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

 

 

 

TRAUMA IN PREGNANCY UPDATE 2018

OB TRAUMA

 

Today’s algorithm is all about Trauma in pregnancy. Its a quick breakdown of the need-to-know basics!

 

 

PRIMARY SURVEY

1.     Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation

2.     If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual

3.     vasopressors in pregnant women because of their adverse effect on uteroplacental perfusion should be used only for intractable hypotension that is unresponsive to fluid resuscitation

4.     After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava. This may be achieved by manual displacement of the uterus or left lateral tilt.

5.     To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available

6.     A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage

ADJUCNTIVE TESTING

1.     FAST is recommended in pregnancy Sn and Sp similar to non-pregnant females

2.     Radiation exposure with a cumulative dose of > 5 rads (50 mGy) is associated with an increased risk to fetus but limited to < 18 weeks gestation. See Appendix for details

3.     Approximate values for CT radiation for >16 wks with cutoff of 250 mGy recommended:

a.     CT Head/Neck and CXR are negligible

b.     CT chest = 0.66 mGy

c.     CT abd = 35 mGy

d.     CT pelvis = 50 mGy

e.     Total for CT C/A/P = 85.66 mGy

SECONDARY/TERTIARY SURVERY

1.     If the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated as soon as feasible.

2.     In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan

3.     In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen.

4.     KB testing should be done in all Rh- negative pregnant trauma patients.

5.     RhogamTM, anti-D IgG, should be given to all Rh D-negative pregnant trauma patients. In Rh-negative pregnant trauma patients, quantification of maternal–fetal hemorrhage by Kleihauer-Betke should be done to determine the need for additional doses.

a.     A single dose of 300 mcg, administered within 72 hours of injury, provides protection against sensitization for up to 30 mL of fetal blood in the maternal circulation.

b.     The feto-placental blood volume is estimated to be 120 mL/kg of fetal weight.

c.     In most cases of traumatic maternal–fetal hemorrhage, the estimated volume of fetal blood in the maternal circulation is less than 15 mL and in more than 90% of cases it is less than 30 mL.

d.     Therefore, the vast majority of Rh-negative patients are protected by one dose.

e.     If the KB test indicates transplacental hemorrhage in excess of 30 mL fetal blood, additional doses of anti-D IgG may be required.

6.     Tetanus vaccination is safe in pregnancy and should be given when indicated

 

OBSERVATION

1.     All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. Ctxs <6/hour consider discharge, Ctxs ≥6/hour consider admission

a.     ACOG recommends a minimum of 2-6 hours of monitoring post-trauma

b.     Abruption has been reported to occur up to 24 hours after a traumatic insult.  It has not been reported when <1 contraction is present in any 10-minute interval over a 4-hour period.

c.     Thus, fetal monitoring can be discontinued after 4 hours if uterine contractions occur less frequently than every 10 minutes, the fetal heart tracing is reassuring, and there is no maternal abdominal pain or vaginal bleeding.

2.     Pregnant trauma patients (≥ 23 weeks) should be admitted for 24-hour observation in the setting of:  uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions, rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury(motorcycle, pedestrian, high speed crash), or serum fibrinogen < 2 g/L

a.     In a prospective cohort study, 85 pregnant women (12 to 41 wks gestation) were compared with a control group of pregnant women matched for gestational age. Study subjects whose placentas were anteriorly placed were at increased risk for fetomaternal transfusion on comparison with other placental positions (47% vs 23.5%, p less than 0.05). Immediate adverse outcomes including abruptio placentae occurred frequently in the study group (9.4%) and were not predictable on the basis of injury severity. Four hours of CTM used as a screening tool was found to be an extremely sensitive (100%) but nonspecific indicator of immediate adverse outcomes. This study recommended that routine screening for fetomaternal transfusion occur in all pregnant women who suffer trauma during pregnancy beyond 11 weeks’ gestation and that a minimum of 4 hours of cardiotocographic monitoring occur in women greater than 20 weeks’ gestation. Patients were discharged home if contractions ceased or were less frequent than once every 15 minutes.  Source: Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol.

b.      Another retrospective study of 271 pregnant patients, suggested monitoring for at least 24 hours only for a selected group of patients at high risk conditions. This high-risk group consisted of patients involved in motorcycle, pedestrian or high velocity collisions, those ejected from motor vehicles and patients demonstrating maternal tachycardia, abnormal fetal heart rate pattern, and high injury severity scores.  Source: Curet MJ, Schermer CR, Demarest GB, Bieneik EJ 3rd, Curet LB. Predictors of outcome in trauma during pregnancy: identification of patients who can be monitored for less than 6 hours. J Trauma 2000;49:18–24.

 

ANTICIPATORY GUIDANCE

1.     Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence.

2.     During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times

RADIATION DOSE

1.     MEASURES OF IONIZING RADIATION

a.     DOSE measured in Rads or Gray(Gy) [1000mGy = 1Gy]

i.     Amount of energy deposited per kg of tissue

b.     Relative Effective Dose measured in Sieverts

                                               i.     Amount of energy deposited per kg of tissue normalized for              biological effectiveness

                                              ii.     1 Gy ~ 1 Sievert

2.     Effect of Gestation Age on Exposure

a.     0-2 weeks         all or none effect (Death of embryo)       50-100 mGy

b.     2-8 weeks         Birth Defect/IUGR                                        200-250 mGy

c.     8-15 weeks       Intellectual disability (high risk)               60-310 mGy

d.     8-15 weeks       IQ drop                                                           25pts / 1Gy

e.     8-15 weeks       microcephaly                                                200 mGy

f.      16-25 wks         Intellectual disability (low risk)                250-280 mGy

3.     Fetal Radiation with Common Testing

a.     Very low dose <0.1mGy

                                               i.     C-spine x-ray 2view

                                              ii.     Head or neck CT

                                             iii.     Extremity x-ray

                                             iv.     Chest x-ray (two views)

b.     Moderate dose <10mGy

                                               i.     Abdominal x-ray (3mGy)

                                              ii.     Lumbar x-ray (10mGy

                                             iii.     Chest CT or CT PE (0.66mGy)

c.     Higher-dose examinations (10–50 mGy)

                                               i.     Abdominal CT   (35 mGy)

                                              ii.     Pelvic CT          (50 mGy)

Source: ACOG Guidelines for Diagnostic Imaging During Pregnancy and Lactation e210 VOL. 130, NO. 4, OCTOBER 2017. Obstetrics and Gynecology

 

 

 

Reversal Agents for Anti-coagulation

For Reversal of Major Bleeding

Definition: Major Bleed(s) are all bleeds associated with hemodynamic compromise, occurring in an anatomically critical site (e.g., intracranial), or associated with a decrease of hemoglobin >2 g/dL (when baseline is known) or requiring transfusion of >2 U of packed RBCs.

Bleeding due to Vitamin K antagonists (VKA):
  1. Vitamin K: 10 mg IV over 30 min in 50 mL NS
    1. Can give PO but then longer reversal times (18-24 hrs)
    2. IV formulation can be given PO if slower reversal times are ok
  2. Give 4F-PCC (K-Centra):
    1. Comes as 500 or 1000 unit kit
    2. Weight based:
      1. INR 2-4 = 25 U/kg
      2. INR 4-6 = 35 U/Kg
      3. INR >6 = 50 U/kg
    3. Low Dose Fixed
      1. 1500 Units for ICH
      2. 1000 Units for all other major bleeds
  3. Alternate to PCC: FFP 10-15 ml/kg (not “2 units”)
  4. Alternate to PCC: FEIBA (contains VIIa)
    1. Give for STD Dosing INR < 5 =  500 IU,  INR > 5 = 1,000 IU.
    2. Lyophilized powder in single-use vials of 500, 1000, or 2500 units per vial
    3. Compared to Wt based dosing of 4F-PCC, FEIBA showed no difference (N=158; 118 FEIBA pts; 78% ICH)
      1. Crit Care Med 2018; 46:943–948
Dabigatran:
  1. Idarucizumab 2.5 g IV repeat 10 min after 1st dose for total of 5g
  2. 4F-PCC [K-Centra] 50 Units/kg IV
  3. aPCC (FEIBA) 50 Units/kg IV
  4. Activated Charcoal
Xa-Inhibitors
  1. 4F-PCC [K-Centra] 50 Units/kg IV
  2. aPCC (FEIBA) 50 Units/kg IV
  3. Activated Charcoal [within 2-4 hours of exposure]
  4. Dialysis for Edoxaban
    1. NOT for rivaroxaban, or apixaban
  5. Andaxanet fXa Inhibitor (FDA approved 2018 limited release until 2019)
    1. Apixaban and >7 hours since Rivaroxaban (low dose)
      1. 400 mg Bolus at 30 mg/min followed by Infusion of 480 mg over 2 hours
      2. Cost for low dose estimated $25,000
    1. Rivaroxaban < 7 hours OR enoxaparin (high dose)
      1. 800 mg Bolus at 30 mg/min followed by Infusion of 960 mg over 2 hours
      2. Cost for high dose estimated at $49,500
  6. Ciraparantag (“Universal Agent”? No yet FDA approved)
    1. Binds anticoagulants via Hydrogen bonds
    2. Made up of 2 L-arginine units
    3. Works on Edoxaban, riva, apixa, dabigatran, lovenox and heparins
      1. Not warfarin or agratroban
    4. Works within 30 min
    5. 300 mg IV Bolus
    6. FDA fast track designation 4/2015

 

Condition Intervention
INR > goal but < 5
No significant bleeding or risk of bleeding
·      Lower dose or omit next dose
INR 5 or < 9
AND
No significant bleeding or risk of bleeding
·      Preferred: Omit next 1-2 doses

·      Alternatively, omit 1-2 doses & give Vitamin K (1-2.5 mg po)

·      Alternatively, for patients at high risk of thrombosis (i.e. valves), omit 1-2 doses and use FFP 2 units IV – DO NOT use Vitamin K

INR 9
No significant bleeding AND/OR Low-moderate risk of bleeding
  • Hold warfarin therapy
  • Give FFP 2 units IV
  • Give Vitamin K (2.5-5 mg po)
  • In patients with prosthetic heart valves, give FFP 2 units IV and lower dose of Vitamin K (1-2.5mg po)

Reference:

Tomaselli GF, Mahaffey KW, Cuker A, Dobesh PP, Doherty JU, Eikelboom JW, Florido R, Hucker W, Mehran R, Messé SR, Pollack CV Jr., Rodriguez F, Sarode R, Siegel D, Wiggins BS. 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. 2017 Dec 19;70(24):3042-3067.

Medical Letter. JAMA. 2018;320(4):399-400