7/28/2019

ATLS 10TH EDITION

A CLINICAL UPDATE
Nicholas McManus
• Emergency Medicine
• WMEMR Core Faculty
• Banana Bag EM Blog founder

I have NO financial disclosure or

conflicts of interest with the
presented material in this
presentation.

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Initial
Assessment

INITIAL ASSESSMENT

no evidence based data identified to justify modification to this approach

in civilian patients.

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INITIAL ASSESSMENT
Peds Adult

1 L of crystalloid Blood Early (1:1:1 ratio) TXA

20 cc/kg < 40 kg 10-20 mL/kg of RBC/FFP/Plt

Airway

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AIRWAY

Rapid Sequence Drug Assisted

Intubation Intubation

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Shock

Mutschler, 2013

Signs and Symptoms of Hemorrhage by Class

PARAMETER CLASS I CLASS II CLASS III CLASS IV
Blood loss < 15% 15-30% 31-40% > 40%
HR
BP
PP
RR
UO
GCS
Base Deficit 0 to -2 -2 to -6 -6 to -10 -10 or less
Need for blood? Monitor Possible Yes Massive Transfusion

Mortality: 7% 51%

Transfused Blood: 1.5 units 20.3 units

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Damage Control Resuscitation

1L
warmed

87-100% survival if Increased mortality Switch to blood Prevent/reverse

used pre-hospital (OR 2.89) when products early coagulopathy
> 1 L given (1:1:1 ratio) (Rotem/TEG)
> 4 units in ED = MTP

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PROMMTT (2013) PROPPR (2015)

• Ratios of less than 1:2 • 1:1:1 vs 1:1:2

had 3-4x increased
mortality than 1:1 • Reduced mortality from
1 1 1
• Only mattered in the
first 24 hours
: : bleeding in first 24 hours
(RRR 25%)

• Overall mortality at 24 hr
• After 24 hours, ratios and 30 days not different
unassociated with
mortality

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CRASH-2 TRIAL
Decreased Mortality 1 gram over 10 minutes
< 1 hr = RR 0.68
1-3 hr = RR 0.79 Give within 3 hours of injury

Increased Mortality
> 3 hr = RR 1.44 Repeat 1 gram over 8 hours in
hospital

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THROMBOELASTOGRAPHY

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Thoracic
Trauma

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LIFE THREATENING INJURIES

Tracheobronchial Injury Flail Chest

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LIFE THREATENING INJURIES

- Airway Obstruction - Tension Pneumothorax - Cardiac Tamponade

- Tracheobronchial Tree Injury - Open Pneumothorax - Traumatic Circulatory Arrest
- Massive Hemothorax

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E-FAST

1 Sub-xiphoid

5 6 2 RUQ US vs CXR
1
for pneumothorax
3 LUQ
2 3
4 Pelvis
Sn 86-98% 28-75%
5 Right Thorax Sp 98-100% 100%
6 Left Thorax
4

Wilkerson, 2010

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NEEDLE DECOMPRESSION

14G 3.25 inch

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NEEDLE DECOMPRESSION

4.5 cm 3.5 cm
57.5% 100%

20 cadavers
(40 attempts)
Inaba, 2011

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ADULT PEDIATRIC

5th ICS MAL 2nd ICS MCL

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FINGER THORACOSTOMY

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CHEST THORACOSTOMY

Does size matter?

• Prospective trial
• 353 chest tubes

28-32 Fr
• 28-32 Fr vs 36-40 Fr
• No difference in…
• Initial volume drained
• Complications
• Reinsertion need
• Hemo vs pneumo

Inaba, 2012

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AORTIC DISSECTION

Blunt Aortic Injury → CTA

Beta Blockers!
→ HR < 80 bpm
→ MAP 60-70 mmHg

Hemodynamically stable → possible endovascular repair

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TRAUMATIC CARDIAC ARREST

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TRAUMATIC CARDIAC ARREST

Operating room with surgeon present is mandatory

First 2 minutes CPR, IV/IO, Fluids, Epi

Bilateral Chest Decompression

First 3 minutes
Anterolateral or Clamshell Thoracotomy
Thoracic injury Abdominal injury
with vertical pericardiotomy

Direct repair Clamp aorta

Death when > 30 min and temp > 33C

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Abdomen/
Pelvis

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DIGITAL RECTAL EXAM FOR URETHRAL INJURY

Ball, 2009
• Retrospective review of 41 patients
• Blunt trauma specific

Results
• DRE: 2%
• Blood at the urethral meatus: 20%
• Hematuria prior to catheter insertion: 17%

“DRE remains clinically indicated in patients with penetrating

trauma in the vicinity of the rectum, pelvic fractures, and spinal
cord injuries…”

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PREPERITONEAL PELVIC PACKING

Cothren, 2007 “PPP is a rapid method for controlling pelvic

• 12 units (pre-PPP) vs 6 units (post-PPP) fracture-related hemorrhage that can supplant
• 75% reduction in need for angiography the need for emergent angiography.”
• No deaths from blood loss
• Lower mortality

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Head
Injury

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GLASGOW COMA SCALE

GCS 15 (E4, V5, M6)

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4TH EDITION BRAIN TRAUMA FOUNDATION GUIDELINES

Avoid prolonged hyperventilation with PC02 <25 mm Hg

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 increased ICP
 no improvement of six-month outcomes
Seizure Prophylaxis
 Phenytoin recommended to decrease incidence of early posttraumatic seizures
(within seven days of injury).
 Not recommended for preventing late posttraumatic seizures.
 Posttraumatic seizure has not been associated with worse outcomes (IIA)

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GOALS OF TREATMENT OF BRAIN INJURY

Clinical Parameters Lab Values

 SBP >100 mm Hg  Glucose 80-180
 Temperature 36-38 C  Hgb > 7
 INR < 1.4

Monitoring Parameters  Na 135-145

 CPP > 60 mmHg  PaO2 > 100 mmHg

 ICP 5-15 mmHg  PaCO2 35-45 mmHg

 PbtO2 > 15 mmHg  pH 7.35-7.45

 Pulse Oximetry > 95%  Platelets > 75 x 103/mm3

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HEAD INJURY ON ANTICOAGULATION

Admission for neurologic observation

• All supra-therapeutically anticoagulated patients
• CT abnormality

Anticoagulation Reversal
• Consideration given to short term reversal of anticoagulation

Timing of repeat Head CT

• At at 12 to 18 hours
• or when even subtle signs of neurologic worsening occurs

Cohen, 2006

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ANTICOAGULATION REVERSAL GUIDELINES

Antiplatelets Platelets, consider DDAVP

Coumadin FFP, Vit. K, PCC, Factor VIIa

Heparin Protamine sulfate

Pradaxa Praxbind, PCC

Xarelto/Eliquis PCC

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PECARN

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PECARN

Is exam abnormal? Get Head CT

- LOC > 5 seconds

- Hematoma (anything but frontal)
- Headache (severe) YES Shared
- Vomiting Discussion
- Severe Mechanism (think c-spine)
- Parental GCS < 15

NO

Don’t get CT
“Larry Hits Head,Very Scared Parents”

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Spine and
Spinal Cord

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SPINE AND SPINAL CORD

Spinal Spinal Motion

Immobilization Restriction

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NEW MYOTOME DIAGRAM

Muscle Strength Grading Myotomes

Score Result C5 Elbow flexors (biceps)
0 Total paralysis C6 Wrist extensors
1 Palpable or visible contraction C7 Elbow extensors (triceps)
2 Full range of motion with gravity eliminated C8 Finger flexors
3 Full range of motion against gravity T1 Finger abductors
4 Full range of motion, but < normal strength L2 Hip flexors
5 Normal strength L3 Knee extensors
NT Not testable L4 Ankle dorsiflexion
L5 Long toe extensors
“Key myotomes are used to evaluate the S1 Ankle plantar flexors
level of motor function…”

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CERVICAL SPINE TRAUMA

Canadian C-Spine Rule (CCR)

Dangerous Mechanisms
1. Age > 65 years • Fall from > 1 meter/5 stairs
• Axial load of head
2. Dangerous mechanism • MVC with ejection, rollover, > 60 mph
3. Paresthesias in extremities • Motorized recreational vehicle collision
4. Rotate neck 45 degrees left and right • Bicycle collision

Low risk factors (prior to assessing ROM)

Imaging indicated if any present
Simple rear-end MVC
Sitting position in ED
Ambulatory at any time
Delayed onset of neck pain
No midline cervical tenderness
Stiell, 2003

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CERVICAL SPINE TRAUMA

NEXUS Criteria

N - Neuro deficit
E - EtOH (alcohol)/intoxication
X - eXtreme distracting injury
U - Unable to provide history (altered LOC)
S - Spinal tenderness (midline)

Imaging indicated if any present

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CERVICAL SPINE TRAUMA

Zoe, 2012
• Meta-analysis of 15 studies

Canadian C-Spine NEXUS criteria

Sn 90-100% Sn 83-100%
Sp 1-77% Sp 2-46%
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THORACIC AND LUMBAR SPINAL TRAUMA

• Clinical Exam
• Pain
• Midline Tenderness Sn 78.4%
• Deformity Sp 72.9%
• Neuro deficit

• Age > 60
• High-Risk Mechanism
• Fall
• Crush
• Motor vehicle crash with ejection/rollover
Sn 98.9%
• Unenclosed vehicle crash Sp 29.0%
Inaba, 2015 • Auto vs. pedestrian

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Musculoskeletal
Trauma

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IV Antibiotics (weight-based dosing guidelines)

1st
Generation If Anaphylactic PCN Aminoglycoside Piperacillin/
Cephalosporins allergy (Gram-Pos coverage) Tazobactam (Broad-
Open Fractures (Gram-Pos coverage Spectrum Gram-
Positive and Neg
Cefazolin Clindamycin Gentamicin Coverage)
Wound < 1 cm; minimal < 50 kg: 2 gm q8 hr < 80 kg: 600 mg q8 hr
contamination or soft 50-100 kg: 2 gm q8 hr > 80 kg: 900 mg q8 hr
tissue damage > 100 kg: 3 gm q8 hr
Wound 1-10 cm; < 50 kg: 2 gm q8 hr < 80 kg: 600 mg q8 hr
moderate soft tissue 50-100 kg: 2 gm q8 hr > 80 kg: 900 mg q8 hr
damage; comminution of > 100 kg: 3 gm q8 hr
fracture
Severe soft-tissue < 50 kg: 2 gm q8 hr < 80 kg: 600 mg q8 hr Loading dose in ER:
damage and substantial 50-100 kg: 2 gm q8 hr > 80 kg: 900 mg q8 hr Child<50 kg: 2.5 mg/kg
contamination with > 100 kg: 3 gm q8 hr Adult: 5 mg/kg
associated vascular
injury
Farmyard, soil or < 100 kg: 3.375 gm q6
standing water., hr
irrespective of wound > 100 kg: 4.5 gm q6 hr
size or severity

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BILATERAL FEMUR FRACTURES = HIGHER MORTALITY

Copeland, 1998 O’Toole, 2014

Bilateral 26% 7%

Unilateral 12% 2%

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Thermal
Injuries

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FLUID RESUSCITATION CHANGES

Electrical Injury

4 ml LR X kg x % TBSA for ALL AGES

Flame or Scald Injury

2 ml LR X kg x % TBSA for ages > 14 years

3 ml LR X kg x % TBSA for ages < 14 years

Add dextrose containing solution at maintenance if < 30 kg

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Trauma in
Pregnancy

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AMNIOTIC FLUID LEAKAGE

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Transfer to
Definitive Care

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AVOID CT PRIOR TO TRANSFER

Onzuka, 2008
• Retrospective review over 2 years
• 249 trauma patients
• No change in Injury Severity Score
• Delayed transfer by 90 minutes

Quick, 2013
• Retrospective review over 3 months
• In-House Interpretation of outside images
• 223 total CT scans
• 25 repeat CT scans
• $4,592 lower cost per patient
• Outside hospital interpretation
• 320 total CT scans
• 62 repeat CT scans

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ABC-SBAR TEMPLATE FOR TRANSFER OF PATIENTS

Airway, Breathing and Circulation Assessment
• Identify problems and perform interventions • Vital signs
• Pertinent physical exam findings
Situation • Patient response to treatment
• Patient name and age
• Referring physician name Recommendation
• Reporting nurse name • Transport mode
• Indication for transfer • Level of transport care
• IV access site, fluid and rate • Medication intervention during transport
• Other interventions completed • Needed assessments and interventions

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