ATLS 10th Edition 2018 Update

Since summer is closing and  “Fall” is upon us I thought it would be a good time to “drop” some Trauma knowledge especially since “Crash (2)” is in the ATLS update. Here are the major changes in the 10th Edition of ATLS. Luckily ATLS is getting closer to the evidence and what many of us are already doing. Of course it wouldn’t be an ACS program without their special stamp of approval so they had to change some names around. For example for some reason RSI is now called Drug Assisted intubation. I still think RSI has a better ring to it. Sorry for the format… I”ll update soon!

ATLS 10thEdition changes

Initial Assessment

  • 1 L of fluid
    • Bolus “isotonic” solution 1 L for adults and 20ml/kg for peds <40kg
    • Early blood
  • MTP (1:1:1)
  • TXA
  • Canadian Cspine and nexus

Airway

  • RSI is now Drug assisted Intubation
  • VL vs DL

Shock Table

  • Base excess added to shock table
  • Early use of blood
  • Management of Coagulopathic patients
  • TXA
    • TXA over 10 min withing 3 horus of injury
    • 1 g over 8 hour infusion after bolus

Thoracic Trauma

  • Flail chest is out
  • Tracheobronchial injury in
  • Tension
    • Needle
      • 5thICS MAL for adult
      • 2ndICS for child
    • 28-32Fr (vs 36-40)
  • Circulatory arrest algorithm
  • Aortic rupture with bb goal HR <80 MAP 60-70
  • Life threatening injuries during primary survey
    • Airway
      • Obstruction
      • Tracheobronchial tree injury
    • Breathing
      • Tension Pnx
      • Open Pnx
    • Circulation
      • Massive Hmthx (1500)
      • Cardiac Tamponade
      • Traumatic circulatory arrest

Abdominal Trauma

  • No more prostate palpation “no high riding prostate”
  • Flow chart for pelvic fx amended
  • “gentle palpation of the bony pelvis for tenderness”
  • An AP pelvic x-ray may help to establish the source of blood loss in hemodynamically abnormal patients and in patients with pelvic pain or tenderness. An alert, awake patient without pelvic pain or tenderness does not require a pelvic radiograph.

Head Injury

  • Maintain SBP >100 mmHg for adults 50-69
  • Maintain SBP >110 for adults 15-49 or >70
  • Goals of Brain injury
    • Clinical:
      • SBP >100
      • Temp 36-38
    • Monitoring
      • CPP >60 mmhg
      • ICP 5-15
      • PBtO2 >15 mmHg
      • Pulse ox >95%
    • Labs
      • Glucose 80-180
      • Hgb >7
      • INR <1.4
      • Na 135-145
      • PaCO2 35-45
      • pH 7.35-7.45
      • Plt >75000
    • Szr prophyaxis
      • PTS – Postratumatic seizures (wthin in 7 days of injury)
      • Prophylactic use not recommended
      • Phenytoin is recommended todecrease the incidene o faerly posttraumatic szr when benefit is felt to more than harm. Hwevver early PTS has not been associated with worse outcomes

C-spine

  • Terminology changed to restriction of spinal motion
  • New myotome diagram
  • Canadian Cspine and Nexus

MSK Trauma

  • Wt based IV abx regimen

Thermal injuries

  • 2ml/kgxwtx%burn adults
  • 3ml/kgxwtx%burn children
  • Fluid titrated to UO
  • Flame vs electrical all ages are 4ml/kg LR x%TBSA

Pediatric Trauma

  • Needle thoracentesis unchanged
  • Limiting crystalloid
    • 20 ml/kg bolus followed by blood 10-20 ml/kg rbc or ffp and platelet
  • PECARN

Transfer to Definitive Care

  • Specific mention of avoiding CT in primary hospital
    • “Do not peform procedures (DPL or CT) that do not change the plan of care
  • SBAR for communcation

 

 

 

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