brett H Waibel and Michael F Rotondo20. The pulseless trauma patient 186 Reuven Rabinovici and Horacio Hojman21. Related blast injury 196 Gidon Almogy, Howard Belzberg, and Avraham I Rivkind22. Pediatric blunt trauma 203 Sarah J McPartland, Carl-Christian A Jackson, and Brian F Gilchrist23. Blunt trauma in pregnancy 227 Amy D Wyrzykowski and Grace S RozyckiII. Surgical Critical Care24. Acute respiratory failure 234 Randall Friese25. Ventilator-associated pneumonia 241 Fredric M Pieracci, Jennifer Dore, and Philip S Barie26. Acute respiratory distress syndrome 252 Nabil Issa and Michael Shapiro27. Weaning and liberation from mechanical ventilation 261 Walter Cholewczynski and Michael Ivy28. Deep vein thrombosis and pulmonary embolism 264 Wesley D McMillian and Frederick B Rogers29 Shock 275 Jill Cherry-Bukowiec and Lena M Napolitano30. Perioperative management of a patient undergoing noncardiac surgery 287 Roxie M Albrecht and Jason S Lees31. Postoperative cardiac arrythmias 293 Scott C Brakenridge and Joseph P Minei32. Oliguria 298 Heather L Evans and Eileen M Bulger33. Hyponatremia in the surgical intensive care unit 305 Christine C Wyrick34. Glycemic control in the critically ill surgical patient 309 Stanley A Nasraway and Jeffrey Lee35. Postoperative anemia: Risks, benefits, and triggers for blood transfusion 315 Matthew D Neal, Samuel A Tisherman, and Jason L Sperry36. Nutritional considerations in the surgical intensive care unit 322 Chaitanya Dahagam and Steven E Wolf37. Pain, agitation, and delirum 330 Aviram Giladi and Bryan A Cotton38. Care of the potential organ donor 339 Carrie A Sims and Patrick Reilly
  6. 6. contents39 End of life care in the icu: Ethical considerations a family-centered, multidisciplinary approach 347 Felix Y Lui, Mark D Siegel, and Stanley Rosenbaum40. Acute trauma-related coagulopathy 352 Bryan A Cotton and John B Holcomb41. Adrenal insufficiency in critical illness 358 Carrie A Sims and Vicente Gracias42. Sepsis 362 Philip A Efron and Craig M Coopersmith43. Catheter-related infections 369 Spiros G Frangos and Heidi L Frankel44. Special populations in trauma 375 Kimberly M Lumpkins and Grant V Bochicchio45. Ultrasound in the intensive care unit 383 Kazuhide Matsushima and Heidi L FrankelIII. Surgical Emergencies46. Appendicitis 390 John W Mah47. Bariatric surgery complications 396 Terrence M Fullum and Patricia L Turner48. Diverticulitis 406 Carrie Allison, Daniel Herzig, and Robert Martindale49 Perforated peptic ulcers 412 Meredith S Tinti and Stanley Z Trooskin50. Acute mesenteric ischemia 418 Daniel T Dempsey51. Acute cholecystitis 427 Adam D Fox and John P Pryor CS†52. Acute pancreatitis 435 Pamela A Lipsett53. Incarcerated femoral and inguinal hernias 449 Robert T Brautigam54. Esophageal perforation 455 Alykhan S Nagji, Christine L Lau, and Benjamin D Kozower55. Acute upper gastrointestinal bleeding 463 Kimberly Joseph56. Acute lower GI hemorrhage 471 Amanda Ayers and Jeffrey L Cohen57. Perirectal and Perineal sepsis 479 Frederick D Cason and Yazan Duwayri58. Necrotizing soft tissue infections 490 Lisa Ferrigno and Andre Campbell59 Acute intestinal obstruction 498 Pierre E de Delva and David L Berger60. Anastomotic leak and postoperative abscess 509 Peter A Pappas and Ernest FJ Block 
  7. 7. contents61. Anesthesia for bedside surgical procedures 515 Richard P Dutton62. Acute care surgery in immunocompromised patients 522 Richard J Rohrer63. Hyperbaric oxygen therapy: A primer for the acute care surgeon 527 Louis DiFazio and George A Perdrizet64. Trauma and surgical critical care system issues 536 Alan Cook and Heidi L FrankelIndex 545
  8. 8. List of contributorsJohn H Adamski II Ernest FJ BlockR Adams Cowley Shock Trauma Centre Department of SurgeryUniversity of Maryland School of Medicine University of Central FloridaBaltimore, Maryland, USA Orlando, Florida, USANasim Ahmed Grant V BochicchioSurgical ICU (SICU) BVAMC RAC Shock Trauma CenterJersey Shore University Medical Center Baltimore, Maryland, USANeptune, New Jersey, USA Scott C BrakenridgeRoxie M Albrecht Department of SurgeryDepartment of Surgery UT Southwestern Medical CenterUniversity of Oklahoma Dallas, Texas, USAOklahoma City, Oklahoma, USA Robert T BrautigamCarrie Allison Department of SurgeryDepartment of Surgery Hartford HospitalOregon Health & Science University Hartford, Connecticut, USAPortland, Oregon, USA Jill Cherry-BukowiecGidon Almogy Division of Acute Care SurgeryDepartment of General Surgery and Shock Trauma Unit Department of SurgeryHadassah University Hospital University of MichiganJerusalem, Israel Ann Arbor, Michigan, USAAmanda Ayers Eileen M BulgerIntegrated General Surgery Program Department of SurgeryUniversity of Connecticut University of WashingtonFarmington, Connecticut, USA Seattle, Washington, USAPhilip S Barie M Ross BullockSurgery and Public Health Department of NeurosurgeryWeill Cornell Medical College University of Miami Miller School of MedicineNew York, New York, USA Lois Pope LIFE Center Miami, Florida, USAErik BarquistJackson South Community Hospital Andre CampbellMiami, Florida, USA Department of Surgery UCSF School of MedicineHoward Belzberg San Francisco General HospitalDepartment of Surgery San Francisco, California, USALos Angeles County and University of Southern California Medical Center Frederick D CasonLos Angeles, California, USA Department of Surgery Louis Stokes Veterans’ Administration Medical CenterDavid L Berger Case Western Reserve University School of MedicineDepartment of Surgery Cleveland, Ohio, USAMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts, USA 
  9. 9. list of contributorsWalter Cholewczynski Jennifer DoreSurgical Critical Care General SurgeryDepartment of Surgery NewYork-Presbyterian Hospital/Weill Cornell Medical CenterBridgeport Hospital New York, New York, USABridgeport, Connecticut, USA Joe DuBoseJeffrey L Cohen Division of Trauma and Surgical Critical CareConnecticut Surgical Group University of Southern CaliforniaDivision of Colon and Rectal Surgery Los Angeles, California, USAHartford HospitalHartford University of Connecticut Richard P DuttonStorrs, Connecticut, USA Department of Anesthesiology University of Maryland School of MedicineStephen M Cohn Baltimore, Maryland, USAUniversity of Texas Health Science CenterSan Antonio, Texas, USA Yazan Duwayri Department of SurgeryAlan Cook Washington University in St LouisDepartment of Surgery St Louis, Missouri, USAEast Texas Medical CenterTyler, Texas, USA Philip A Efron Laboratory of Inflammation Biology and Surgical ScienceCraig M Coopersmith Department of Surgery, Division of Acute Care Surgery andEmory University School of Medicine, Surgical Critical CareAtlanta, Georgia, USA University of Florida, Health Science Center Gainesville, Florida, USABryan A CottonThe University of Texas Health Science Center Heather L EvansDepartment of Surgery Department of SurgeryThe Center for Translational Injury Research University of WashingtonHouston, Texas, USA Harborview Medical Center Seattle, Washington, USAChaitanya DahagamDepartment of Surgery Timothy C FabianUniversity of Texas Health Science Center Harwell Wilson Professor and ChairmanSan Antonio, Texas, USA Department of Surgery University of Tennessee Health Sciences CenterPierre E de Delva Memphis, Tennessee, USADivision of Thoracic SurgeryMassachusetts General Hospital David V FelicianoHarvard Medical School Emory University School Of Medicine Surgeon-in-ChiefBoston, Massachusetts, USA Grady Memorial Hospital Atlanta, Georgia, USADemetrios DemetriadesEmergency Surgery and Surgical Critical Care Lisa FerrignoUniversity of Southern California General SurgeryLos Angeles, California, USA Medical University of South Carolina Charleston, South Carolina, USADaniel DempseyDepartment of Surgery Adam D FoxTemple University School of Medicine Division of Traumatology and Surgical Critical CarePhiladelphia, Pennsylvania, USA University of Pennsylvania Philadelphia, Pennsylvania, USALouis DiFazioDepartment of SurgeryMorristown Memorial HospitalMorristown, New Jersey, USA
  10. 10. list of contributorsSpiros G Frangos Eric B HarrisDepartment of Surgery Department of Orthopaedic SurgerySection of Surgical Critical Care New York University School of Naval Medical Center San Diego Medicine San Diego, California, USANew York, New York, USA Leo HarrisHeidi L Frankel Department of NeurosurgeryDivision of Trauma University of Miami Miller School of MedicineAcute Care and Critical Care Surgery Lois Pope LIFE Center,Shock Trauma Center Miami, Florida, USAPenn State Milton S. Hershey Medical CenterThe Pennsylvania State University College of Medicine Daniel HerzigHershey, Pennsylvania, USA Division of General Surgery Oregon Health & Science UniversityRandall Friese Portland, Oregon, USADepartment of SurgeryUniversity of Arizona Health Sciences Center Asher HirshbergTucson, Arizona, USA Department of Surgery SUNY Downstate College of MedicineTerrence M Fullum Emergency Vascular SurgeryDivision of Minimally Invasive and Bariatric Surgery Kings County Hospital CenterHoward University Department of Surgery Brooklyn, New York, USAWashington, DC, USA Horacio HojmanLi Gang Surgical Intrensive Care UnitHarvard Medical School Tufts Medical CenterBoston, Massachusetts, USA and Tufts University School of MedicineAviram Giladi Boston, Massachusetts, USADepartment of Plastic SurgeryUniversity of Michigan Hospitals John B HolcombAnn Arbor, Michigan, USA Center for Translational Injury Research (CeTIR) Department of SurgeryBrian F Gilchrist The University of Texas Medical SchoolPediatric Surgery Houston, Texas, USAChildren’s InitiativesThe Elliot Hospital System Brian HoodManchester, New Hampshire, USA Department of Neurosurgery University of Miami Miller School of MedicineVicente Gracias Lois Pope LIFE Center,Trauma/Surgical Critical Care Miami, Florida, USAUMDNJ-Robert Wood Johnson Medical SchoolRobert Wood Johnson University Hospital (RWJUH) Nabil IssaNew Brunswick, New Jersey, USA Northwestern University Feinberg School of Medicine Department of SurgeryDJ Green Division of Trauma and Surgical Critical CareDivision of Trauma & Surgical Critical Care Chicago, Illinois, USALAC+USC Medical CenterNaval Trauma Training Center Rao R IvaturyLos Angeles, California, USA Division of Trauma, Critical Care & Emergency Surgery Virginia Commonwealth University Medical CenterScott L Hansen Richmond, Virginia, USADivisions of Plastic and Reconstructive SurgeryDepartment of Surgery Michael IvyUniversity of California Bridgeport HospitalSan Francisco, California, USA Bridgeport, Connecticut, USA 
  11. 11. list of contributorsCarl-Christian A Jackson Jason S LeesPediatric Surgery Department of SurgeryTufts University School of Medicine University of OklahomaFloating Hospital for Children at Tufts Medical Center Oklahoma City, Oklahoma, USABoston, Massachusetts, USA Pamela A LipsettKimberly Joseph Surgery, Anesthesiology and Critical Care Medicine, andRush University College of Medicine NursingDepartment of Trauma General Surgery and Surgical Critical CareJHS Cook County Hospital Surgical Intensive Care UnitsChicago, Illinois, USA Johns Hopkins University Schools of Medicine and Nursing Baltimore, Maryland, USAFrancis X KellyR Adams Cowley Shock Trauma Center Felix Y LuiUniversity of Maryland School of Medicine Section of TraumaBaltimore, Maryland, USA Surgical Critical Care & Surgical Emergencies Department of SurgeryOrlando C Kirton Yale University School of MedicineDepartment of Surgery New Haven, Connecticut, USAUniversity of Connecticut School of MedicineHartford Hospital Kimberly M LumpkinsHartford, Connecticut, USA Department of Surgery University of Maryland School of MedicineLeslie Kobayashi Baltimore, Maryland, USADivision of Trauma and Surgical Critical CareDepartment of General Surgery Jonathan B LundyLAC+USC Medical Center Trauma/Surgical Critical CareLos Angeles, California, USA Brooke Army Medical Center Fort Sam Houston, Texas, USABenjamin D KozowerGeneral Thoracic Surgery John W MahUniversity of Virginia Hartford HospitalCharlottesville, Virginia, USA Department of Surgery University of Connecticut School of MedicineMichael M Krausz Hartford, Connecticut, USADepartment of SurgeryUniversity of Oklahoma Robert MartindaleOklahoma City, Oklahoma, USA Division of General Surgery Oregon Health & Science UniversityChristine L Lau Portland, Oregon, USAGeneral Thoracic SurgeryUniversity of Virginia Wesley D McMillianCharlottesville, Virginia, USA Department of Pharmacy Fletcher Allen Health CareJames Lawrence Burlington, Vermont, USADivision of OrthopaedicsAlbany Medical College Sarah J McPartlandCapital Region Spine General SurgeryAlbany, New York, USA Tufts Medical Center Boston, Massachusetts, USAJeffrey LeeDivision of Surgical Critical Care Joseph P MineiDepartment of Surgery Division of Burn, Trauma and Critical CareTufts University School of Medicine Department of SurgeryTufts Medical Center UT Southwestern Medical CenterBoston, Massachusetts, USA Dallas, Texas, USA
  12. 12. list of contributorsThomas C Mort George A PerdrizetAnesthesiology & Surgery UCONN Department of SurgeryHartford Hospital Simulation Center Morristown Memorial HospitalSimulation Center Morristown, New Jersey, USAHartford, Connecticut, USA Fredric M PieracciAlykhan S Nagji Acute Care SurgeryGeneral Thoracic Surgery Denver Health Medical CenterUniversity of Virginia Denver, Colorado, USACharlottesville, Virginia, USA Joseph V PortereikoKimberly K Nagy Divisions of Trauma & Surgical Critical CareCook County Trauma Unit Department of SurgeryStroger Hospital of Cook County Hartford Hospitaland Rush University University of Connecticut School of MedicineChicago, Illinois, USA Hartford, Connecticut, USALena M Napolitano John P Pryor CS†Division of Acute Care SurgeryDepartment of Surgery Reuven RabinoviciUniversity of Michigan Division of Trauma and Acute Care SurgeryAnn Arbor, Michigan, USA Tufts Medical Center Tufts University Medical SchoolStanley A Nasraway Boston, Massachusetts, USADivision of Surgical Critical CareDepartment of Surgery Patrick ReillyTufts University School of Medicine Trauma and Surgical Critical CareTufts Medical Center University of PennsylvaniaBoston, Massachusetts, USA Philadelphia, Pennsylvania, USAMatthew D Neal Peter RheeDepartment of Surgery Trauma, Critical Care, Emergency SurgeryDivision of Pediatric Surgery University of Arizona,University of Pittsburgh Medical Center Tucson, Arizona, USAPittsburgh, Pennsylvania, USA Jeffrey RihnPatricia O’Neill Department of Orthopaedic SurgeryDivision of Trauma and Surgical Critical Care The Rothman InstituteState University of New York Thomas Jefferson University HospitalDownstate Medical Center Philadelphia, Pennsylvania, USAKings County Hospital CenterBrooklyn, New York, USA Avraham I Rivkind Department of General Surgery and Shock Trauma UnitPeter A Pappas Hadassah University HospitalDivision of Trauma Surgery Jerusalem, IsraelDepartment of SurgeryHolmes Regional Medical Center Frederick B RogersMelbourne, Florida, USA Lancaster General Hospital Lancaster, Pennsylvania, USALisa PattersonDepartment of Surgery Richard J RohrerBaystate Medical Center Tufts University School of MedicineSpringfield, Massachusetts, USA Division of Transplant Surgery, Tufts Medical Center Boston, Massachusetts, USA 
  13. 13. list of contributorsStanley Rosenbaum Sonia SilvaInternal Medicine & Surgery UCSF Department of SurgeryDepartment of Anesthesiology San Francisco General HospitalYale University School of Medicine San Francisco, California, USANew Haven, Connecticut, USA Carrie A SimsMichael F Rotondo Division of Traumatology and Surgical Critical CareDepartment of Surgery, Brody School of Medicine University of PennsylvaniaEast Carolina University Philadelphia, Pennsylvania, USAandPitt County Memorial Hospital Jason L SperryCenter of Excellence for Trauma and Surgical Critical Care Division of Trauma and General SurgeryUniversity Health Systems of Eastern Carolina Department of SurgeryGreenville, North Carolina, USA University of Pittsburgh Pittsburgh, Pennsylvania, USAGrace S RozyckiDivision of Trauma/Surgical Critical Care Gainosuke SugiyamaDepartment of Surgery Department of SurgeryEmory University School of Medicine SUNY Downstate College of MedicineAtlanta, Georgia, USA Brooklyn, New York, USAThomas M Scalea Meredith S TintiR Adams Cowley Shock Trauma Center Division of General SurgeryUniversity of Maryland School of Medicine Section of Trauma/Surgical Critical CareBaltimore, Maryland, USA UMDNJ- Robert Wood Johnson University Hospital New Brunswick, New Jersey, USASamuel C SchecterUCSF- East Bay Department of Surgery Samuel A TishermanSan Francisco, California, USA Departments of Critical Care Medicine and Surgery University of PittsburghWilliam P Schecter Pittsburgh, Pennsylvania, USAUniversity of California, San FranciscoSan Francisco General Hospital Judy S TownsendSan Francisco, California, USA Department of Surgery University of Virginia Health SystemKevin Schuster Charlottesville, Virginia, USADepartment of SurgerySection of Trauma, Surgical Critical Care and Surgical Stanley Z TrooskinEmergencies Yale University School of Medicine New Haven, Division of General SurgeryConnecticut, USA UMDNJ- Robert Wood Johnson University Hospital New Brunswick, New Jersey, USAMichael ShapiroDepartment of Surgery Patricia L TurnerNorthwestern University Feinberg School of Medicine Division of General SurgeryChicago, Illinois, New Jersey Department of Surgery University of MarylandAnthony Shiflett Baltimore, Maryland, USATrauma/Critical Care SurgeryUniversity of Southern California Alexander R VaccaroLos Angeles, California, USA Departments of Orthopaedic and Neurosurgery Thomas Jefferson University HospitalMark D Siegel Philadelphia, Pennsylvania, USAPulmonary & Critical Care SectionDepartment of Internal MedicineNeuroscience Intensive Care UnitMedical Critical CareYale University School of MedicineNew Haven, Connecticut, USA
  14. 14. list of contributorsJerome J Vernick Steven E WolfDepartment of Surgery Department of SurgeryJersey Shore University Medical Center, Neptune University of Texas Health Science CenterRobert Wood Johnson School of Medicine Clinical TrialsNew Brunswick, New Jersey, USA United States Army Institute of Surgical Research San Antonio, Texas, USABrett H WaibelDepartment of Surgery Christine C WyrickThe Brody School of Medicine at East Carolina University Division of Critical Care MedicineGreenville, North Carolina, USA Department of Anesthesiology and Pain Management UT Southwestern Medical Center Dallas, Texas, USAAaron WinnickDepartment of Surgery Amy D WyrzykowskiState University of New York Emory UniversityDownstate Medical Center School of MedicineBrooklyn, New York, USA Surgical Critical Care Grady Memorial HospitalEleanor S Winston Atlanta, Georgia, USADepartment of SurgeryBaystate Medical CenterSpringfield, Massachusetts, USADavid WisnerUniversity of California, DavisDavis, California, USA 
  15. 15. PrefaceThis book focuses on trauma, surgical critical care, and surgical surgical emergencies, and as most surgical societies aggressivelyemergencies. Each of these surgical subspecialties involves promote this concept, we believe that this book has a clearcritically ill patients, who by virtue of their diseases require niche in the surgical literature. This textbook aims to provide aimmediate attention by an expert surgeon as well as allocation comprehensive and contemporary discussion of the three arms ofof specific resources. Although trauma, surgical critical care, and acute care surgery. By providing a single resource where surgeonssurgical emergencies inherently complement each other, they can find answers to most questions related to this subspecialty,were integrated into one surgical specialty, termed Acute Care we hope to improve the care of trauma, surgical critical care, andSurgery, only recently following several evolutionary processes. surgical emergency patients. We also hope that this book willFirst, trauma surgery became much less operative with the advent assist trauma, critical care, and general surgeons in addressing theof computed tomography, interventional radiology, intravascular formidable challenges of managing acutely ill surgical patients.stenting, and improved resuscitation modalities. In addition, the Finally, we believe that this textbook will be useful to surgicalincidence of penetrating trauma, the most common mechanism fellows, residents and medical students, as they develop intoof injury requiring operative intervention, has sharply declined mature surgeons.due to improved policing and more efficient drug control. Lastly, This textbook includes evidence-based analysis by leadingthe philosophy of “total commitment” of the trauma surgeon, experts in the field of cases representing fundamental clinicaladvocated by the American College of Surgeons Committee issues and controversies. Each of the 65 chapters starts withon Trauma, led to diminished involvement of other specialists a case presentation, which is being followed as the chapterin the management of trauma patients. As a result, trauma evolves. The authors review key points in an evidence-basedexperts got more involved in the non-operative management of fashion and correlate them to the presented case. Unless statedpatients with extra-torso trauma. These practice trends shrunk otherwise, the authors used the GRADE evidence classificationthe scope of trauma surgery and forced trauma surgeons, who system established the American College of Chest Physicians (seeonly a decade ago used to be busy operating on almost all body Appendix 1). This case- and evidence-based approach makes ourareas, to look for other options to maintain their operative skills. book livelier and easier to read than the traditional textbook. It hasThe most natural option has been caring for surgical emergency three sections: Trauma Surgery edited by Dr. Reuven Rabinovici,patients, who like trauma victims, present with acute conditions Surgical Critical Care edited by Dr. Heidi Frankel, and Surgicalrequiring attention by an immediately available surgeon. The Emergencies edited by Dr. Orlando Kirton.fusion of trauma surgery and emergency general surgery was We were proud to invite Dr. Erwin Hirsh and Dr. John Pryorfacilitated by a second evolutionary process. Due to deteriorating to contribute to this book. Unfortunately, Dr. Hirshs unexpectedreimbursements and changes in lifestyles, many general surgeons death prevented him from completing his chapter on blunt splenicbecame more reluctant to take general surgery calls, which injury. We are forever grateful to Dr. Pryor, who died while oninterfere with the more profitable elective operative schedule and active duty in Iraq, for his most comprehensive chapter on acutewhich negatively impact quality of life. Third, surgical critical cholecystitis. We dedicate our book to the memory of these twocare developed into a highly specific, viable field, which attracted outstanding surgeons.many trauma surgeons wishing to provide an entire spectrum of Finally, we would like to acknowledge the support we got fromcare to their patients. Consequently, a large number of institutions our families, mentors, and colleagues. We recognize that withoutcombined their trauma and surgical critical care fellowships and their assistance this book would have not been possible.many hospitals are now requiring newly recruited attending tohave both trauma and critical care qualifications. Reuven Rabinovici, MD Since an increasing number of trauma surgeons across the Heidi L Frankel, MDcountry combine trauma care with both surgical critical care and Orlando C Kirton, MD 
  16. 16. Evidence-based Medicine in Emergency Surgical CareTimothy C Fabianintroduction to discrete sequencing of care. Examples would include manage-I became involved with evidence-based medicine about a decade ment of pneumonia, acute myocardial infarction, and the timedago by way of activities associated with the Eastern Association for implementation of various components of the care of patientsthe Surgery of Trauma (EAST).(1) At that time, the organization undergoing elective operative procedures such as coronary bypassbecame interested in developing practice management guidelines grafting, or gastrointestinal resection. They are less easily applied tofor trauma care. This was a somewhat novel and controversial trauma patients because of the heterogeneity of patients, especiallyconcept at that time. In retrospect, it seems rather ironic to con- relative to multiplicity and combinations of injury types as wellsider using evidence-based methodology to drive standards of as to variations in patient ages and co-morbidities. For diagnosismedical care as controversial. The paradox can be underscored and management of specific organ injuries management guide-through a little vignette from that time. lines tend to be more practicable. Protocols are formulas used for I was traveling on an airplane for a meeting dealing with evi- guideline application and these include algorithms and decisiondence-based medicine. While reviewing my computer presen- analyses trees. They can be considered diagrammatic illustrationstation on the plane, the lady sitting next to me apologized for of management guidelines. They usually take an “if––then” for-interrupting, but was intrigued by my preoccupation with the mat. Since practice management guidelines are the most workablecomputer screen. She asked what I was working on and I told her, evidence-based tools for use in trauma care, this chapter will deal“It’s a fairly new concept involving evidence-based care in medi- primarily with guideline utilization and the processes used for theircine. We have begun to base management decisions on objective development.evidence accumulated through various clinical research studies.”Somewhat astonished, she asked, “What has medical care beenbased on up to now?” That lady’s startled response instantly drove evolution of clinical decision making Clinical management “guidelines” in the broad sense could behome to me the rather rudimentary manner in which clinical care considered to be steeped in the days of medical apprenticeship.has developed over time. Apprenticeship, a system largely based upon individual experience, In this chapter, some of the nomenclature and definitions required was the standard method of physician learning up to the early partfor an understanding of the applications of evidence-based medi- of the 20th Century. A substantial part of medical care developedcine (EBM) will be discussed. Arguments for and against EBM will through local/regional customs, hearsay, and dogma—a phenom-be considered. Several methodologies related to the development enon that continues today. Textbooks gradually became an impor-of evidence-based approaches to care will be described. The chap- tant adjunct for clinical care, but were not widely available to traineester will conclude with considerations for the future development until well into the 20th Century. Textbooks continue to provide anof evidence-based medical processes, and the important considera- important background of evidence for medical care because of thetion of how they can be disseminated and applied. inefficiencies associated with the traditional publishing processes. The data contained in textbooks is usually several years behind timesnomenclature of evidence-based medical relative to new discoveries which have occurred in the publicationpractice interval—a disturbing thought relative to this enterprise!The definition of evidence-based medicine seems to originate from Medical journals have become the leading source for providingMcMaster University in Hamilton, Ontario in the early 1990s: objective data for rational clinical practice. But, given the current“Evidence-Based Medicine––The conscientious and judicious use structure of medical practice, a significant drawback to relyingof current best evidence from clinical care research in the manage- only on the raw information generated from the medical journalment of individual patients.”(2) Over the last 15 years, three general literature for decision-making, is the fact that the sheer numbertypes of evidence-based tools have been applied in clinical practice. of journals overwhelms even the most dedicated practitioner.These include practice management guidelines, clinical pathways, When speaking on current information management, Al Goreand protocols. Management Guidelines describe approaches for noted: “… resembling the worst aspects of our agricultural policy,prevention, diagnosis, evaluation, and/or management of actual which left grain rotting in thousands of storage bins while peo-or potential disease processes. Clinical Pathways are care plans ple were starving.” Indeed, that is the sad status of a lot of goodestablished in a time-dependent fashion for disease management. clinical research. There are significant quantities of research inClinical pathways have become widely applied in inpatient care the medical literature but it is next to impossible for the averageespecially by the nursing profession. Pathways lend themselves well person to digest much more than a small fragment. There simplyto disease diagnosis and management for those problems which are is not enough time to keep up with all data generated unless onerelatively homogenous in presentation and which lend themselves is involved only in an extremely isolated and focused area. 
  17. 17. trauma, surgical critical care, and surgical emergencies In order for information to be clinically useful it must be government will fill the vacuum. Milliman and Robertson, Inc. readily accessible. produced Healthcare Management Guidelines ™ in seven vol- umes ( (4): Inpatient and Surgical (Relevance) (Validity) Care, Return to Work Planning, Ambulatory Surgery Guidelines, Usefulness of Medical Information = Work Homecare and Case Management, Primary and Pharmaceutical Care, Case Management: Recovery Facility Care, Worker’s Com­ Usefulness is directly proportional to relevance and validity pen­ ation. Their development processes are proprietary and not sand indirectly proportional to the effort required to obtain the transparent.information. Management guidelines can improve the usefulness The Centers for Medicare and Medicaid Services (CMS) haveof the extant medical literature by classifying and synthesizing begun utilizing the Surgical Care Improvement Project (SCIP)the clinical research and minimize the effort when professional (5) measures to evaluate hospital performance, and ultimatelyorganizations develop organized evidence-based evaluations. those measures will be applied for individual physician trackingAdditionally, the clinical research required for decision-making and profiling. Indeed, pay for performance (“p4p”) initiatives areprocesses in most areas of practice today is completely inade- being designed with these evidence-based principles as a metricquate. Those problems have led to formalized processes for devel- for hospital and physician performance. The initial SCIP meas-opment of the evidence-based management tools. ures address appropriate prophylactic antibiotic administration, Systematic approaches for data analysis have been developed in venous thromboembolism prophylaxis, stress ulcer prophylaxis,recent decades. One of the earliest and most extensively applied mechanical ventilator weaning protocols and nosocomial pneu-has been the Delphi method, which is a structured approach to monia prevention measures. CMS is also in the process of discon-developing consensus using a panel of independent experts.(3) tinuing payment for in-hospital complications that they insinuateThe Delphi method has been widely utilized by the National can be reduced by application of evidence-based practice pat-Institutes of Health to make recommendations through consen- terns, some of which are included in the SCIP measures. Thesus panels on a myriad of healthcare issues addressing disease complications CMS plan on stop reimbursing include central linemanagement and prevention. But, consensus statements are now infections, urinary tract infection associated with bladder cath-giving way to more data driven approaches for management eterization, and nosocomial pneumonia. CMS may expand non-recommendations. reimbursement policies via the pay for performance program in the future. But, it should be noted that the process of utilizationrationale for evidence-based of evidence-based practices are being measured rather than out-medical practice comes. The application of evidence-based practice and manage-Healthcare has been gradually gravitating toward evidence-based ment guidelines should reduce, but not eliminate, many of thesepractice over the last decade. There are multiple forces that have complications. Other forces promoting the use of practice guide-led to adoption of these principles. Those forces include utiliza- lines include implications that they will decrease diagnostic test-tion management in an attempt to maximize quality and effi- ing, reduce practice pattern variation, and that those measuresciency in the delivery of healthcare. “Score cards” based on process will ultimately improve quality of care and patient outcomes.evaluation of the use of evidence based patient management are Only time will tell if all of these advantages will be realized.being employed. These auditing processes are increasingly being All of the interest in the application of management guide-applied for profiling of hospitals as well as credentialing of indi- lines has not been positive. There have been concerns that thevidual physicians. Many institutions rely on them for risk man- use of evidence-based guidelines could have deleterious effectsagement tracking. Those score cards are also used in managed on medicolegal issues. Most of the apprehension centers aroundcare contract negotiations. Unfortunately, hospital systems are the concept of “standard of care,” which is generally defined asusing them today for marketing activities––perhaps a healthcare the degree of knowledge, skill, and care that a competent practi-example of the rich getting richer, and the poor getting poorer. tioner would have exercised under circumstances similar to thoseI hope their reporting is honest and accurate. faced by a physician accused of malpractice. Arguments against The primary rationale for management guidelines should be evidence-based guidelines are that the standard of care might beto aid in provision of high quality, efficient patient care. It has defined more rigidly than is justified. It must be recognized thatbeen suggested, though not documented, that in addition to management guidelines are, in fact, guidelines. They are intendedmaximizing quality, management guidelines are also cost effec- for application to populations of patients and not necessarily totive. Financial value should be attained by helping establishing each individual. Indeed, it can be argued that there is insufficientbest practices and from the prevention of complications. This data in most areas to establish true “standards”. Nonetheless,approach leads to efficiencies gained through minimization of standards of care are established in the courtroom from manydisparate approaches to the same problem. While management sources. Traditionally, textbooks and medical journals have beenguidelines should be directed by physicians involved in the area applied in the courts for defining standards of care in medicalof care for which the guideline was developed, multispecialty col- malpractice. Expert witness testimony is also heavily relied upon.laboration with nursing, pharmacy, and other departments pro- As alluded to, the utilization of textbook standards becomesvides for optimal development and compliance. problematic because from the time of authorship to that of pub- If the medical profession fails to establish evidence-based lication, textbook development is generally 2–4 years. Clinicalguidelines, then other organizations including industry and research may have occurred in the interval, which essentially puts
  18. 18. evidence-based medicine in emergency surgical caresome of the information in textbooks out of date by the time the significant, i.e. with a p-value of p < .05; this is when the one inbooks are published. 20 exceptions occurs. Beta error, also referred to as type II error, is Because of these issues, practice management guidelines have made in testing a hypothesis when it is concluded that the resultbeen promoted for use related to liability. It has been suggested is negative when it really is positive. Beta error is often referredthat they can have both inculpatory and exculpatory purposes. to as a false negative. A beta error occurs in trials where no sig-A report on 259 medicolegal claims addressed the use of guide- nificant differences are found, but in fact the trial was too small,lines.(6) Seventeen of the 259 were guidelines cases and the and not powered to detect the truly significant differences. This isremaining 242 did not involve guidelines. Of the 17 cases, four a common finding in single institution RCTs. It is an importantwere used for exculpatory purposes and 12 used for inculpatory consideration for many clinical questions and which underscorespurposes. Of the 12 inculpatory applications, there was one jury the importance of performing multi-institutional trials in orderverdict for the defendant, eight settled with payment to the plain- to have a large enough population to test management uncertain-tiff, one was closed with no payment, and at the time of the pub- ties. Publication bias occurs when no differences are found in alication of the article, two remained open. Of the four cases where trial. Journals are reluctant to publish “negative results.” Negativeevidence-based guidelines were used for exculpatory purposes, trials can be quite helpful in developing management recom-one had a jury verdict for the plaintiff, one settled with payment mendations as well as framing questions for future research. Oneto the plaintiff, and two remained open at the time of publication. attempt to alleviate this problem is a registry for all RCTs that hasOverall, current evidence seems to be neither particularly strong been established by the Cochrane Collaboration.(7)for, nor against, the use of guidelines relative to medicolegal risk There are two general approaches to development of thefor defendants. EBOE––Statistical Analysis and Critical Analysis. Statistical Analysis requires RCTs and if there are enough robust trials avail-management guideline development processes able, recommendations can be made solely on the basis of theA structured process for evaluation of clinical research has RCTs results. Unfortunately, there are very few areas in clinicalbecome the key tool for development of management guide- medicine that have a satisfactory number and/or quality of RCTslines. This process will be referred to as the evidence-based out- which alone provide an adequate amount of information to drivecome evaluation (EBOE). Several organizations have developed decision-making. Hence, meta-analytic tools have been used asmanagement guidelines using this fundamental approach. It is a another form of statistical analysis.(8)defined structure for evaluation of clinical research that results Meta-analysis involves evaluation of multiple small, rand-in recommendations based on the quality and strength of the omized, controlled trials to address the clinical question. If sev-available evidence. The EBOE becomes the engine driving man- eral trials are available, meta-analytic techniques may provide aagement guidelines. It is a major undertaking for an association high degree of confidence of effect impact. However, there areto adopt the methodologies involved with production of EBOEs several shortcomings of meta-analysis for decision-making.and the subsequent development of management guidelines. Many RCTs are single institutional trials that contain relativelyResources including time, organizational energy, and money are small numbers of patients. They usually do not include exactlydedicated not only to guideline development, but also to the criti- the same types of patients, data sets are rarely uniform, and whilecally important issue of keeping the management guidelines up the outcomes evaluated may be similar, they are often not identi-to date and accurate. Ongoing peer reviews of existing manage- cal. While meta-analyses can provide focused, strong recommen-ment guidelines are required to keep them current relative to the dations for management guidelines, more often vagaries amongstgeneration of new information from clinical research which has the included trials do not lend themselves to firm recommenda-emerged since the guideline was established. Importantly, major tions for management.goals of the EBOE are evaluation for bias in the literature, and to Critical Analysis is used to formulate EBOEs by strictly definedminimize the impact of bias on management recommendations. data collection and classification methodology of the medical lit-There are several types of bias that need to be screened. Allocation erature on particular management questions, and to apply assess-or selection bias occurs with enrollment of patients into a rand- ments based on evaluation of the accumulated literature reviewomized controlled trial (RCT). Appropriate randomization proc- in order to make recommendations and develop patient man-esses can minimize selection bias, with double-blinding being the agement guidelines. Several organizations have used the criticaloptimal randomization method for controlled trials. Investigator analytic processes to develop management guidelines. While thebias may occur at many steps in the clinical trial beginning with processes used by the various organizations to develop guidelinesallocation of the research subject into the trial arm. Furthermore, are not identical, they are a blinded trial, allocation blinding should not be broken until The Agency for Healthcare Quality and Research (AHQR) hasthe analysis is completed. Some RCTs become contaminated due provided significant guidance in the whole arena of evidence-to early violation of this principle. Investigator bias can be dif- based medicine. An important consideration for guideline devel-ficult to ascertain. Statistical bias can occur from both alpha and opment is the starting point of topic selection. AHRQ suggestsbeta errors. Alpha error, also referred to as type I error, is made in selecting areas of high incidence or prevalence and areas asso-testing an hypothesis when it is concluded that a result is positive ciated with high cost. It is also advisable to select areas wherewhen it really is not. Alpha error is often referred to as a false posi- there is controversy or equipoise relative to diagnosis or man-tive. Alpha error occurs when there is no difference between the agement. Realms for study in which there is potential to reducealternatives in a randomized trial although the p-value is deemed significant variations in practice are fertile grounds for guideline 
  19. 19. trauma, surgical critical care, and surgical emergenciesdevelopment. When several approaches to patient care are beingapplied, common sense dictates that all cannot be optimal, and Review Reviewdirection is desirable. Wennberg, and colleagues have produced group groupa large amount of data documenting wide variations in the per-formance of multiple surgical procedures. A 20-fold difference in Editorialcarotid endarterectomy in 16 large communities in four states has groupbeen reported.(9) The rate of tonsillectomy in Vermont has beendemonstrated to vary 8–70% among regions.(10) Hysterectomy Review Reviewwas reported in Maine to vary between 20 and 70%.(10) Chassen group grouphas likewise demonstrated a variation of over 300% for over halfof the procedures for Medicare in 13 metropolitan areas in theUnited States.(11) Dissemination of EBOE’s For topic selection it is also advisable to select domains inwhich there is a reasonable availability of scientific data in order Figure 1  Schematic overview of the process for evidence based outcome evaluationto make sound decisions. Ideally, the area of study should have (EBOE) development.the potential for reasonably rapid implementation in order tojustify the expense and energy put into the process. Table 1  Grading system developed by the Canadian and U.S. The following steps are generally followed by professional organi- Preventative Task Force.zations which embark on management guideline development.(12) Class I: Prospective randomized, controlled trials––may be weak1. Formulation of clear definition, scope, and impact of a disease Class II: Prospective, nonrandomized, retrospective analyses, clear over time using a multidisciplinary team. controls2. Generation of specific clinical and economic questions and Class III: Retrospective, observational, expert opinion search the literature.3. Critically appraise and synthesize the evidence.4. Evaluate the benefits, risks, and costs. Table 2  Grading system used by EAST.5. Develop evidence-based guidelines, pathways, and protocols.6. Implement the guidelines, pathways, and protocols. Level I: Justified based on scientific evidence––usually Class I data Level II: Reasonably justified by scientific evidence and strongly supported The entire process of management guideline development cent- by expert opinion––usually Class I or II data*ers around recruiting study groups of individuals with the appro- Level III: Supported by available data, but scientific evidence is lacking*priate expertise and energy required for the somewhat intricate Levels II and III are useful for guiding further researchand arduous processes of developing the EBOE (Figure 1). Panelsand panel chairpersons should be selected for each topic selected.Members of the panel often require varied physician specialists, In this book, the authors use a grading system established by thenurses, pharmacists, methodologists, health economists, and other American College of Chest Physicians (Table 3).(13) This system,disciplines. The importance of multi-disciplinary participation for which is a modification of the grading scheme formulated by the inter-both expertise and acceptance cannot be overemphasized. national GRADE group, classifies recommendations as strong (grade Step 3, which involves literature search and data classification, 1) or weak (grade 2), according to the balance among benefits, risks,is the foundation for reliable, high quality guidelines. Expertise burdens, and possibly cost, and the degree of confidence in estimatesprovided by formally trained methodologists adds greatly to the of benefits, risks, and burdens. The system classifies quality of evidencequality of guideline development. They have defined approaches as high (grade A), moderate (grade B), or low (grade C) according toto search out even unpublished trials which may provide impor- factors that include the study design, the consistency of the results, andtant direction for completion of the resulting EBOE. Both the directness of the evidence. Again, this is a system similar to thoseMEDLINE (Pub Med) and EMBASE (European medical litera- used by other organizations for guideline formulation.ture data base) should be routinely used. The references from Several organizations have developed guidelines for traumaarticles identified by the primary literature searches should also patient management based on these principles of critical queried. Following literature retrieval, the quality of the indi- The Brain Trauma Foundation has used this approach in devel-vidual studies is assessed. Table 1 Illustrates an assessment clas- oping multiple guidelines related to management of traumaticsification system which was developed by the Canadian and U.S. brain injury ( Those guidelines havePreventative Task Force. been published in three treatises which address prehospital man- Similar classifications are used by all organizations involved agement of severe traumatic brain injury, management of severewith guideline development. The final step is to make recommen- traumatic brain injury, and the surgical management of traumaticdations based on the classified data. brain injury. The Society of Critical Care Medicine has developed Table 2 Illustrates the system of confidence levels used by the several guidelines pertaining to critical care management includ-Eastern Association for the surgery of trauma for their Trauma ing sepsis, sedation, venous thromboembolism, and ventilatoryGuidelines Project.(12) management.(15)
  20. 20. evidence-based medicine in emergency surgical careTable 3  Grading system of the ACCP Used in This Book. Grade of Recommendation/ Benefit vs. Risk and Burdens Methodological Quality of Supporting Implications Description Evidence 1A/strong recommendation, Benefits clearly outweigh risk RCTs without important limitations or Strong recommendations, can apply to most high-quality evidence and burdens, or vice versa overwhelming evidence from observational patients in most circumstances without studies reservation 1B/strong recommendation, Benefits clearly outweigh risk RCTs with important limitations Strong recommendation, can apply to most moderate quality evidence and burdens, or vice versa (inconsistent results, methodological flaws, patients in most circumstances without indirect or imprecise) or exceptionally reservation strong evidence from observational studies. 1C/strong recommendation, Benefits clearly outweigh risk Observational studies or case series Strong recommendation but may change low-quality, or very low-quality and burdens, or vice versa when higher quality evidence becomes evidence available. 2A/weak recommendation, Benefits closely balanced with RCTs without important limitations or Weak recommendation, best action may high-quality evidence risks and burden overwhelming evidence from observational differ depending on circumstances or studies. patients’ or societal values. 2B/weak recommendation, Benefits closely balanced with RCTs with important limitations Weak recommendation, best action may moderate-quality evidence risks and burden (inconsistent results, methodological flaws, differ depending on circumstances or indirect or imprecise) or exceptionally patients’ or societal values. strong evidence from observational studies 2C/weak recommendation, Uncertainty in the estimates Observational studies or case series Very weak recommendations: other low-quality or very low- of benefits, risks and burdens; alternatives may be equally reasonable. quality evidence benefits, risk and burden may be closely balancedTable 4  Patient Management Guidelines for trauma care developed by the Eastern Association for the Surgery of Trauma (located Penetrating Intraperitoneal Injuries Prophylactic Antibiotics in Tube Thoracostomy for Prophylactic Antibiotics in Open Fractures Traumatic Hemopneumothorax Prophylactic Antibiotics in Penetrating Abdominal Management of Venous Thromboembolism in Screening of Blunt Cardiac Injury Trauma Trauma Patients Identifying Cervical Spine Injuries Following Identifying Cervical Spine Injuries Following Primer on Evidence Based Medicine Trauma Trauma––Update Diagnosis and Management of Blunt Aortic Injury Optimal Timing of Long Bone Fracture Management of Mild Traumatic Brain Injury Stabilization in Polytrauma Patients Management of Pelvic Hemorrhage in Pelvic Evaluation of Blunt Abdominal Trauma Geriatric Trauma Fracture Management of Penetrating Trauma to the Lower Emergency Tracheal Intubation Following Endpoints of Resuscitation Extremity Traumatic Injury Evaluation of Genitourinary Trauma Nonoperative Management of Blunt Injury to the Nutritional Support in Trauma Patients Liver and Spleen Pain Management in Blunt Thoracic Trauma Management of Genitourinary Trauma Diagnosis and Management of Injury in the Pregnant Patient Timing of Tracheostomy in Trauma Patients Management of Pulmonary Contusion and Flail Screening the Thoracolumbar Spine Chest Nonoperative Management of Penetrating Small Bowel Obstruction Blunt Cerebrovascular Injury Abdominal Trauma Management of Penetrating Stress Ulcer Prophylaxis Neck Injuries The Cochrane Collaboration is one of the foremost organi- listed. Approximately 25% of the randomized, controlled trialszations using critical analysis to guide care.(7) The Cochrane located by the Cochrane Collaboration cannot be found via onlineCollaboration was founded in the United Kingdom in 1993 and medical libraries such as Medline or PubMed. A major goal of thewas named after the British epidemiologist, Archie Cochrane. In Cochrane Collaboration is to promote research to improve sys-the subsequent 15 years, it has spread throughout the world using tematic reviews. Cochrane has established collaborative Reviewa sophisticated collaborative, multi-specialty approach. It now Groups, and they have developed a sophisticated methodologyconsists of 25 centers. They have established a register of all ran- for their reviews. Fifty-two review groups have been organized.domized, controlled trials. Currently, there are over 150,000 trials Cochrane Reviews address clinical management in essentially 
  21. 21. trauma, surgical critical care, and surgical emergenciesall areas of medicine. The Reviews are succinct with clear rec-ommendations. There are several Cochrane Reviews addressing ACSareas of injury management. They are mostly, but not entirely,focused on neurologic injury and fluid resuscitation. Perusal ofthat website is quite worthwhile. The Eastern Association for the Surgery of Trauma has investedheavily in their Trauma Practice Guideline Project ( They were among the first professional organizations apply-ing evidence-based principles for patient care. Their initial guide- Guidelines WTA Clinical Trials EASTlines were produced in 1998, and to date they have developed32 practice guidelines specific to trauma care (Table 4).evidence-based trauma care—thoughts forthe futureWhile the rationale for practice management guidelines develop-ment now seems fairly clear, there are substantial challenges to AASTguideline development. These include consistency and continuityin the development process. Those organizations embarking on Figure 2  Proposed collaboration by North American professional traumaguideline projects should establish timelines for the varied proc- organizations for evidence-based medicine development through clinical trialsesses involved in creating the individual guidelines, and designate with those results transferred into the development of practice managementtiming for guideline reviews to update them based on ongoing guidelines. (ACS=American College of Surgeons; EAST=Eastern Association forinformation found through literature searches to make sure the Surgery of Trauma; AAST=American Association for the Surgery of Trauma; WTA=Western Trauma Association).they are updated. To be relevant guidelines must be consideredas living documents. In order for guidelines to be useful, theyalso must have monitoring of their utilization and validity, and Guideline Consistency: Methodology of study groups Continuity: Communication with study groups & committesideally, there should be coordination of clinical trials amongstorganizations to make sure there is not duplication of valuableeffort to ensure that scarce resources of manpower and energyare efficiently applied. Relative to the development of evidence-based medicine for PROJECT OFFICEtrauma, in the United States there should be coordination amongthe professional trauma organizations including the AmericanAssociation for the Surgery of Trauma, Eastern Associationfor the Surgery of Trauma, Western Trauma Association, and Coordinate Clinical Trials: Monitor Utilization/Validity:the American College of Surgeons Committee on Trauma. NIDB & COT Multi-Institutional Trials Committees of EAST, AAST, & WTACollaboration is the key to having maximum impact. The col-laboration of the North American trauma organizations is envi- Figure 3  Overview of a management structure for collaboration by the Northsioned in Figure 2. Ideally, the organizations would work together American professional trauma organizations to develop and utilize evidence-for evidence-based guideline development and dissemination. based processes for provision of trauma care. (NTDB=National Trauma DataA schema for intra-organizational collaboration is outlined in Bank of the American College of Surgeons, COT=Committee on Trauma of theFigure 3. Several important components of an effective process American College of Surgeons.are illustrated. These include consistency in the methodology ofguideline development. Coordination and continuity of the proc- to establish a guideline of importance, randomized clinical trialsess should be established, and on-going communication among could be developed through the multi-institutional trials com-the study groups and committees from the professional organiza- mittees of the professional trauma organizations. In instancestion would be necessary to avoid duplication of effort. Monitoring of insufficient class 1 data, the available information could beof utilization and validity could be done by making use of the utilized to direct hypotheses for the clinical trials based on theNational Trauma Data Bank and through efforts of the American EBOE.College of Surgeons Committee on Trauma. Optimal develop- Some have questioned whether management guidelines will inment of evidence-based practice should also consider when fur- fact have an impact. Is it worth the effort? I would suggest that ifther evidence may be required to establish guidelines.. All of this you build a better mousetrap, it will catch more mice. High qual-activity could be coordinated through a central office. Figure 4 is ity management guidelines will attain traction and will substan-a suggested model for the application of evidence-based outcome tially influence medical practice. Development of the guidelineevaluations. There are some areas in which there is already strong is of critical importance, but of equal significance is appropriateclass 1 data available, and in that circumstance there would be no dissemination. This can involve print, compact disc, and web-need to have further clinical trials and that data may be used to based dissemination. Over the last decade, it has become increas-establish an appropriate guideline. When there is insufficient data ingly clear that web-based dissemination is the most powerful
  22. 22. evidence-based medicine in emergency surgical care Selected Topic   2. Sackett DL, Roseberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023): 71–2.   3. Turoff M, Linstone H. The Delphi method: techniques and applications. New Jersey Institute of Technology, 2002.Data Accumulation: Strong Class I Data Class III Data   4. “Evidence-based Medicine” Milliman Care Guidelines. Milliman and Primarily Class II or Robertson, Inc. <> Minimal Class I/   5. "Surgical Care Improvement Project"; National SCIP Partnership, 2008. Solid Class III Data < >   6. Hoyt DB. Clinical practice guidelines. Am J Surg 1997; 173(1): 32–6.Data Accumulation: Level I   7. "Evidence-based Health Care"; The Cochrane Collaboration, 2008. <http:// Level III(Level of Confidence) Level II>   8. Cornell, JE, Mulrow CD. Meta-analysis. In: HJ Adèr, GJ Mellenbergh, eds. Research Methodology in the Social, Behavioral and Life Sciences. London:Application: Practice Guidelines Clinical Trials Sage, 1999: 285–323.   9. Birkmeyer JD, Sharp SM, Finlayson SR, Fisher ES, Wennberg JE. Bariation profiles of common surgical procedures. Surgery 1998; 124(5): 917–23. 10. McPherson K, Wennberg JE, Hoving OB, Clifford P. Small-area variations Institutional Protocols & Pathways in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med 1982; 307(21): 1310–4.Figure 4  Suggested model for application of evidence-based outcome evaluations 11. Chassin MR, Kosecoff J, Park RE et al. Does inappropriate use explain geo-(EBOEs). graphic variations in the use of health care services? A study of three proce- dures. JAMA 1987; 258(18): 2533–7. 12. "Trauma Practice Guidelines" Eastern Association for the Surgery of Trauma, 2008. <> 13. Guyatt G, Gutterman D, Baumann MH et al. Grading strength of recom-approach as computerization has rapidly entered bedside clini- mendations and quality of evidence in clinical guidelines: physicians taskcal practice. Ideally, all of these methods of dissemination will be force report from an American College of Chest Physicians task force. Chestutilized. 2006; 129; 174–81. 14. “Guidelines for Prehospital Management of Severe Traumatic Brain Injury”. The Brain Trauma Foundation, 2008. < PageServer?pagename=Guidelines>  1. Fabian TC. Evidence-based medicine in trauma care: whither goest thou? 15. “Guidelines”. Society of Critical Care Medicine 2008. <http://www.learnicu. J Trauma 1999; 47(2): 225–32. org/Quick_Links/Pages/default.aspx#clinguide> 