ATLS 10th ed. Course Structure and Content Changes. Current Update on ATLS For Trauma Patients
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1 ATLS 10th ed. Course Structure and Content Changes Current Update on ATLS For Trauma Patients
2 ATLS 10th ed. Course Structure and Content Changes International ATLS 86 countries > 1 million trained > 50% courses outside North America MyATLS mobile app 181 countries
3 ATLS 10th ed. Course Structure and Content Changes Trauma - Worldwide Disease Unintentional injury and violence 5.8 million people die per year More than nine every minute 18% of world burden of disease Motor vehicle crashes More than 1 million deaths 20 to 50 million significant injuries Other 17% Road traffic 25% Self-inflicted16% Interpersonal violence 10% Drowning 9% Fires 5% Poison 6% Falls 6% War 6%
4 Program Goals Rapid and accurate assessment Resuscitate and stabilize by priority Determine needs and capabilities Arrange for transfer to definitive care Ensure optimum care
5 The Need ATLS provides a common language
6 The Beginning
7 The Beginning When I can provide better care in the field with limited resources than what my children and I received at the primary care facility there is something wrong with the system, and the system has to be changed. James Styner, MD, FACS 1977
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9 KEGIATAN ATLS TAHUN 1995 SD Juni 2018 N O TAHUN JUMLAH KURSUS JUMLAH PESERTA
10 KEGIATAN ATLS TAHUN 1995 SD Juni 2018 N O TAHU N JUMLAH KURSUS JUMLAH PESERTA
11 KEGIATAN ATLS TAHUN 1995 SD Juni 2018 NO TAHUN JUMLAH KURSUS JUMLAH PESERTA Juni (128) 1743 JUMLAH Terdiri dari : Dokter umum, dokter spesialis dan dokter gigi
12 History ATLS in Indonesia April 1994 Dr. Aryono D. Pusponegoro collaboration with Dr. Brent E. Krantz FACS (Chairman ATLS Subcommittee Trauma American College of Surgeons/ACS) and Ministry of Health Indnesia (Dirjen YANMED) discusion of ATLS Program at Indonesia March,5 8, st ATLS Course at Department of Surgery Cipto Mangunkusumo Jakarta with 32 student., Edition ATLS Book in Indonesia from 6th edition until 9th edition. Recently, USA and Australia already use ATLS Book 10th edition
13 Content update: Chapter 1: Initial assessment Initial fluid bolus of 1 liter may be required. Fluids are administered judiciously, as aggressive resuscitation before control of bleeding has been demonstrated to increase mortality. Coagulopathy associated with severe trauma can be fueled by resuscitative measures. Use of massive transfusion protocols with blood components administered a predefined low ratios may mitigate this.
14 Be Prepared Equipment: Suction, 0 2, oropharyngeal and nasopharyngeal airways, bag-mas, laryngoscope, gum elastic bougie (GEB), extraglottic devices, surgical or needle cricothyroidotomy kit, endotracheal tubes, pulse oximetry, C0 2 detection device, drugs Restrict cervical spinal motion! Preoxygenate 0 2 +/- bag-mask +/- oral airway +/- nasal airway Able to oxygenate YES Assess airway anatomy Predict ease of intubation (LEMON) EASY NO DIFFICULT Content Update Chapter 2 : Airway and Ventilatory Management Definitive airway/surgical airway Change term RSI (rapid sequence intubation) to DAI (drug assisted intubation) Intubation +/- drug-assisted intubation Cricoid pressure Call for assistance, if available UNSUCCESSFUL Consider adjunct (e.g. GEB/LMA/LTA) Consider awake intubation Definitive airway/surgical airway
15 Content update Chapter 3 : Shock Fluid resuscitation 1 L warm crystalloid Minimum 18 gauge peripheral access X 2 Choice of site for alternate access based clinician experience and skill Early resuscitation with blood and blood products must be considered in patients with evidence of class III and IV hemorrhage. Early administration of blood products at a low ratio of packed red blood cells to plasma and platelets can prevent the development of coagulopathy and thrombocytopenia.
16 Content update Chapter 3 : Shock Massive transfusion define as > 10 units prbc in 24 hours or more than 4 units in 1 hour. Thromboeleastography and Rotational thromboelastometry can be helpful in determining the clotting deficiency and appropriate blood components to correct the deficiency. Some jurisdictions administer tranexamic acid in prehospital setting to severely injured patients in response to studies that demonstrated improved survival when this drug is administered within 3 hours of injury. The first dose is usually given over 10 minutes and is administered in the field; the follow up dose of 1 gram is given over 8 hours.
17 10 th Edition ATLS Skills Station update Parameter Approximate blood loss Heart rate Blood pressure Pulse pressure Respiratory rate Urine Output GCS Base deficit Class I Class II (mild) Class III (moderate) Class IV (severe) < 15 % 15 30% 31 40% > 40% 0 to 2 meq/l 2 to 6 meq/l / / / / 6 to 10 meq/l 10 meq/l or more Need for Blood Products Monitor Possible Yes MTP
18 Content update Chapter 4 : Thoracic Trauma Tension pneumothorax Presentation Spontaneous ventilation air hunger, desaturation Mechanical ventilation- hemodynamic compromise Treatment Decompression Needle Site 4 th or 5 th ICS Adults may fail bc kinking or CW thickness Finger
19 Content update Chapter 4 : Thoracic Trauma Hemothorax (smaller just as good) CT size F Blunt aortic injury medical management HR and BP control rupture Targets HR = 80 MAP = mm HG if no contraindications
20 10 th Edition ATLS Skills Station update Content update: Chapter 5 Abdomen and Pelvic Trauma Include blast mechanism in addition to penetrating and blunt injury. Palpation of the prostate gland is not a reliable sign of urethral injury
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22 10 th Edition ATLS Skills Station update Content update Chapter 6 : Head Trauma
23 10 th Edition ATLS Skills Station update Content update Chapter 6 : Head Trauma
24 10 th Edition ATLS Skills Station update
25 Content update: Chapter 7 Spine and Spinal cord injury 10 th Edition ATLS Skills Station update L4 Ankle dorsiflexion L5 long toe extensors
26 Content update Chapter 8 : Musculoskeletal Trauma Bilateral femur Risk factor for complications and death Should alert the clinician to the possibility of associated injures because of the significant force required to result in the injury. Extended
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28 Content update Chapter 9: Thermal Injury Fluid resuscitation for patient with deep partial and full thickness burns involving > 20% BSA should begin with 2ml of Lactated ringer s X patient s weight in kg X % BSA burn Fluid is titrated based on adequacy of the urine output. Avoid fluid boluses unless the patient is hypotensive. Resuscitate pediatric patients using 3ml/kg/%TBSA
29 Content update: Chapter 10 Pediatric Trauma Use of Don t be a DOPE mnemonic to remember common causes of deterioration in intubated patients. D dislodgement O obstruction P pneumothorax E equipment failure Note no change in site for needle decompression in children 2 nd intercostal space mid clavicular line.
30 Content update: Chapter 10 : Pediatric trauma Damage control resuscitation in children represents a move toward limiting crystalloid resuscitation. 20 ml/kg bolus ml/kg of PRBC ml/kg of fresh frozen plasma and platelet as part of massive transfusion protocol No survival advantage has been demonstrated
31 Chapter Content: Chapter 10 Geriatric Trauma Preexisting conditions impact morbidity and mortality. The five that appear to influence outcome in trauma patients are cirrhosis, congenital coagulopathy, chronic obstructive pulmonary disease, ischemic heart disease and diabetes mellitus Patients with one or more of these PECs twice as likely to die as those without. Mortality from pelvic fracture 4 X higher in older than younger patients Need for blood transfusion even with stable fracture is higher Longer hospital stays and less return to independent lifestyles
32 Content update Chapter 12 : Trauma in Pregnancy and Intimate partner violence Indication of amniotic fluid leak is vaginal fluid ph of > 4.5
33 Content update Chapter 13 : Transfer to Definitive Care Significant portion of trauma patients transferred to regional trauma centers undergo CT scanning at the primary hospital Increased length of stay before transfer Much of the time delay between injury and transfer is related to performing diagnostic studies despite lack of a surgeon to provide definitive care. CT scans done before transfer to definitive care are often repeated upon arrival to the trauma center Making the necessity of a pre-transfer CT questionable. Multiple scans result in increased radiation exposure and additional hospital costs
34 SUMMARY Beginning ATLS at USA was first introduced by American College of Surgeons (ACS), Commitee of Trauma (COT) in 1980 Indonesia, first ATLS March, 5 8, 1995 Jakarta Its courses provide you with a safe and reliable method for immediate management of injured patients Courses ATLS in Indonesia until June 2018 = 1638 courses used ATLS Books 6th 9th. Ed. Change Update 10th edition started at USA and Australia
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