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.

Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.

https://www.mayoclinicproceedings.org/article/S0025-6196(13)00555-7/pdf

Etiology and Therapeutic Approach to Elevated Lactate Levels

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

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.

Background:Acute lower extremity compartment syndrome (ALECS) is a devastating complication that often presents silently in critically injured patients; therefore, we developed a protocol to screen high-risk patients.Methods:This prospective observational study included all Shock Trauma intensive ca

Roman Kosir

Papers

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

Acute lower extremity compartment syndrome (ALECS) screening protocol in critically ill trauma patients.