atls 8th edition

5/28/2018 ATLS 8th Edition

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Advanced Trauma Life Support8thEditionThe Evidence for Change

Volume 64(6). June 2008.1638-1650

http://decode-medicine.blogspot.com/summarized b sun aichen
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ATLS 8e Compendium of Changes

History

The ATLS course for doctors wasintroduced in Nebraska in 1978.

It was adopted by the American

College of Surgeons and was

rapidly introduced across North

America in the early 1980s. Doctor James K. Styner


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ATLSProgram Overview

Access the patients condition rapidlyand accurately.

Resuscitate and stabilize the patientaccording to priority.

Determine if the patients needs exceeda facilitys capacity.

Arrange appropriately for the patientsinter-hospital transfer(who, what, when,and how).

Assure that optimum care is providedand that the level of care does notdeteriorate at any point during theevaluation, resuscitation, or transfer

process.


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A Brief Summary of Wright et al. Levels of Evidence. JBJS(A)

Treatment Prognosis Diagnosis Economic and Decision analysis

Level of Evidence

1 RCT with significant

difference or narrow

confidence intervals

Prospective study with

single inception cohort

and 80% follow-up

Testing of previously

applied diagnostic criteria

in a consecutive series

against a gold standard

Clinically sensible costs and

alternatives; values obtained from

many studies; multiway

sensitivity analyses

Systematic reviews

of level 1 studies

Systematic review of

level 1 studies

Systematic review of level

1 studies


level 1 studies

2 Prospective cohort,

poor quality RCT

Retrospective study,

untreated controls

from a previous RCT

Development of

diagnostic criteria on basis

of consecutive patients

against a gold standard

Clinically sensible costs and

alternatives, values cobtained from

limited studies, multiway

sensitivity analyses

Systematic reviews

of level 2 studies


level 2 studies


level 2 studies

Systematic review of level 2

studies

3 Casecontrol study Study of nonconsecutive

patients (no consistently

applied gold standard)

Limited alternatives and costs;

poor estimates

Retrospective cohortstudy


level 3 studies


level 3 studies

Systematic review of level 3

studies

4 Case series Case series Casecontrol study

Poor reference standard

No sensitivity analyses

5 Expert opinion Expert opinion Expert opinion Expert opinion


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Initial assessment


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Rectal examination

7thEdition

A rectal examination should be performed before

inserting a urinary catheter

8thEdition

A rectal examination should be performed selectively

before placing a urinary catheter. If the rectal

examination is required the doctor should assess forthe presence of blood within the bowel lumen, a high-

riding prostate, the presence of pelvic fractures, the

integrity of the rectal wall, and the quality of the

sphincter tone.


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Airway


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Carbon dioxide detectors

7thEdition

A CO2detector (colorimetric CO2monitoring

device) is indicated to help confirm proper

intubation

8thEdition

A CO2detector (ideally capnography but if not

available by a colorimetric CO2monitoring device)

is indicated to help confirm proper intubation of

the airway


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Laryngeal mask airway (LMA)

7thEdition The LMAs role in the resuscitation of the

injured patient has not been defined

8thEdition

There is an established role for the LMA in the management

of a patient with a difficult airway, particularly if attempts at

tracheal intubation or bag-valve-mask ventilation havefailed. The LMA does not provide a definitive airway.

When a patient has an LMA in place on arrival in the

emergency department, the doctor must plan for definitive

airway.


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Laryngeal tube airway (LTA)

7thEdition

New material

8thEdition The LTA is an extraglottic airway device with

similar capability to provide successful ventilation

to the patient as that of the LMA.

The LTA is not a definitive airway device and plans

to provide a definitive airway must be

implemented.


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Gum Elastic Bougie

7thEdition New Material

8thEdition

An useful tool when faced with the difficult airway is theEschmann tracheal tube introducer (ETTI) also known as the gum

elastic bougie (GEB). It is a 60 cm long, 15 French intubating

stylette. The ETTI is employed when vocal cords cannot be

visualized on direct laryngoscopy. In multiple operating room

studies, successful intubation is seen at rates greater than 95%with ETTI.

In cases where potential cervical spine injury is suspected, ETTI-

aided intubation was successful in 100% of cases in less than 45s .

This simple device allowed rapid intubation of nearly 80% ofprehospital patients with difficult direct laryngoscopy.


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Difficult airway

7thEdition New material

8thEdition

It is important to assess the patients airway before

attempting intubation to predict the likely difficulty.

Factors which may predict difficulties with airway

maneuvers include significant maxillofacial trauma, limited

mouth openingand anatomical variation such as receding

chin, overbite, or a short thick neck.The mnemonic LEMON

(look, evaluate, mallampatti, obstruction, neck) is helpful as

a prompt when assessing the potential for difficulty.


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Shock


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Crystalloid

7thEdition

Warmed isotonic electrolyte solutions are used for

initial resuscitation. Lactate ringers (RL) is the initial

fluid of choice. Normal saline is the second choice.

8thEdition

Warmed isotonic electrolyte solutions (eg RL or

normal saline), are used for initial resuscitation.

An alternative initial fluid is hypertonic saline

although current literature does not demonstrate

any survival advantage.


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Fluid resuscitation

7thEdition

Initial fluid resuscitation based on the 4 ATLS

classes of hemorrhage is presented. Assess the

patients response to fluid resuscitation and

evidence of adequate end organ perfusion

d f h


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Fluid resuscitation

8thEdition The goal of resuscitation is to restore organ perfusion.

This is accomplished by the use of resuscitation fluids, and

has been guided by the goal of restoring a normal blood

pressure. It has been emphasized that if blood pressure israised rapidly before the hemorrhage has been definitely

controlled, increased bleeding may occur. Persistent

infusion of large volumes of fluids in an attempt to achieve

a normal blood pressure is not a substitute for definitivecontrol of bleeding.

Fluid resuscitation and avoidance of hypotension are

important principles in the initial management of blunt

traumapatients particularly with TBI.

ATLS 8 C di f Ch


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Fluid resuscitation

8thEdition In penetrating trauma with hemorrhage, delaying

aggressive fluid resuscitationuntil definitive control may

prevent additional bleeding. Although complications

associated with resuscitation injury are undesirable, thealternative of exsanguination is even less so.

Balancing the goal of organ perfusion with the risks of

rebleeding by accepting a lower than normal blood

pressurehas been called Controlled resuscitation,Balanced Resuscitation, Hypotensive Resuscitation and

Permissive Hypotension. The goal is the balance, not the

hypotension.

Such a resuscitation strategy may be a bridge to but is alsonot a substitute for definitive surgical control of bleeding.

ATLS 8 C di f Ch


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Angio-embolization and

definitive control of hemorrhage

7thEdition

Angio-embolization described for hemodynamically

abnormal pelvic fractures with negative DPL

8thEdition

Failure to respond to crystalloid and blood

administration in ED dictates the need for

immediate definitive intervention to control

exsanguinating hemorrhage, (e.g. operation or

angioembolization)

ATLS 8 C di f Ch


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Treatment of cardiac tamponade

7thEdition

Pericardiocentesis is the initial management of

traumatic tamponade

8thEdition

Acute cardiac tamponade due to trauma is best

managed by thoracotomy.

Pericardiocentesis may be used as a temporizing

maneuver when thoracotomy is not an available

option

ATLS 8 C di f Ch


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Base deficit & lactate

7thEdition

Base deficit may be useful in determining the

severity of the acute perfusion deficit

8thEdition

Base deficit and/or lactatecan be useful in

determining the presence and severity of shock.

Serial measurement of these parameters can be

used to monitor the response to therapy


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Thoracic trauma



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Treatment of pneumothorax

7thEdition Observation and/or aspiration of a pneumothorax

are risky

8thEdition

A pneumothorax is best treated with a chest tube in

the 4thor 5thintercostal space, just anterior to the

midaxillary line. Observation and/or aspiration of an

asymptomatic pneumothorax should be determined

by a qualified physician, otherwise placement of

chest tube should be performed



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ED thoracotomy

7thEdition Penetrating thoracic trauma patients, who arrive

pulseless with electrical activity may be

candidates for resuscitative thoracotomy (RT).

Patients sustaining blunt injuries who arrive

pulseless with myocardial electrical activity are

not candidates for RT



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ED thoracotomy

8thEdition A patient sustaining a penetrating wound, who has

required CPR in the prehospital setting should be

evaluated for any signs of life*. If there are none and

no cardiac electrical activity is present, no furtherresuscitative effort should be made.

* The recommendation on ED thoracotomy includes a review of

signs of life for penetrating trauma (reactive pupils, spontaneous

movement, organized EKG activity). Patients sustaining blunt injuries who arrive pulseless

but with myocardial electrical activity (PEA) are not

candidates for resuscitative thoracotomy (RT).



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Blunt traumatic aortic injury


8thEdition Techniques of endovascular repair are rapidly

evolving as an alternate approach for surgical

repair of blunt traumatic aortic injury.


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Abdomen



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Explosive devices

7thEdition New Material

8thEdition Explosive devices cause injuries through several

mechanisms. These include penetrating fragment

wounds and blunt injuries from the patient being

thrown or struck. Patients close to the source of

the explosion may have additional pulmonaryor

hollow viscus injuries related to blast pressure

which may have delayed presentation.



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Hemo-dynamically abnormal pelvic fractures

7thEdition Describes management based on DPL+ (celiotomy) and DPL

(angiography-embolization)

8thEdition

The pelvis should be temporarily stabilized or closed using

an available commercial compression device or sheet to

decrease bleeding.

Intraabdominal sources of hemorrhage must be excluded or

treated operatively. Further decisions to control ongoing

pelvic bleeding include angiographic embolization, surgical

stabilization, or direct surgical control.


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Head trauma



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Classification and head CT

7thEdition Mild brain injury defined as GCS 1415.

CT is ideal in all patients except completely asymptomatic

and neurologically normal

8thEdition

The categorization of traumatic brain injury reflects a

continuum. The definition of minor traumatic brain injury

has reverted to GCS 1315, with moderate changed to 912.

The Canadian CT Head Rule has been adopted as a guide to

clarifying when CT scans of the head should be used.



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Canadian CT Head Rule for patients with minor head injury

Failure to reach GCS of 15 within 2 h Suspected open or depressed skull fracture

Any sign of basal skull fracture (haemotympanum, racoon

eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign)

Vomiting >2 episodes

Age >65 years

Amnesia before impact >30 min

Dangerous mechanism (pedestrian struck by motor vehicle,

occupant ejected from motor vehicle, fall from height >3 feet

or 5 stairs)

Minor head injury is defined as witnessed loss of consciousness, definite amnesia,

or witnessed disorientation in a patients with a GCS score of 1315

Lancet. 2001 May 5;357(9266):1391-6.



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Penetrating brain injury


8th

Edition Objects that penetrate the intracranial

compartment or infratemporal fossa must be left in

place until possible vascular injury has been

evaluated and definitive neurosurgicalmanagement is established. Disturbing or removing

penetrating objects prematurely may lead to fatal

vascular injury or ICH.



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Penetrating brain injury

8thEdition More extensive wounds with nonviable scalp, bone, or

dura are treated with careful debridement before

primary closure or grafting to secure a watertight wound.

Significant mass effect is addressed by evacuating

intracranial hematomas, and debridement of necrotic

brain tissue and safely accessible bone fragments.

In the absenceof significant mass effect, surgical

debridement of the missile track in the brain, routinesurgical removal of fragments distant from the entry site

and reoperation solely to remove retained bone or

missile fragments does not measurably improve outcome

and is not recommended.


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Spine



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p g

Blunt carotid and vertebral vascular injuries (BCVI)


8thEdition

Blunt trauma to the head and neck has been recognized as a risk

factor for carotid and vertebral arterial injuries. Early recognition

and treatment of these injuries may reduce the risk of stroke.

Suggested criteria for screening include:

a) C13 fractureb) C spine fracture with subluxation

c) Fractures involving the foramun transversarium.

Approximately 1/3 of these patients will have BCVI when imaged

with CT angiography of the neck



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Steroids

7thEdition In North America high dose methyprednisolone

given to the patient with nonpenetrating spinal

cord injury . . . is a currently accepted treatment

8thEdition

There is insufficient evidence to support the

routine use of steroids in spinal cord injury atpresent.



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CT evaluation of the cervical spine


8th

Edition CTmay be used in lieu of plain images to evaluate

the C Spine.



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Atlantooccipital dislocation


8th

Edition Aids to identification of atlanto-occipital dislocation

on spine films including Powers ratio are included

in the spinal skills station.

Power's Ratio:

A = C1 anterior arch,

B = basion (anterior margin of foramen magnum),

C = anterior portion of the posterior ring of C1,

O = opsthion (posterior margin of foramen magnum).

If BC/AO greater than 1,

anterior occipitoatlantal dislocation exists.



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Powers ratio to diagnose AOD shown on plain

radiographs and CT scans of a patient without injury

From:Dziurzynski: Spine, Volume 30(12). June 15, 2005.1427-1432


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Musculoskeletal trauma andextremity trauma



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Tourniquet

7thEdition The judicious use of a pneumatic tourniquet may be helpful

and lifesaving

8thEdition

The use of a tourniquet while controversial may occasionally

be life and/or limb saving in the presence of ongoing

hemorrhage uncontrolled by direct pressure. A tourniquet

must occlude arterial inflow, as occluding only the venous

system can increase hemorrhage. The risks of tourniquet

use increase with time. If a tourniquet must remain in place

for a prolonged period to save a life, the physician must be

clear that the choice of life over limb has been made.



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Compartment syndrome

7thEdition A palpable distal pulse usually is present in

compartment syndrome

8thEdition

Absence of a palpable distal pulse usually is an

uncommon finding and should not be relied upon

to diagnose a compartment syndrome. Earlyfindings of compartment syndrome are emphasized

in the text


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Trauma in women



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Restraints


8

th

Edition Compared with restrained pregnant women

involved in collisions, unrestrained pregnant

women have a higher risk of premature delivery

and fetal death.



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Airbags


8

th

Edition There does not appear to be any increase in

pregnancy-specific risks from deployment of

airbags in motor vehicles.


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Functional outcome


8

th

Edition Long-term follow-up of functional outcome

indicates that while victims of major trauma during

childhood may retain functional disabilities, quality

of life remains very high.



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Abdominal imaging CT


8

th

Edition The presence of a splenic blush on CT with

intravenous contrast does not mandate exploration,

and the decision to operate continues to be based

on the amount of blood lost as well as abnormalphysiologic parameters.



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Abdominal imaging FAST

7thEdition The role of abdominal ultrasound in children with

abdominal injury remains to be defined

8thEdition

If large amounts of intraabdominal blood are found,

significant injury is certain to be present.

However, operative management is indicated not by the

amount of intraperitoneal blood, but by hemodynamic

abnormality and its response to treatment.

FAST is incapable of identifying isolated intraparenchymal

injuries, which account for up to 1/3 of solid organ injuries

in children.



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Abdominal bruising


8

th

Edition The incidence of intraabdominal injury is

significantly higher if abdominal wall bruising is

observed during the primary or secondary survey.

atls 8th edition

Documents

atls course

styner5282018 atls

blog atls

level of care

e compendium of changeshistory

rectal wall

fromlimited studies

basisof consecutive