Background
Methods
Clinical question | P | I | C | O |
---|---|---|---|---|
What part of the trauma population should be screened for BCVI? | In-hospital trauma population | Clinical critera | Various screening criteria | Indications for radiological investigation |
Which radiological method should be applied for screening? | Selected trauma population | Angiogram | CTA versus DSA | Vessel injury |
How should BCVI be treated? | Trauma patients with vessel injury on angiogram | Medical or interventional treatment | Medical versus interventional versus no treatment | Stroke |
How should patients with BCVI be handled over time? | Trauma patients with vessel injury on angiogram | Follow-up controls | Life long versus period of treatment | Stroke |
Results
Clinical question | Recommendation | Strength of recommendation | Level of evidence | Rationale (Benefits and harms) |
---|---|---|---|---|
What part of the trauma population should be screened for BCVI? | Apply expanded Denver screening criteria | Strong | Low | A documented screening tool ensures focus on the condition. Possible danger of overtriage and unnecessary use of imaging. |
Which radiological method should be applied for screening? | CTA has acceptable specificity and sensitivity. DSA remains gold standard | Strong | Moderate | DSA is time consuming, invasive with potential complications and often not available 24–7. CTA is fast and available with lower complication risk. CTA has higher radiation exposure with a risk of false positive findings. |
How should BCVI be treated? | Early treatment with either LMWH or AP medication | Strong | Low | Uncertainty of treatment effect. Studies show that early treatment is safe. Risk is worsening of existing hemorrhage. |
Continue treatment with LMWH or AP for at least 3 months | Strong | Low | Long term AP treatment is generally safe, but may cause side effects such as peptic ulcer. | |
Pseudoaneurysm or high-grade vessel injury may be considered for endovascular treatment | Conditional | Low | May prevent new or recurrent stroke, but uncertainty of treatment effect or stent patency. Double platelet-inhibitors increases risk of hemorrhage in trauma patients. | |
How should patients with BCVI be handled over time? | Perform re-imaging at 7 days and 3 months. | Conditional | Low | Repeat imaging can confirm or discard the diagnosis of BCVI. Risk is radiation exposure. |
Clinical question 1: What part of the trauma population should be screened for BCVI?
Recommendation
Signs/symptoms of BCVI | |
Arterial hemorrhage from neck/nose/mouth | |
Cervical bruit in patients < 50 years | |
Expanding cervical hematoma | |
Focal neurological deficit | |
Neurological exam incongruous with head CT findings | |
Stroke on secondary CT scan | |
Risk factors for BVCI
(High-energy transfer mechanism with):
| |
Le Fort II or III | |
Mandible fracture | |
Complex skull fracture/basilar skull fracture/occipital condyle fracture | |
Severe traumatic brain injury (TBI) with GCS < 6 | |
Cervical spine fracture, subluxation or ligamentous injury at any level | |
Near hanging with anoxic brain injury | |
Seat belt abrasion with significant swelling, pain or altered mental status | |
TBI with thoracic injury | |
Scalp degloving | |
Thoracic vascular injury | |
Blunt cardiac rupture | |
Upper rib fracture |
Evidence and rationale
Clinical question 2: Which radiological method should be applied for screening?
Recommendation
Biffl injury grade | Angiograhic characteristics |
---|---|
I | Luminal irregularity or dissection with < 25% luminal narrowing |
II | Dissection or intramural hematoma with ≥25% luminal narrowing |
III | Pseudoaneurysm |
IV | Occlusion |
V | Transection with free extravasation |