ATLS 10th edition offers new insights into managing trauma patients

The Advanced Trauma Life Support^® (ATLS^®) program has endured for nearly 40 years across six continents in 86 countries through 64,000 courses offered to more than 1.1 million students. The American College of Surgeons (ACS) Committee on Trauma (COT) course remains true to its core mission—to provide health care professionals with access to education that will enhance their ability to accurately provide an initial assessment, resuscitate, stabilize, and determine next steps in the care of the injured patient.

The ATLS global educational curriculum provides a systematic, concise approach to trauma patient care in an effort to improve trauma outcomes around the world. The content and skills taught in the course are designed to be adaptable to all health care settings for the care of patients and are intended for the immediate management of the injured patient. The knowledge gained through the course allows participants to rapidly and accurately assess the patient; stabilize and resuscitate by priority; determine the needs of the patient and whether those needs exceed the resources of the treatment facility; arrange for appropriate definitive care; and ensure that optimal care is provided.

Modifications occur in both format and content with each new edition. This article offers a chapter-by-chapter description of what is covered in the 10th edition of ATLS, which was published in January.

Chapter 1: Introduction and Initial Assessment

A key tenet of the curriculum that remains the same is the ABCDE (airway, breathing, circulation, disability, exposure) algorithmic approach to the rapid initial evaluation of the injured patient. Despite the revision of this approach adopted in the combat and disaster setting, ATLS continues to support prioritizing the rapid assessment and treatment of life-threatening airway and breathing problems ahead of circulation problems. No evidence-based data were identified that justified a modification to this approach in the care of civilian patients.

Chapter 2: Airway and Ventilation

The rapid assessment of the airway by determining the ability of the patient to speak and answer questions appropriately, in addition to verifying adequate ventilation and circulation, has long been a key element in the treatment of trauma patients. In this edition of ATLS, drug-assisted intubation has replaced rapid sequence intubation (RSI) as a broad term that describes RSI and the use of medications to assist with intubation of a patient with intact gag reflexes.

Chapter 3: Shock

Recognizing shock is one of the greatest challenges in the management of the injured patient. During the early management of the injured patient, shock is identified by evidence of end-organ hypoperfusion present on physical examination. Later, simple adjunctive measures can be added to improve the precision of the diagnosis. The classification of shock based on easily measured physiologic variables is attractive.

A table relating physiologic variables with hemorrhage severity has been a part of several ATLS editions. However, some recent literature challenges the accuracy of the classification of hemorrhage and the attributable clinical findings. A retrospective review of severely injured patients in the German trauma registry found variability in clinical findings and ATLS shock classification. The study found base deficit (BD), easily available in many settings, decreased the variability. BD and the need for blood transfusion or the massive transfusion protocol are now included in Table 3.1, reproduced here as Table 1.

Table 1. Signs and symptoms of hemorrhage by class

The initial resuscitation with crystalloid fluid still begins with a 1 liter bolus of warmed isotonic fluid. Large volume fluid resuscitation is not a substitute for prompt control of hemorrhage. Infusion of more than 1.5 liters of crystalloid fluid has been associated with increased mortality. Early control of external hemorrhage is pivotal to the management of the injured patient. Though direct pressure is the first measure instituted to control external hemorrhage in civilian trauma, military experience supports the judicious use of tourniquets placed above the area of injury in uncontrolled hemorrhage. 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. The injury is medically managed by decreasing the heart rate (<80 bpm) and mean arterial pressure (60–70 mm Hg) through the use of beta blockers.

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.

The new Glasgow Coma Scale (GCS) is introduced in the 10th edition. 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.

The 4th edition of the Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury that are applicable to the early management of the brain-injured patient have been included in the new edition of the ATLS course. These guidelines include avoiding prolonged hyperventilation with PC02 <25 mm Hg; maintaining systolic blood pressure >100 mm Hg for patients 50–69 years and >110 mm Hg or higher for patients ages 15–49 or older than 70 years old to decrease mortality and improve outcomes; diprivan (Propofol) is recommended for the control of increased intracranial pressure but not for improvement of six-month outcomes; barbiturates are not recommended to induce burst suppression measured by electroencephalogram  to prevent the development of intracranial hypertension; and prophylactic use of phenytoin or valproate is not recommended for preventing late posttraumatic seizures. 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. The Canadian Cervical-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) provide guidelines that can aid in the decision-making process, and these guidelines are included in the chapter and skills stations.

Another change in chapter 7 pertains to the term “spinal immobilization,” which has been replaced with “spinal motion restriction.” An error in the myotome diagram of L4 ankle dorsiflexion and L5 long toe extension has been corrected.

Chapter 8: Musculoskeletal Trauma

Bilateral femur fractures are markers of significant energy mechanism and are risk factors for complications and death in blunt trauma. Antibiotics used to treat open fractures should be dosed based on the patient’s weight to ensure adequate tissue levels are achieved. Table 8.1 in the manual, titled Common Joint Dislocation Deformities, has been changed to correctly identify the deformity seen with anterior hip dislocations, extension, abduction, and external rotation.

Chapter 9: Thermal Injuries

Modern burn resuscitation has mirrored the changes in trauma fluid resuscitation. Adult patients with deep-partial and full-thickness burns involving more than 20 percent of the total body surface area (TBSA) should receive initial fluid resuscitation of 2 ml of lactated ringers/%TBSA. Target fluid resuscitation is calculated based on 3 ml/kg/%TBSA in pediatric trauma patients and 4 ml/kg/%TBSA for electrical burns.

Half of the fluid is given over the course of eight hours and the remaining half is provided over a span of 16 hours. The rate of fluid administration should be titrated to effect using a target urine output of 0.5 ml/kg/hr in adults or 1 ml/kg/hr in children who are hemodynamically normal. Boluses are reserved for unstable patients.

Chapter 10: Pediatric Trauma

The recommendation for the site for needle decompression of the chest continues to be the second intercostal space mid-clavicular line in this new edition. Damage control resuscitation for pediatric trauma patients is defined as an attempt to limit the use of crystalloid resuscitation, as in adults. An initial bolus of 20 ml/kg bolus of fluid is followed by 10–20 ml/kg of packed red blood cells and 10–20 ml/kg of fresh frozen plasma and platelets as part of a massive transfusion protocol. Thus far, no survival advantage has been demonstrated with this approach.

Chapter 11: Geriatric Trauma

Nearly every country in the world is experiencing a growth in the proportion of older people in their population. The elderly are becoming an increasingly prevalent demographic among trauma patients. The following five preexisting conditions affect morbidity and mortality:

• Cirrhosis
• Coagulopathy
• Chronic obstructive pulmonary disease
• Ischemic heart disease
• Diabetes mellitus

Elderly patients with one or more of these preexisting conditions are twice as likely to die as those without.

Pelvic fractures in older patients result in a greater need for transfusion even with stable patterns of injury. The mortality is four times higher with these injuries, hospital stays are longer, and these patients may not return to independent lifestyles.

Chapter 12: Trauma in Pregnancy and Interpersonal Violence

The key content update in this chapter concerns the following: Indication of amniotic fluid leakage is vaginal fluid ph of >4.5.

Chapter 13: Transfer to Definitive Care

Transfer to a higher level of care is necessary when the patient’s needs exceed the capabilities of the institution, and delays in care have the potential to diminish patient outcomes. Performing unnecessary diagnostic tests, particularly computed tomography (CT) scans, may produce such delays. All too frequently, CT scans done before transfer to definitive care are repeated, resulting in time delays to definitive treatment, increased radiation exposure, and increased cost of care. Clear communication between transferring and receiving institutions is important. SBAR (also known as situation, background, assessment, and recommendations) is a useful guide to ensure all important information is relayed.

Optional Chapter: ATLS and Trauma Team Resource Management

Successful care of the injured patient requires not only knowledge of ATLS but also coordinated care by a team using these principles. This Optional Chapter highlights the way the ATLS team can effectively work to deliver care using the ATLS model—stressing the role of the trauma team leader and effective two-way communication.

Instructor update process

All ATLS faculty (coordinators, educators, instructors, and course directors) must be aware of these content updates to be eligible to teach and facilitate 10th edition courses. In addition to the content changes summarized in this article, a number of other changes in the conduct and organization of the course have been implemented. To learn about these changes, an in-person or online update must be completed. In-person updates are encouraged and may be offered by faculty who have been trained in the updates at the regional, state, or site level. In the summer of 2018, an online update course through the ACS learning management system will be available for those individuals who are unable to attend an in-person update. Continuing Medical Education (CME) credits will be offered for the online update and may be offered for the in-person update if the CME award schedule and documentation compliances are followed by the site hosting the update course. Once the faculty member has completed training, a link to a multiple-choice examination will be sent via e-mail for completion.

Acknowledgment

The ATLS Subcommittee and ATLS family are owed a debt of thanks for their tireless contributions to the support and improvement of the ATLS course. The list of those who contributed to this new edition is too lengthy to accurately detail here, but on behalf of the entire ACS COT, the author extends a sincere thank you.

Bibliography

Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: Does the digital rectal examination really help us? 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, fourth edition. 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.

Cohen 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 J Qual Patient Saf. 2012;38(6):261-268.

Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing for hemodynamically 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 in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomized controlled trial. Lancet. 2011;377(9771):1096-1101.

Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010;19(4):286-291.

Dressler AM, Finck CM, Carroll CL, Bonanni CC, Spinella PC. Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child. J Pediatr Surg. 2010;45(7):1530-1533.

Gunst M, Ghaemmaghami V, Gruszecki A, et al. Changing epidemiology of trauma deaths leads to a bimodal distribution. 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 in transfused pediatric trauma patients. J Pediatr. 2012;160(2):204-209.

Hendrickson JE, Shaz BH, Pereira G, et al. Implementation of a pediatric trauma massive transfusion protocol: One institution’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-based study. J Trauma. 2011;71(5):1099-1103.

Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest 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 spine evaluation after blunt trauma: An American Association for the Surgery of Trauma multi-institutional trials group study. 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 with increased 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 geriatric complications in severely injured geriatric patients. J Trauma Acute Care Surg. 2013;74(4):1125-1132.

Mutschler 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 the TraumaRegister DGU^®. Crit Care. 2013;17(2):R42.

Neff NP, Cannon JW, Morrison JJ, Edwards MJ, Spinella PC, Borgman MA. Clearly defining pediatric mass transfusion: Cutting through the fog and friction using combat data. J Trauma Acute Care Surg. 2014;78(1):21-28.

Onzuka J, Worster A, McCreadie B. Is computerized tomography of trauma patients associated with a transfer delay to a regional trauma centre? CJEM. 2008;10(3):205-208.

Osborn PM, Smith WR, Moore EE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54-60.

O’Toole RV, Lindbloom BJ, Hui E, et al. Are bilateral femoral fractures no longer a marker for death? J Orthop Trauma. 2014;28(2):77-81.

Quick JA, Bartels AN, Coughenour JP, et al. Trauma transfers and definitive imaging: Patient benefit but at what cost? Am Surg. 2013;79(3):301-304.

Roberts D, Leigh-Smith S, Faris P, et al. Clinical presentation of patients with tension pneumothorax: A systematic review. Ann Surg. 2015;261(6):1068-1078.

Schmitt SK, Sexton DJ, Baron EL. Treatment and prevention of osteomyelitis following trauma in adults. UpToDate. www.uptodate.com/contents/treatment-and-prevention-of- osteomyelitis-following-trauma-in-adults. Accessed April 12, 2018.

Shrestha B, Holcomb JB, Camp EA, et al. Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury. J Trauma. 2015;78(2):336-341.

Snyder D, Tsou A, Schoelles K. Efficacy of prehospital application of tourniquets and hemostatic dressings to control traumatic external hemorrhage. Washington, DC: National Highway Traffic Safety Administration; May 2014.

Steinhausen E, Lefering R, Tjardes T, et al. A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: An analysis based on the trauma registry of the German Trauma Society. J Trauma. 2014;76(5):1288-1293.

Sussman M, DiRusso SM, Sullivan T, et al. Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma. 2002;53(2):219-224.

United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Ageing. Available at: www.un.org/esa/population/publications/worldageing19502050/. Accessed April 12, 2018.

Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2013;60(Suppl 1):82-91.

Washington CW, Grubb RL, Jr. Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? J Neurosurg. 2012;116(3):549-557.

Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17.