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GUIDELINES UPDATE
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Advanced
PracticeTrauma July 2011
November 2009
PAGE
PAGE 2 |2|Clinical
Life Support,
Benign Paroxysmal
Guideline:
CurrentParoxysmal
Benign Guidelines Positional
For Volume 3, Number 27
Volume 1, Number
8th Edition,
Positional Vertigo The Advanced
Vertigo AndTrauma Life Support
Acute Otitis Externa
Authors
Editor-In-Chief
Daniel Lakoff, MD
Evidence For Change
In The Emergency Department Reuben J. Strayer, MD
Department of Emergency Medicine, Mount Sinai School of Medicine, New
York, NY
Assistant Professor of Emergency Medicine,
PAGE 3 | Practice Parameter:
JournalForofBenign
Trauma In The ED: Current Guidelines Mount Sinai
Kaushal SchoolMD,
H. Shah, of Medicine,
FACEP New York, NY

II
Therapies Associate Professor, Mount Sinai School of Medicine, New York, NY

Paroxysmal Positional n this issue of EM Practice Guidelines Update, we review the Editorial Board
Editor-In-Chief
Vertigo (An Evidence-Based Inchanges
this issueand additions
of EM Practice to the Advanced
Guidelines Update,Trauma
we reviewLife2 Sup- Andy Jagoda,
Reuben MD,
J. Strayer, MDFACEP
| References
PAGE 7Review): Report Of The port (ATLS) guidelines leading to the 8th Edition.
guidelines that address the diagnosis and management Since
of its
Professor
Assistant and Chair,
Professor Department
of Emergency of Emergency
Medicine, Mount SinaiMedicine
School of Medicine,
Mount
New Sinai
York, NY School of Medicine, New York, NY
Quality Standards Subcom- inception in 1978, ATLS
benign paroxysmal has improved
positional trauma
vertigo (BPPV) andcare internation-
1 guideline on Erik Kulstad,
Editorial Board MD, MS
ally by serving as a standard for focused trauma assessment Research Director, Advocate Christ Medical Center
PAGE 8mittee
| CME Of Questions
The American the topic of acute otitis externa (AOE). BPPV is the most common Nicole C. Bouchard, MD, FRCPC
Department of Emergency Medicine, Oak Lawn, IL
Academy of Neurology and of
cause management
vertigo, withas well as prevalence
a lifetime a languageofthat allows
2.4%, physicians
and while Assistant Clinical Professor, Assistant Site Director; Director of Medical Toxicology,
Eddy
New S. Lang, MDCM,
York-Presbyterian CCFP University
Hospital, Columbia (EM), CSPQ Medical Center, New York, NY
it is not dangerous per se, it is an important cause of patient to work
in emergency departments (EDs) and on trauma teams Associate
Andy Professor,
Jagoda, McGill University, SMBD Jewish General
MD, FACEP
synchronously
discomfort and provide
and missed work asconsistent trauma
well as falls, management.
particularly in the Hospital,and
Montreal, Canada of Emergency Medicine, Mount Sinai School of
5| Clinical
PAGE Editors Practice
Note: To read Guideline:
more about this publication
and the background and methodologies for practice
Professor
Lewis S.
Medicine,
Chair, Department
Nelson,
New York, NY MD
Acute
guideline Otitis go
development, Externa
to: elderly. The most common emergency department therapies for Director,
Erik Fellowship
Kulstad, MD, MSin Medical Toxicology, New York City Poison
http://www.ebmedicine.net/introduction Practice
BPPV Guideline
(antihistamines, Impact
anticholinergics, and sedatives) are not Control Center,
Research Director,Associate
DepartmentProfessor, Department
of Emergency of Emergency
Medicine, Advocate Christ
Medicine,
Medical NYU
Center, OakMedical Center, New York, NY
Lawn, IL
recommended by specialists.
A rectal examination is not mandatory for all trauma patients. It Gregory
Eddy M. Press,
S. Lang, MDCM,MD, CCFP RDMS(EM), CSPQ
Prior to beginning this activity, see CME Information can be performed selectively based on clinical judgment. Assistant
Senior Professor,
Researcher, Director
Alberta HealthofServices;
Emergency Ultrasound,
Associate Emergency
Professor, University of
on page 9. The second topic for review, AOE, is a prevalent and painful Ultrasound
Calgary; Fellowship
Adjunct Professor,Director, Department
McGill University, of Emergency
Montreal, Medicine,
Quebec, Canada
University of TexasMDat Houston Medical School, Houston, TX
condition seen by emergency clinicians whose management can be Lewis S. Nelson,
ATLS guidelines now recognize the value of the CO2 detector, Scott M.
Associate Silvers,
Professor MD Medicine, New York University School of
of Emergency
complicated by several common pitfalls. Medicine; Director, Fellowship
Chair, Department in Medical Toxicology,
of Emergency MedicineNew York City Poison Control
laryngeal mask airway (LMA), and gum elastic bougie in airway Center, New York, NY
Mayo Clinic, Jacksonville, FL
management
Practice Guidelineof the trauma patient.
Impact: Gregory M. Press, MD, RDMS
Scott Weingart, MD FACEP
Assistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound
Vestibular suppressant medications of the benzodiazepine, Assistant Professor, Department of Emergency Medicine, Elmhurst
Fellowship Director, Department of Emergency Medicine, University of Texas at
Hospital Center, Mount Sinai School of Medicine, New York, NY
The guidelines clearly
anticholinergic, state that there
and antihistamine is insufficient
classes evidence
have a limited role Houston Medical School, Houston, TX

to advocate for steroids

in the management of BPPV. in spinal cord trauma. Maia S.beginning
Prior to
Medical
Rutman,this
MDactivity, see Physician CME Information on
page 7.Director, Pediatric Emergency Services, Dartmouth-Hitchcock Medical
Center; Assistant Professor of Pediatric Emergency Medicine, Dartmouth
Clear
A particle repositioning
criteria maneuver
exist for when is the
to screen fortherapy of choice
blunt carotid andin Medical School, Lebanon, NH
Editors Note: Introduction to a New Series
Scott M. Silvers, MD
the management of BPPV and should be performed in
vertebral vascular injury via computed tomography (CT)-angi- the ED EM Practice
Chair, DepartmentGuidelines
of EmergencyUpdate
Medicine,is a new
Mayo publication
Clinic, from
Jacksonville, FL
or arranged
ography. from the ED. EB Medicine
Scott Weingart,that
MD, will
FACEPhelp emergency department clini-
Associate Professor,
cians stay Director
current withof the Division of
practice Emergency Critical
guidelines. To read Care,
more
Systemic antibiotics should be avoided in most cases of Department of Emergency Medicine, Mount Sinai School of Medicine,
about this
New York, NY
publication and the background and method-
diffuse AOE. ologies for practice guideline development, http://www.
Research Editor
ebmedicine.net/introduction
Phillip G. Blanc, MD, MPH
Department of Emergency Medicine, Mount Sinai School of Medicine, New
York, NY
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Advanced Trauma Life Support, 8th Edition, The Evidence For
Change.1
The Journal of Trauma Injury, Infection, and Critical Care. 2008;64(6):1638-1650.
Link: http://journals.lww.com/jtrauma/pages/results.aspx?k=ATLS%208th%20edition&Scope=AllIssues&txtKeywords=ATLS%208th%20edition
U
ntil recently, the ATLS guidelines and program curriculum were
developed by expert consensus without a rigorous literature
reviewand distributed internationally in the form of a textbook
and course. In its newest iteration, recommendations were augmented
with an attributed level of evidence (LOE). International contributors
were asked to provide recommendations with supporting evidence,
the ATLS subcommittee subsequently reviewed the data, and using a
LOE scale,2 the data were classified in accordance to the type of study
(treatment, prognostic, diagnostic, or economic and decision analysis)
as well as by the quality of study. The quality of each study ranged
from 1 to 5, and include the best available studies in each category,
from the gold standard study (1) to expert opinion (5). The following
excerpts included here are from the ATLS 8th Edition Compendium of
Changes, followed by editorial comment, as appropriate. Items noted
as "New" are new in the 8th Edition. The number of studies examined
and the level of evidence are noted in parentheses.
Initial Assessment
Rectal Examination: A rectal examination should be performed se-
lectively before placing a urinary catheter. If the rectal examination is
required, the doctor should assess for the presence of blood within the
bowel lumen, a high-riding prostate, the presence of pelvic fractures,
the integrity of the rectal wall, and the quality of the sphincter tone. (1
study LOE 4
Editorial Comment: Initial Assessment
This is one of the major revisions for the 8th Edition. The adage, ev-
eryone needs a rectal exam unless they dont have a rectum or you
dont have a finger no longer applies. The performance of a rectal
EM Practice Guidelines Update 2011 2
Current Guidelines On Advanced Trauma Life Support In The ED
examination is a clinical decision and, like any diagnostic maneuver,
should be employed only if clinically warranted. It is not necessary to
perform a rectal examination solely for the purpose of insertion of a
Foley catheter.
Airway
Carbon Dioxide Detector: A carbon dioxide (CO2) detector (ide-
ally capnography, but if not available, by colorimetric CO2 monitoring
device) is indicated to help confirm proper intubation of the airway. (2
studies LOE 3)
Laryngeal Mask Airway: There is an established role for the LMA in
the management of a patient with a difficult airway, particularly if at-
tempts at tracheal intubation or bag-valve-mask ventilation have failed.
The LMA does not provide a definitive airway. Proper placement of
this device is difficult without appropriate training. When a patient has
a LMA in place on arrival in the ED, the doctor must plan for definitive
airway. (3 studies LOE 2, 5 studies LOE 3, 1 study LOE 1)
Laryngeal Tube Airway (New): The laryngeal tube airway (LTA) is an
extraglottic airway device with similar capability to provide successful
ventilation to the patient as that of the LMA. The LTA is not a definitive
airway device, and plans to provide a definitive airway must be imple-
mented. (1 study LOE 2, 2 studies, LOE 4)
Gum Elastic Bougie (New): A useful tool when faced with the dif-
ficult airway is the Eschmann tracheal tube introducer (ETTI) also
known as the gum elastic bougie (GEB). (1 study LOE 4) It is a 60-
cm long, 15 French intubating stylette. (1 study LOE 5) The ETTI is
employed when vocal cords cannot be visualized on direct laryngos-
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copy. (1 study LOE 5) In multiple operating room studies, successful
intubation is seen at rates greater than 95% with ETTI. (1 study LOE
2, 1 study LOE 3, 3 studies LOE 4, 3 studies LOE 5) In cases where
potential cervical spine injury is suspected, ETTI-aided intubation was
successful in 100% of cases in less than 45 seconds. (1 study LOE 5)
This simple device allowed rapid intubation of nearly 80% of prehospi-
tal patients with difficult direct laryngoscopy. (1 study LOE 4)
Difficult Airway (New): It is important to assess the patients airway
before attempting intubation to predict the likely difficulty. Factors
which may predict difficulties with airway maneuvers include significant
maxillofacial trauma, limited mouth opening, and anatomical variation
such as receding chin, overbite, or a short, thick neck. The mnemonic
LEMON (look, evaluate, Mallampatti, obstruction, neck) is helpful as a
prompt when assessing the potential for difficulty. (1 study LOE 1, 1
study LOE 4)
Editorial Comment: Airway
Airway is the initial and most crucial part of the trauma algorithm, and
can be the most difficult aspect of managing a crashing trauma patient.
The need for difficult airway evaluation prior to intubation and the use-
fulness of CO2 detection after intubation is well known to emergency
clinicians; however, comfort with rescue airway devicesspecifically
the gum elastic bougie and the LMAmay not be universal. Emergen-
cy clinicians caring for sick trauma patients should familiarize them-
selves with these devices and, if they are not already a part of their
airway skillset, should consider acquiring them for their departments.
This section of the compendium is not a comprehensive guideline on
airway management and does not meet the emergency clinician skill-
set in this area. Notably, we disagree with the logic regarding the use
of short-acting paralytics (SAP)usually succinylcholineas a safety
mechanism in the event of a failed airway. It is recommended that SAP
be used because in the event of a failed airway, the practitioner can
ventilate the patient via bag valve mask (BVM) until paralysis resolves.
This is not sound reasoning, however, because the return of airway re-
flexes in the midst of airway management is dangerous, and resolution
of paralysis does not obviate the need to intubate the patient.
EM Practice Guidelines Update 2011 3
Current Guidelines On Advanced Trauma Life Support In The ED
Shock
Crystalloid: Warmed isotonic electrolyte solutions (eg, lactated Ring-
ers [RL] or normal saline) are used for initial resuscitation. This type of
fluid provides transient intravascular expansion and further stabilizes
the vascular volume by replacing accompanying fluid losses into the
interstitial and intracellular spaces. An alternative initial fluid is hy-
pertonic saline, although current literature does not demonstrate any
survival advantage. (2 studies LOE 2, 2 studies LOE 3)
Fluid Resuscitation: The goal of resuscitation is to restore organ per-
fusion. This is accomplished by the use of resuscitation fluids to replace
lost intravascular volume and has been guided by the goal of restoring
a normal blood pressure. It has been emphasized that if blood pressure
is raised rapidly before the hemorrhage has been definitely controlled,
increased bleeding may occur. This may be seen in the small subset of
patients in the transient or nonresponder categories. Persistent infusion
of large volumes of fluids in an attempt to achieve a normal blood pres-
sure is not a substitute for definitive control of bleeding. Fluid resus-
citation and avoidance of hypotension are important principles in the
initial management of blunt trauma patients, particularly with traumatic
brain injury (TBI). In penetrating trauma with hemorrhage, delaying
aggressive fluid resuscitation until definitive control may prevent ad-
ditional bleeding. Although complications associated with resuscitation
injury are undesirable, the alternative of exsanguination is even less
so. A careful balanced approach with frequent reevaluation is required.
Balancing the goal of organ perfusion with the risks of rebleeding by ac-
cepting a lower-than-normal blood pressure has been called controlled
resuscitation, balanced resuscitation, hypotensive resuscitation,
and permissive hypotension. The goal is the balance, not the hypoten-
sion. Such a resuscitation strategy may be a bridge to but is also not a
substitute for definitive surgical control of bleeding. (2 studies LOE 2, 1
study LOE 3, 1 study LOE 4, 4 studies LOE 5)
Angioembolization And Definitive Control Of Hemorrhage: Failure
to respond to crystalloid and blood administration in the ED dictates
the need for immediate definitive intervention to control exsanguinating
hemorrhage, (eg, operation or angioembolization). (1 study LOE 2, 2
studies LOE 3, 12 studies LOE 4)
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Treatment Of Cardiac Tamponade: Acute cardiac tamponade due to
trauma is best managed by thoracotomy. Pericardiocentesis may be
used as a temporizing maneuver when thoracotomy is not an available
option. (8 studies LOE 4)
Base Deficit And Lactate: Base deficit and/or lactate can be useful in
determining the presence and severity of shock. Serial measurement
of these parameters can be used to monitor the response to therapy.
(2 studies LOE 2, 2 studies LOE 3
Editorial Comment: Shock
In hypovolemic shock, initial resuscitation with crystalloids is recom-
mended both as a diagnostic and therapeutic measure. Once the
patient has been identified as having hypovolemic shock, volume
expansion options should be carefully weighed. Ideally, these patients
are managed with aggressive transfusion of warmed blood products.
We recommend an institution-specific massive transfusion protocol to
facilitate this process.
Massive transfusion protocols are designed to provide a balanced
transfusion of packed red blood cells, platelets, and plasma factors.
Contrary to the recommendation in the compendium that calcium sup-
plementation is not necessary, we believe there is evidence for calcium
to be administered in patients receiving massive transfusion because
of the chelation agents used in packed blood cells.3 Ideally, calcium
therapy is guided by serial measurements of ionized calcium; however
in the acute phase of trauma resuscitation, persistent hypotension de-
spite multiple transfusions indicates that the patient may benefit from
calcium supplementation.
Although not specifically addressed in the guidelines, pain and its
accompanying sympathetic tone may significantly contribute to blood
pressure in badly injured trauma patients. Analgesia should be titrated
carefully in this setting, recognizing the potential to precipitate hypoten-
sion. Ideally, blood pressure and organ perfusion targets are met with
the patient comfortably analgesed.
EM Practice Guidelines Update 2011 4
Current Guidelines On Advanced Trauma Life Support In The ED
The ATLS guidelines cautiously address the concept of permissive
hypotension; despite convincing animal studies, there has been only
1 randomized trial demonstrating a benefit. Appropriate emphasis is
placed on definitive control of bleeding before aggressive fluid resus-
citation in penetrating trauma patients. Normotensive resuscitation
should never be withheld from head trauma patients, as hypotension
has been clearly demonstrated to result in worse outcomes.
The Lethal Triad
M
ia
Ac
rm
ido
the
sis
po
Hy
Coagulopathy
bleeding
Crystalloid &
PRBC Administration
In critically bleeding patients, emergency clinicians manage the lethal triad of hypother-
mia, acidosis, and coagulopathy. Reprinted with permission from www.emcrit.org.
Thoracic Trauma
Treatment Of Pneumothorax: A pneumothorax is best treated with
a chest tube in the fourth or fifth intercostal space, just anterior to the
midaxillary line. Observation and/or aspiration of an asymptomatic
pneumothorax may be appropriate but should be determined by a
qualified physician; otherwise, placement of chest tube should be per-
formed. (1 study LOE 2, 1 study LOE 4)
Emergency Department Thoracotomy: A patient sustaining a pene-
trating wound who has required cardiopulmonary resuscitation (CPR) in
the prehospital setting should be evaluated for any signs of life. If there
are none and no cardiac electrical activity is present, no further resusci-
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tative effort should be made. Patients sustaining blunt injuries who arrive
pulseless but with myocardial electrical activity (PEA) are not candidates
for resuscitative thoracotomy (RT). (5 studies LOE 4) Multiple reports
confirm that ED thoracotomy for patients with blunt trauma and cardiac
arrest is rarely effective.
Blunt Traumatic Aortic Injury (New): Techniques of endovascular
repair are rapidly evolving as an alternate approach for surgical repair
of blunt traumatic aortic injury. (1 study LOE 3, 1 study LOE 4)
Editorial Comment: Thoracic Trauma
Small traumatic pneumothoraces can be managed with observation or
aspiration; however, moderate to large pneumothoraces require chest
tubes. These decisions should be made in conjunction with the admitting
trauma or surgery service.
All patients with penetrating chest wounds and loss of vital signs
presenting to the ED with any signs of life should receive an RT, as
these patients are the most likely to survive a traumatic arrest. On
the other hand, we agree with the recommendation that patients with
blunt cardiac injury arriving with no electrical activity or in PEA are
poor candidates for RT. Ideally, qualified surgeon is present at the
time of the first incision; however, initiation of a RT should not be
delayed while the surgeon is on the way.
Abdomen
Explosive Devices (New): Explosive devices cause injuries through
several mechanisms. These include penetrating fragment wounds and
blunt injuries from the patient being thrown or struck. Patients close to
the source of the explosion may have additional pulmonary or hollow
viscus injuries related to blast pressure that may have delayed presen-
tation. The potential for pressure injury should not distract the doctor
from a systematic A, B, C approach to identification and treatment of
the more common blunt and penetrating injuries. (1 study LOE 3, 6
studies LOE 4, 5 studies LOE 5)
Hemodynamically Abnormal Pelvic Fractures: The pelvis should
be temporarily stabilized or closed using an available commercial
EM Practice Guidelines Update 2011 5
Current Guidelines On Advanced Trauma Life Support In The ED
compression device or sheet to decrease bleeding. Intra-abdominal
sources of hemorrhage must be excluded or treated operatively. Fur-
ther decisions to control ongoing pelvic bleeding include angiographic
embolization, surgical stabilization, or direct surgical control. (1 study
LOE 2, 3 studies LOE 3, 12 studies LOE 4)
Editorial Comment: Abdomen
Pelvic fractures are associated with hemodynamic instability and have
the highest mortality of any skeletal injury. Because patients often
rapidly decompensate, assessment and stabilization of the pelvis is an
early priority in the care of hypotensive trauma patients. If instability
of the pelvis is identified, a single maneuver should be performed by
maintaining hand positions and instructing other team members to ap-
ply the stabilization device (a sheet or commercially available appara-
tus). Repetitive movements of the pelvis can lead to significant internal
bleeding and multiple examinations by various members of the trauma
team should be avoided.
Head Trauma
Classification And Head Computed Tomography: The categoriza-
tion of TBI reflects a continuum. The definition of "minor" TBI has re-
verted to Glasgow Coma Scale Score (GCS) 13-15, with the definition
of "moderate" changed to 9-12. Neurotrauma literature varies on these
ranges, but multiple major organizations including the Eastern Asso-
ciation for the Surgery of Trauma and the Centers for Disease Control
and Prevention use 13-15, which is also consistent with the Canadian
CT Head Rule introduced in this revision. The Canadian CT Head Rule
has been adopted as a guide to clarifying when CT scans of the head
should be used. (3 studies LOE 3, 3 studies LOE 2, 2 studies LOE 4)
Penetrating Brain Injury (New): Objects that penetrate the intra-
cranial compartment or infratemporal fossa must be left in place until
possible vascular injury has been evaluated and definitive neurosurgi-
cal management is established. Disturbing or removing penetrating
objects prematurely may lead to fatal vascular injury or intracranial
hemorrhage. More extensive wounds with nonviable scalp, bone, or
dura are treated with careful debridement before primary closure or
grafting to secure a watertight wound. In patients with significant frag-
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mentation of the skull, debridement of the cranial wound with opening
or removing a portion of the skull is necessary. Significant mass effect
is addressed by evacuation of intracranial hematomas and debride-
ment of necrotic brain tissue and safely accessible bone fragments.
In the absence of significant mass effect, surgical debridement of the
missile track in the brain, routine surgical removal of fragments distant
from the entry site, and reoperation solely to remove retained bone or
missile fragments do not measurably improve outcome and are not
recommended. Repair of open-air sinus injuries and cerebrospinal
fluid (CSF) leaks that do not close spontaneously (or with temporary
CSF diversion) is recommended, using careful watertight closure of
the dura. (2 studies LOE 4)
Editorial Comment: Head Trauma
The Canadian CT Head Rule is useful in determining which patients
with minor head injury should receive brain imaging. The particular
benefit of the Canadian CT Head Rule is that it was derived using
neurosurgical intervention as the outcome of interest rather than the
presence of abnormalities on brain imaging. The American College of
Emergency Physicians (ACEP) Clinical Policy on mild traumatic head
injury,4 which includes several features not found in the Canadian CT
Head Rule, sacrifices specificity for additional sensitivity in identifying
patients with positive brain imaging studies who may or may not require
neurosurgical intervention.
Spine
Spine Blunt Carotid And Vertebral Vascular Injuries (BCVI)
(New): Blunt trauma to the head and neck has been recognized as
a risk factor for carotid and vertebral arterial injuries. Early recognition
and treatment of these injuries may reduce the risk of stroke. Indica-
tions for screening are evolving. Suggested criteria for screening
include: (a) C1-3 fracture, (b) C-spine fracture with subluxation, and (c)
fractures involving the foramen transversarium. Approximately one-
third of these patients will have BCVI when imaged with CT angiogra-
phy of the neck. (1 study LOE 1, 2 studies LOE 2, 2 studies LOE 3)
EM Practice Guidelines Update 2011 6
Current Guidelines On Advanced Trauma Life Support In The ED
Steroids: There is insufficient evidence to support the routine use of
steroids in spinal cord injury at present. (6 studies LOE 1, 4 studies
LOE 2, 1 study LOE 3)
CT Evaluation Of The Cervical Spine (New): CT may be used in lieu
of plain images to evaluate the C-spine. (2 studies LOE 1, 2 studies
LOE 2, 7 studies LOE 3)
Atlantooccipital Dislocation (New): Aids to identification of atlanto-
occipital dislocation on spine films including Powers ratio are includ-
ed in the spinal skills station. (2 studies LOE 3)
Editorial Comment: Spine
With improved imaging techniques (specifically multidetector CT),
emergency clinicians are able (and expected) to quickly and easily
identify blunt carotid and vertebral vascular injuries. In addition to the
indications mentioned in the guideline, other scenarios in which CT
neck angiography may be indicated include neurological deficits not
explained by brain imaging, the presence of a neck seat-belt sign,
LeForte II or II fractures, basilar skull fractures, hanging mechanisms,
and diffuse axonal injury with GCS < 6.
Evidence does not support the use of high-dose steroids in spinal cord
injuries and this practice should be abandoned, especially in the multi-
trauma patient who requires intensive care unit (ICU) management.
Musculoskeletal Trauma And Extremity Trauma
Tourniquet: An acutely avascular extremity must be recognized
promptly and treated emergently. The use of a tourniquet, while con-
troversial, may occasionally be life and/or limb saving in the presence
of ongoing hemorrhage uncontrolled by direct pressure. A properly
applied tourniquet, while endangering the limb, can save a life. A
tourniquet must occlude arterial inflow, as occluding only the venous
system can increase hemorrhage. The risks of tourniquet use increase
with time. If a tourniquet must remain in place for a prolonged period to
save a life, the physician must be clear that the choice of life over limb
has been made. (3 studies LOE 4, 5 studies LOE 5)
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Compartment Syndrome: Absence of a palpable distal pulse usually
is an uncommon finding and should not be relied upon to diagnose
compartment syndrome. (1 study LOE 3, 2 studies LOE 5)
Editorial Comment: Musculoskeletal Trauma And Extremity Trauma
Tourniquets are more likely to be overused than underused, but there
is a role for placing a tourniquet when exsanguinating hemorrhage
cannot be controlled by direct or proximal pressure. The loss of distal
pulses is a late finding in compartment sydrome. When an injured
arm or leg feels firm, more important signs include pain out of pro-
portion to what would be expected given the injury and examination
findings, paresthesias, and severe pain with passive stretching of the
affected area.
Trauma In Women
Restraints (New): Compared with restrained pregnant women involved
in collisions, unrestrained pregnant women have a higher risk of prema-
ture delivery and fetal death. (2 studies LOE 2, 5 studies LOE 4)
Airbags (New): There does not appear to be any increase in preg-
nancy-specific risks from deployment of airbags in motor vehicles. (2
studies LOE 4)
Pediatric Trauma
Functional Outcome (New): Long-term follow-up of functional out-
come indicates that while victims of major trauma during childhood
may retain functional disabilities, quality of life remains very high. (1
study LOE 3)
Abdominal Imaging, CT (New): The presence of a splenic blush on
CT with intravenous contrast does not mandate exploration, and the
decision to operate continues to be based on the amount of blood lost
as well as abnormal physiologic parameters. (1 study LOE 4)
Abdominal Imaging, FAST: The use of focused assessment by
sonography in trauma (FAST) in the injured child is rapidly evolving. If
large amounts of intra-abdominal blood are found, significant injury is
certain to be present. However, even in these patients, operative man-
EM Practice Guidelines Update 2011 7
Current Guidelines On Advanced Trauma Life Support In The ED
agement is indicated not by the amount of intraperitoneal blood but by
hemodynamic abnormality and its response to treatment. FAST is inca-
pable of identifying isolated intraparenchymal injuries, which account
for up to one-third of solid organ injuries in children. (9 studies LOE 3)
Abdominal Bruising (New): The incidence of intra-abdominal injury
is significantly higher if abdominal wall bruising is observed during the
primary or secondary survey. (1 study LOE 3)
Disaster
New Appendix And Optional Lecture (New): There is little evidence
at present, other than case reports and expert opinion, to support and
guide current practice in disaster medicine. However, case reports of
recent mass casualty events involving physical trauma, systematic
review of previous reports, and computer modeling of likely disaster
scenarios have all been helpful in developing the rationale for current
approaches to the medical and surgical response to injured patients in
disasters. (4 studies LOE 3, 9 studies LOE 5)
References
1. Kortbeek JB, Al Turki SA, Ali J, et al. Advanced trauma life
support, 8th edition, the evidence for change. J Trauma.
2008;64(6):1638-1650. (Review)
2. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels
of evidence to the journal. J Bone Joint Surg Am. 2003;85-
A(1):1-3.
3. Sihler KC, Napolitano LM. Complications of massive transfu-
sion. Chest. 2010 Jan;137(1):209-220. (Review) Erratum in:
Chest. 2010;137(3):744.
4. Jagoda AS, Cantrill RL, Wears RL, et al. Clinical policy: neuro-
imaging and decisionmaking in adult mild traumatic brain injury
in the acute setting. Ann Emerg Med. 2008;52(6):714-748.
(Clinical Policy)
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CME Questions
1. According to updated ATLS guidelines, which of the following is
described as a newly accepted adjunct to traditional airway man-
agement?
a. Video laryngoscopy
b. Bag valve mask
c. Eschmann tracheal tube introducer (aka gum elastic bougie)
d. Lighted stylette
2. An obese 45-year-old motorcyclist is brought into a community
hospital ED exhibiting significant maxillofacial trauma sustained
from a head-on motor vehicle collision. The most recent ATLS
guidelines endorse the following as a first step in airway assess-
ment:
a. Carefully opening the patient's mouth using the "scissor"
technique
b. Placing lubricated nasal trumpets through bilateral nares
c. Performing immediate bag valve mask using the "E" technique
d. Looking for obstruction and determining a Mallampatti score
EM Practice Guidelines Update 2011 8
Current Guidelines On Advanced Trauma Life Support In The ED
3. According to revised ATLS guidelines, which of the following is true
regarding initial fluid resuscitation strategies in trauma patients?
a. Administering hypertonic saline offers distinct survival advan-
tages over normal saline.
b. Achieving definitive hemostasis in the hemorrhaging trauma
patient takes priority over aggressive fluid resuscitation.
c. TBI patients may benefit from maintaining systolic blood pres-
sures (SBPs) less than 100.
d. Resuscitation injury, including the risk of rebleeding, is no lon-
ger a real concern in trauma resuscitation decision-making.
4. Which of the following trauma patients is considered at greatest
risk for blunt carotid and vertebral vascular injuries?
a. 57-year-old osteopenic female sustaining a C-5 spinal process
fracture, after falling down a flight of stairs
b. 37-year-old hypertensive male sustaining a C-2 transverse pro-
cess fracture noted, after colliding with a tree while skiing
c. 28-year-old asthmatic male with limited range of neck motion
and T-1 point tenderness without radiologic evidence of frac-
ture, after being assaulted in this area with an aluminum base-
ball bat
d. 49-year-old female with known breast cancer on tamoxifen,
presenting with significant zone II bruising without radiologic
evidence of fracture, after falling from her moped onto concrete
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EM Practice Guidelines Update 2011 9
Current Guidelines On Advanced Trauma Life Support In The ED
CME information for EM Practice Guidelines Update
To take the CME test, visit: www.ebmedicine.net/cme
Date of Original Release: July 1, 2011. Date of most recent review: June 10, 2010. Termination date:
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Goals: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making
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Objectives: Upon completion of this article, you should be able to: 1) identify example airway devices that
should be available to the clinician managing a trauma airway, (2) describe key concepts in fluid resuscita-
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and vertebral vascular injuries in the setting of certain injuries.
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Send to: EB Medicine / 5550 Triangle Pkwy, Ste 150 / Norcross, GA 30092. Or fax to: 770-500-1316.
Send to: EB Medicine / 5550
Or visit: www.ebmedicine.net/subscribe and Triangle Pkwy,
then enter Ste Code
Promo 150 / Norcross,
NE12AD inGA 30092.
your Or call:
cart. Or fax to: 770-500-1316.or 678-366-7933.
1-800-249-5770
Or visit: www.ebmedicine.net/subscribe and then enter Promo Code ISSUEG in your cart. Or call: 1-800-249-5770 or 678-366-7933.

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EM Practice Guidelines
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Update 2011
Guidelines Update 2009
2009 11 10 EBMedicine.net
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ebmedicine.net
EBMedicine.net November 2009
July 2011
2009