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),16–19

(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



 It is important to assess the patient’s 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)47–50 (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),54–57 (LOE 3),58 (LOE 4),59–67 (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).70–77



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)85–91 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)96–99 (LOE 3)100 (LOE 4)101–104 (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),106–111 (LOE 3),112 (LOE 4),113–117

(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 13–15, with moderate

changed to 9–12. 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 13–15, 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


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)129–134


Spine Blunt carotid

and vertebral

vascular injuries


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) C1–3 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



CT may be used in lieu of plain images to evaluate the C Spine.

(LOE 3),152–158 (LOE 1),159 (LOE 2),160 (LOE 1),161 (LOE 2)162


Aids to identification of atlantooccipital dislocation on spine films including

Power’s 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)178–180 (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


June 2008


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