ATLS 8e, The Evidence for Change

ATLS 8e, The Evidence for Change from Sun YaiCheng

J trauma. Volume 64(6). June 2008.1638-1650

ATLS 2008
New Topic or New Change

Airway
Laryngeal tube airway (LTA)
Gum Elastic Bougie
Difficult airway (maxillofacial trauma, limited mouth opening and anatomical variation such as receding chin, overbite, or a short thick neck.)

Fluid resuscitation
The use of resuscitation fluids 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.

In penetrating trauma with hemorrhage, delaying aggressive fluid resuscitation until definitive control may prevent additional bleeding.
“Controlled resuscitation,” “Balanced Resuscitation,” “Hypotensive Resuscitation” and “Permissive Hypotension.”

Treatment of cardiac tamponade
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

ED thoracotomy
A patient sustaining a penetrating wound, who has required CPR 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.

Hemo-dynamically abnormal pelvic fractures
Intraabdominal sources of hemorrhage must be excluded or treated operatively.

Canadian CT Head Rule for patients with minor head injury
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

• Failure to reach GCS of 15 within 2 h
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (haemotympanum, racoon eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign)
• Vomiting >2 episodes
• Age >65 years
• Amnesia before impact >30 min
• Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or 5 stairs)

Penetrating brain injury

Blunt carotid and vertebral vascular injuries (BCVI)
Suggested criteria for screening include:

• C1–3 fracture
• C -spine fracture with subluxation
• Fractures involving the foramun transversarium

CT evaluation of the cervical spine

Atlanto-occipital dislocation
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.