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Tue Oct 3 05:49:40 BST 2006

Dear list

Karim asked me to forward to the list to stimulate more discussion.

>  -----Original Message-----
> From: 	Hardcastle, Tim, Dr <tch at sun.ac.za>  
> Sent:	Monday, October 02, 2006 6:49 PM
> To:	'atls at trauma.org'
> Subject:	ATLS Revision suggestions
> Listed find my suggestions for the updated ATLS 8th ed manual. While all the suggestions are not evidence based statements, they address issues I've found to be under-appreciated / misunderstood by most non-surgeon traumatologists or are simply suggestions to improve the overall content of ATLS. References are listed as applicable. I will leave you to decide what the level of evidence is or not for each suggestion.
> 
> Chap 1 Initial assessment
> Point 2f) pg 34: remove reference to PASG/MAST as good option for open book pelvis. 
> 	See Cochrane Database Systemic Review, 2000, Dickinson and Roberts CD001856
> 
> Pg 36 D2 Management: "Attach the chest tube to underwater-seal drainage device"; Not all chest drains have an underwater seal and there is no evidence to suggest a valve type (Heimlich or other) is less efficatious, suggest change to make the statement more general. See: Vuorisalo S, Aarnio P, Hannukainen J. Comparison between flutter valve drainage bag and underwater seal device for pleural drainage after lung surgery. Scand J Surg. 2005;94(1):56-8. See also: Cooper C, Hardcastle T: X-pand chest drain: assessing equivalence to standard therapy, a randomised control trial. S Afr J Surg 2006, IN PRESS
> E2 point b, pg 36: Specify the position of optimal placement of the sheet wrap (over the greater trochanters) - I've mostly seen it placed to high over the iliac wings and then it does very little!
> Chapter 2: Breathing and Ventilation
> Pg 44, point 3 OPA - suggest scrapping alternate technique altogether, it is associated with problems in adults too - See the ILCOR consensus 2002.
> Pg 46 Intubation. Would like to suggest emphasising the temporary removal of immobilisation devices during airway instrumentation and teaching a minimum 3-person technique: One intubator, a second for cricoid pressure and a third for in-line manual stabilisation. This is stated, but maybe not strongly enough.
> Pg 50 G Ventilation: Suggest add some of the ARDSnet criteria, 6-8ml/kg tidal vols / PEEP - FiO2 ratios of 1:5 etc and pressure control ventilation.
> Chapter 3: Shock
> Pg 78 section C: Include some more explanatory text about the role of "permissive hypotension" for non-compressible trunkal haemorrhage and early "Damage Control" surgery. Under this section one could include something about the usefulness of Lactates as a guideline of tissue perfusion aiming for a lactate less than 5mmol/l (See the DSTC handbook)
> Pg 80 blood transfusion point 3: No evidence to support routine use of Rh(-) blood in females routinely. See Dutton et al, J Trauma Dec 2005, 59(6): 1445 - 1449
> Chapter 4: Thoracic Trauma
> Wherever the statement is made about "thoracotomy" and "qualified surgeon" (Pg 107-108), I accept that this may apply in the USA, where only surgeons operate, but in many other countries, including RSA, any medical practitioner trained in a particular procedure may perform such a procedure, especially where this may be life-saving if a surgeon is not present. We know that pericardiocentesis is unreliable in penetrating cardiac trauma. Rather reword the statement to say something like: "A  sub-xiphoid window may be therapeutic and thoracotomy should only be performed by someone trained in this procedure when the patient is in extremis". 
> I would like to suggest the technique of extra-peritoneal sub-xiphoid window be taught to all participants rather than pericardiocentesis! (Understand that I write from a context with a high stab-heart incidence and with limited access to major hospitals)
> Chapter 5: Abdominal Trauma
> Pg 134 Remove reference to "rebound tenderness" as part of the clinical exam of the abdomen - percussion is as sensitive and more specific. See: Bemelman WA, Kievit J [Pysical examination--rebound tenderness] Ned Tijdschr Geneeskd. 1999 Feb 6;143(6):300-3. Review. Dutch> 
> Chap 7: Spinal Cord
> pg 188 Remove steroid therapy in spinal cord injury - evidence against > evidence for. See Hurlburt J: Methylprednisolone for acute spinal cord injury: an inappropriate standard of care. J Neurosurg. 2000 Jul;93(1 Suppl):1-7 and also Spine 2001; 26(24 Suppl): S39 - S46 - an evidence based review. Also: Bledsoe BE, Wesley AK, Salomone JP; National Association of EMS Physicians Standards and Clinical Practice Committee. High-dose steroids for acute spinal cord injury in emergency medical services.
> Prehosp Emerg Care. 2004 Jul-Sep;8(3):313-6. Review. 
> 
> Chapter 8: Musculo-skeletal
> Suggest include something about CpK levels and myoglobinuric renal damage. Emphasise the need for early and aggresive crystalloid "flushing" of the kidneys rather than alkalinisation and mannitol, using a higher than normal urine output goal. See Brown C et al: Preventing Renal Failure in Patients with Rhabdomyolysis: Do Bicarbonate and Mannitol Make a Difference? J Trauma Volume 56(6) June 2004 pp 1191-1196.
> 
> I thank you for taking time to consider these suggestions.
> Regards
> Tim
> Dr T C Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
> ATLS  instructor and DSTC Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med (Emergency Medicine) Executive Committee member
> Clinical Head (Director): Diana Princess of Wales Trauma Unit
> Division of Surgery (General) Room 4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281 or 4911 pager 0302
> 
> 

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