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Advanced Trauma Life Support Update

Posted Oct 05 2009 10:03pm

Maureen McCunn, M.D. provides a summary of some of the changes in the most recent edition of the Advanced Trauma Life Support Guidelines(ATLS):  The current 8th Edition of ATLS has numerous important changes of interest to anesthesiologists, including a renewed focus on the airway and resuscitation endpoints.

v      The Difficult Airway is finally addressed, as the new ATLS guidelines recommend that Airway evaluation be performed prior to attempting rapid sequence intubation (RSI), and a new evaluation mnemonic has been suggested “LEMON”: Look, Evaluate, Mallampati, Observe, and Neck.  Confirmation of intubation using a CO2 detector is now required (capnography is preferred, but if not available, colorimetric techniques are acceptable). The roles of the laryngeal mask airway (LMA), laryngeal tube airway (LTA), and gum elastic bougie, are specifically recognized as important adjuncts during emergency airway management.  Drugs recommended for RSI are left more to local practice, rather than advocating a single "ATLS" cocktail for the whole world.

v      ATLS now includes a far more extensive discussion on the importance of balancing the concept of “limited resuscitation” with the reality of experience demonstrating that excessive early crystalloid administration may dilute blood, dislodge clot and increase hemorrhage; but, inadequate fluid resuscitation in hypotensive, bleeding patients will result in exsanguination following penetrating torso injury.  A more developed discussion is now offered on the equivalency of Ringers lactate and normal saline during the initial resuscitation for shock, and that hypertonic saline is at least equivalent, and perhaps superior, in patients with traumatic brain injury. There is increased emphasis on using multiple end-points for resuscitation.

v      Tourniquets are now endorsed for the first time for use in exsanguinating extremity injury during the prehospital phase.

v      A new pelvic fracture algorithm is offered that emphasizes the use of pelvic binders and angiography.

v      Blast injury is now specifically addressed, because of the recent military experience with improvised explosive devices.

v      There is increased emphasis on early recognition of blunt carotid injury.

v      Methylprednisolone is no longer advocated for the management of acute spinal cord injury.

 

Maureen McCunn, M.D., Assistant Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania

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