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Practice Management Guidelines for Trauma from the Eastern Association for the Surgery of Trauma

1998; Lippincott Williams & Wilkins; Volume: 44; Issue: 6 Linguagem: Inglês

10.1097/00005373-199806000-00001

1529-8809

Michael D. Pasquale, Timothy C. Fabian,

Sepsis Diagnosis and Treatment

Clinical practice guidelines are being used as a means of reducing inappropriate care, controlling geographic variations in practice patterns, and making more effective use of health care resources. Developments at the national health policy level, as well as managed care imperatives, suggest that clinical practice guidelines will play an increasingly prominent role in the practice of medicine. These guidelines can contribute to medicine as an aid in clinical decision making and improving clinical practice [1,2] and as a research tool and an educational resource. We, as trauma surgeons, should participate in such endeavors in an effort to improve trauma care and guide future research. The Agency for Health Care Policy and Research (AHCPR) has led the way in guideline development methodology and currently has published 20 guidelines addressing a variety of topics. [3] Its initial work has led others to develop an evidence-based approach to care. Evidence-based guidelines have been published on intravenous analgesia, sedation, sustained neuromuscular blockade in the intensive care unit, and management of severe head injury. [4-6] Clinical computerized bedside protocols have improved outcome in adult respiratory distress syndrome and hypoxia. [7,8] National literature/consensus-based guidelines have also been published for stress ulcer prophylaxis and albumin transfusion and are currently in development for antibiotic use and fever workup in the intensive care unit. [9,10] The role of the Eastern Association for the Surgery of Trauma (EAST) and other national organizations will be to provide a series of national consensus-based guidelines from which institutionally specific clinical management protocols or pathways can be developed (see Figure 1).Figure 1: Guideline and protocol development.A step-by-step process of practice management guideline development, largely adapted from AHCPR recommendations, has been derived [11] to ensure a combination of rigorous methodology and practical feasibility that can be adapted to clinical decision making at any institution (Table 1). Key to guideline development is assessment of the scientific evidence and formulation of recommendations (Table 2).Table 1: Steps to practice management guideline developmentTable 2: Classification of scientific evidence and formulation of recommendationsA current limitation on the concept of guideline development is the paucity of prospective, randomized class I data for the development of more secure evidence-based guidelines. It is hoped that through the development of guidelines, a baseline can be created to direct future research and create more class I data. With these thoughts in mind, a consensus conference of 20 trauma surgeons interested in guideline development was held and initial topics were selected for development. Each member of the conference selected topics that he or she felt were important for development. Four topics were then selected by majority consensus. Each topic was assigned a chairperson, and the chairperson was then responsible for selecting his or her committee members. The individual committees were given latitude on how to approach their topics, but all were expected to conform to the process described above. Once completed, the guidelines were reviewed by the committee chairperson and the chairperson of the guideline committee and returned for revision. The revised guidelines were submitted to the EAST program chairman, the president of EAST, and the board members. The guidelines were presented at the annual meeting of EAST in 1997, and revisions were made based on comments and suggestions from the members. What follows is an abridged version of these guidelines. The unabridged version, which contains a more lengthy discussion of the scientific evidence, data classification, and evidentiary tables, as well as a complete bibliography, is available through the EAST web page (www.east.org) or by written request. Send requests to: EAST Guidelines, c/o Judith Schultz, Trauma Program Development Office, Lehigh Valley Hospital, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105-1556. Practice Management Guidelines for Screening of Blunt Cardiac Injury Michael D. Pasquale, MD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; Kimberly K. Nagy, MD, Department of Trauma, Cook County Hospital, Chicago, Ill; John R. Clarke, MD, Department of Surgery, Allegheny University Hospital, Philadelphia, Pa. Practice Management Guidelines for Identifying Cervical Spine Injuries after Trauma Donald W. Marion, MD, Chairman, Department of Neurosurgery, Presbyterian University Hospital, Pittsburgh, Pa; Robert Domeier, MD, Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Mich; C. Michael Dunham, MD, St. Elizabeth Hospital Trauma Center, Youngstown, Ohio; Fred A. Luchette, MD, Division of Trauma/Critical Care, University of Cincinnati College of Medicine, Cincinnati, Ohio; Regis Haid, MD, Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Ga; Scott C. Erwood, MD, Emory Clinic, Atlanta, Ga. Practice Management Guidelines for Penetrating Intraperitoneal Colon Injuries C. Gene Cayten, MD, Institute for Trauma and Emergency Care, New York Medical College, Valhalla, NY; Timothy C. Fabian, MD, University of Tennessee College of Medicine, Memphis, Tenn; Victor F. Garcia, MD, Division of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, Ohio; Rao R. Ivatury, MD, Department of Surgery, New York Medical College/Lincoln Hospital, Bronx, NY; John A. Morris, Jr., MD, Division of Trauma and Surgical Critical Care, Vanderbilt University, Nashville, Tenn. Practice Management Guidelines for Venous Thromboembolism in Trauma Patients - The Use of Low-Dose Heparin (LDH) for Deep Venous Thrombosis/Pulmonary Embolus (DVT/PE) Prophylaxis - The Use of Sequential Compression Devices (SCDs) in the Prevention of DVT/PE - The Role of Low Molecular Weight Heparin in Venous Thromboembolism Prophylaxis in Trauma Patients - The Role of Arteriovenous Foot Pumps in the Prophylaxis of DVT/PE in the Trauma Patient - The Role of the Vena Cava Filter in the Prophylaxis and Treatment of PE - The Role of Treatment of Established DVT/PE with Anticoagulation in the Trauma Patient - The Role of Ultrasonography in Diagnostic Imaging for DVT in Trauma - The Role of Impedance Plethysmography (IPG) in Diagnostic Imaging for DVT in Trauma - The Role of Venography in the Diagnosis of DVT in Trauma Patients Frederick B. Rogers, MD, Department of Surgery, University of Vermont College of Medicine, Burlington, Vt; Mark D. Cipolle, MD, PhD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; James G. Cushman, MD, Division of Trauma/Surgical Critical Care, Lehigh Valley Hospital, Allentown, Pa; Paul A. Kearney, MD, Department of Surgery, University of Kentucky Chandler Medical Center, Lexington, Ky; Grace S. Rozycki, MD, Department of Surgery, Emory University School of Medicine, Atlanta, Ga; William H. Geerts, MD, Sunnybrook Health Science Center/University of Toronto, Toronto, Ontario, Canada. PRACTICE MANAGEMENT GUIDELINES FOR SCREENING OF BLUNT CARDIAC INJURY I. Statement of the Problem The reported incidence of blunt cardiac injury (BCI), formerly called myocardial contusion, depends on the modality and criteria used for diagnosis and ranges from 8 to 71% in patients who sustain blunt chest trauma. The true incidence remains unknown because there is no diagnostic gold standard, i.e., the available data are conflicting with respect to how the diagnosis should be made (electrocardiogram (EKG), enzyme analysis, echocardiogram, etc.) The lack of such a standard leads to confusion with respect to making a diagnosis and makes the literature difficult to interpret. Key issues involve identifying a patient population at risk for adverse events from BCI and then appropriately monitoring and treating these patients. Conversely, patients not at risk could potentially be discharged from the hospital with appropriate follow-up. II. Process A MEDLINE search from January 1986 through February 1997 was performed. All English-language citations during this period with the subject words "myocardial contusion," "blunt cardiac injury," and "cardiac trauma" were retrieved. Letters to the editor, isolated case reports, series of patients presenting in cardiac arrest, and articles focusing on emergency room thoracotomy were excluded from the review. This left 56 articles that were primarily well-conducted studies or reviews involving the identification of BCI. III. Recommendations A. Level I An admission EKG should be performed for all patients in whom there is suspected BCI. B. Level II 1. If the admission EKG results are abnormal (arrhythmia, ST changes, ischemia, heart block, unexplained ST), the patient should be admitted for continuous EKG monitoring for 24 to 48 hours. Conversely, if the admission EKG results are normal, the risk of having a BCI that requires treatment is insignificant, and the pursuit of diagnosis should be terminated. 2. If the patient is hemodynamically unstable, an imaging study (echocardiogram) should be obtained. If an optimal transthoracic echocardiogram cannot be performed, then the patient should have a transesophageal echocardiogram. 3. Nuclear medicine studies add little compared with echocardiography and, thus, are not useful if an echocardiogram has been performed. C. Level III 1. Elderly patients with known cardiac disease, unstable patients, and those with an abnormal admission EKG can be safely operated on provided that they are appropriately monitored. Consideration should be given to placement of a pulmonary artery catheter in such cases. 2. The presence of a sternal fracture does not predict the presence of BCI and, thus, does not necessarily indicate that monitoring should be performed. 3. Neither creatine phosphokinase with isoenzyme analysis nor measurement of circulating cardiac troponin T are useful in predicting which patients have or will have complications related to BCI. IV. Summary In general, the diagnosis of BCI should be suspected in patients with an appropriate mechanism of injury or in those who manifest an inappropriately or abnormally poor cardiovascular response to their injury. At present, no single test or combination of tests has proven consistently reliable in detecting cardiac injury. The diagnosis of BCI will be directly proportional to the aggressiveness with which it is sought. The appropriate choice demands achieving a balance between cost-effectiveness of the tests used and the effect of the information acquired on clinical management decisions. V. Future Investigations Future studies should focus on patients who develop complications secondary to BCI. Diagnostic testing should be compared with the less invasive and less expensive tests currently recommended. A cost-benefit analysis should be considered in all future studies. VI. References Class I 1. Frazee RC, Mucha P Jr, Farnell MB, Miller FA Jr. Objective evaluation of blunt cardiac trauma. J Trauma. 1986;26:510-520. 2. Reif J, Justice JL, Olsen WR, Prager RL. Selective monitoring of patients with suspected blunt cardiac injury. Ann Thorac Surg. 1990;50:530-532. 3. Gunnar WP, Martin M, Smith RF, et al. The utility of cardiac evaluation in the hemodynamically stable patient with suspected myocardial contusion. Am Surg. 1991;57:373-377. 4. Karalis DG, Victor MF, Davis GA, et al. The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study. J Trauma. 1994;36:53-58. Class II 1. Kettunen P, Neiminen M. Creatine kinase MB and M-mode echocardiographic changes in cardiac contusion. Ann Clin Res. 1985;17:292-298. 2. Markiewicz W, Best LA, Burstein S, et al. Echocardiographic evaluation after blunt trauma of the chest. Int J Cardiol. 1985;8:269-274. 3. Andersen PT, Moller-Petersen J, Nielsen LK, Molgaard J. Comparisons between CK-B and other clinical indicators of cardiac contusion following multiple trauma. Scand J Thorac Cardiovasc Surg. 1986;20:93-96. 4. Flancbaum L, Wright J, Siegel JH. Emergency surgery in patients with post-traumatic myocardial contusion. J Trauma. 1986;26:795-803. 5. Rosenbaum RC, Johnston GS. Posttraumatic cardiac dysfunction: assessment with radionuclide ventriculography. Radiology. 1986;160:91-94. 6. Waxman K, Soliman MH, Braunstein P, et al. Diagnosis of traumatic cardiac contusion. Arch Surg. 1986;121:689-692. 7. Soliman MH, Waxman K. Value of a conventional approach to the diagnosis of traumatic cardiac contusion after chest injury. Crit Care Med. 1987;15:218-220. 8. Bodin L, Rouby JJ, Viars P. Myocardial contusion in patients with blunt chest trauma as evaluated by thallium 201 myocardial scintigraphy. Chest. 1988;94:72-76. 9. Brunel W, Stoll J, May K, et al. Routine intensive care unit admission is not indicated for suspected myocardial contusion. J Int Care Med. 1988;3:253-257. 10. Fabian TC, Mangiante EC, Patterson CR, Payne LW, Isaacson ML. Myocardial contusion in blunt trauma: clinical characteristics, means of diagnosis, and implications for patient management. J Trauma. 1988;28:50-57. 11. Hiatt JR, Yeatman LA Jr, Child JS. The value of echocardiography in blunt chest trauma. J Trauma. 1988;28:914-922. 12. Keller KD, Shatney CH. Creatine phosphokinase-MB assays in patients with suspected myocardial contusion: diagnostic test or test of diagnosis? J Trauma. 1988;28:58-63. 13. Schamp DJ, Plotnick GD, Croteau D, Rosenbaum RC, Johnston GS, Rodriguez A. Clinical significance of radionuclide angiographically-determined abnormalities following acute blunt chest trauma. Am Heart J. 1988;116:500-504. 14. Baxter BT, Moore EE, Moore FA, McCroskey BL, Ammons LA. A plea for sensible management of myocardial contusion. Am J Surg. 1989;158:557-562. 15. Dubrow TJ, Mihalka J, Eisenhauer DM, et al. Myocardial contusion in the stable patient: what level of care is appropriate? Surgery. 1989;106:267-274. 16. Helling TS, Duke P, Beggs CW, Crouse LJ. A prospective evaluation of 68 patients suffering blunt chest trauma for evidence of cardiac injury. J Trauma. 1989;29:961-966. 17. Miller FB, Shumate CR, Richardson JD. Myocardial contusion: when can the diagnosis be eliminated? Arch Surg. 1989;124:805-808. 18. Ross P Jr, Degutis L, Baker CC. Cardiac contusion: the effect on operative management of the patient with trauma injuries. Arch Surg. 1989;124:506-507. 19. Foil MB, Mackersie RC, Furst SR, et al. The asymptomatic patient with suspected myocardial contusion. Am J Surg. 1990;160:638-643. 20. Healey MA, Brown R, Fleiszer D. Blunt cardiac injury: is this diagnosis necessary? J Trauma. 1990;30:137-146. 21. Holness R, Waxman K. Diagnosis of traumatic cardiac contusion utilizing single photon-emission computed tomography. Crit Care Med. 1990;18:1-3. 22. Norton MJ, Stanford GG, Weigelt JA. Early detection of myocardial contusion and its complications in patients with blunt trauma. Am J Surg. 1990;160:577-582. 23. Wisner DH, Reed WH, Riddick RS. Suspected myocardial contusion: triage and indications for monitoring. Ann Surg. 1990;212:82-86. 24. Fabian TC, Cicala RS, Croce MA, et al. A prospective evaluation of myocardial contusion: correlation of significant arrhythmias and cardiac output with CPK-MB measurements. J Trauma. 1991;31:653-660. 25. Illig KA, Swierzewski MJ, Feliciano DV, Mortor JH. A rational screening and treatment strategy based on the electrocardiogram alone for suspected cardiac contusion. Am J Surg. 1991;162:537-544. 26. McCarthy MC, Pavlina PM, Evans DK, Broadie TA, Park HM, Schauwecker DS. The value of SPECT-thallium scanning in screening for myocardial contusion. Cardiovasc Intervent Radiol. 1991;14:238-240. 27. McLean RF, Devitt JH, Dubbin J, McLellan BA. Incidence of abnormal RNA studies and dysrhythmias in patients with blunt chest trauma. J Trauma. 1991;31:968-970. 28. Brooks SW, Young JC, Cmolik B, et al. The use of transesophageal echocardiography in the evaluation of chest trauma. J Trauma. 1992;32:761-768. 29. Cachecho R, Grindlinger GA, Lee VW. The clinical significance of myocardial contusion. J Trauma. 1992;33:68-73. 30. Godbe D, Waxman K, Wang FW, McDonald R, Braunstein P. Diagnosis of myocardial contusion: quantitative analysis of single photon emission computed tomographic scans. Arch Surg. 1992;127:888-892. 31. Hendel RC, Cohn S, Aurigemma G, et al. Focal myocardial injury following blunt chest trauma: a comparison of indium-111 antimyosin scintigraphy with other noninvasive methods. Am Heart J. 1992;123:1208-1215. 32. McLean RF, Devitt JH, McLellan BA, Dubbin J, Ehrlich LE, Dirkson D. Significance of myocardial contusion following blunt chest trauma. J Trauma. 1992;33:240-243. 33. Paone RF, Peacock JB, Smith DL. Diagnosis of myocardial contusion. South Med J. 1993;86:867-870. 34. Biffl WL, Moore FA, Moore EE, Sauaia A, Read RA, Burch JM. Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion. Am J Surg. 1994;168:523-528. 35. Fildes JJ, Betlej TM, Manglano R, Martin M, Rogers F, Barrett JA. Limiting cardiac evaluation in patients with suspected myocardial contusion. Am Surg. 1995;61:832-835. 36. Adams JE 3rd, Davila-Roman VG, Bessey PQ, Blake DP, Ladenson JH, Jaffe AS. Improved detection of cardiac contusion with cardiac troponin I. Am Heart J. 1996;131:308-312. 37. Dowd MD, Krug S. Pediatric blunt cardiac injury: epidemiology, clinical features, and diagnosis. Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. J Trauma. 1996;40:61-67. 38. Maenza RL, Seaberg D, D'Amico F. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med. 1996;14:237-241. 39. Weiss RL, Brier JA, O'Connor W, Ross S, Brathwaite CM. The usefulness of transesophageal echocardiography in diagnosing cardiac contusions. Chest. 1996;109:73-77. 40. Ferjani M, Droc G, Dreux S, et al. Circulating cardiac troponin T in myocardial contusion. Chest. 1997;111:427-433. PRACTICE MANAGEMENT GUIDELINES FOR IDENTIFYING CERVICAL SPINE INSTABILITY AFTER TRAUMA I. Statement of the Problem Determination of the stability of the cervical spine is a common problem encountered by those charged with the responsibility for the acute care of trauma patients. Several specific issues are of particular concern for medical, economic, and legal reasons. Who needs cervical spine radiographs? What views of the cervical spine should be obtained? When should flexion/extension radiographs, fluoroscopic radiographs, computed tomographic (CT) scans, or magnetic resonance imaging (MRI) scans be obtained? And how do we demonstrate the absence of significant ligamentous injury in the comatose trauma patient? II. Process A. Identification of References A computerized search of the National Library of Medicine was undertaken using Grateful Med software. All English-language citations from the last 20 years with "cervical spine" in the title and the subject words "radiography," "cervical vertebrae," or "trauma" were retrieved. Of the 961 citations retrieved, 160 dealt with the determination of cervical spine stability in the first few hours after trauma, and these articles were selected for further review. Ninety-eight were either general reviews, letters to the editor, or were considered of such poor quality as to not warrant inclusion in this document. This left 62 articles that were primarily original studies of large groups of patients or smaller, well-conducted studies addressing specific questions relevant to this practice guideline. B. Quality of the References The quality-assessment instrument applied to the references was developed for this project. There have been no such instruments developed previously for use with articles that do not deal with therapies, and clearance of the cervical spine is a question of diagnosis rather than therapy. Five factors were considered essential to high-quality articles regarding the diagnosis of cervical spine injury: (1) a study population greater than 100 patients; (2) a well-defined population at risk; (3) a prospective study; (4) a description of the specialty or specialties of the physicians charged with interpreting the radiographic studies; and (5) a specific description of the studies obtained. III. Recommendations A. Level I There is insufficient evidence to support a level I recommendation for this practice management guideline. B. Level II 1. Trauma patients who are alert, awake, have no mental status changes, no neck pain, no distracting pain, and no neurologic deficits may be considered to have a stable cervical spine and need no radiologic studies of their cervical spine. 2. All other trauma patients should have the following three cervical spine radiographs: lateral view revealing the base of the occiput to the upper border of the first thoracic vertebra; anteroposterior view revealing the spinous processes of the second cervical through the first thoracic vertebra; and an open mouth odontoid view revealing the lateral masses of the first cervical vertebra and the entire odontoid process. Axial CT scans with sagittal reconstruction should be obtained for any questionable level of injury, or through the lower cervical spine if this area cannot be visualized on plain radiographs. All life-threatening hemodynamic and pulmonary problems should be addressed before a prolonged cervical spine evaluation is undertaken. Before removing cervical spine immobilization devices, all radiographs should be read by an experienced trauma surgeon, emergency medicine physician, neurosurgeon, orthopedic spine surgeon, radiologist, or other physician with expertise in interpreting these studies. 3. If the cervical spine radiographic results are normal but the patient complains of significant neck pain, cervical spine radiographs with the patient actively positioning the neck in extreme flexion and extension should be obtained. 4. If the patient has a neurologic deficit that may be referable to a cervical spine injury, an immediate surgical subspecialty consultation and MRI scan of the cervical spine should be obtained. 5. Trauma patients who have an altered level of consciousness attributable to a traumatic brain injury or other causes that are considered likely to leave the patient unable to complain of neck pain or neurologic deficits for 24 or more hours after injury may be considered to have a stable cervical spine if adequate three-view plain radiographs (CT supplementation as necessary) and thin-cut axial CT images through C1 and C2 are read as normal by an experienced physician. 6. If the patient has abnormalities of the cervical spine discovered on any of the radiographic or MRI images as recommended above, the surgical subspecialists responsible for spinal trauma should be consulted. IV. Summary Because of the lack of class I data, no level I recommendations can be made for this topic. There have been numerous prospective and retrospective cohort studies of large numbers of trauma patients that provide some insight into the incidence of cervical spine injuries after blunt trauma (2-6%), the indications for cervical spine radiographs, and the types of radiographs most likely to detect cervical spine injuries. Virtually all of the publications fail to clearly define the criteria used to decide who gets cervical spine radiographs and who does not. No researchers have carefully conducted long-term follow-up on all of their trauma patients to identify all cases of cervical spine injury missed in the acute setting. The true incidence of cervical spine injury is thus not known. It is clear from the literature that no imaging modality is accurate 100% of the time. Most studies have found that a three-view spine series (anteroposterior, lateral, and open mouth odontoid view), supplemented by thin-cut axial CT images with sagittal reconstruction through suspicious areas or inadequately visualized areas, provides a false-negative rate of less than 0.1% if the studies are technically adequate and properly interpreted. CT scans alone, MRI scans, and flexion/extension radiographs have all been shown to miss injuries and have not been shown to be more accurate than the guidelines mentioned above. V. Future Investigations Future studies should prospectively evaluate and identify those imaging studies that should be used to make an acute determination of cervical spine injury and stability. VI. References Class II 1. Jacobs LM, Schwartz R. Prospective analysis of acute cervical spine injury: a methodology to predict injury. Ann Emerg Med. 1986;15:44-49. 2. Ross SE, Schwab CW, David ET, Delong WG, Born CT. Clearing the cervical spine: initial radiologic evaluation. J Trauma. 1987;27:1055-1060. 3. Neifeld GL, Keene JG, Hevesy G, Leikin J, Proust A, Thisted RA. Cervical injury in head trauma. J Emerg Med. 1988;6:203-207. 4. Roberge RJ, Wears RC, Kelly M, et al. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. J Trauma. 1988;28:784-788. 5. Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma. Ann Emerg Med. 1989;18:818-821. 6. Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients. J Trauma. 1989;29:1438-1439. 7. Schleehauf K, Ross SE, Civil ID, Schwab CW. Computed tomography in the initial evaluation of the cervical spine. Ann Emerg Med. 1989;18:815-817. 8. Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT. J Emerg Med. 1990;8:183-198. 9. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21:1454-1460. 10. Davis JW, Parks SN, Detlefs CL, Williams GG, Williams JL, Smith RW. Clearing the cervical spine in obtunded patients: the use of dynamic fluoroscopy. J Trauma. 1995;39:435-438. PRACTICE MANAGEMENT GUIDELINES FOR PENETRATING INTRAPERITONEAL COLON INJURIES I. Statement of the Problem Management of penetrating colon wounds has been evolving during the last three decades. Before that time, most colon wounds in the civilian population were managed by exteriorization of the wound or proximal colostomy because of the fear of a high rate of breakdown. In the past 20 years, there has been a trend toward increased use of primary repair. Advantages of primary repair are the avoidance of colostomy, with the subsequent reduction in the morbidity of the colostomy itself and the cost associated with colostomy care and the subsequent hospitalization for closure. Potential drawbacks of primary repair are the morbidity and mortality associated with failure of repair. If there is no difference in morbidity between the approaches, primary repair would be preferred. In recent years, there have been several prospective studies that support primary repair over colostomy; however, there is continued confusion regarding when primary repair is appropriate. II. Process A computerized search of the National Library of Medicine was undertaken using Knowledge Server software. English-language citations during the period 1979 through 1996 using the words "colon injury" and "colon trauma" were identified from the database of journal articles. Of the 113 articles identified, those dealing with either prospective or retrospective series of injuries were selected. The following groups of articles were excluded from analysis: (1) literature review articles; (2) wartime experiences; and (3) articles from institutions that were duplicative. This left 42 articles that were institutional studies of groups of patients who sustained penetrating abdominal trauma with intraperitoneal colon injury and in which the method of surgical management was evaluated. Another group of articles reported on colostomy closure after penetrating injury. The articles were reviewed by a group of five trauma surgeons who collaborated to produce this practice management guideline. III. Recommendations A. Level I There are sufficient class I and class II data to support a standard of primary repair for nondestructive (involvement of 50% of the bowel wall or devascularization of a bowel segment) can undergo resection and primary anastomosis if they: - are hemodynamically stable without evidence of shock (sustained preoperative or intraoperative hypotension as defined by systolic blood pressure < 90 mm Hg); - have no significant underlying disease; - have minimal associated injuries (Penetrating Abdominal Trauma Index < 25, Injury Severity Score (ISS) < 25, Flint grade < 11); - have no peritonitis. 2. Patients with shock, underlying disease, significant associated injuries, or peritonitis should have destructive colon wounds managed by resection and colostomy. 3. Colostomies performed after colon and rectal trauma can be closed within 2 weeks if contrast enema is performed to confirm distal colon healing. This recommendation pertains to patients who do not have nonhealing bowel injury, unresolved wound sepsis, or are unstable. 4. A barium enema should not be performed to rule out colon cancer or polyps before colostomy closure for trauma in patients who otherwise have no indications for being at risk for colon cancer or polyps. IV. Summary The decreased morbidity associated with avoidance of colostomy, the disability associated with the interval from creation to closure of the colostomy, and the charges associated with colostomy an