ATLS was a mandatory course during my emergency medicine training with recertification every few years. One of the greatest benefits was recognizing the need to asign a leader and develop a systematic approach to the trauma patient. There is always controvrsy surrounding proptocols and recommendations but the 10th edition is based on decades of trauma experience.
One of the new changes in the shock and circulation section is an emphasis on tourniquets, packing and the application of pressure; some very basic methods that can quickly control hemorrhage. Where do you focus your attention first? Airway? Hemorrhage control?
Wherever you practice and no matter the resources available you will find something in this podcast to strengthen your skills. Take a listen to the September 2019 EM:RAP podcast or read the PDF called: Trauma Surgeons Gone Wild: ATLS 10th edition update by Stuart Swadron MD, Kenji Inaba MD, and Billy Mallon MD.
Morell Wellcome tourniquets. (courtesy WikiMedia Commons)
Who Knew? The first recorded efforts to prevent arterial bleeding has been ascribed to Sushruta, the father of surgical art and science, in 600 B.C At that time, he pressed the arteries with pieces of leather that he made himself and it is said that he had used a device in which we now call the tourniquet. (NCBI)
Ambroise Paré, on the battlefield using a ligature for the artery of an amputated leg of a soldier.(Photo Wikipedia)
Under the best of situations major trauma centers can be overwhelmed with dozens of seriously injured patients but for many CMES participants limited resources are an everyday reality. The August EM:RAP podcast titled, “Blast Injuries” by Anand Swaminathan MD and Josh Bucher MD will help you piece together triage and treatments for a mass casualty.
Tactical Combat Casualty Care (TCCC) uses the mnemonic MARCH for military battlefield medicine.
- Massive hemorrhage is managed through the use of tourniquets, hemostatic dressings, junctional devices, and pressure dressings.
- Airway is managed by rapid and aggressive opening of the airway to include cricothyroidotomy for difficult airways.
- Respirations and breathing is managed by the assessment for tension pneumothorax and aggressive use of needle decompression devices to relieve tension and improve breathing.
- Circulation impairment is assessed and managed through the initiation of intravenous access followed up by administration of tranexamic acid (TXA) if indicated, and a fluid resuscitation challenge using the principles of hypotensive resuscitation. TCCC promotes the early and far forward use of blood and blood products if available over the use colloids and discourages the administration of crystalloids such as normal saline (sodium chloride).
- Hypothermia prevention is an early and critical intervention to keep a traumatized casualty warm regardless of the operational environment.
A wounded knight is carried on a medieval stretcher. (Photo Wikipedia)
Who Knew? An early stretcher, possibly made of wicker over a frame, appears in a manuscript from c.1380.
Ambroise Pare (c. 1510-1590) is considered one of the fathers of surgery and modern forensic pathology and a pioneer in surgical techniques and battlefield medicine.