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    Mahesh Rajwal
    The ATLS update 2018 document provides revisions to trauma management guidelines including: 1) Emphasizing early use of blood products for class III and IV hemorrhage and monitoring coagulation with thromboelastography. 2) Updating guidelines for traumatic brain injury to classify injuries as mild, moderate or severe based on Glasgow Coma Scale and maintain systolic blood pressure at 100-110 mmHg depending on age. 3) Revising guidelines for managing potential spinal cord injuries to restrict spine motion rather than immobilization and using clinical decision rules to determine need for cervical spine imaging.

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    Atls

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    Mahesh Rajwal
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    The ATLS update 2018 document provides revisions to trauma management guidelines including: 1) Emphasizing early use of blood products for class III and IV hemorrhage and monitoring coagulation with thromboelastography. 2) Updating guidelines for traumatic brain injury to classify injuries as mild, moderate or severe based on Glasgow Coma Scale and maintain systolic blood pressure at 100-110 mmHg depending on age. 3) Revising guidelines for managing potential spinal cord injuries to restrict spine motion rather than immobilization and using clinical decision rules to determine need for cervical spine imaging.

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    The ATLS update 2018 document provides revisions to trauma management guidelines including: 1) Emphasizing early use of blood products for class III and IV hemorrhage and monitoring coagulation with thromboelastography. 2) Updating guidelines for traumatic brain injury to classify injuries as mild, moderate or severe based on Glasgow Coma Scale and maintain systolic blood pressure at 100-110 mmHg depending on age. 3) Revising guidelines for managing potential spinal cord injuries to restrict spine motion rather than immobilization and using clinical decision rules to determine need for cervical spine imaging.

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    199 views32 pages

    Atls

    Uploaded by

    Mahesh Rajwal
    The ATLS update 2018 document provides revisions to trauma management guidelines including: 1) Emphasizing early use of blood products for class III and IV hemorrhage and monitoring coagulation with thromboelastography. 2) Updating guidelines for traumatic brain injury to classify injuries as mild, moderate or severe based on Glasgow Coma Scale and maintain systolic blood pressure at 100-110 mmHg depending on age. 3) Revising guidelines for managing potential spinal cord injuries to restrict spine motion rather than immobilization and using clinical decision rules to determine need for cervical spine imaging.

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    of 32

    ATLS UPDATE 2018

    DR. ADITI RANAUT


    JUNIOR RESIDENT III
    DEPTT. OF ANAESTHESIA
    INITIAL ASSESSMENT
     GOLDEN HOUR- First hour after injury will largely
    determine a critically injured person’s chances for
    survival.
     Its not a strictly defined time period, for some patients
    it can be minutes.
     PLATINUM 10 MINUTES- latest concept.
     “SCOOP AND RUN” approach to pre hospital care
    rather than “STAY AND PLAY”.
    AIRWAY AND VENTILAION
    • RSI changed to Drug Assisted Intubation.
    • Use of video-laryngoscopy.
    • NEW CONCEPT- PARAOXYGENATION.
    • C-spine immobilization changed to Restriction
    of spine motion.
    SHOCK
    • Class of haemorrhage table amended: Base deficit included.
    • Bolus of isotonic solution 1L for adults and 20ml/kg for
    paediatric patients(<40kg).
    • Early use of blood and blood products.

    • Give blood 1:1:1 as part of a massive transfusion protocol.

    • Tranexamic acid- over 10 minutes with in 3 hours of injury.


    • Management of coagulopathy- uncontrolled bleeding in patients
    taking anticoagulants or antiplatelet medication.
    • Monitor coagulation with thromboelastography or rotational
    thromboelastometry.
    ATLS classification of
    hypovolemic shock

    *
    Early use of blood and blood
    products
     Early resuscitation with blood and blood products must
    be considered in patients with evidence of class III and
    IV hemorrhage.
     Early administration of blood products at a low ratio of
    packed red blood cells to plasma and platelets can
    prevent the development of coagulopathy and
    thrombocytopenia.
    Management of coagulopathy
     Uncontrolled blood loss can occur in patients
    taking antiplatelet or anticoagulant medications.
     Prevention
     Obtain medication list as soon as possible.
     Administer reversal agents as soon as possible.
     Where available, monitor coagulation with
    thromboelastography (TEG) or rotational
    thromboelastometry (ROTEM).
     Consider administering platelet transfusion,
    even with normal platelet count.
    Tranexamic acid (TXA)
    European and American military studies
    demonstrate improved survival when
    TXA is administered over 10 minutes
    within 3 hours of injury.
    When bolused in the field, follow up
    infusion TAX 1 gram over 8 hours in
    the hospital.
    THORACIC TRAUMA
    • Life Threatening Injuries
    Tracheobronchial injury( Flail chest out)
    • Tension pneumothorax-
    e FAST: seashore sign, stratosphere sign in M-mode.
    • Needle thoracocentesis
    - 5th ICS MAL for adult
    - UNCHANGED 2nd ICS for child
    • 28-32 Fr chest drain for hemothorax (not 36-40 Fr).
    • Algorithm for circulatory arrest approach
    • Aortic rupture management with Beta Blocker
    Goal heart rate<80 b/min and MAP= 60-70 mmHg.
     CARDIAC TEMPONADE- Emergency thoracotomy
    or sternotomy.
     If surgical intervention is not possible- therapeutic
    pericardiocentesis.
    Life-threatening injuries during
    primary survey
    Airway
    • Airway Obstruction
    • Tracheobronchial Tree Injury

    Breathing
    • Tension Pneumothorax
    • Open Pneumothorax

    Circulation
    • Massive Hemothorax
    • Cardiac Tamponade
    • Traumatic Circulatory Arrest
    Algorithm for
    management of
    traumatic
    circulatory arrest.
    ECM = external cardiac
    massage;
    OTI = orotracheal
    intubation;
    IVL = intravenous line;
    IOL = intraosseous line.
    ABDOMINAL AND PELVIC
    TRAUMA
    • Palpation of prostate gland no longer recommended for
    urethral injury.
    HEAD INJURY
    • CLASSIFICATION- “ MINOR” traumatic brain injury
    changed to “MILD” traumatic brain injury-
    • Mild(GCS 13-15), Moderate(GCS 9-12),Severe(GCS<8).
    GLASGOW COMA SCALE-
     PAIN is replaced by PRESSURE.
     Addition of NON- TESTABLE.
    • SBP MANAGEMENT-
    Maintain SBP at ≥ 100 mmHg for patients 50-69 years
    SBP≥ 110 mmHg for patients 15-49 years or older than 70
    years.
    • SEIZURE PROPHYLAXIS- Phenytoin (decrease incidence
    of early post traumatic seizure)
    • Prophylactic use of phenytoin or valproate is not
    recommended for preventing late post traumatic seizures.
    Dr.abd elaal elbahnasy Egypt
    MANAGEMENT PRINCIPLES OF ICP
     The main goal for patients with TBI is to control ICP.
     INDICATIONS OF ICP MONITORING-
     Severe TBI,GCS<8, abnormal CT scan.
     GCS=<8 and normal CT but with adverse features- age>40
    yrs, SBP<90mmHg, U/L or B/L posturing.
     Moderate TBI if abnormal CT.
     Patient with GCS >8- prolonged anaesthesia for surgery for
    multiple injuries.
     CPP goals are redefined to be kept between 60 mmHg –
    70mmHg ( previous recommendations were to maintain
    CPP at or above 70mmHg).
     OSMOTIC THERAPY-
     Mannitol – 20 or 25 percent solution.
     Dose - .25-1g/kg
     Hypertonic saline alone or in combination with dextran
    (if intracranial hypertension refractory to mannitol
    therapy).
     VENTILATION STRATEGIES- NORMOCARBIA
    should be maintained.
    Goals of treatment of
    brain injury
    Clinical Parameters Laboratory Parameters
    • Systolic BP ≥ 100 mmHg • Glucose 80–180 mg/dL
    • Temperature 36–38°C • Hemoglobin ≥ 7 g/dl
    • INR ≤ 1.4
    Monitoring Parameters • Na 135–145 meq/dL
    • CPP ≥ 60 mm Hg* • PaO2 ≥ 100 mmHg
    • ICP 5–15 mm Hg* • PaCO2 35–45 mmHg
    • PbtO2 ≥ 15 mm Hg* • pH 7.35–7.45
    • Pulse oximetry ≥ 95% • Platelets ≥ 75 X103/mm3
    *Unlikely to be available in the EDor in low-resourcesettings
    Data from ACSTQIPBest Practices in the Management of Traumatic BrainInjury.
    ACSCommittee on Trauma, January 2015.
    Anticoagulation reversal guidance
    Spine and
    Spinal Cord Trauma
    • C-spine protection changed to ‘Restriction of
    spinal motion’
    • New myotome diagram
    • Canadian C-Spine Rule (CCR) and NEXUS Criteria
    used to
    evaluate the
    level of motor
    function
    Musculoskeletal
    Trauma
    • Weight based IV antibiotic regime
    • Highlighting risk factor of bilateral femur fractures
    • Trauma team
    Highlighting risk factor of bilateral
    femur fractures
    Compared with patients with unilateral
    femur fractures, patients with bilateral
    femur fractures are at higher risk for
    significant blood loss, severe associated
    injuries, pulmonary complications, multiple
    organ failure, and death.
    Paediatric Trauma
    • Needle thoracocentesis UNCHANGED
    2nd ICS.

    • Pediatric Emergency Care Applied Research Network


    (PECARN) Criteria for Head CT
    • Trauma team
    Pediatric Mass Transfusion
    Protocol

     Initial 20 mL/kg bolus of isotonic crystalloid followed


    by weight-based blood product resuscitation with 10-20
    mL/kg of RBC and 10-20 mL/kg of FFP and platelets.
    Pediatric Emergency Care Applied Research Network
    (PECARN) Criteria for Head CT. Suggested CT algorithm for
    children younger than 2 years (A) and for those aged 2 years
    and older (B) with GCS scores of 14-15 after head trauma.*

    Identification of children at very low risk of clinically important brain injuries


    after head trauma: a prospective cohort study. Lancet 374: 2009; 1160–1170.)
    Thermal Injuries
    • 2 ml/kg × weight × % burn adults
    • 3 ml/kg × weight × % burn children
    • Fluid titrated to urine output.
    ABC-SBAR FOR TRANSFER
    OF PATIENT
    • Weight based IV antibiotic regime.
    • Specific mention of avoiding CT scan in primary hospital.
    • Airway, Breathing and Circulation maintained.
    • Situation: patient name, age, referring facility, referring
    physician name, reporting nurse name, indication for
    transfer, IV access site, IV fluid and rate and others.
    • Background: event history, AMPLE assessment, blood
    products, 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

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