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7/28/2019ATLS 10TH EDITIONA CLINICAL UPDATENicholas McManus Emergency Medicine WMEMR Core Faculty Banana Bag EM Blog founder1I have NO financial disclosure orconflicts of interest with thepresented material in thispresentation.21

7/28/2019InitialAssessment3INITIAL ASSESSMENTno evidence based data identified to justify modification to this approachin civilian patients.42

7/28/2019Peds AdultINITIAL ASSESSMENT1 L of crystalloidBlood Early (1:1:1 ratio)20 cc/kg 40 kg10-20 mL/kg of RBC/FFP/PltTXA5Airway63

7/28/2019AIRWAYRapid SequenceIntubationDrug AssistedIntubation784

7/28/2019Shock9Mutschler, 2013Signs and Symptoms of Hemorrhage by ClassPARAMETERCLASS ICLASS IICLASS IIICLASS IVBlood loss 15%15-30%31-40% 40%HRBPPPRRUOGCSBase Deficit0 to -2-2 to -6-6 to -10-10 or lessNeed for blood?MonitorPossibleYesMassive TransfusionMortality:Transfused Blood:7%51%1.5 units20.3 units105

7/28/2019Damage Control Resuscitation1Lwarmed87-100% survival ifused pre-hospitalIncreased mortality(OR 2.89) when 1 L givenSwitch to bloodproducts early(1:1:1 ratio)Prevent/reversecoagulopathy(Rotem/TEG) 4 units in ED MTP11PROPPR (2015)PROMMTT (2013) Ratios of less than 1:2had 3-4x increasedmortality than 1:1 Only mattered in thefirst 24 hours After 24 hours, ratiosunassociated withmortality 1:1:1 vs 1:1:21:1:1 Reduced mortality frombleeding in first 24 hours(RRR 25%) Overall mortality at 24 hrand 30 days not different126

7/28/2019CRASH-2 TRIALDecreased Mortality 1 hr RR 0.681-3 hr RR 0.79Increased Mortality 3 hr RR 1.441 gram over 10 minutesGive within 3 hours of injuryRepeat 1 gram over 8 hours inhospital13THROMBOELASTOGRAPHY147

7/28/2019ThoracicTrauma15LIFE THREATENING INJURIESTracheobronchial InjuryFlail Chest168

7/28/2019LIFE THREATENING INJURIES- Airway Obstruction- Tracheobronchial Tree Injury- Tension Pneumothorax- Open Pneumothorax- Massive Hemothorax- Cardiac Tamponade- Traumatic Circulatory Right ThoraxSp 98-100%6Left ThoraxUSvsCXRfor pneumothorax86-98%28-75%100%Wilkerson, 2010189

7/28/2019NEEDLE DECOMPRESSION14G3.25 inch19NEEDLE DECOMPRESSION4.5 cm57.5%3.5 cm100%20 cadavers(40 attempts)Inaba, 20112010

7/28/2019ADULTPEDIATRIC5th ICS MAL2nd ICS MCL21FINGER THORACOSTOMY2211

7/28/2019CHEST THORACOSTOMYDoes size matter?28-32 Fr Prospective trial353 chest tubes28-32 Fr vs 36-40 FrNo difference in Initial volume drained Complications Reinsertion need Hemo vs pneumoInaba, 2012232412

7/28/2019AORTIC DISSECTIONBlunt Aortic Injury CTABeta Blockers! HR 80 bpm MAP 60-70 mmHgHemodynamically stable possible endovascular repair25TRAUMATIC CARDIAC ARREST2613

7/28/2019TRAUMATIC CARDIAC ARRESTOperating room with surgeon present is mandatoryFirst 2 minutesCPR, IV/IO, Fluids, EpiBilateral Chest DecompressionFirst 3 minutesThoracic injuryAnterolateral or Clamshell Thoracotomywith vertical pericardiotomyDirect repairAbdominal injuryClamp aortaDeath when 30 min and temp 33C27Abdomen/Pelvis2814

7/28/2019DIGITAL RECTAL EXAM FOR URETHRAL INJURYBall, 2009 Retrospective review of 41 patients Blunt trauma specificResults DRE: 2% Blood at the urethral meatus: 20% Hematuria prior to catheter insertion: 17%“DRE remains clinically indicated in patients with penetratingtrauma in the vicinity of the rectum, pelvic fractures, and spinalcord injuries ”293015

7/28/2019PREPERITONEAL PELVIC PACKINGCothren, 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 angiographythe need for emergent angiography.” No deaths from blood loss Lower mortality31HeadInjury3216

7/28/2019GLASGOW COMA SCALEGCS 15 (E4, V5, M6)334TH EDITION BRAIN TRAUMA FOUNDATION GUIDELINESAvoid prolonged hyperventilation with PC02 25 mm HgSystolic 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 yearsSedation Propofol recommended for the control of increased ICP no improvement of six-month outcomesSeizure 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)3417

7/28/2019GOALS OF TREATMENT OF BRAIN INJURYClinical ParametersLab Values SBP 100 mm Hg Glucose 80-180 Temperature 36-38 C Hgb 7 INR 1.4Monitoring 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/mm335HEAD INJURY ON ANTICOAGULATIONAdmission for neurologic observation All supra-therapeutically anticoagulated patients CT abnormalityAnticoagulation Reversal Consideration given to short term reversal of anticoagulationTiming of repeat Head CT At at 12 to 18 hours or when even subtle signs of neurologic worsening occursCohen, 20063618

7/28/2019ANTICOAGULATION REVERSAL GUIDELINESAntiplateletsPlatelets, consider DDAVPCoumadinFFP, Vit. K, PCC, Factor VIIaHeparinProtamine sulfatePradaxaPraxbind, PCCXarelto/EliquisPCC37PECARN3819

7/28/2019PECARNIs exam abnormal?Get Head CT- LOC 5 seconds- Hematoma (anything but frontal)- Headache (severe)- Vomiting- Severe Mechanism (think c-spine)- Parental GCS 15YESSharedDiscussionNODon’t get CT“Larry Hits Head,Very Scared Parents”39Spine andSpinal Cord4020

7/28/2019SPINE AND SPINAL CORDSpinalImmobilizationSpinal MotionRestriction41NEW MYOTOME DIAGRAMMuscle Strength GradingMyotomesScoreResultC5Elbow flexors (biceps)0Total paralysisC6Wrist extensors1Palpable or visible contractionC7Elbow extensors (triceps)2Full range of motion with gravity eliminatedC8Finger flexors3Full range of motion against gravityT1Finger abductors4Full range of motion, but normal strengthL2Hip flexors5Normal strengthL3Knee extensorsNTNot testableL4Ankle dorsiflexionL5Long toe extensorsS1Ankle plantar flexors“Key myotomes are used to evaluate thelevel of motor function ”4221

7/28/2019CERVICAL SPINE TRAUMACanadian C-Spine Rule (CCR)1.2.3.4.Age 65 yearsDangerous mechanismParesthesias in extremitiesRotate neck 45 degrees left and rightImaging indicated if any presentDangerous Mechanisms Fall from 1 meter/5 stairs Axial load of head MVC with ejection, rollover, 60 mph Motorized recreational vehicle collision Bicycle collisionLow risk factors (prior to assessing ROM)Simple rear-end MVCSitting position in EDAmbulatory at any timeDelayed onset of neck painNo midline cervical tendernessStiell, 200343CERVICAL SPINE TRAUMANEXUS CriteriaN - Neuro deficitE - EtOH (alcohol)/intoxicationX - eXtreme distracting injuryU - Unable to provide history (altered LOC)S - Spinal tenderness (midline)Imaging indicated if any present4422

7/28/2019CERVICAL SPINE TRAUMAZoe, 2012 Meta-analysis of 15 studiesCanadian C-SpineNEXUS criteriaSn 90-100%Sp 1-77%Sn 83-100%Sp 2-46%45THORACIC AND LUMBAR SPINAL TRAUMA Clinical Exam Pain Midline Tenderness Deformity Neuro deficit Inaba, 2015Sn 78.4%Sp 72.9%Age 60High-Risk Mechanism Fall Crush Motor vehicle crash with ejection/rollover Unenclosed vehicle crash Auto vs. pedestrianSn 98.9%Sp 29.0%4623

7/28/2019MusculoskeletalTrauma47IV Antibiotics (weight-based dosing guidelines)1stOpen FracturesWound 1 cm; minimalcontamination or softtissue damageGenerationCephalosporins(Gram-Pos coverageIf Anaphylactic PCNallergyCefazolinClindamycin 50 kg: 2 gm q8 hr50-100 kg: 2 gm q8 hr 100 kg: 3 gm q8 hr 80 kg: 600 mg q8 hr 80 kg: 900 mg q8 hrWound 1-10 cm; 50 kg: 2 gm q8 hrmoderate soft tissue50-100 kg: 2 gm q8 hrdamage; comminution of 100 kg: 3 gm q8 hrfracture 80 kg: 600 mg q8 hr 80 kg: 900 mg q8 hrSevere soft-tissuedamage and substantialcontamination withassociated vascularinjury 80 kg: 600 mg q8 hr 80 kg: 900 mg q8 hrFarmyard, soil orstanding water.,irrespective of woundsize or severity 50 kg: 2 gm q8 hr50-100 kg: 2 gm q8 hr 100 kg: 3 gm q8 hrAminoglycosidePiperacillin/(Gram-Pos coverage) Tazobactam (BroadSpectrum GramPositive and NegGentamicinCoverage)Loading dose in ER:Child 50 kg: 2.5 mg/kgAdult: 5 mg/kg 100 kg: 3.375 gm q6hr 100 kg: 4.5 gm q6 hr4824

7/28/2019BILATERAL FEMUR FRACTURES HIGHER MORTALITYCopeland, 1998O’Toole, 5025

7/28/2019FLUID RESUSCITATION CHANGESElectrical Injury4 ml LR X kg x % TBSA for ALL AGESFlame or Scald Injury2 ml LR X kg x % TBSA for ages 14 years3 ml LR X kg x % TBSA for ages 14 yearsAdd dextrose containing solution at maintenance if 30 kg51Trauma inPregnancy5226

7/28/2019AMNIOTIC FLUID LEAKAGE53Transfer toDefinitive Care5427

7/28/2019AVOID CT PRIOR TO TRANSFEROnzuka, 2008 Retrospective review over 2 years249 trauma patientsNo change in Injury Severity ScoreDelayed transfer by 90 minutesQuick, 2013 Retrospective review over 3 monthsIn-House Interpretation of outside images 223 total CT scans 25 repeat CT scans Outside hospital interpretation 320 total CT scans 62 repeat CT scans 4,592 lower cost per patient55ABC-SBAR TEMPLATE FOR TRANSFER OF PATIENTSAirway, Breathing and Circulation Identify problems and perform interventionsSituation Patient name and age Referring physician name Reporting nurse name Indication for transfer IV access site, fluid and rate Other interventions completedAssessment Vital signs Pertinent physical exam findings Patient response to treatmentRecommendation Transport mode Level of transport care Medication intervention during transport Needed assessments and interventionsBackground Event history AMPLE assessment Blood products Medications given (date and time) Imaging performed Splinting5628

7/28/201957REFERENCESBall CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: Does the digital rectal examination really helpus? Injury. 2009;40(9):984-986.Cancio LC. Initial assessment and fluid resuscitation of burn patients. Surg Clin North Am. 2014;94(4):741-754.Carcillo JA. Intravenous fluid choices in critically ill children. Curr Opin Crit Care. 2014;20(4):396-401.Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourthedition. Neurosurgery. 2017;80(1):6-15.Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg.2012;73(5):1273-1277.5829

7/28/2019REFERENCESCohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma. 2006;60(3):553-557.Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm JQual Patient Saf. 2012;38(6):261-268.Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing forhemodynamically unstable pelvic fracture: A paradigm shift. J Trauma. 2007;62(4):834-839.CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid inbleeding trauma patients: An exploratory analysis of the CRASH-2 randomized controlled trial. Lancet.2011;377(9771):1096-1101.59REFERENCESDehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin PediatrSurg. 2010;19(4):286-291.Dressler AM, Finck CM, Carroll CL, Bonanni CC, Spinella PC. Use of a massive transfusion protocol with hemostaticresuscitation for severe intraoperative bleeding in a child. J Pediatr Surg. 2010;45(7):1530-1533.Gunst M, GhaemmaghamiV, Gruszecki A, et al. Changing epidemiology of trauma deaths leads to a bimodaldistribution. Proc (Bayl Univ Med Cent). 2010;23(4):349-354.Hadley MN, Walters BC, Aarabi B, et al. Clinical assessment following acute cervical spinal cord injury. Neurosurgery.2013;72(Suppl 2):40-53.Hendrickson JE, Shaz BH, Pereira G, et al. Coagulopathy is prevalent and associated with adverse outcomes intransfused pediatric trauma patients. J Pediatr. 2012;160(2):204-209.6030

7/28/2019REFERENCESHendrickson JE, Shaz BH, Pereira G, et al. Implementation of a pediatric trauma massive transfusion protocol: Oneinstitution’s experience. Transfusion. 2012;52(6):1228-1236.Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion(PROMMTT) study: Comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg.2013;148(2):127-136.Hurlbert J, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery.2013;72(Suppl 2):93-105.Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: A cadaver-basedstudy. J Trauma. 2011;71(5):1099-1103.61REFERENCESInaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28–32 versus 36–40 Frenchchest tube size in trauma. J Trauma Acute Care Surg. 2012;72(2):422-427.Inaba K, Nosanov L, Menaker J, et al. Prospective derivation of a clinical decision rule for thoracolumbar spineevaluation after blunt trauma: An American Association for the Surgery of Trauma multi-institutional trials groupstudy. J Trauma. 2015;78(3):459-465.Ley E, Clond M, Srour M, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated withincreased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70(2):398-400.Min L, Burruss S, Morley E, et al. A simple clinical risk nomogram to predict mortality-associated geriatriccomplications in severely injured geriatric patients. J Trauma Acute Care Surg. 2013;74(4):1125-1132.6231

7/28/2019REFERENCESMutschler M, Nienaber U, Brockamp T, et al. Renaissance of base deficit for the initial assessment of trauma patients:A base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from theTraumaRegister DGU . Crit Care. 2013;17(2):R42.Neff NP, Cannon JW, Morriso