Advanced Trauma Life Support (ATLS): 8 th edition-Changes of Importance to Anesthesiologists Journal Club October 2009 Hiral Patel, D.O.

Overview This article was chosen for discussion as the 8 th edition of ATLS has important changes of interest to anesthesiologists. The changes place special emphasis on airway and resuscitation endpoints. Scientific background of this study is discussed for transfusion practice. The hypothesis states that 1:1:1 transfusion of packed red blood cells (pRBC) :fresh frozen plasma(FFP) :platelets will improve overall mortality. Design of this particular research was a retrospective analysis of 252 massive transfusion patients at two U.S. Army Combat Support Hospitals.

Summary of Findings The difficult airway is finally addressed in the new ATLS. The ATLS guidelines recommend that airway evaluation be performed before attempting rapid sequence intubation (RSI). The new evaluation includes the following: Look, Evaluate, Mallampati, Observe, and Neck (Mnemonic “LEMON”). Also there is a required confirmation of placement of an endotracheal tube with a CO2 detector; although capnography is preferred other colorimetric techniques are accepted.

Summary of findings continued… The new ATLS guidelines also now have included the difficult airway devices and their importance in managing the emergent airway: Laryngeal mask airway (LMA), laryngeal tube airway (LTA) and gum elastic bougies. ATLS now includes balanced concept of limited resuscitation and damage control resuscitation. It states that excessive early crystalloid may dilute blood, dislodge clot and increase hemorrhage but too little resuscitation fluid in hypotensive bleeding patients will result in exsanguination following penetrating torso injury.

Summary of Findings Cont…. It states either crystalloid (Lactated Ringers vs. Normal Saline) is acceptable as initial resuscitation for shock. It also states that hypertonic saline is at least equivalent and maybe superior in patients with traumatic brain injury. Tourniquets are now regarded as important for use in exsanguinating extremity injury in the pre- hospital phase. The new pelvic fracture algorithm includes use of pelvic binders and angiography.

Summary of findings continued…. Blast injury is now included in the ATLS guidelines due to recent military experience with improvised explosive devices. Increased emphasis is now placed on early recognition of blunt carotid injury and methylprednisolone is no longer advocated for the management of acute spinal cord injury.

Summary of findings cont… Clearing the Cervical Spine in blunt trauma patients with head injury: Guidelines are under revision for identifying c-spine injuries after trauma. The new guideline does state that MR imaging is no longer required to clear the c-spine as the negative predictive values for CT are 98.9 percent for ligament injury and 100 percent for unstable c-spine injury.

Summary of findings cont… Blunt thoracic aortic trauma and anesthesia: Options for management of blunt aortic trauma (BAI) include open surgical and stent graft repair. Endovascular repair has replaced open repair in many centers resulting in major reduction of mortality and procedure related paraplegia. Military experience states multiple studies show a decrease mortality in 1:1 transfusion practice. Overall mortality of 30 percent with military transfusion guidelines. Civilian data gathered from 467 massive transfusion patients from 16 level 1 trauma centers between July 2005-June 2006 showed variable survival range from percent by center. The plasma :pRBC ranged from 0:2.89 and platelets :pRBC High plasma :pRBC (>1:2) and high platelet :pRBC (<1:2) transfusion ratios decreaesd truncal hemorrhage and icu ventilator and hospital free days.

Critique of article Good points: 1) The article goes over the new guidelines in trauma patients which is relevant to anesthesia practice. 2)Difficult airway is addressed and also the adjuncts that can be used. 3)It addresses how either crystalloid is acceptable which was a question in the past. 4)For blunt thoracic aortic trauma, it states the superiority of endovascular stenting under local and regional anesthesia and avoiding thoractomy, one lung ventilation, aortic cross clamping/bypass. 5)It states that avoidance of thoracotomy minimizes postoperative pain and associated respiratory compromise and also cross clamping of aorta reduces blood pressure shifts and blood loss with minimal organ ischemia time. This is beneficial as it states the option of endovascular stenting being superior and more beneficial in numerous ways. 6)This article also states the superiority of 1:1:1 transfusion of pRBC, plasma, and platelets and has positive outcomes and should be adopted as mortality rates have been shown to decrease.

Critique of article continued… Bad points: 1)It should address the entire difficult airway algorithm and not just the different adjuncts available. It does not talk about the glidescope as adjunct for c-spine injuries or an awake fiberoptic intubation being an option. 2)This article should go into more detail about the types of patients that had the endovascular stenting done and which patients still had to have a thoracotomy. 3)It does not state the new guidelines for identifying c- spine injuries after trauma.

How does this apply to our practice? It identifies the importance of difficult airway and to actually evaluate the airway before RSI. The new guidelines are useful as they are placing emphasis on the difficult airway in trauma care and offering adjuncts. It also states that a c-spine is adequate for ruling out cervical spine injury and MRI is not necessary This article also has solid data about transfusion guidelines and resuscitation which can be helpful in our massive transfusions. This article also states the importance of avoiding thoracotomy if possible as endovascular stenting has been so beneficial for blunt aortic trauma. Again, the risks are far greater for a thoracotomy then with endovascular stenting.

Open discussion……