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Advanced Trauma Life Support, 8th Edition, The Evidence For Change
Advanced Trauma Life Support, 8th Edition, The Evidence For Change
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OBJECTIVES
a. To present the content changes in the 8th edition of the
ATLS course.
b. To present the supporting evidence evaluated by the
ATLS subcommittee.
METHODS
In 2007, the COT increased international participation
by creating three new international regions. These regions
were also invited to appoint representatives to the ATLS
subcommittee. The revision process for the 8th edition was
broadcasted through the International ATLS subcommittee
membership, through Trauma.Org, a dedicated trauma interest web site with broad international subscription as
well as being disseminated through major North American
stakeholders including the AAST.
Contributors were asked to submit proposed changes by
chapter along with supporting evidence to the ATLS office
through http://www.trauma.org/ or directly through http://
web.facs.org/atls/atlscourserevisionsdefault.htm. Many systems to classify medical evidence have been published and
promoted over the past 15 years. The system by Wright
et al.8 12 was chosen as it has been adopted by several
prominent journals, is easily interpreted and appears to have
a high rate of interobserver agreement (Table 1).
The compilation of suggested changes was then reviewed by the ATLS subcommittee in serial meetings in
2006/2007 leading to the final revisions. An expert panel
assigned a level of evidence rating to each reference cited
in the compendium of changes13205 (Table 2). The ATLS
subcommittee did not perform systematic reviews on all
suggested changes and in many cases evidence for formal
systematic review was lacking. The committee did incorporate these reviews when available. The emphasis on one
safe way was used to guide approval of these changes
particularly where the level of supporting evidence was
poor. The ATLS course will not be at the sharp edge of
changes in trauma assessment, resuscitation, and adoption
of new technology. It will serve as a common baseline for
continued innovation and challenge of existing paradigms
in trauma care. The revision process was also cognizant of
significant regional variation in practice. Once again it is
hoped that wherever these deviate significantly from
course content that they will foster well designed trials to
evaluate and support alternate and new approaches to
trauma care.
Prognosis
Diagnosis
Systematic reviews of
level 1 studies
Prospective cohort, poor
quality RCT
Systematic review of
level 1 studies
Retrospective study,
untreated controls
from a previous RCT
Systematic review of
level 1 studies
Development of diagnostic
criteria on basis of
consecutive patients
against a gold standard
Systematic review of
level 2 studies
Systematic reviews of
level 2 studies
Casecontrol study
Systematic review of
level 2 studies
Study of nonconsecutive
patients (no consistently
applied gold standard)
Retrospective cohort
study
Systematic review of
level 3 studies
Case series
Case series
Expert opinion
Expert opinion
Level of
evidence
1
Systematic review of
level 3 studies
Casecontrol study
Poor reference standard
Expert opinion
Systematic review of
level 3 studies
No sensitivity analyses
Expert opinion
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Shock
Carbon dioxide
detectors
Airway
New material*
Difficult airway
New Material*
Gum Elastic
Bougie
New material*
Crystalloid
7th Edition
Laryngeal tube
airway
Laryngeal mask
airway (LMA)
Rectal examination
Subject
Initial
assessment
Chapter
8th Edition
June 2008
Volume 64 Number 6
Thoracic trauma
Chapter
Angio-embolization
and definitive
control of
hemorrhage
Treatment of
cardiac
tamponade
Emergency
Department
thoracotomy
Treatment of
pneumothorax
7th Edition
Subject
Fluid resuscitation
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. 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)8591 Multiple reports confirm that emergency
department (ED) thoracotomy for patients with blunt trauma and cardiac
arrest is rarely effective.
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Head trauma
Abdomen
Chapter
New material*
Penetrating brain
injury
Hemo-dynamically
abnormal pelvic
fractures
Classification and
head CT
New Material*
New material*
7th Edition
Explosive devices
Blunt traumatic
aortic injury
Subject
8th Edition
June 2008
Volume 64 Number 6
Pediatric trauma
Trauma in
women
Musculoskeletal
trauma and
extremity
trauma
Spine
Chapter
New material*
New material*
Abdominal imaging
CT
New material*
Airbags
Functional
outcome
New material*
Restraints
Compartment
syndrome
New material*
Steroids
CT evaluation of
the cervical
spine
Atlantooccipital
dislocation
Tourniquet
New material*
7th Edition
Blunt carotid
and vertebral
vascular injuries
(BCVI)
Subject
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) C13 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
2)151
8th Edition
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New material*
Abdominal bruising
New appendix and optional lecture
New material*
7th Edition
Abdominal imaging
FAST
Subject
There is little evidence at present, other than case reports and expert opinion,
to support and guide current practice in disaster medicine. However, case
reports of recent mass casualty events involving physical trauma,
systematic review of previous reports and computer modeling of likely
disaster scenarios have all been helpful in developing the rationale for
current approaches to the medical and surgical response to injured patients
in disasters. (LOE 3)98,194196 (LOE 5)197205
8th Edition
* New material: This content was not included in the 7th edition.
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.
Disaster
Chapter
June 2008
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Volume 64 Number 6
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APPENDIX
From the Department of Surgery (J.B.K.), University of
Calgary and Calgary Health Region, Calgary, Alberta; General Surgery/Trauma (J.A.), Department of Surgery (F.B.),
University of Toronto, Toronto, Ontario; Trauma Services
(M.V.W.), University of Alberta Hospitals, Edmonton, Alberta, Canada; Academic Affairs Department (S.A.A.T.) and
Department Orthopedic Surgery (W.T.), King Abdulaziz
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June 2008