Anesthesia Management: ASA meeting: ATLS: Updates to Trauma Processes

The Advanced Trauma Life Support (ATLS) program helps train emergency personnel in the management of acute trauma cases, and a session Tuesday served as both a review and an update of trauma processes for physician anesthesiologists.

“ATLS asks you to think differently,” said Dr. McCunn, of the Department of Anesthesiology and Critical Care Medicine, Divisions of Trauma Anesthesiology and Surgical Critical Care at the University of Maryland R Adams Cowley Shock Trauma Center, Baltimore. “ATLS says we are going to treat what’s killing the patient.”

The session started by emphasizing that ATLS says patients are best assessed by a team, with one leader. In the U.S., the leader is the trauma surgeon, but in Europe the leader is the physician anesthesiologist, she said. The presentation then focused on the greatest threats to life during trauma:

– Airway with cervical spine protection

– Breathing

– Circulation with hemorrhage control

– Disability or neurologic status

– Exposure (undress) and environment (temperature control).

In dealing with the airway for rapid-sequence intubation, ATLS calls for the physician anesthesiologist to pre-oxygenate and use cricoid pressure, and if they cannot intubate to “bag-mask until paralysis resolves.”

Dr. McCunn said this is best only for non-acute situations, adding, “For trauma, it is not a reality.”

Regarding the use of cricoid pressure, she said, “My opinion on cricoid is changing from year to year. There are several challenges. It may worsen the view.” Some groups, including the American Heart Association, no longer recommend using cricoid pressure because it may impede airway management.

In the review for breathing, the one note was that patients ventilated protectively showed better pulmonary function tests. “If you look at measures of pulmonary function, if you ventilate protectively, you may be improving that patient’s outcome,” Dr. McCunn said.

In the area of circulation, the best method of access is a cordis introducer of 8.5 French or larger above and below the diaphragm, she said, joking, “This is one time in life when short and fat is better than tall and thin.”

Dr. McCunn also emphasized that the five locations where a patient can bleed to death are the chest, abdomen, pelvis/retroperitoneum, long bones and the “street”/floor.

For disability, in brain injury, new guidelines call for maintaining a cerebral perfusion pressure of 50-70 mmHg. She also reminded attendees that in brain injury, mortality doubles with one episode of hypotension and triples with hypotension plus hypoxia.

If a patient has neurogenic shock with cervical spine injury, only give maintenance rates of fluids.

Finally, when dealing with exposure and environment, it is best to avoid hypothermia by keeping the patient warm. Also, in orthopedic emergencies, fracture management has evolved to early fixation when it is physiologically appropriate, Dr. McCunn said.