Introduction. Preparation. • Prehospital Phase. • Hospital Phase. Triage. • Multiple Casualties. • Mass Casualties. Primary Survey. • Special Populations. Series. ATLS®. University of Rochester School of Medicine and Dentistry. Kessler Trauma Center &. American College of Surgeons Committee on Trauma. Journal of Trauma and Acute Care Surgery: May - Volume 74 - Issue 5 - p The Advanced Trauma Life Support (ATLS) course was introduced in
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TENTH EDITION ATLS ® Advanced Trauma Life Support® Student Course Manual JAMA Peds ; Implementation of a pediatric trauma massive . PDF | Advanced trauma life support orients doctors to the initial assessment and to provide emergency trauma care for the priorities of emergency trauma care according to the ATLS .. February · Nigerian journal of clinical practice. PDF | On Jan 1, , Shahram Paydar and others published Advanced Trauma Life Support (ATLS) Tips to Be Kept In Mind.
Massive transfusion is defined as the transfusion of more than 10 units of blood in 24 hours or more than four units in one hour. Early resuscitation with blood and blood products in low ratios is recommended in patients with evidence of Class III and IV hemorrhage.
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.
Some jurisdictions are using tranexamic acid in the prehospital setting.
A large prospective study demonstrated decreased mortality when tranexamic acid is given within three hours of injury. When a 1 g dose is given in the prehospital setting, a repeat dose is administered in the emergency department. Early monitoring of coagulation and replacement of clotting factors can minimize transfusion needs, which is particularly important in patients who are taking anticoagulant medications. Thromboelastography and rotational thromboelastometry are helpful when available to pinpoint the precise coagulation deficiency.
Chapter 4: Thoracic Trauma Life-threatening thoracic injury can result from airway obstruction, tracheal bronchial tree injury, tension pneumothorax, open pneumothorax, massive hemothorax, and cardiac tamponade. Patients with tension pneumothorax who are spontaneously breathing generally present with tachypnea, air hunger, and desaturation. Most of these injuries can be managed through relatively simple maneuvers such as airway control or decompression of the chest.
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 to ensure successful access to the thoracic cavity.
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 fourth or fifth intercostal space 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. 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. Evidence-based research and clinical experience indicate that size matters with respect to the optimal size chest tube required to drain a hemothorax.
Prospective analysis has shown 28—32 F to effectively drain hemothorax without resulting in increased retained hemothorax. The focused abdominal sonography for trauma also known as FAST technique has been modified to include evaluation of the thoracic cavity for the presence of air.
It can aid in the rapid diagnosis of pneumothorax in the emergency department. The presentation and treatment of blunt aortic injury has evolved with the use of thoracic computerized tomographic angiography also known as CTA to evaluate for blunt aortic injury.
Hemodynamically normal patients with partial injury are now managed with endovascular techniques. A new algorithm for management of patients presenting in traumatic circulatory arrest is included in chapter 4, Figure 4—7 reproduced here as Figure 1.
Figure 1. Algorithm for management of traumatic circulatory arrest Chapter 5: Abdominal and Pelvic Trauma In addition to a discussion of blunt and penetrating mechanisms of injury, the 10th edition includes a discussion of injury resulting from explosive forces.
The signs of bladder injury have historically included blood at the urethral meatus, perineal ecchymosis, and a high-riding prostate on physical examination.
Today, the high-riding prostate indicator is considered unreliable and not useful in determining which patients should undergo further investigation. Given the successful use of preperitoneal pelvic packing to control pelvic hemorrhage from pelvic fractures, this section was updated to include this option. Chapter 6: Head Trauma Elderly patients suffering ground-level falls are an increasing trauma patient demographic.
Many of these patients are treated with anticoagulation, and the use of these medications should be relayed to consulting neurosurgeons. This version of the GCS 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. Phenytoin is recommended to decrease the incidence of early posttraumatic seizures within seven days of injury.
Chapter 7: Spine and Spinal Cord Trauma Determining which patients require imaging to evaluate for spine and spinal cord injury is not always straightforward. Chapter 8: Musculoskeletal Trauma Bilateral femur fractures are markers of significant energy mechanism and are risk factors for complications and death in blunt trauma. It was firstly based on the opinions and consensus view of the experts and specialists of trauma towards trauma management.
During past decades, the ATLS guidelines evolved and improved based on the evidences provided from the studies. It is well established that improving the standards of care process would reduce mortality and morbidity in trauma systems .
In this regards ATLS subcommittee performs sequential editions to the guidelines based on expert opinion and select review of current literature . However, the increasing international audience for the course and the recognition of the importance of evidence-based medicine fostered a need to update the revision process .
Although the ATLS is revised meticulously, however some points are less emphasized. In this short letter, we review some important parts of ATLS which should be kept in mind for trauma practice.
The first critical point which should be considered by the medical personnel at the first contact with a trauma patient should be an investigation of the patient for signs of life such as: breathing efforts, voluntary or involuntary body movements, reactive pupils to light and having palpable carotid or radial pulses.
In cases where T these evaluations fail to show any signs of life, recording the electrical activity of heart should be taken in to consideration. In the cases where clinical signs and symptoms propose the diagnosis of tension pneumothorax for a patient, ATLS guidelines have recommended that an angiocatheter or needle should be inserted to the chest cavity in the 2nd intercostal space at the mid-clavicular line, in order to deflate the air which is trapped in the pleural cavity.
Regarding the management of patients with chest trauma who have GCS less than 8, immediate airway maintenance is indicated by performing endotracheal intubation. Therefore in cases where existence of simple pneumothorax is suspected, a needle should be inserted in a proper anatomic site of chest wall in order to deflate the air which is trapped in pleural space.
Maintaining air way by performing endotracheal intubation would be the next step and ultimately inserting a chest tube would be the gold standard treatment.
Induction of tension pneumothorax is prevented if the patient is treated step by step in the manner which is mentioned above.
Considering the ATLS guideline, evaluation of the patients with chest trauma for existence of flail chest should be done during the primary survey, although the condition itself poses no immediate life threatening risks even if not treated emergently; therefore there would be no need for emergent therapeutic interventions, even if the diagnosis of flail chest is made only by clinical evaluations.
On the other hand, with respect to previous studies , in many cases, the diagnosis of flail chest is not achievable only by performing physical examination in the first minutes of patient arrival and other diagnostic procedures such as: obtaining a chest X-ray and a chest CT scan would be needed in order to have a definite diagnosis. Thus, it is recommended that the evaluation of the patients with chest trauma for flail chest should be left for the secondary survey.
Regarding the trauma patients who have low levels of systemic blood pressure at the time of arrival to Emergency Department, it would be better to evaluate the patient in order to find possible sources of internal or external bleedings during the primary survey.
In other words it is recommended that ATLS should have a clear statement regarding the order of diagnostic procedures in hypotensive patients which could be as follows, first step: evaluation of internal and external bleeding in chest, abdomen and pelvic cavity. Over all the above mentioned evaluations should take place after primary survey before starting the secondary survey.
If the patient was discovered to have unstable vital signs in the primary survey, inserting NasoGastric NG tubes and urinary catheters should be considered before performing secondary survey. Otherwise, placing NG tubes and urinary catheters is indicated based on finding of the secondary survey. Overall, the type fluid therapy for the trauma patients with hemorrhagic shock is not clearly discussed in ATLS.