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Evaluation and Management of Blunt Traumatic Aortic Injury

A Practice Management Guideline From the Eastern Association for the Surgery of Trauma

Fox, Nicole MD; Schwartz, Diane MD; Salazar, Jose H. MD; Haut, Elliott R. MD; Dahm, Philipp MD; Black, James H. MD; Brakenridge, Scott C. MD; Como, John J. MD; Hendershot, Kimberly MD; King, David R. MD; Maung, Adrian A. MD; Moorman, Matthew L. MD; Nagy, Kimberly MD; Petrey, Laura B. MD; Tesoriero, Ronald MD; Scalea, Thomas M. MD; Fabian, Timothy C. MD

doi: 10.1097/JTN.0000000000000118
GUIDELINES
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Background: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST.

Methods: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair.

Results: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines.

Conclusion: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients. (J Trauma Acute Care Surg. 2015;78: 125–135.

Level of Evidence: Systematic reviews and meta-analyses, level III.

From the Department of Surgery (N.F.), Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey; Department of Surgery (D.S.), The Johns Hopkins Bayview Medical Center; Department of Surgery (J.S.O., E.R.H.), The Johns Hopkins School of Medicine; Department of Vascular Surgery and Endovascular Therapy (J.H.B.), The Johns Hopkins Hospital and Johns Hopkins Medical Institutions; and Department of Surgery (R.T., T.M.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Urology (P.D.), Malcom Randall VAMC, University of Florida College of Medicine; and Department of Surgery (S.C.B.), University of Florida Health Science Center, UF Health Shands Hospital, Gainesville, Florida; Department of Surgery (J.J.C.), MetroHealth Medical Center; and Division of Acute Care Surgery (M.L.M.), Cleveland Clinic Lerner College of Medicine, Cleveland; and Department of Surgery, Wright State University, Boonshoft School of Medicine, Dayton, Ohio; Department of Surgery (D.R.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (A.A.M.), Yale University School of Medicine, New Haven, Connecticut; Department of Surgery (K.N.), Cook County Trauma Unit of Stroger Hospital, Chicago, Illinois; Department of Surgery (L.B.P.), Baylor University Medical Center, Dallas, Texas; Department of Surgery (T.C.F.), The University of Tennessee Health Science Center, Memphis, Tennessee.

Correspondence: Nicole Fox, MD, Trauma, Critical Care, Emergency Surgery, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103 (e-mail: fox-nicole@cooperhealth.edu).

Submitted: July 7, 2014, Revised: August 4, 2014, Accepted: September 2, 2014.

DISCLOSURE: The authors declare no conflicts of interest.

T.M.S. and T.C.F. should be noted as cosenior authors.

These practice management guidelines were presented at the 26th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 15-19, 2013, in Scottsdale, Arizona.

Copyright © 2015 by the Society of Trauma Nurses.