ATLS
J Trauma Volume 64
Number 6 1639
Table 2
ATLS 8th Edition Compendium of Changes
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. (LOE 4)13
A carbon dioxide (CO2) detector (ideally capnography but if not available by a
colorimetric CO2 monitoring device) is indicated to help confirm proper
intubation of the airway (LOE 3)14,15
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.
Proper placement of this device is difficult without appropriate training.
When a patient has an LMA in place on arrival in the emergency
department, the doctor must plan for definitive airway . (LOE 3),1619
(LOE 2),20 (LOE 3),21 (LOE 2),22,23 (LOE 4)24
An useful tool when faced with the difficult airway is the Eschmann tracheal
tube introducer (ETTI) also known as the gum elastic bougie (GEB).
(LOE 4).28 It is a 60 cm long, 15 French intubating stylette (LOE 5).29 The
ETTI is employed when vocal cords cannot be visualized on direct
laryngoscopy. (LOE 5).30 In multiple operating room studies, successful
intubation is seen at rates greater than 95% with ETTI30 (LOE 4)31,32 (LOE
2)33 (LOE 3)34
(LOE 5)35 (LOE 4)36 (LOE 5).37,38 In cases where potential cervical spine
injury is suspected, ETTI-aided intubation was successful in 100% of cases
in less than 45s (LOE 5).39 This simple device allowed rapid intubation of
nearly 80% of prehospital patients with difficult direct laryngoscopy. (LOE
4)40
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 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. (LOE 4),41
(LOE 1)42
Warmed isotonic electrolyte solutions (eg lactate ringers (RL) or normal saline),
are used for initial resuscitation. This type of fluid provides transient
intravascular expansion and further stabilizes the vascular volume by
replacing accompanying fluid losses into the interstitial and intracellular
spaces. An alternative initial fluid is hypertonic saline although current
literature does not demonstrate any survival advantage. (LOE 3)43,44
(LOE 2)45,46
The goal of resuscitation is to restore organ perfusion. This is accomplished
by the use of resuscitation fluids to replace lost intravascular volume, 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.
This may be seen in the small subset of patients in the transient or
nonresponder categories. 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. Fluid resuscitation and avoidance of hypotension are
important principles in the initial management of blunt trauma patients
particularly with TBI. 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. A careful
balanced approach with frequent reevaluation is required. 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. Such a
resuscitation strategy may be a bridge to but is also not a substitute for
definitive surgical control of bleeding. (LOE 3)44 (LOE 5)4750 (LOE 2)51
(LOE 4)52 (LOE 2)53
Failure to respond to crystalloid and blood administration in the emergency
department dictates the need for immediate definitive intervention to control
exsanguinating hemorrhage, (e.g. operation or angioembolization)
(LOE 4),5457 (LOE 3),58 (LOE 4),5967 (LOE 3)68 (LOE 2)69
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 (LOE 4).7077
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 (LOE 2)78,79 (LOE 3).80,81
A pneumothorax is best treated with a chest tube in the fourth or fifth
intercostal space, just anterior to the midaxillary line. Observation and/or
aspiration of an asymptomatic pneumothorax may be appropriate but
should be determined by a qualified physician, otherwise placement of
chest tube should be performed (LOE 2)82 (LOE 4)83,84
A patient sustaining a penetrating wound, who has required CPR in the prehospital
setting should be evaluated for any signs of life (reactive pupils, spontaneous movement, organized EKG activity). If there are none
and no cardiac electrical activity is present, no further resuscitative effort
should be made. Patients sustaining blunt injuries who arrive pulseless but
with myocardial electrical activity (PEA) are not candidates for resuscitative
thoracotomy (RT). (LOE 4)8591 Multiple reports confirm that emergency
department (ED) thoracotomy for patients with blunt trauma and cardiac
arrest is rarely effective.
New material* Techniques of endovascular repair are rapidly evolving as an alternate
approach for surgical repair of blunt traumatic aortic injury. (LOE 4)92
(LOE 3)93
Abdomen Explosive devices New Material* 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. The potential for pressure injury
should not distract the doctor from a systematic A, B, C approach to
identification and treatment of the more common blunt and penetrating
injuries. (LOE 4)94,95 (LOE 5)9699 (LOE 3)100 (LOE 4)101104 (LOE 5)105
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.
(LOE 4),55,57,62,64,65,66 (LOE 3),68 (LOE 4),106111 (LOE 3),112 (LOE 4),113117
(LOE 2),118 (LOE 4),119 (LOE 3)120
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. Neurotrauma literature varies on these ranges, but
multiple major organizations including Eastern Association for the Surgery of
Trauma and the Center for Disease Control use 1315, which is also
consistent with the Canadian CT Head Rule introduced in this revision. The
Canadian CT Head Rule has been adopted as a guide to clarifying when CT
scans of the head should be used. (LOE 4),121 (LOE 1),122,123 (LOE 2),124
(LOE 1),125 (LOE 2),126,127 (LOE 4)128
Penetrating brain
injury
New material* 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
intracranial hemorrhage. More extensive wounds with nonviable scalp,
bone, or dura are treated with careful debridement before primary closure or
grafting to secure a watertight wound. In patients with significant
fragmentation of the skull, debridement of the cranial wound with opening
or removing a portion of the skull is necessary. Significant mass effect is
addressed by evacuating intracranial hematomas, and debridement of
necrotic brain tissue and safely accessible bone fragments. 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. Repair of open-air
sinus injuries and CSF leaks that do not close spontaneously (or with
temporary CSF diversion) is recommended, using careful watertight closure
of the dura. (LOE 4)129134
Spine Blunt carotid
and vertebral
vascular injuries
(BCVI)
New material* 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. Indications for screening are
evolving. Suggested criteria for screening include: (a) C13 fracture (b) 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. (LOE 2)135 (LOE 2),136 (LOE 1)137
(LOE 3)139,140
There is insufficient evidence to support the routine use of steroids in spinal
cord injury at present. (LOE 1)141 (LOE 3)142 (LOE 1),143 (LOE 1),44
(LOE 2),145 (LOE 1),146 (LOE 2),147 (LOE 1),148 (LOE 1),149 (LOE 2),150 (LOE
2)151
CT may be used in lieu of plain images to evaluate the C Spine.
(LOE 3),152158 (LOE 1),159 (LOE 2),160 (LOE 1),161 (LOE 2)162
Aids to identification of atlantooccipital dislocation on spine films including
Powers ratio are included in the spinal skills station. (LOE 3)163,164
An acutely avascular extremity must be recognized promptly and treated
emergently. 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 properly applied tourniquet, while endangering the
limb, can save a live. 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. (LOE 5),96,165 (LOE 4),166,167 (LOE 5),168,169 (LOE 4),170
(LOE 5)171
Absence of a palpable distal pulse usually is an uncommon finding and should
not be relied upon to diagnose a compartment syndrome. (LOE 3),172
(LOE 5),173,174 Early findings of compartment syndrome are emphasized in
the text
Compared with restrained pregnant women involved in collisions, unrestrained
pregnant women have a higher risk of premature delivery and fetal death.
(LOE 4),175,176 (LOE 2)177 (LOE 4)178180 (LOE 2)181
There does not appear to be any increase in pregnancy-specific risks from
deployment of airbags in motor vehicles. (LOE 4)178,180
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. (LOE 3)182
The presence of a splenic blush on computed tomography (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. (LOE 4)183
Fluid resuscitation. The 7th edition did state that fluid resuscitation should be guided by response and that requirements are difficult to predict. The 8th edition emphasizes the
concept of balanced resuscitation and introduces the clinical scenario (e.g., TBI vs. penetrating injury) as a consideration in resuscitation.
The recommendation on ED thoracotomy includes a review of signs of life for penetrating trauma (reactive pupils, spontaneous movement, organized EKG activity). The
recommendation regarding blunt trauma emphasizes that ED thoracotomy is not indicated for blunt trauma in PEA.
§ The management algorithm for pelvic fractures has been updated to reflect the complementary roles of temporary stabilization, surgery, fixation, and angioembolization.
The Journal of
TRAUMA Injury, Infection, and Critical Care
1644
June 2008
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