Episode 12 – New Trauma Guidelines: ATLS and Spine

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Today, we discuss two new Trauma Guidelines

ATLS 9th Ed.

The 9th edition of ATLS has been published. In this episode, I review the changes from the 8th edition.

Management of C-Spine Injuries

We also go over the new management of spinal cord injuries from the Neurosurgeons

Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries from the American Association of Neurological Surgeons

What’s EMCrit Drinking?

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Comments

  1. Prevention of secondary injury in SCI is key. Many SCI are missed initially, and if you think they’re bleeding you *may* be tempted to not bump up their MAP to 90. If spinal shock, they should be bradycardic instead of tachycardic. And if spinal shock with no obvious bleeding, may not need blood products like you’ve mentioned in the podcast. I think you could give crystalloids and start pressors early, but this is if you suspect SCI and not hemorrhage.

  2. Minh Le Cong says:

    just one point of terminology
    spinal shock is not neurogenic shock, which is the correct trauma term in my opinion
    spinal shock relates to loss of spinal cord reflexes in acute period of SCI, and these may recover with time.
    Sorry. it isa pedantic point by one of my neurosurgical mentors.

  3. Ross Hofmeyr says:

    Great ‘cast Scott. I (COI: ATLS instructor/course director) agree with your comments that ATLS is a foundation – we as specialists in our fields should certainly be aware of the more current directions…but equally aware of when current trends go awry!

    Small correction: ETT cuff pressure should be less than 30 cmH20, not 30 mmHg (a little over 40cmH20). Fortunately, most pressure manometers are marked in cmH20 ;)

    • Ross,

      If you asked me clinically, I would absolutely agree with you. 30 cmH2O is our cuff cut-off and the the peds studies cited actually used 20 cm H2O.

      However the podcast was based on this document:
      http://web15.facs.org/atls_cr/help/9th_Edition_Compendium_for_Update_FINAL.pdf
      on the American College of Surgeons website.

      So either their summary is incorrect or their rec is high in both of our minds.

      Can you take a cell phone shot of anything they have written with the values you mention.

  4. Mary Shue says:

    Did they address therapeutic hypothermia (or relative hypothermia) in the acute sci guidelines?
    Mary Shue
    Emergency Department Pharmacist
    University of Michigan Health System

  5. Minh Le Cong says:

    good point ROss. I did wonder about that mmHg reference too. OUr manometers read in cmH2O as well.

  6. Brendon says:

    Just a technical glitch – the link for the c-spine update directs to the stroke guidelines. Can it be redirected?
    (Neurosurgery 2013;72(supplement 2):1-259 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries)

  7. re: cuff pressure discussion.

    the units are a bear here. there are mmHg and mmH2O and cmH2O in regular use in medicine.

    the 9e FACS ATLS changes doc seems a bit off, as suggested. of the two citations they gave for the 30mmHg sentence quoted above: the first had no mention of appropriate cuff pressures (that i could find) and the second was a prospective trial that used and suggested pressures <= 20cmH20 (equivalent to about 15mmHg, very roughly 1.5x smaller. 1 mmHg = 13.6 mmH2O = 1.36 cmH2O).

    A quick glance at some random online lit confirms 20-30cmH20 is normal for ET tubes (which is equivalent to ~15 – 22 mmHg)

    The manometers I have seen RTs use to measure cuff pressures (generally only in peds ICU, honestly) measure in cmH20. so do anesthesia machines, ventilators, CPAP machines, etc. Everything else I have ever seen measure body fluids and compartment pressures (invasive monitors, standard blood pressure monitors, stryker needles, etc) measures in mmHg. For folks who don't have access to respiratory manometers, just taking air out of the cuff with a syringe until you have a minimal reasonable leak pressure (say 15 or something? i forget) would be my best (unvalidated, unexpert) guess. I have used my high-quality WA hand aneroid BP manometer to play around with getting ET cuff pressures in the right range, and it's ok, but requires a little fidgeting around. at these low ranges I would be skeptical of even this technique, and definitely with a junk manometer.

Trackbacks

  1. [...] Scott Weingart’s podcast on the new ATLS guidelines and new spinal cord injury [...]

  2. [...] Also Mr EmCrit just posted a new podcast on his Practical Evidence blog on new ATLS guidelines on spinal cord injury. [...]

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