Chapter 72 Evaluating Trauma Literature
INTRODUCTION
In contrast, conclusions based on carefully analyzed evidence in the literature have played an ever-increasing role in the development of clinical guidelines in trauma care. The most prominent early example of evidence-based guidelines in trauma grew out of important work performed by the Brain Trauma Foundation, in collaboration with the American Association of Neurologic Surgeons.1 Guidelines were developed around 13 specific clinical issues in patients with severe traumatic brain injuries.
PITFALL 1: GENERATING A CLASS I RECOMMENDATION BASED ON CLASS III DATA
In 1943, the Surgeon General of the United States issued guidelines that all colon injuries sustained by soldiers in the North African theater during World War II be managed by colostomy either at or proximal to the site of injury, rather than by primary repair or resection and anastomosis.2 Retrospective analysis of this recommendation included the observations that colon injuries during the Civil War carried an associated 90% mortality, whereas those experienced during World Wars I and II carried a 60% and a 30% mortality, respectively. The reduced mortality of injuries experienced during World War II was attributed to the policy of mandatory colostomies, ignoring the contribution of advances in fluid resuscitation, plasma preservation, blood-banking techniques, the availability of antimicrobial agents, and superior military triage and evacuation.
• Consequence
• Repair/Prevention
PITFALL 2: INAPPROPRIATE COMPARISON OF COMPLICATION RATES BETWEEN RETROSPECTIVE AND PROSPECTIVE SERIES
When a clinical researcher and a study nurse formally define complications (such as intra-abdominal abscess after colon repairs) and prospectively compile them, the magnitude of the complication rates will almost always be higher than the complication rates generated by chart reviews and retrospective recall. An example of a remarkably low complication rate generated by retrospective methodology is seen in a 1984 study of traumatic colon injuries at an urban trauma center.4 In this series of 56 patients over a 6-year period, none developed an intra-abdominal abscess. These incredible results raise the question as to whether more severely injured patients who developed complications somehow eluded the investigators’ chart reviews. Subsequent retrospective series published over the ensuing decade would echo a near 0% septic complication rate among patients undergoing primary repair of penetrating colon injuries.5,6 Interestingly, these excellent outcomes are unattainable when the same patients are evaluated prospectively.7,8
• Consequence
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
Stay updated, free articles. Join our Telegram channel
![](https://clinicalpub.com/wp-content/uploads/2023/09/256.png)
Full access? Get Clinical Tree
![](https://videdental.com/wp-content/uploads/2023/09/appstore.png)
![](https://videdental.com/wp-content/uploads/2023/09/google-play.png)
![](https://clinicalpub.com/wp-content/uploads/2023/09/banner1.png)