ATLS 8e, The Evidence for Change


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Advanced Trauma Life Support®, 8th Edition, The Evidence for Change
J Trauma. Volume 64(6). June 2008.1638-1650

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ATLS 8e, The Evidence for Change

  1. 1. Advanced Trauma Life Support ® , 8 th Edition, The Evidence for Change Volume 64(6). June 2008.1638-1650 summarized by sun yaicheng
  2. 2. History <ul><li>The ATLS course for doctors was introduced in Nebraska in 1978. It was adopted by the American College of Surgeons and was rapidly introduced across North America in the early 1980s. </li></ul>Doctor James K. Styner
  3. 3. ATLS ® Program Overview <ul><li>Access the patient’s condition rapidly and accurately . </li></ul><ul><li>Resuscitate and stabilize the patient according to priority . </li></ul><ul><li>Determine if the patient’s needs exceed a facility’s capacity. </li></ul><ul><li>Arrange appropriately for the patient’s inter-hospital transfer (who, what, when, and how). </li></ul><ul><li>Assure that optimum care is provided and that the level of care does not deteriorate at any point during the evaluation, resuscitation, or transfer process. </li></ul>
  4. 4. 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 Case–control study Study of nonconsecutive patients (no consistently applied gold standard) Limited alternatives and costs; poor estimates Retrospective cohort study Systematic review of level 3 studies Systematic review of level 3 studies Systematic review of level 3 studies 4 Case series Case series Case–control study Poor reference standard No sensitivity analyses 5 Expert opinion Expert opinion Expert opinion Expert opinion
  5. 5. Initial assessment
  6. 6. Rectal examination <ul><li>7 th Edition </li></ul><ul><li>A rectal examination should be performed before inserting a urinary catheter </li></ul><ul><li>8 th Edition </li></ul><ul><li>A rectal examination should be performed selectively before placing a urinary catheter. If the rectal examination is required the doctor should assess for the 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 . </li></ul>
  7. 7. Airway
  8. 8. Carbon dioxide detectors <ul><li>7 th Edition </li></ul><ul><li>A CO 2 detector (colorimetric CO 2 monitoring device) is indicated to help confirm proper intubation </li></ul><ul><li>8 th Edition </li></ul><ul><li>A CO 2 detector (ideally capnography but if not available by a colorimetric CO 2 monitoring device) is indicated to help confirm proper intubation of the airway </li></ul>
  9. 9. Laryngeal mask airway (LMA) <ul><li>7 th Edition </li></ul><ul><li>The LMA’s role in the resuscitation of the </li></ul><ul><li>injured patient has not been defined </li></ul><ul><li>8 th Edition </li></ul><ul><li>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 have failed. The LMA does not provide a definitive airway. </li></ul><ul><li>When a patient has an LMA in place on arrival in the emergency department, the doctor must plan for definitive airway. </li></ul>
  10. 10. Laryngeal tube airway (LTA) <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>The LTA is an extraglottic airway device with similar capability to provide successful ventilation to the patient as that of the LMA. </li></ul><ul><li>The LTA is not a definitive airway device and plans to provide a definitive airway must be implemented. </li></ul>
  11. 11. Gum Elastic Bougie <ul><li>7 th Edition </li></ul><ul><li>New Material </li></ul><ul><li>8 th Edition </li></ul><ul><li>An useful tool when faced with the difficult airway is the Eschmann 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. </li></ul><ul><li>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% of prehospital patients with difficult direct laryngoscopy. </li></ul>
  12. 12. Difficult airway <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>It is important to assess the patient’s airway before attempting intubation to predict the likely difficulty. </li></ul><ul><li>Factors which may predict difficulties with airway maneuvers include significant maxillofacial trauma , limited mouth opening and 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. </li></ul>
  13. 13. Shock
  14. 14. Crystalloid <ul><li>7 th Edition </li></ul><ul><li>Warmed isotonic electrolyte solutions are used for initial resuscitation. Lactate ringers (RL) is the initial fluid of choice. Normal saline is the second choice. </li></ul><ul><li>8 th Edition </li></ul><ul><li>Warmed isotonic electrolyte solutions (eg RL or normal saline), are used for initial resuscitation. </li></ul><ul><li>An alternative initial fluid is hypertonic saline although current literature does not demonstrate any survival advantage. </li></ul>
  15. 15. Fluid resuscitation <ul><li>7 th Edition </li></ul><ul><li>Initial fluid resuscitation based on the 4 ATLS classes of hemorrhage is presented. Assess the patient’s response to fluid resuscitation and evidence of adequate end organ perfusion </li></ul>
  16. 16. Fluid resuscitation <ul><li>8 th Edition </li></ul><ul><li>The goal of resuscitation is to restore organ perfusion. </li></ul><ul><li>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 is raised 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 definitive control of bleeding. </li></ul><ul><li>Fluid resuscitation and avoidance of hypotension are important principles in the initial management of blunt trauma patients particularly with TBI . </li></ul>
  17. 17. Fluid resuscitation <ul><li>8 th Edition </li></ul><ul><li>In penetrating trauma with hemorrhage, delaying aggressive fluid resuscitation until definitive control may prevent additional bleeding. Although complications associated with resuscitation injury are undesirable, the alternative of exsanguination is even less so. </li></ul><ul><li>Balancing the goal of organ perfusion with the risks of rebleeding by accepting a lower than normal blood pressure has been called “ Controlled resuscitation ,” “ Balanced Resuscitation ,” “ Hypotensive Resuscitation ” and “ Permissive Hypotension .” The goal is the balance, not the hypotension. </li></ul><ul><li>Such a resuscitation strategy may be a bridge to but is also not a substitute for definitive surgical control of bleeding. </li></ul>
  18. 18. Angio-embolization and definitive control of hemorrhage <ul><li>7 th Edition </li></ul><ul><li>Angio-embolization described for hemodynamically abnormal pelvic fractures with negative DPL </li></ul><ul><li>8 th Edition </li></ul><ul><li>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) </li></ul>
  19. 19. Treatment of cardiac tamponade <ul><li>7 th Edition </li></ul><ul><li>Pericardiocentesis is the initial management of traumatic tamponade </li></ul><ul><li>8 th Edition </li></ul><ul><li>Acute cardiac tamponade due to trauma is best managed by thoracotomy . </li></ul><ul><li>Pericardiocentesis may be used as a temporizing maneuver when thoracotomy is not an available option </li></ul>
  20. 20. Base deficit & lactate <ul><li>7 th Edition </li></ul><ul><li>Base deficit may be useful in determining the severity of the acute perfusion deficit </li></ul><ul><li>8 th Edition </li></ul><ul><li>Base deficit and/or lactate can be useful in determining the presence and severity of shock. Serial measurement of these parameters can be used to monitor the response to therapy </li></ul>
  21. 21. Thoracic trauma
  22. 22. Treatment of pneumothorax <ul><li>7 th Edition </li></ul><ul><li>Observation and/or aspiration of a pneumothorax are risky </li></ul><ul><li>8 th Edition </li></ul><ul><li>A pneumothorax is best treated with a chest tube in the 4 th or 5 th intercostal 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 </li></ul>
  23. 23. ED thoracotomy <ul><li>7 th Edition </li></ul><ul><li>Penetrating thoracic trauma patients, who arrive pulseless with electrical activity may be candidates for resuscitative thoracotomy (RT). </li></ul><ul><li>Patients sustaining blunt injuries who arrive pulseless with myocardial electrical activity are not candidates for RT </li></ul>
  24. 24. ED thoracotomy <ul><li>8 th Edition </li></ul><ul><li>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 further resuscitative effort should be made. </li></ul><ul><ul><li>* The recommendation on ED thoracotomy includes a review of signs of life for penetrating trauma ( reactive pupils, spontaneous movement, organized EKG activity ). </li></ul></ul><ul><li>Patients sustaining blunt injuries who arrive pulseless but with myocardial electrical activity (PEA) are not candidates for resuscitative thoracotomy (RT). </li></ul>
  25. 25. Blunt traumatic aortic injury <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>Techniques of endovascular repair are rapidly evolving as an alternate approach for surgical repair of blunt traumatic aortic injury. </li></ul>
  26. 26. Abdomen
  27. 27. Explosive devices <ul><li>7 th Edition </li></ul><ul><li>New Material </li></ul><ul><li>8 th Edition </li></ul><ul><li>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 pulmonary or hollow viscus injuries related to blast pressure which may have delayed presentation . </li></ul>
  28. 28. Hemo-dynamically abnormal pelvic fractures <ul><li>7 th Edition </li></ul><ul><li>Describes management based on DPL+ (celiotomy) and DPL – (angiography-embolization) </li></ul><ul><li>8 th Edition </li></ul><ul><li>The pelvis should be temporarily stabilized or “closed” using an available commercial compression device or sheet to decrease bleeding. </li></ul><ul><li>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. </li></ul>
  29. 29. Head trauma
  30. 30. Classification and head CT <ul><li>7 th Edition </li></ul><ul><li>Mild brain injury defined as GCS 14–15. </li></ul><ul><li>CT is ideal in all patients except completely asymptomatic and neurologically normal </li></ul><ul><li>8 th Edition </li></ul><ul><li>The categorization of traumatic brain injury reflects a continuum. The definition of minor traumatic brain injury has reverted to GCS 13–15 , with moderate changed to 9–12. </li></ul><ul><li>The Canadian CT Head Rule has been adopted as a guide to clarifying when CT scans of the head should be used. </li></ul>
  31. 31. Canadian CT Head Rule for patients with minor head injury <ul><li>Failure to reach GCS of 15 within 2 h </li></ul><ul><li>Suspected open or depressed skull fracture </li></ul><ul><li>Any sign of basal skull fracture (haemotympanum, racoon eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign) </li></ul><ul><li>Vomiting >2 episodes </li></ul><ul><li>Age >65 years </li></ul><ul><li>Amnesia before impact >30 min </li></ul><ul><li>Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or 5 stairs) </li></ul><ul><li>Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15 </li></ul>Lancet. 2001 May 5;357(9266):1391-6.
  32. 32. Penetrating brain injury <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>Objects that penetrate the intracranial compartment or infratemporal fossa must be left in place until possible vascular injury has been evaluated and definitive neurosurgical management is established. Disturbing or removing penetrating objects prematurely may lead to fatal vascular injury or ICH. </li></ul>
  33. 33. Penetrating brain injury <ul><li>8 th Edition </li></ul><ul><li>More extensive wounds with nonviable scalp, bone, or dura are treated with careful debridement before primary closure or grafting to secure a watertight wound. </li></ul><ul><li>Significant mass effect is addressed by evacuating intracranial hematomas, and debridement of necrotic brain tissue and safely accessible bone fragments. </li></ul><ul><li>In the absence of significant mass effect, surgical debridement of the missile track in the brain, routine surgical 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 . </li></ul>
  34. 34. Spine
  35. 35. Blunt carotid and vertebral vascular injuries (BCVI) <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>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. </li></ul><ul><li>Suggested criteria for screening include: </li></ul><ul><ul><li>C1–3 fracture </li></ul></ul><ul><ul><li>C spine fracture with subluxation </li></ul></ul><ul><ul><li>Fractures involving the foramun transversarium. </li></ul></ul><ul><li>Approximately 1/3 of these patients will have BCVI when imaged with CT angiography of the neck </li></ul>
  36. 36. Steroids <ul><li>7 th Edition </li></ul><ul><li>In North America high dose methyprednisolone given to the patient with nonpenetrating spinal cord injury . . . is a currently accepted treatment </li></ul><ul><li>8 th Edition </li></ul><ul><li>There is insufficient evidence to support the routine use of steroids in spinal cord injury at present. </li></ul>
  37. 37. CT evaluation of the cervical spine <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>CT may be used in lieu of plain images to evaluate the C Spine. </li></ul>
  38. 38. Atlantooccipital dislocation <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>Aids to identification of atlanto-occipital dislocation on spine films including Power’s ratio are included in the spinal skills station. </li></ul>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.
  39. 39. Power’s 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
  40. 40. Musculoskeletal trauma and extremity trauma
  41. 41. Tourniquet <ul><li>7 th Edition </li></ul><ul><li>The judicious use of a pneumatic tourniquet may be helpful and lifesaving </li></ul><ul><li>8 th Edition </li></ul><ul><li>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. </li></ul>
  42. 42. Compartment syndrome <ul><li>7 th Edition </li></ul><ul><li>A palpable distal pulse usually is present in compartment syndrome </li></ul><ul><li>8 th Edition </li></ul><ul><li>Absence of a palpable distal pulse usually is an uncommon finding and should not be relied upon to diagnose a compartment syndrome. Early findings of compartment syndrome are emphasized in the text </li></ul>
  43. 43. Trauma in women
  44. 44. Restraints <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>Compared with restrained pregnant women involved in collisions, unrestrained pregnant women have a higher risk of premature delivery and fetal death. </li></ul>
  45. 45. Airbags <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>There does not appear to be any increase in pregnancy-specific risks from deployment of airbags in motor vehicles. </li></ul>
  46. 46. Pediatric trauma
  47. 47. Functional outcome <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>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. </li></ul>
  48. 48. Abdominal imaging CT <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>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 abnormal physiologic parameters . </li></ul>
  49. 49. Abdominal imaging FAST <ul><li>7 th Edition </li></ul><ul><li>The role of abdominal ultrasound in children with abdominal injury remains to be defined </li></ul><ul><li>8 th Edition </li></ul><ul><li>If large amounts of intraabdominal blood are found, significant injury is certain to be present. </li></ul><ul><li>However, operative management is indicated not by the amount of intraperitoneal blood, but by hemodynamic abnormality and its response to treatment. </li></ul><ul><li>FAST is incapable of identifying isolated intraparenchymal injuries, which account for up to 1/3 of solid organ injuries in children. </li></ul>
  50. 50. Abdominal bruising <ul><li>7 th Edition </li></ul><ul><li>New material </li></ul><ul><li>8 th Edition </li></ul><ul><li>The incidence of intraabdominal injury is significantly higher if abdominal wall bruising is observed during the primary or secondary survey. </li></ul>