T Advanced Trauma Life Support (ATLS) course was introduced in 1978 and is currently taught in more than 60 countries. It continues to be a widely accepted standard for the initial care of the trauma patient. Begun as a consensus view of recognized experts on safe initial management of a trauma patient, it combines didactic information with procedural skills, culminating with management of simulated patients. Evidence of its effectiveness includes ascertainment and retention of both knowledge and skills as well as reduced morbidity and mortality after introduction of the ATLS program. The ATLS course undergoes revision approximately every 4 years, with early editions primarily revising old and incorporating new content. The eight edition, published in 2008, established a new process for incorporating change. All content changes in that edition and all subsequent editions required evidence rather than opinion for change. Suggestions for change are submitted directly to the ATLS revision Web site, with the opportunity to provide references and the level of evidence. The ninth edition continues to rely on evidence to support changes in ATLS content. However, the major changes in the ninth edition are format and delivery changes rather than content changes. The drivers for format changes come primarily from the increasing understanding of adult education along with the educational preferences of the next generations. In both content and format, two principles in addition to level of evidence continue to guide any changes to the ATLS course. The course continues to emphasize one safe way to care for the trauma patient during initial assessment; it is not meant to incorporate the most advanced, cutting edge information or technology. In addition, with the increasing penetrance of ATLS around the world, there is increasing variation in local resources and practice. The ATLS vision is to embrace those differences that do not affect the ultimate delivery of safe care and allow flexibility for course directors to choose safe options that reflect their local practice.

Advanced trauma life support (ATLS®): the ninth edition.

Background. The deterioration of hemodynamics instantly endangers the patients' life after polytrauma. As accidental hypothermia frequently occurs in polytrauma, therapeutic hypothermia still displays an ambivalent role as the impact on the cardiopulmonary function is not yet fully understood. Methods. We have previously established a porcine polytrauma model including blunt chest trauma, penetrating abdominal trauma, and hemorrhagic shock. Therapeutic hypothermia (34°C) was induced for 3 hours. We documented cardiovascular parameters and basic respiratory parameters. Pigs were euthanized after 15.5 hours. Results. Our polytrauma porcine model displayed sufficient trauma impact. Resuscitation showed adequate restoration of hemodynamics. Induced hypothermia had neither harmful nor major positive effects on the animals' hemodynamics. Though heart rate significantly decreased and mixed venous oxygen saturation significantly increased during therapeutic hypothermia. Mean arterial blood pressure, central venous pressure, pulmonary arterial pressure, and wedge pressure showed no significant differences comparing normothermic trauma and hypothermic trauma pigs during hypothermia. Conclusions. Induced hypothermia after polytrauma is feasible. No major harmful effects on hemodynamics were observed. Therapeutic hypothermia revealed hints for tissue protective impact. But the chosen length for therapeutic hypothermia was too short. Nevertheless, therapeutic hypothermia might be a useful tool for intensive care after polytrauma. Future studies should extend therapeutic hypothermia.

/pdf/induced-hypothermia-does-not-harm-hemodynamics-after-2ttznq462g.pdf

Induced Hypothermia Does Not Harm Hemodynamics after Polytrauma: A Porcine Model

#### Summary points

Military conflict has always driven innovation and technical advances in medicine and surgery. Accepted concepts of trauma resuscitation and surgery have been challenged in the wars in Iraq and Afghanistan, and novel approaches have been developed to address the current complexity and severity of military trauma.1 A number of these new strategies have evolved into a single seamless approach that extends from the point of wounding to surgery, and on to critical care. Although the precise contribution of medical care is difficult to ascertain, better trauma management has almost certainly contributed to a remarkable reduction in the lethality of war wounds. Only 10% of United States servicemen wounded in Iraq and Afghanistan between 2003 and 2009 died, compared with 24% in the first Gulf War (1990-1991) and Vietnam War (1961-1973).w1 Initially derived from clinical experience, new concepts in caring for the injured have been refined with experiment and study and have been translated back to the battlefield in a dynamic process.2 Many of these advances are also relevant to trauma care in civilian practice. The aim of this article is to provide an overview of a new approach …

http://www.gicu.sgul.ac.uk/teaching/resources/trauma-1/documents-and-files/dmge_cntrl_BMJ2009.pdf

Damage control resuscitation for patients with major trauma

Trauma in pregnancy: an updated systematic review

BACKGROUND: The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidencebased guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI. METHODS: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). RESULTS: The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines. CONCLUSION: The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation. (J Trauma Acute Care Surg. 2012;73: S333YS340. Copyright * 2012 by Lippincott Williams & Wilkins)

/pdf/emergency-tracheal-intubation-immediately-following-wz4almla11.pdf

Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

/pdf/advanced-trauma-life-support-8th-edition-the-evidence-for-34jozy38jk.pdf

Advanced trauma life support, 8th edition, the evidence for change.

Introduction Patients with small volume intracranial hemorrhage (ICH) are categorized as modified Brain Injury Guidelines (mBIG) 1 and are managed with a 6-h emergency department (ED) observation period. The current study aimed to describe the mBIG 1 patient population and determine the utility of the ED observation period. Methods A retrospective analysis was performed on trauma patients with small volume ICH. Exclusion criteria were Glasgow Coma Scale (GCS) < 13 and penetrating injuries. Results 359 patients were identified over the 8-year study period. The most common ICH was SDH (52.7%) followed by SAH (50.1%). Two patients (0.56%) had neurologic deterioration, but neither had radiographic progression. Overall, 14.3% of the cohort had radiographic progression; none required neurosurgical intervention. Four patients (1.1%) had readmission related to TBI from the index admission. Conclusion There were no patients with small volume ICH that required neurosurgical intervention despite a small subset of patients having radiographic or clinical deterioration. Patients who meet the mBIG 1 criteria may be managed safely without an ED observation period. 

John H. McVicker

Papers

Advanced trauma life support, 8th edition, the evidence for change.

To observe or not to observe: Evaluation of the modified brain injury guideline management of small volume intracranial hemorrhage.