2017年12月18日 星期一

ATLS® 第10版 更新摘要



ATLS 10th Edition Compendium of Change

Primary Survey
Airway Maintenance with Restriction of Cervical Spine Motion
  • “cervical spine protection” changed to ”Restriction of Cervical Spine Motion
  • RSI changed to ”Drug Assisted Intubation
Breathing and Ventilation 
Circulation with Hemorrhage Control
  • Initial resuscitation: Adult: 1 L isotonic solution; Child < 40 kg: 20 ml/kg
  • Tranexamic acid: 1 g over 10 min within 3 hr, then 1 g over 8 hr
  • Hemorrhagic shock classification table amended: Base excess 

Thoracic Trauma
  • Life threatening chest injury: flail chest out, tracheobrochial injury now in
  • Tension pneumothorax:
    • Needle thoracocentesis
      • 5th  ICS mid-axillary line for adult
      • UNCHANGED 2nd ICS mid-clavicular line for child
    • 28-32 Fr chest drain for hemothorax (not 36-40 Fr)
      • eFAST (extended FAST): seashore, bar code, or stratosphere sign in M mode
    • Aortic rupture management with Beta Blocker (esmolol): goal heart rate < 80 bpm and MAP 60-70 mmHg
    • Algorithm for circulation arrest approach

    Abdominal and Pelvic Trauma
    • Palpation of prostate gland no longer recommended for urethral injury

    Head Trauma
    • Classification: “minor” changed to “mild” head trauma
    • Detailed guidance on SBP management
      • Maintain SBP at ≥ 100 mmHg for patients 50-69 years or at ≥ 110 mmHg for patients 15-49 years or older than 70 years.
    • Anticoagulation reversal guidance

    Spine and Spinal Cord Trauma
    • New myotome diagram
    • Canadian C-Spine Rule (CCR) and NEXUS Criteria




      Musculoskeletal Trauma
      • Highlighting risk factor of bilateral femur fractures

      Thermal Injury

      Paediatric Trauma
      • Pediatric Emergency Care Applied Research Network (PECARN) Criteria for Head CT

        Transfer to Definitive Care
        • Specific mention of avoiding CT in primary hospital
        • SBAR template for communication

        Mobile ATLS: New to this edition

        Royal College Surgeons ATLS course 時程公告:
        2018年 2月   以前,ATLS 第 9 版
        2018年 3月到 5月,ATLS 第 9 版 + 第 10版 重點導讀
        2018年 6月   以後,ATLS 第 10版

        2017年9月7日 星期四

        The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: 4E



        The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fourth Edition

        Rossaint et al. Critical Care (2016) 20:100
        DOI 10.1186/s13054-016-1265-x


        Major Bleeding
        • FAST, CT 找出血
        • Damage control surgery if shock or coagulopathy
        • Damage control resuscitation 直到找到出血來源並控制
        • Restricted volume replacement: target SBP: 80-90 mmHg; severe TBI (GCS ≤8): MAP ≥80 mmHg
        • Tranexamic acid (TXA) as early as possible (< 3hr): loading dose TXA 1 g over 10 min, followed by TXA 1 g over 8 h
        Transfusion
        • Restrictive RBC transfusion: target Hb 7–9 g/dl
        • FFP-RBC ratio >1:2
        • Fibrinogen maintain at 1.5–2 g/l
        • FFP administered to maintain PT and APTT ≤ 1.5 times the normal control
        • Platelet count >100K
        • PCC administered in patients pre-treated with warfarin or direct-acting oral coagulants
        • Off-label use of rFVIIa only if major bleeding and traumatic coagulopathy persist despite standard attempts to control bleeding and best practice use of conventional hemostatic measures.

        2017年2月4日 星期六

        Surviving Sepsis Guidelines 2016



        Surviving Sepsis Campaign:
        International Guidelines for Management of Sepsis and Septic Shock: 2016


        Intensive Care Medicine 2016
        doi: 10.1007/s00134-017-4683-6



        Initial Resuscitation
        ☑ Crystalloid fluid ≥ 30 ml/kg within the first 3 hrs
        ☐ Target MAP ≥ 65 mmHg
        ☐ Normalize lactate
        ☒ EGDT, CVP, ScvO2

        Antimicrobial Therapy
        ☐ Empiric broad-spectrum antibiotics within 1 hr
        ☐ Procalcitonin to support the discontinuation of antibiotics

        Source Control
        ☐ As soon as possible

        Fluid Therapy
        ☑ Crystalloids ± albumin
        ☒ HESs

        Vasopressors
        ☑ Norepinephrine ± vasopressin or epinephrine
        ☐ Dopamine only in bradycardia

        Corticosteroids
        ☐ Hydrocortisone 200 mg per day for refractory shock

        Blood Products
        ☐ pRBC: Hb < 7
        ☐ platelet: 10K, 20K, 50K

        Glucose Control
        ☐ Target blood glucose ≤ 180 mg/dl

        Bicarbonate Therapy
        ☐ pH < 7 .15


        《Surviving Sepsis Guidelines 2016 改版摘要》


        初步復甦
        • 3小時內給予 Crystalloid fluid ≥ 30 ml/kg
        • 復甦目標 MAP > 65 mmHg, lactate 降至正常
        • EGDT, CVP, ScvO2 不再被建議用來評估復甦成效!改以非侵入性動態指標監測
        • 不建議使用 hydroxyethyl starches 作為急救輸液
        一小時內給予廣效性經驗性抗生素治療
        利用 procalcitonin 輔助決定是否停用抗生素

        第一線強心劑首選:Levophed

        輸血時機:Hb小於 7
        輸血小板時機:
            血小板 < 1萬
            血小板 < 2萬,有出血風險
            血小板 < 5萬,有出血或執行侵入性處置

        血糖控制目標 ≤ 180 mg/dl

        Bicarbonate 時機: pH 小於 7.15