Blog

ATLS 10th Edition Update
Nicholas McManus

Nicholas McManus

ATLS 10th Edition Update Summary

Print 🖨 PDF 📄

Initial Assessment

  • ABCDE is still the recommended approach – there is no evidence-based data identified to justify modification to this approach in civilian patients.

Fluid Resuscitation

  • Provide only 1 L of WARMED crystalloid fluid for adults (20 cc/kg in children < 40 kg) and move to blood products if patient does not respond to initial fluid. 
    • Aggressive resuscitation before control of bleeding has shown to increase mortality 
  • Massive transfusion should be utilized, if needed
  • Blood should be given in a 1:1:1 ratio
    • 10-20 mL/kg or PRBC’s/FFP/PLT in children
  • TXA is recommended (more on this later)

Airway

  • The term RSI is out…it is now called “Drug Assisted Intubation”
  • RSI is still way easier to say
  • Videolaryngoscopy is beneficial and should be used when able

Shock

Classification of Shock

Recognizing shock is one of the greatest challenges in the management of the injured patient

  • During initial evaluation, shock is identified by evidence of end-organ hypoperfusion.
  • Traditional teachings classify stages of shock based on physiologic variables such as estimated blood loss, heart rate, blood pressure, pulse pressure, respiratory rate and urine output.
  • A retrospective review of trauma patients from the German trauma registry found variables with the traditional classifications and suggest that measurement of base deficit (BD) decreased the variability.
  • Therefore, ATLS 10 now includes base deficit in this classification to assist with determination of need for blood transfusion or the massive transfusion protocol.

Hemorrhage Control

  • Though direct pressure is the first measure instituted to control external hemorrhage in civilian trauma, military experience supports the judicious use of tourniquets placed above the area of injury in uncontrolled hemorrhage. 

Early Use of Blood Products

  • Initial resuscitation with 1 L WARMED crystalloid as we discussed above
  • Use blood products early in patients with evidence of class III and IV hemorrhage.
  • Infusion of more than 1.5 liters of crystalloid fluid has been associated with increased mortality.
  • Patients with severe shock resulting from trauma can present with or develop coagulopathy from blood loss, dilution from large volume crystalloid fluid resuscitation, or hypothermia.
  • Early administration of blood in a low ratio of 1:1:1 for pRBC’s/FFP/Platelets can prevent coagulopathy and thrombocytopenia
  • Need for massive transfusion is defined by > 10 pRRBCs in 24 hours or 4 units in 1 hour.


Tranexamic Acid

  • TXA is beneficial within 3 hours and should be given
  • The benefits are time dependent, so the earlier it is given, the better. 
  • Prehospital TXA is being used in some jurisdictions
  • A large prospective study demonstrated decreased mortality when tranexamic acid is given within three hours of injury.
  • When a 1 gram dose is given in the prehospital setting, a repeat dose of 1 gram over 8 hours is administered in the hospital.
  • Early monitoring of coagulation and replacement of clotting factors can minimize transfusion needs, which is particularly important in patients who are taking anticoagulant medications.

Management of Coagulopathy

  • When available, use Thromboelastography (TEG) or Rotational Thromboelastometry (ROTEM) to pinpoint the precise coagulation deficiency.
  • Consider administering platelets, even when normal platelet count. 

Thoracic Trauma

Life Threatening Injuries

  • Flail chest is out, and tracheobronchial injury is now included

extended FAST (eFAST)

  • When available, tension pneumothorax can be diagnosed using eFAST
  • Appearance of seashore, bar code or stratosphere sign in M mode 

  • Successful decompression is dependent on the needle reaching the thoracic cavity, the patency of the catheter, and the correct identification of the appropriate landmarks.
  • Increasing chest wall thickness has led to recommendations to use longer angiocatheters.
  • Studies of both prehospital and hospital providers have demonstrated that though landmarks can be appropriately recited, they are not always accurately identified.
  • Cadaver studies have shown improved success in reaching the thoracic cavity when the 4th or 5th intercostal space slightly anterior to the mid-axillary line is used instead of the second intercostal space mid-clavicular line in adult patients. ATLS now recommends this location for needle decompression in adult patients. 
  • Location is still the 2nd intercostal space for children. 

Finger Thoracostomy

  • Needle decompression can fail to improve clinical decompensation in patients who have hemothorax or in whom the angiocatheter has kinked.
  • Performing a finger thoracostomy can ensure adequate decompression of the chest and eliminate tension pneumothorax as the cause of decompensation.


Tube Thoracostomy

  • Does Size Matter?
  • Inaba, 2012
    • Prospective analysis
    • 353 chest tubes
    • 28-32 Fr vs 36-40 Fr
    • No difference in…
      • Initial volume drained
      • Complications
      • Reinsertion need
      • Both hemothorax and pneumothorax equivalent is regards to 
         
  • A 28–32 F can effectively drain hemothorax without resulting in increased retained hemothorax and is now recommended in the ATLS 10th edition update. Not 36-40, like it used to be.

Aortic Dissection

  • CTA is now recommended to evaluate for blunt aortic injury.
  • Hemodynamically normal patients with partial injury can now be managed with endovascular techniques.
  • The injury is medically managed with beta blockers to decrease the heart rate (<80 bpm) and mean arterial pressure (60–70 mm Hg).

Traumatic Cardiac Arrest

  • A new algorithm for management of patients presenting in traumatic circulatory arrest is included

Abdomen/Pelvis

Bladder Injury

  • Ball, 2009
    • Retrospective study of 41 patients
    • Blunt trauma specific
    • Results:
      • Digital Rectal Exam: abnormal in 2%
      • Blood at the urethral meatus: present in 20%
      • Hematuria prior too catheter insertion: present in 17%
  • Signs of bladder injury have traditionally included blood at the urethral meatus, perineal ecchymosis, and a high-riding prostate.
  • A high-riding prostate is considered unreliable and not useful in determining which patients should undergo further investigation.
  • DRE remains clinically indicated in patients with penetrating trauma in the vicinity of the rectum, pelvic fractures, and spinal cord injuries…

Pelvic Fractures

  • Cothren, 2007
    • Less blood products when PPP is done
    • 12 units (pre-PPP_ vs 6 units (post-PPP)
    • 75% reduction in need for angiography
    • No deaths from blood loss
    • Lower mortality
  • Preperitoneal pelvic packing to control pelvic hemorrhage from pelvic fractures has been shown to be successful
  • This section was updated to include this option.
  • Flow chart for pelvic fractures and hemorrhagic shock management amended

Head Injury

Glasgow Coma Scale (GCS)

  • GCS calculation 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.
  • Example: GCS 15 (E4, V5, M6)

Early management of the brain-injured patient have been included in the new edition of the ATLS course.

4th Edition Brain Trauma Foundation Guidelines

Systolic Blood Pressure Guidelines

  • >100 mm Hg for patients 50–69 years
  • >110 mm Hg or higher for patients ages 15–49 or older than 70 years

Sedation

  • Propofol recommended for the control of ↑ ICP
    • no improvement of 6 month outcome
  • Avoid prolonged hyperventilation with PC02 <25 mm Hg

Seizure Prophylaxis

  • Phenytoin recommended to decrease incidence of early post-traumatic seizures (within seven days of injury), if benefit is felt to outweigh risks of treatment.
  • Anti-epileptics are NOT recommended for preventing late post-traumatic seizures.
  • Post-traumatic seizure has not been associated with worse outcomes

Goals of Treatment of Brain Injury

Clinical Parameters

  • SBP > 100 mm Hg
  • Temperature 36-38ºC

Monitoring Parameters

  • CPP > 60 mmHg
  • ICP 5-15 mmHg
  • PbtO2 > 15 mmHg
  • Pulse Oximetry > 95%

Lab Values

  • Glucose 80-180
  • Hgb > 7
  • INR < 4
  • Na 135-145
  • PaO2 > 100 mmHg
  • PaCO2 35-45 mmHg
  • pH 7.35-7.45
  • Platelets > 75 x 103/mm3

Anticoagulation Reversal Guidelines

Neuroimaging rules

  • Emphasizes utilizing PECARN rules for pediatric head injury

Spine and Spinal Cord Trauma

  • The term “Spinal Immobilization” is out and “Spinal Motion Restriction” is in

Myotomes

  • A new myotome diagram has been added for simplicity in evaluating the level of motor function or dysfunction.

C-Spine Rules

  • Determining which patients require imaging to evaluate for spine and spinal cord injury is not always straightforward.
  • The Canadian Cervical-Spine Rule (CCR) and the NEXUS provide guidelines that can aid in the decision-making process

thoracic and Lumbar Spinal Rules

  • Unlike C-spine rule, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist
  • This 2015 study of 3,065 patient set out to define features that could be used to develop a clinical decision rule

Musculoskeletal Trauma

Open Fracture Antibiotic Recommendations

  • Antibiotics used to treat open fractures should be dosed based on the patient’s weight to ensure adequate tissue levels are achieved.

Bilateral Femur Fractures

  • Bilateral femur fractures are markers of significant energy mechanism and are risk factors for complications and death in blunt trauma
  • 2 studies, done the same way at the same institution, 15 years apart assessed mortality with femur fractures. Advancements in trauma care and improvements in vehicle safety are likely the reason for improved mortality.
  • However, mortality is still quite high with bilateral injuries
  • Damage control fixation with external fixation is now becoming favored in high risk patients 

Thermal Injuries

Fluid Resuscitation Changes

  • Half of the fluid is given over the course of eight hours and the remaining half is provided over a span of 16 hours.
  • Fluid administration rate should be titrated to effect using a target urine output of 0.5 ml/kg/hr in adults or 1 ml/kg/hr in children who are hemodynamically normal.
  • Fluid boluses are reserved for unstable patients

Trauma in Pregnancy

Indication of amniotic fluid leakage is vaginal fluid ph of > 4.5

Transfer to Definitive Care

  • Performing unnecessary diagnostic tests, particularly computed tomography (CT) scans contribute to de
  • 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
  • Do not perform diagnostic procedures that do not change plan of care
  • However, if needed to stabilize immediate life-threatening conditions, these should be performed. 

ABC-SBAR Template recommended for transfer of patients

Airway, Breathing and Circulation

  • Identify problems and perform interventions

Situation

  • Patient name and age
  • Referring physician name
  • Reporting nurse name
  • Indication for transfer
  • IV access site, fluid and rate
  • Other interventions completed

Background

  • Event history
  • AMPLE assessment
  • Blood product
  • Medications given (date and time)
  • Imaging performed
  • Splinting

Assessment

  • Vital signs
  • Pertinent physical exam findings
  • Patient response to treatment

Recommendation

  • Transport mode
  • Level of transport care
  • Medication intervention during transport
  • Needed assessments and interventions

References used to support this update

  1. Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: Does the digital rectal examination really help us? Injury. 2009;40(9):984-986.
  2. Cancio LC. Initial assessment and fluid resuscitation of burn patients. Surg Clin North Am. 2014;94(4):741-754.
  3. Carcillo JA. Intravenous fluid choices in critically ill children. Curr Opin Crit Care. 2014;20(4):396-401.
  4. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6-15.
  5. Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012;73(5):1273-1277.
  6. Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma. 2006;60(3):553-557.
  7. Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38(6):261-268.
  8. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing for hemodynamically unstable pelvic fracture: A paradigm shift. J Trauma. 2007;62(4):834-839
  9. CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomized controlled trial. Lancet. 2011;377(9771):1096-1101.
  10. Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010;19(4):286-291.
  11. Dressler AM, Finck CM, Carroll CL, Bonanni CC, Spinella PC. Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child. J Pediatr Surg. 2010;45(7):1530-1533.
  12. Gunst M, Ghaemmaghami V, Gruszecki A, et al. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc (Bayl Univ Med Cent). 2010;23(4):349-354.
  13. Hadley MN, Walters BC, Aarabi B, et al. Clinical assessment following acute cervical spinal cord injury. Neurosurgery. 2013;72(Suppl 2):40-53.
  14. Hendrickson JE, Shaz BH, Pereira G, et al. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr. 2012;160(2):204-209.
  15. Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: Comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127-136.
  16. Hurlbert J, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013;72(Suppl 2):93-105.
  17. Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: A cadaver-based study. J Trauma. 2011;71(5):1099-1103.
  18. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422-427.
  19. Inaba K, Nosanov L, Menaker J, et al. Prospective derivation of a clinical decision rule for thoracolumbar spine evaluation after blunt trauma: An American Association for the Surgery of Trauma multi-institutional trials group study. J Trauma. 2015;78(3):459-465.
  20. Ley E, Clond M, Srour M, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70(2):398-400.
  21. Min L, Burruss S, Morley E, et al. A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients. J Trauma Acute Care Surg. 2013;74(4):1125-1132.
  22. Mutschler M, Nienaber U, Brockamp T, et al. Renaissance of base deficit for the initial assessment of trauma patients: A base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®. Crit Care. 2013;17(2):R42.
  23. Neff NP, Cannon JW, Morrison JJ, Edwards MJ, Spinella PC, Borgman MA. Clearly defining pediatric mass transfusion: Cutting through the fog and friction using combat data. J Trauma Acute Care Surg. 2014;78(1):21-28.
  24. Onzuka J, Worster A, McCreadie B. Is computerized tomography of trauma patients associated with a transfer delay to a regional trauma centre? CJEM. 2008;10(3):205-208.
  25. Osborn PM, Smith WR, Moore EE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54-60.
  26. O’Toole RV, Lindbloom BJ, Hui E, et al. Are bilateral femoral fractures no longer a marker for death? J Orthop Trauma. 2014;28(2):77-81.
  27. Quick JA, Bartels AN, Coughenour JP, et al. Trauma transfers and definitive imaging: Patient benefit but at what cost? Am Surg. 2013;79(3):301-304.
  28. Roberts D, Leigh-Smith S, Faris P, et al. Clinical presentation of patients with tension pneumothorax: A systematic review. Ann Surg. 2015;261(6):1068-1078.
  29. Schmitt SK, Sexton DJ, Baron EL. Treatment and prevention of osteomyelitis following trauma in adults. UpToDate. www.uptodate.com/contents/treatment-and-prevention-of-osteomyelitis-following-trauma-in-adults. Accessed April 12, 2018.
  30. Shrestha B, Holcomb JB, Camp EA, et al. Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury. J Trauma. 2015;78(2):336-341.
  31. Snyder D, Tsou A, Schoelles K. Efficacy of prehospital application of tourniquets and hemostatic dressings to control traumatic external hemorrhage. Washington, DC: National Highway Traffic Safety Administration; May 2014.
  32. Steinhausen E, Lefering R, Tjardes T, et al. A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: An analysis based on the trauma registry of the German Trauma Society. J Trauma. 2014;76(5):1288-1293.
  33. Sussman M, DiRusso SM, Sullivan T, et al. Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma. 2002;53(2):219-224.
  34. United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Ageing. Available at: www.un.org/esa/population/publications/worldageing19502050/. Accessed April 12, 2018.
  35. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2013;60(Suppl 1):82-91.
  36. Washington CW, Grubb RL, Jr. Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? J Neurosurg. 2012;116(3):549-557.
  37. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17.
Want updates in your inbox?
I agree to have my personal information transfered to MailChimp ( more information )
Subscribe and receive email alerts when new topics are published.
We hate spam. Your email address will not be sold or shared with anyone else.
Nicholas McManus
Latest posts by Nicholas McManus (see all)

Share this post

Share on facebook
Share on google
Share on twitter
Share on print
Share on email