Advanced Trauma Life Support Protocol Research Articles

Emergency Department Assessment and Management of Facial Trauma From War-Related Injuries

Facial trauma related to combat injury is of increasing prevalence and complex in nature when associated with the multiply injured trauma victim. Although rarely life-threatening, the treating physician must be aware of the presence of facial trauma and its associated injuries to seamlessly treat the combat casualty in accordance to the Advanced Trauma Life Support protocol while maintaining the armed forces' ultimate goals of returning "the greatest possible number of soldiers to combat and the preservation of life, limb and eyesight in those who must be evacuated." To this end, the treating physician must maintain a high index of suspicion for injury and have various maneuvers available to handle immediate threats to life, limb, or sight. This article will review the proper emergency department assessment and management of prevalent injuries associated with war-related facial trauma.

Invited Commentary

The authors report an interesting series of blunt trauma patients who had deep pulmonary lacerations during a 20-year period stratified by the adoption of a modified advanced trauma life support (ATLS) protocol in 2000 [1]. The overall survival was 69%. We are not informed regarding the mortality of the two time periods, which is a significant regrettable omission. The poor prognostic factors were signs of shock on admission, and more blood loss at the time of chest tube insertion (or within 2 hours of insertion) and at thoracotomy.

A retrospective analysis of the incidence of hemolysis in type and screen specimens from trauma patients

Hemolysis of blood samples has been a concern in hospitals. Currently, residents and nurses have replaced traditional teams of skilled phlebotomists for both routine and 'stat' blood draws. Although this leads to a decreased operating cost for institutions, the lack of skill and experience leads to a higher percentage of hemolyzed specimens. To determine the incidence of hemolyzed 'type and screen' blood samples at Staten Island University Hospital (SIUH) (New York, USA). The study group comprised 615 consecutive trauma patients at SIUH between July 2006 and June 2007. Patients were treated according to the Advanced Trauma Life Support protocol. The primary survey for a trauma patient consists of 'airway', 'breathing' and 'circulation'. The primary objective of 'circulation' is to establish vascular access and collect blood samples for analysis. The SIUH in-house laboratory provided all of the reports. Of the 615 samples collected, 155 samples (25.2%) were hemolyzed. The hemolysis rate of 25.2% for type and screen samples is higher than previously reported in the literature. The data suggest that the high rate of hemolysis in these trauma patients is due to the residents' lack of experience and skills required to obtain an adequate blood draw.

Personal experience with whole-body, low-dosage, digital X-ray scanning (LODOX-Statscan) in trauma

BackgroundLodox-Statscan is a whole-body, skeletal and soft-tissue, low-dose X-ray scanner Anterior-posterior and lateral thoraco-abdominal studies are obtained in 3-5 minutes with only about one-third of the radiation required for conventional radiography. Since its approval by the Food and Drug Administration (FDA) in the USA, several trauma centers have incorporated this technology into their Advanced Trauma Life Support protocols. This review provides a brief overview of the system, and describes the authors' own experience with the system.MethodsWe performed a PubMed search to retrieve all references with 'Lodox' and 'Stat-scan' used as search terms. We furthermore used the google search engine to identify existing alternatives. To the best of our knowledge, this is the only FDA-approved device of its kind currently used in trauma.Results and ConclusionThe intention of our review has been to sensitize the readership that such alternative devices exist. The key message is that low dosage full body radiography may be an alternative to conventional resuscitation room radiography which is usually a prelude to CT scanning (ATLS algorithm). The combination of both is radiation intensive and therefore we consider any reduction of radiation a success. But only the future will show whether LS will survive in the face of low-dose radiation CT scanners and magnetic resonance imaging devices that may eventually completely replace conventional radiography.

Protocol compliance and time management in blunt trauma resuscitation

To study advanced trauma life support (ATLS) protocol adherence prospectively in trauma resuscitation and to analyse time management of daily multidisciplinary trauma resuscitation at a level 1 trauma centre, for both moderately and severely injured patients. All victims of severe blunt trauma were consecutively included. Patients with a revised trauma score (RTS) of 12 were resuscitated by a "minor trauma" team and patients with an RTS of less than 12 were resuscitated by a "severe trauma" team. Digital video recordings were used to analyse protocol compliance and time management during initial assessment. From 1 May to 1 September 2003, 193 resuscitations were included. The "minor trauma" team assessed 119 patients, with a mean injury severity score (ISS) of 7 (range 1-45). Overall protocol compliance was 42%, ranging from 0% for thoracic percussion to 93% for thoracic auscultation. The median resuscitation time was 45.9 minutes (range 39.7-55.9). The "severe team" assessed 74 patients, with a mean ISS of 22 (range 1-59). Overall protocol compliance was 53%, ranging from 4% for thoracic percussion to 95% for thoracic auscultation. Resuscitation took 34.8 minutes median (range 21.6-44.1). Results showed the current trauma resuscitation to be ATLS-like, with sometimes very low protocol compliance rates. Timing of secondary survey and radiology and thus time efficiency remains a challenge in all trauma patients. To assess the effect of trauma resuscitation protocols on outcome, protocol adherence needs to be improved.

Survival After Concurrent Traumatic Dislocation of the Atlanto-Occipital and Atlanto-Axial Joints

A case report of a patient who survived a traumatic disassociation of both atlanto-occipital and atlantoaxial joints. OBJECTIVE.: To describe a rare case of concurrent atlanto-occipital and atlantoaxial dislocation with a review of the related literature regarding occipitocervical dislocation. Cases of isolated atlanto-occipital or atlantoaxial dislocation have typically resulted in death or devastating neurologic deficit. Survival after the simultaneous dislocation at both joints is extremely rare. The initial evaluation, subsequent management, and surgical treatment of a 25-year-old male who sustained a concurrent dislocation of the atlantoaxial and atlanto-occipital joints from a motor vehicle collision are reported and the related literature is discussed. The patient was transferred to our hospital after initial stabilization according to Emergency Medical Service criteria and management based on the Advanced Trauma Life Support protocol. A complete (ASIA A) spinal cord injury was diagnosed on admission. Radiographic evaluation revealed dislocations of the atlanto-occipital and atlantoaxial joints. Subsequently, the patient underwent surgical stabilization with instrumented posterior fusion from the occiput to C5. Intraoperatively, traumatic pseudomeningocele was diagnosed and repaired with pericranial autograft. The vital function parameters currently remain stable, but the patient is ventilator-dependent and did not regain motor or sensory function. The rapid response time of emergency medical services and stabilization according to the Advanced Trauma Life Support protocol now lead to the survival of patients with significant deficit from occipitocervical injuries. A high index of suspicion is required to appropriately manage a patient with this devastating injury in order to maximize the chance for survival.

Critical Primary Survey Injuries

The primary survey as established by the advanced trauma life support protocol includes a directed history and physical exam aimed at the rapid diagnosis of life-threatening thoracic injuries. Most of these injuries can and should be found and treated during the initial evaluation of the patient without the need for additional diagnostic studies. In this article we review the role of the primary survey in the diagnosis and treatment of major thoracic injuries.

Use of Nasogastric Tubes in Trauma Patients – A Review

Traditionally, suspected basal skull fractures have been considered a relative contra-indication to inserting a nasogastric tube(NGT). In patients with basal skull fractures the Advanced Trauma Life Support protocol recommends that...

Elaboração e aplicação de um instrumento de avaliação no pós-operatório imediato com base no protocolo do Advanced Trauma Life Suport

OBJETIVO: Elaborar e aplicar um instrumento de avaliação do paciente no pós-operatório imediato (POI) de anestesia geral baseado no protocolo do Advanced Trauma Life Suport. MÉTODOS: Foi criado um instrumento baseado no ABCDE do Trauma e aplicado na Sala de Recuperação Pós-Anestésica em todos os pacientes adultos submetidos a cirurgias sob efeito de anestesia geral no período de setembro a novembro de 2007. RESULTADOS: Observou-se que 93,5% dos pacientes tinham vias aéreas pérvias, porém 92,2% necessitaram de oxigênio suplementar. Houve alteração na ausculta pulmonar de 15,6% dos pacientes, hipotensão em 16,9% e hipotermia em 23,4%. Observou-se também uma diferença estatisticamente significativa sugerindo que as mulheres apresentam melhores condições de recuperação que os homens. CONCLUSÃO: O exame físico na seqüência proposta pelo ABCDE do Trauma permitiu identificar as principais alterações fisiológicas no POI contribuindo para a assistência de enfermagem.

The importance of re-evaluation of the trauma patient

It is accepted that the Advanced Trauma Life Support (ATLS) method, published by the American College of Surgeons, should be used in the initial assessment and management of the injured patient. It is recognised that mortality secondary to trauma follows a trimodal distribution. Catastrophic internal injuries cause death in seconds to minutes after injury, with other severe injuries often associated with significant blood loss, resulting in death minutes to hours later. The third peak is days to weeks later and is usually due to multi-organ failure. The quality of the management of the trauma patient in the first few hours following injury markedly affects the outcome. The ATLS protocol contains a primary and secondary survey, which provides a systematic way of identifying and treating injuries sustained. However there are circumstances when a potential threat to life may not easily be recognised. Most commonly errors occur in polytrauma patients when the secondary survey cannot be completed, due to primary survey findings requiring immediate intervention. Other factors that contribute to diagnostic errors are distracting injuries, where pain from one injury disguises another, or where the history is misleading or incomplete.

Gunshot wounds to the head and neck

Gunshot wounds to the head and neck result in significant bone and soft tissue loss. These defects pose a challenge to the facial reconstructive surgeon. This paper reviews the current literature on the management of ballistic injuries to the head and neck and outlines a treatment algorithm. With recent advances in free tissue transfer, early definitive reconstruction of bone and soft tissue deficits with vascularized flaps has become the treatment of choice. Computed tomography angiography of the neck has been shown to be a sensitive, specific, and safe technique in screening for vascular injuries. Management of ballistic injuries to the head and neck begins with advanced trauma life support protocols. Computed tomography angiography is now widely available and provides an accurate and rapid evaluation of head and neck vasculature. The initial operation aims to establish occlusion, stabilize bone and close soft tissue defects. Serial debridement of wounds with delayed reconstruction has given way to early definitive repair with vascularized tissue. This has led to improved function, fewer operations, and shorter hospital stays.

A cadaveric study of complications associated with the subxiphoid and transthoracic approaches to emergency pericardiocentesis

The aim of this cadaveric study was to compare three commonly used approaches for emergency pericardiocentesis and to determine the safest approach. Thirteen cadavers were injected at three sites with three different coloured dyes, one for each of the three different recommended approaches. The approaches used were (1) ATIP: anterior transthoracic in the fifth left intercostal space (Advanced Cardiac Life Support protocol), (2) SXP1: immediately subxiphoid and (3) SXP2: subxiphoid approach 1.5 cm inferior to SXP1 (Advanced Trauma Life Support protocol). The needles were left in the chest cavity to confirm their course on the way into the pericardial sac. Once the chest plate was removed, the location of the needle and the presence of dye enabled the identification of structures damaged and cavities entered by the needle. The associated complications from the three approaches were then recorded and compared. The anterior transthoracic intercostal pericardiocentesis approach to pericardiocentesis (2/39) and an immediately subxiphoid approach SXP1 (1/39) produced fewer potential complications than SXP2 (4/39). The SXP1 approach appeared to be the safest, followed by anterior transthoracic intercostal pericardiocentesis. The SXP2 approach caused the highest amount of complications, resulting from the needle entering the abdominal cavity. The presence of intra-abdominal pathology and the possibility of post-mortem changes in the position of the diaphragm, however, might have been a causative factor in this finding.

Prioritization and Treatment of Patients with Thoracolumbar Trauma and Multiple Injuries

Individuals with thoracolumbar trauma commonly sustain other injuries. Proper prioritization of these injuries is critical for obtaining optimal patient outcomes. Initial treatment should focus on life-threatening injuries utilizing advanced trauma life support (ATLS) and advanced cardiac life support (ACLS) protocols; when stabilized, the patient's skeletal injuries should be addressed. A thoracolumbar injury can be considered an additional long bone fracture when prioritizing treatment. Neurological status dictates which injuries are addressed initially. Worsening neurologic status, specifically cauda equina syndrome, dictates urgent (<48 hours) decompression and stabilization if necessary. Long bones (especially the femur) should be addressed definitively within 24 hours whenever possible, but complex fractures may require temporary stabilization (i.e., external fixation). Spinal surgery performed within 72 hours of injury is also recommended and can be performed concomitantly with limb injuries if the...

Delays and Difficulties in the Diagnosis of Lower Urologic Injuries in the Context of Pelvic Fractures

This article describes the characteristics of missed lower urologic injuries at a level 1 trauma center using advanced trauma life support protocols. Between 1991 and 1996, 635 patients were treated for traumatic pelvic fractures. For the 43 patients with missed urologic diagnoses, the pelvic fracture pattern, initial evaluation, average delay to diagnosis and treatment, reason for the delay, and manner in which the lower urinary tract injury was discovered and treated were identified. Of 43 patients with pelvic fracture, 10 (23%) with concomitant urologic injury had initially missed diagnoses. Delay in diagnosis and treatment averaged 19 hours for missed intraperitoneal bladder ruptures and 6.7 days for missed extraperitoneal bladder ruptures. The findings show that 23% of all bladder and urethral disruptions associated with pelvic fractures were missed at initial evaluation. The pelvic fracture pattern, in addition to physical examination, should direct the urologic evaluation for trauma patients.

Key factors in out-of-hospital intubation suggested for further training

Study objectives: We identify key factors affecting out-of-hospital intubation attempts. Methods: This was a retrospective review of consecutive patients transported by the primary ambulance service of a large Midwestern city. Patients were identified as requiring emergency intubation if they were newly unresponsive without a gag reflex, unresponsive with persistent pulse oximetry below 90%, or having a respiratory rate less than 10 breaths/min or greater than 30 breaths/min with persistent pulse oximetry below 90%. Analysis was done using a multiple regression model. Results: From March 2003 to June 2003, 386 transported patients required emergency intubation. Intubation was attempted in 42 (11%) patients and successful in 10 (24%, 95% confidence interval [CI] 11% to 37%), which is consistent with previous studies. Using a multiple regression model, 3 factors were identified that were associated with failure to attempt intubation when indicated: Glasgow Coma Scale (GCS) score of 9 or greater (odds ratio [OR] 18.2, 95% CI 6.5 to 29.9), failure to obtain intravenous access (OR 1.8, 95% CI 0.9 to 2.7), and performing bag-valve-mask or positive pressure ventilation (PPV) (OR 50.4, 95% CI 12.8 to 88.0). Although PPV is a temporizing measure, it does not provide a definitive airway. Whether or not it should preclude out-of-hospital intubation should be addressed prospectively, especially because more than 50% of patients had persistent pulse oximetry between 80% and 90% despite PPV. Out-of-hospital personnel may benefit from further training in optimal techniques for PPV. Likewise, although advanced trauma life support protocols use GCS score as an indication for intubation, it may not be the best indication of the need for intubation, because many patients had GCS score greater than 9 but were in respiratory failure, which suggests an area for further education. Finally, the ability to establish intravenous access was a weak but persistent factor affecting intubation attempts and may be an important area for ongoing training. Conclusion: GCS score of 9 or greater, the ability to obtain intravenous access, and performing PPV were 3 factors affecting intubation attempts and may be important areas for the further training of out-of-hospital personnel.

Management of a pancreatic duct injury with an endoscopically placed stent

A 17-year-old woman was a belted, front-seat passenger in a head-on motor vehicle collision. On arrival at a local medical center, the patient was awake and alert with stable vital signs and complaining predominantly of abdominal and flank pain. Advanced Trauma Life Support protocol was followed. Laboratory evaluations were normal with the exception of a serum amylase greater than 1500 U/L (normal 28–100) and a serum lipase greater than 3000 U/L (normal 16–63). An urgent computed tomography (CT) scan of the abdomen and pelvis revealed a contusion of the left lateral segment of the liver and a fracture at the junction of the body and tail of the pancreas just lateral to the spine. There was no evidence of pancreatic necrosis. The patient was kept non per os (nothing by mouth) and showed a rapid normalization of her hyperamylasemia and hyperlipasemia during the next few days. She was discharged on hospital day 4, free of symptoms and tolerating a regular diet.

International Trauma Anesthesia and Critical Care Society (ITACCS).

International Trauma Anesthesia and Critical Care Society (ITACCS).

Magnetic resonance imaging of the knee after ipsilateral femur fracture.

The purpose of this study is to identify and characterize the nature of internal knee derangement associated with ipsilateral femur fractures. A prospective consecutive investigation with the musculoskeletal radiologist being blinded to the clinical examination. A certified Level I trauma center. All adult (skeletally mature) patients with femur fractures resulting from blunt traumatic injury were included. Patients with penetrating, periprosthetic, pathologic, or previous femur fractures were excluded. In addition, all patients with previous knee injuries or previous knee surgery were excluded. Of the fifty-one patients with diaphyseal femur fractures originally enrolled in this investigation, fifteen were excluded by protocol and eleven were unable to obtain timely MRI studies. All patients were evaluated initially according to Advanced Trauma Life Support protocol. When appropriate, skeletal traction was used as provisional fracture stabilization. In most cases, however, operative fixation was performed immediately. In one case open reduction internal fixation was performed. In the remainder, fracture fixation with an anterograde ( = nineteen) or retrograde ( = seven) intramedullary nail was used. After surgical fixation, twenty-five patients with twenty-seven knees were examined clinically and with an MRI. Five anterior cruciate ligament and two posterior cruciate ligament injuries were discovered (19 percent and 7 percent, respectively). Four complete (Grade 3) medial meniscus tears (15 percent) and seven complete lateral meniscus tears (26 percent) were identified by postoperative MRI studies. The medial collateral ligament was injured in eleven knees (41 percent), with five (19 percent) identified as complete (Grade 3) injuries. The lateral collateral ligament was also injured in eight knees (30 percent); in half (15 percent) the injury was complete. Bone contusions (periarticular infractions of cortical and medullary trabecular bone) were noted in eight (30 percent) tibia (equally divided between medial and lateral compartments) and in 17 (63 percent) femurs (also equally divided between medial and lateral condyles). Given the large number of soft tissue injuries about the knee, it would be prudent to emphasize the importance of a thorough intraoperative examination once the femur fracture has been stabilized. Additionally, there should be a low threshold to obtain an MRI if the postoperative clinical examination suggests an associated knee injury. Bone bruises, which can only be identified by MRI studies, are increasingly being acknowledged as a source of persistent symptoms.

Metabolic and Clinical Markers of Prognosis in the Era of CT Imaging in Children with Acute Epidural Hematomas

Acute epidural hematoma (AEH), a relatively common complication of head injury in children, persists in bearing high morbidity and mortality. Early establishment of prognosis could guide optimal patient allocation, and early identification of predictive signs could assist in choosing appropriate therapeutic interventions. This study aimed to delineate expeditiously obtainable prognostic markers for determining outcome in a subset of children with AEH. We reviewed our 11-year experience with 61 consecutive children <16 years old with head trauma and isolated AEH. Treatment followed a standard advanced trauma life support protocol. A medical history was obtained, and all patients underwent neurosurgical and physical evaluations. CT scans were performed, as were laboratory tests which included arterial blood gases, glucose, electrolytes (K⁺, Na⁺), hemoglobin and coagulation studies. Evaluation of the data collected on cause of injury, interval between trauma occurrence and presentation, clinical symptoms, Glasgow Coma Scale (GCS) scores, vital signs, laboratory test results, physical findings and surgical versus conservative management revealed that the best single predictors of outcome following AEH were the GCS and focal neurological deficits. Of all laboratory data obtained on admission, the blood potassium, pH and glucose test results correlated significantly with prognosis. Prognosis can be adequately and expeditiously estimated by selected markers within a comprehensive evaluation of children with AEH.

Acute injuries of the trachea and major bronchi: importance of early diagnosis

Background. Tracheobronchial injuries are encountered with increasing frequency because of improvements in prehospital care and early initiation of the Advanced Trauma Life Support protocol. We review our experience with these injuries with the hypothesis that the leading determinant of patient outcome is the time interval to diagnosis.Methods. Patients with tracheobronchial injury were identified from the registry of our level 1 trauma center during a 10-year period ending December 1997. Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed.Results. Twenty patients with ten cervical tracheal injuries and ten intrathoracic tracheobronchial injuries were treated. The mechanism of injury involved blunt trauma in 11 and penetrating trauma in 9. All patients underwent surgical debridement and primary repair. Patients with isolated airway injuries were discharged home after a mean hospital stay of 6 days and had no early complications. Three patients had delayed diagnosis (> 24 hours), and all sustained complications including death (1 patient) and multiorgan system failure (2 patients). The overall mortality rate was 15%.Conclusions. Operative management of tracheobronchial injuries can be achieved with acceptable mortality. Independent of mechanism or anatomic location of injury, delay in diagnosis is the single most important factor influencing outcome. Early recognition of tracheobronchial injury and expedient institution of appropriate surgical intervention are essential in these potentially lethal injuries.