Atls guidelines 8th edition

Drug-assisted intubation has now replaced rapid sequence intubation RSI as the broad term that describes the use of drugs to assist intubation and the intubation process itself in trauma patients with intact gag reflexes.

Videolaryngoscopy has also been highlighted for its usefulness in trauma patients requiring definitive airways. The infusion of greater than 1. For this reason, the early use of blood products is advocated, and there is no place for the infusion of large volumes of crystalloid fluid in trauma patients. Massive transfusion should be utilised if needed and is defined as the transfusion of more than 10 units of blood in 24 hours, or more than four units of blood in one hour.

Early resuscitation with blood and blood products in low ratios is recommended in patients with evidence of Class III and IV haemorrhage. Following the results of several important trials, including the landmark CRASH-2 study , tranexamic acid is now recommended within 3 hours at a loading dose of 1 g IV over 10 minutes, followed by 1 g infused over eight hours.

In some areas, tranexamic acid is also being used in the pre-hospital setting. The life-threatening thoracic injuries have been modified, flail chest being replaced by tracheobronchial tree injury.

The life-threatening thoracic injuries are now:. Traditionally needle thoracocentesis has been performed by inserting a large-bore needle or cannula into the 2nd intercostal space in the mid-clavicular line of the affected hemithorax.

Cadaver studies , however, have shown improved success in reaching the thoracic cavity when the 4th or 5th intercostal space in the mid-axillary line is used instead of the 2nd intercostal space in the mid-clavicular line in adult patients. ATLS now recommends this location for needle decompression in adult patients. The location in children remains unchanged, and the 2nd intercostal space in the midclavicular line should still be used.

Needle thoracocentesis is a temporising measure only, and definitive treatment remains the insertion of a chest drain.

The focused abdominal sonography for trauma FAST technique has been modified to include an evaluation of the thoracic cavity for the presence of air, which can aid in the rapid diagnosis of pneumothorax.

A new algorithm outlining the management of patients presenting in traumatic circulatory arrest is also included in the thoracic trauma chapter.

This algorithm is shown below:. A high-riding prostate on digital rectal examination has traditionally been included as part of the evaluation or urethra and bladder injury. This is no longer considered an accurate or useful determiner and is no longer recommended. Recent success using preperitoneal pelvic packing in patients with haemodynamic instability due to severe pelvic fractures has led to its inclusion in the management of haemorrhage algorithm.

Elderly patients that are anticoagulated are becoming an increasingly large trauma patient demographic. In view of this, an anticoagulation reversal table is now included in the guidance. A revised version of the Glasgow Coma Scale GCS has been introduced, the scale remains the same, but there has been clarification added for the terms used, and the importance of reporting the numerical components of the score is stressed.

A new designation, NT not testable , has also been added and should be used when a component of the score cannot be assessed. More detailed guidance on systolic blood pressure management and seizure prophylaxis is now also included. Determining which patients require imaging to evaluate for spine and spinal cord injury can be challenging in the trauma setting.

Fluid resuscitation in burns has been adjusted to mirror the changes in trauma fluid resuscitation. The first half of the fluid should be given over the course of eight hours, and the remaining half is provided over a span of 16 hours.

The rate of fluid administration should be titrated to effect using a target urine output of 0. Fluid boluses should be reserved for use in unstable patients only. Hemodynamically normal patients with partial injury are now managed with endovascular techniques. A new algorithm for management of patients presenting in traumatic circulatory arrest is included in chapter 4, Figure 4—7 reproduced here as Figure 1.

In addition to a discussion of blunt and penetrating mechanisms of injury, the 10th edition includes a discussion of injury resulting from explosive forces. The signs of bladder injury have historically included blood at the urethral meatus, perineal ecchymosis, and a high-riding prostate on physical examination.

Today, the high-riding prostate indicator is considered unreliable and not useful in determining which patients should undergo further investigation. Given the successful use of preperitoneal pelvic packing to control pelvic hemorrhage from pelvic fractures, this section was updated to include this option.

Elderly patients suffering ground-level falls are an increasing trauma patient demographic. Many of these patients are treated with anticoagulation, and the use of these medications should be relayed to consulting neurosurgeons.

This version of the GCS stresses reporting the numerical components of the score and adds a new designation, NT not testable , to be used when a component of the score cannot be assessed. Phenytoin is recommended to decrease the incidence of early posttraumatic seizures within seven days of injury. Determining which patients require imaging to evaluate for spine and spinal cord injury is not always straightforward. Bilateral femur fractures are markers of significant energy mechanism and are risk factors for complications and death in blunt trauma.

Table 8. Modern burn resuscitation has mirrored the changes in trauma fluid resuscitation. Half of the fluid is given over the course of eight hours and the remaining half is provided over a span of 16 hours.

The rate of fluid administration should be titrated to effect using a target urine output of 0. Boluses are reserved for unstable patients. The recommendation for the site for needle decompression of the chest continues to be the second intercostal space mid-clavicular line in this new edition.

Damage control resuscitation for pediatric trauma patients is defined as an attempt to limit the use of crystalloid resuscitation, as in adults. Thus far, no survival advantage has been demonstrated with this approach. Nearly every country in the world is experiencing a growth in the proportion of older people in their population. The elderly are becoming an increasingly prevalent demographic among trauma patients.

The following five preexisting conditions affect morbidity and mortality:. Elderly patients with one or more of these preexisting conditions are twice as likely to die as those without. Pelvic fractures in older patients result in a greater need for transfusion even with stable patterns of injury.

The mortality is four times higher with these injuries, hospital stays are longer, and these patients may not return to independent lifestyles. Performing unnecessary diagnostic tests, particularly computed tomography CT scans, may produce such delays. All too frequently, CT scans done before transfer to definitive care are repeated, resulting in time delays to definitive treatment, increased radiation exposure, and increased cost of care.

Clear communication between transferring and receiving institutions is important. SBAR also known as situation, background, assessment, and recommendations is a useful guide to ensure all important information is relayed. Successful care of the injured patient requires not only knowledge of ATLS but also coordinated care by a team using these principles. This Optional Chapter highlights the way the ATLS team can effectively work to deliver care using the ATLS model—stressing the role of the trauma team leader and effective two-way communication.

All ATLS faculty coordinators, educators, instructors, and course directors must be aware of these content updates to be eligible to teach and facilitate 10th edition courses. In addition to the content changes summarized in this article, a number of other changes in the conduct and organization of the course have been implemented. To learn about these changes, an in-person or online update must be completed. In-person updates are encouraged and may be offered by faculty who have been trained in the updates at the regional, state, or site level.

In the summer of , an online update course through the ACS learning management system will be available for those individuals who are unable to attend an in-person update. Continuing Medical Education CME credits will be offered for the online update and may be offered for the in-person update if the CME award schedule and documentation compliances are followed by the site hosting the update course.

Once the faculty member has completed training, a link to a multiple-choice examination will be sent via e-mail for completion. The list of those who contributed to this new edition is too lengthy to accurately detail here, but on behalf of the entire ACS COT, the author extends a sincere thank you. Traumatic urethral injuries: Does the digital rectal examination really help us? 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.

Levels of Evidence. Retrospective cohort study Systematic review of level 3 studies 4 5 Case series Expert opinion Case series Expert opinion Systematic review of level 3 studies Casecontrol study Poor reference standard Expert opinion Systematic review of level 3 studies No sensitivity analyses Expert opinion. Rectal examination 7th Edition A rectal examination should be performed before inserting a urinary catheter 8th Edition 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 highriding prostate, the presence of pelvic fractures, the integrity of the rectal wall, and the quality of the sphincter tone. Carbon dioxide detectors 7th Edition A CO2 detector colorimetric CO2 monitoring device is indicated to help confirm proper intubation 8th Edition A CO2 detector ideally capnography but if not available by a colorimetric CO2 monitoring device is indicated to help confirm proper intubation of the airway.

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.

When a patient has an LMA in place on arrival in the emergency department, the doctor must plan for definitive airway. The LTA is not a definitive airway device and plans to provide a definitive airway must be implemented. It is a 60 cm long, 15 French intubating stylette. The ETTI is employed when vocal cords cannot be visualized on direct laryngoscopy.

Difficult airway 7th Edition New material 8th Edition 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.

Crystalloid 7th Edition Warmed isotonic electrolyte solutions are used for initial resuscitation. Lactate ringers RL is the initial fluid of choice. Normal saline is the second choice. An alternative initial fluid is hypertonic saline although current literature does not demonstrate any survival advantage. Assess the patients response to fluid resuscitation and evidence of adequate end organ perfusion. 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 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. 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. 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.

Treatment of cardiac tamponade 7th Edition Pericardiocentesis is the initial management of traumatic tamponade 8th Edition 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.

Serial measurement of these parameters can be used to monitor the response to therapy. ED thoracotomy 7th Edition 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. 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. Blunt traumatic aortic injury 7th Edition New material 8th Edition Techniques of endovascular repair are rapidly evolving as an alternate approach for surgical repair of blunt traumatic aortic injury.

Explosive devices 7th Edition New Material 8th Edition Explosive devices cause injuries through several mechanisms. A systematic, concise approach to the early care of trauma patients is the hallmark of the ATLS Program. The Preface and Acknowledgments sections of this book contain the names and affiliations of these individuals. The COT believes that the people who are responsible for caring for injured patients will find the information extremely valuable.

The principles of patient care presented in this manual may also be beneficial to people engaged in the care of patients with nontrauma-related diseases. Injured patients present a wide range of complex problems.