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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
Systematic review of
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
Systematic review of
level 2 studies
Systematic review of
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
Systematic review of
level 3 studies
Systematic review of
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
7thEdition New material
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
ATLS 8e Compendium of Changes
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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
ATLS 8e Compendium of Changes
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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
7thEdition New material
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
ATLS 8e Compendium of Changes
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p g
Blunt carotid and vertebral vascular injuries (BCVI)
7thEdition New material
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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p g
CT evaluation of the cervical spine
7thEdition New material
8th
Edition CTmay be used in lieu of plain images to evaluate
the C Spine.
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p g
Atlantooccipital dislocation
7thEdition New material
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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p g
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
7thEdition New material
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
7thEdition New material
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
7thEdition New material
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
7thEdition New material
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
7thEdition New material
8
th
Edition The incidence of intraabdominal injury is
significantly higher if abdominal wall bruising is
observed during the primary or secondary survey.