Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma

Easter Association of Surgery of Trauma issued practice management guideline on Evaluation and management of blunt traumatic aortic injury. The major recommendations are as follows:-

Population, Intervention, Comparator, and Outcome (PICO) Question 1

In patients with suspected blunt traumatic aortic injury (BTAI), should computed tomography (CT) of the chest with intravenous contrast be used versus conventional catheter-based angiography for the identification of clinically significant BTAI?

Recommendation

Despite the overall quality of evidence being low, the panel considered that most patients would place a high value on identification of clinically significant BTAI. The sensitivity of CT of the chest is comparable with aortography. There are also a higher number of "false positives" with CT of the chest, indicating that this screening modality may potentially identify minimal aortic injuries not identified on aortography. Furthermore, CT of the chest with intravenous contrast has the advantage of being readily available, less invasive, being less time consuming, and allowing for identification of other intrathoracic injuries. All of these factors resulted in the formulation of a strong recommendation by the committee.

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

PICO Question 2

In patients with BTAI, should endovascular repair be performed versus open repair to minimize mortality, stroke, paraplegia, and renal failure?

Recommendation

Despite the overall quality of evidence being low (mortality, stroke) to moderate (paraplegia), the panel considered that most patients would place a high value on a less invasive procedure that carries a significantly lower risk of blood loss, mortality, and paraplegia and a comparable risk of stroke. The panel also considered the fact that endovascular repair is performed more frequently than open repair, resulting in decreased experience with and training in open repair. In addition, initial concerns regarding a high rate of device-related complications seem unfounded as the current literature suggests that complication rates are low and continue to improve as technology evolves. All of these factors resulted in the formulation of a strong recommendation by the committee.

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

PICO Question 3

In patients with BTAI, should timing of repair be delayed or immediate to minimize mortality, stroke, paraplegia, and renal failure?

Recommendation

The overall quality of evidence ranged from very low (stroke) to high (paraplegia). However, the panel considered that most patients would place a high value on BTAI repaired in a delayed fashion because it results in decreased mortality and paraplegia. Rates of renal failure were nearly identical. The panel discussed the fact that the patients who benefit the most from delayed repair are those who have major associated injuries. These patients clearly require resuscitation and treatment of immediately life-threatening injuries before aortic repair. The data are not as clear 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. Although the studies included in the evidence profile demonstrated decreased incidence of mortality, stroke, and paraplegia with delayed repair, it should be noted that the reason the majority of patients in these studies underwent delayed repair was because they had associated life-threatening injuries and/or a requirement for further resuscitation. Only one study evaluated the effect of delayed repair in a select group of patients without major associated injuries, and the number of patients in this group was small (n=108). It is important to consider that in that group of patients, the benefit of delayed repair was only related to mortality. The incidence of paraplegia and renal failure in this subset of patients was higher. The consideration of these factors resulted in the formulation of a conditional recommendation by the committee.

In patients diagnosed with BTAI, the guideline committee suggests delayed repair. It is critical that effective blood pressure control with antihypertensive medication is used in these patients.



For full guidelines, click on the following link

Artical Source : Fox N, Schwartz D, Salazar JH, Haut ER, Dahm P, Black JH, Brakenridge SC, Como JJ, Hendershot K, King DR, Maung AA, Moorman ML, Nagy K, Petrey LB, Tesoriero R, Scalea TM, Fabian TC. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jan;78(1):136-46.