Tag Archives: ATLS

Evidence refutes ATLS shock classification

I have always had a problem with the ATLS classification of hypovolaemic shock, and omit it from teaching as any clinical applicability and reproducibility seem to be entirely lost on me. I was therefore reassured to read that real physiological data from the extensive national trauma registry in the UK (TARN) of 107,649 adult blunt trauma patients do not strongly support this classification. A key observation we regularly make in trauma patients is the frequent presence of normo- or bradycardia in hypovolaemic patients, which is well documented in the literature.

Unreferenced dogma that became viral

An excellent discussion section in this paper states: ‘it is clear that the ATLS classification of shock that associates increasing blood loss with an increasing heart rate, is too simplistic. In addition, blunt injury, which forms the majority of trauma in the UK, is usually a combination of haemorrhage and tissue injury and the classification fails to consider the effect of tissue injury
Testing the validity of the ATLS classification of hypovolaemic shock
Resuscitation. 2010 Sep;81(9):1142-7

Military pre-hospital thoracotomy

Military doctors in Afghanistan reviewed their experience of thoracotomy done within 24 hours of admission to their hospital. The ballistic nature of thoracic penetrating trauma (mainly Afghan civilians without body armour) differs from the typical knife-wound related injury seen in survivors of thoracotomy reported in the pre-hospital literature.
Six of the patients presented in cardiac arrest – four PEA and two asystole. One of the PEA patients survived; this patient had sustained a thoracoabdominal GSW and had arrested 8 minutes from hospital. Following emergency thoracotomy, aortic control, and concomitant massive transfusion, return of spontaneous circulation (ROSC) was achieved and damage control surgery undertaken in both chest and abdomen.
The two patients in asystole had sustained substantial pulmonary and hilar injuries, and ROSC was never achieved. The patients in PEA all had arrested as a consequence of hypovolaemia from solid intra-abdominal visceral haemorrhage. All patients in PEA had ROSC achieved, albeit temporarily.
Following thoracotomy, patients required surgical manoeuvres such as pulmonary hilar clamping, packing and temporary aortic occlusion; hypovolaemia was the leading underlying cause of the cardiac arrest. These factors lead the authors to conclude that although isolated cardiac wounds do feature in war, they are unusual and the injury pattern of casualties in conflict zones are often complex and multifactorial.
Is pre-hospital thoracotomy necessary in the military environment?
Injury. 2010 Jul;41(7):1008-12

Vital signs of severely injured children

Systolic blood pressures of severely injured children are very often hypertensive compared with APLS ‘norms’. A lower pulse rate is associated with more severe brain injury

SBP (Mean+/- 95% confidence limits) in moderately injured children with and without TBI by age and Advanced Paediatric Life Support (APLS) range for normal systolic blood pressure (shaded region)

Comparing the systolic blood pressure (SBP) and pulse rate (PR) in injured children with and without traumatic brain injury
Resuscitation. 2010 Apr;81(4):418-21

European Trauma Bleeding Guidelines updated


Update 2013: since this post was written in 2010, new guidelines have been written entitled: “Management of bleeding and coagulopathy following major trauma: an updated European guideline” which are available here

The 2007 guidelines on management of bleeding in trauma have been updated in the light of new evidence and modern practice. The guideline group summarises their recommendations as:

  1. We recommend that the time elapsed between injury and operation be minimised for patients in need of urgent surgical bleeding control. (Grade 1A).
  2. We recommend adjunct tourniquet use to stop life-threatening bleeding from open extremity injuries in the pre-surgical setting. (Grade 1C).
  3. We recommend that the physician clinically assess the extent of traumatic haemorrhage using a combination of mechanism of injury, patient physiology, anatomical injury pattern and the patient’s response to initial resuscitation. (Grade 1C).
  4. We recommend initial normoventilation of trauma patients if there are no signs of imminent cerebral herniation. (Grade 1C).
  5. We recommend that patients presenting with haemorrhagic shock and an identified source of bleeding undergo an immediate bleeding control procedure unless initial resuscitation measures are successful. (Grade 1B).
  6. We recommend that patients presenting with haemorrhagic shock and an unidentified source of bleeding undergo immediate further investigation. (Grade 1B).
  7. We recommend early imaging (FAST or CT) for the detection of free fluid in patients with suspected torso trauma. (Grade 1B).
  8. We recommend that patients with significant free intraabdominal fluid and haemodynamic instability undergo urgent intervention. (Grade 1A).
  9. We recommend further assessment using computed tomography for haemodynamically stable patients who are either suspected of having torso bleeding or have a high risk mechanism of injury. (Grade 1B).
  10. We do not recommend the use of single haematocrit measurements as an isolated laboratory marker for bleeding. (Grade 1B).
  11. We recommend both serum lactate and base deficit measurements as sensitive tests to estimate and monitor the extent of bleeding and shock. (Grade 1B).
  12. We recommend that routine practice to detect post-traumatic coagulopathy include the measurement of international normalised ratio (INR), activated partial thromboplastin time (APTT), fibrinogen and platelets. INR and APTT alone should not be used to guide haemostatic therapy. (Grade 1C) We suggest that thrombelastometry also be performed to assist in characterising the coagulopathy and in guiding haemostatic therapy. (Grade 2C).
  13. We recommend that patients with pelvic ring disruption in haemorrhagic shock undergo immediate pelvic ring closure and stabilisation. (Grade 1B).
  14. We recommend that patients with ongoing haemodynamic instability despite adequate pelvic ring stabilisation receive early preperitoneal packing, angiographic embolisation and/or surgical bleeding control. (Grade 1B).
  15. We recommend that early bleeding control of the abdomen be achieved using packing, direct surgical bleeding control and the use of local haemostatic procedures. In the exsanguinating patient, aortic cross-clamping may be employed as an adjunct. (Grade 1C).
  16. We recommend that damage control surgery be employed in the severely injured patient presenting with deep hemorrhagic shock, signs of ongoing bleeding and coagulopathy. Additional factors that should trigger a damage control approach are hypothermia, acidosis, inaccessible major anatomic injury, a need for time-consuming procedures or concomitant major injury outside the abdomen. (Grade 1C).
  17. We recommend the use of topical haemostatic agents in combination with other surgical measures or with packing for venous or moderate arterial bleeding associated with parenchymal injuries. (Grade 1B).
  18. We recommend a target systolic blood pressure of 80-100 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury. (Grade 1C).
  19. We recommend that crystalloids be applied initially to treat the bleeding trauma patient. (Grade 1B) We suggest that hypertonic solutions also be considered during initial treatment. (Grade 2B) We suggest that the addition of colloids be considered within the prescribed limits for each solution in haemodynamically unstable patients. (Grade 2C).
  20. We recommend early application of measures to reduce heat loss and warm the hypothermic patient in order to achieve and maintain normothermia. (Grade 1C).
  21. We recommend a target haemoglobin (Hb) of 7-9 g/dl. (Grade 1C).
  22. We recommend that monitoring and measures to support coagulation be initiated as early as possible. (Grade 1C).
  23. We recommend that ionised calcium levels be monitored during massive transfusion. (Grade 1C) We suggest that calcium chloride be administered during massive transfusion if ionised calcium levels are low or electrocardiographic changes suggest hypocalcaemia. (Grade 2C).
  24. We recommend early treatment with thawed fresh frozen plasma in patients with massive bleeding. (Grade 1B) The initial recommended dose is 10-15 ml/kg. Further doses will depend on coagulation monitoring and the amount of other blood products administered. (Grade 1C).
  25. We recommend that platelets be administered to maintain a platelet count above 50 × 109/l. (Grade 1C) We suggest maintenance of a platelet count above 100 × 109/l in patients with multiple trauma who are severely bleeding or have traumatic brain injury. (Grade 2C) We suggest an initial dose of 4-8 platelet concentrates or one aphaeresis pack. (Grade 2C).
  26. We recommend treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by thrombelastometric signs of a functional fibrinogen deficit or a plasma fibrinogen level of less than 1.5-2.0 g/l. (Grade 1C) We suggest an initial fibrinogen concentrate dose of 3- 4 g or 50 mg/kg of cryoprecipitate, which is approximately equivalent to 15-20 units in a 70 kg adult. Repeat doses may be guided by thrombelastometric monitoring and laboratory assessment of fibrinogen levels. (Grade 2C).
  27. We suggest that antifibrinolytic agents be considered in the bleeding trauma patient. (Grade 2C) We recommend monitoring of fibrinolysis in all patients and administration of antifibrinolytic agents in patients with established hyperfibrinolysis. (Grade 1B) Suggested dosages are tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg per hour or ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/h. Antifibrinolytic therapy should be guided by thrombelastometric monitoring if possible and stopped once bleeding has been adequately controlled. (Grade 2C).
  28. We suggest that the use of recombinant recombinant activated coagulation factor VII (rFVIIa) be considered if major bleeding in blunt trauma persists despite standard attempts to control bleeding and best-practice use of blood components. (Grade 2C).
  29. We recommend the use of prothrombin complex concentrate for the emergency reversal of vitamin K-dependent oral anticoagulants. (Grade 1B).
  30. We do not suggest that desmopressin (DDAVP) be used routinely in the bleeding trauma patient. (Grade 2C) We suggest that desmopressin be considered in refractory microvascular bleeding if the patient has been treated with platelet-inhibiting drugs such as aspirin. (Grade 2C).
  31. We do not recommend the use of antithrombin concentrates in the treatment of the bleeding trauma patient. (Grade 1C).

Management of bleeding following major trauma: an updated European guideline.
Crit Care. 2010 Apr 6;14(2):R52 (Pub Med abstract)
Full Text Link

Battlefield resuscitation

An excellent review of the current British military practice to prevent and treat the acute coagulopathy of trauma shock (ACoTS) describes pathophysiology and treatment options and offers an algorithm for management. Key components of the system (when indicated according to their algorithm) outlined include:

  • Pre-hospital damage control shock resuscitation by a forward medical team, consisting of RSI with reduced dose thio or ketamine with suxamethonium or rocuronium, large bore sublclavian access, and early use of warmed blood products
  • 1:1:1 packed red cells, fresh frozen plasma, and platelets,
  • Cryoprecipitate
  • Tranexamic acid
  • Recombinant activated factor VII
  • Permissive hypotension aiming for a systolic BP of 90 mmHg, using blood products and avoiding vasopressors according to a ‘flow rather than pressure’ philosophy
  • Avoiding hypothermia by giving warmed blood products and employing active patient warming methods
  • Buffering acidosis using Tris-hydroxymethyl aminomethane (THAM), which may be superior to bicarbonate by not affecting minute ventilation or coagulation, and maintaining its efficacy in hypothermic conditions
  • Minimising hypoperfusion with an anaesthetic strategy that provides effective analgesia and vasodilation, using high dose fentanyl and a low concentration volatile agent
  • Using fresh whole blood for resistant coagulopathy

Battlefield resuscitation
Curr Opin Crit Care. 2009 Dec;15(6):527-35

Sorting ABCD issues pre-hospital

Prospectively collected data on 727 major trauma patients from a Portugese trauma centre registry enabled the comparison of mortality between three groups of patients with a priori defined life threatening ‘ABCD’ problems: those whose ABCD issues were treated in the field by a pre-hospital emergency physician, those that were treated at another hospital prior to trauma centre transfer, and those whose ABCD issues were first treated on arrival at the trauma centre. The study population included mixed urban and rural trauma.
Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre.
Patients whose life- threatening events were treated in the pre-hospital environment had lower mortality but at the same time were younger and less severely injured, so a multivariate logistic regression was performed to adjust the odds of death to patient characteristics and trauma severity as well as time from accident to trauma centre. Logistic regression showed that increases in mortality were associated with female gender and older age, penetrating type of trauma, higher anatomic severity (ISS), higher physiological severity (RTS) and having the life-threatening events corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.
Correcting life-threatening events pre- trauma centre (pre-hospital and first hospital) increased the total time from the accident to trauma centre, but long pre-hospital times were not associated with worse outcome.
The importance of pre-trauma centre treatment of life-threatening events on the
mortality of patients transferred with severe trauma

Resuscitation. 2010 Apr;81(4):440-5

Guidelines on penetrating abdominal trauma

The Eastern Association for the Surgery of Trauma has published guidelines on the nonoperative management of penetrating abdominal trauma.


  • Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1).
  • Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1).
  • A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds (SWs) without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2).
  • A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds (GSWs) if the wounds are tangential and there are no peritoneal signs (level 2).
  • Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2).
  • In patients selected for initial nonoperative management, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2).
  • Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3).
  • The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3).
  • Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2).

Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma
J Trauma. 2010 Mar;68(3):721-733

Whole-body CT during trauma resuscitation

German trauma patients are more likely to survive if they have a whole body CT rather than selective scans. Or that’s what this paper would have you believe IF you’re happy with the retrospective comparison, multivariate adjustments, and potential confounders. Still, if it helps you get your radiologists to play ball, the reference is…
Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre studyLancet. 2009 Apr 25;373(9673):1455-61

Pre-hospital thoracotomy and aortic clamping in blunt trauma

This is one of those ‘wow they really do that!?‘ papers…Patients undergoing thoracotomy and aortic clamping for pre-hospital blunt traumatic arrest either in the field or in the ED were evaluated for the outcome of survival to ICU admission. None of the 81 patients who underwent this intervention survived to discharge.
Field thoracotomy resulted in shorter times from arrival of the emergency medical team to performance of the thoracotomy (19.2 vs 30.7 mins). Patients who arrested in front of the team had a greater ICU admission rate than those who were already in cardiac arrest when the team arrived (70% vs 8%).
One may argue against an intervention that seems to have resulted in no benefit to the patient. However a counterargument might be that an ICU admission allows for better end-of-life management for grieving families, and for the possibility of organ donation.
Interestingly, there were some neurologically intact survivors of emergency thoracotomy for blunt trauma by this service, although they were excluded from the study for either (i) receiving the field thoracotomy before full arrest or (ii) arresting after arrival in the ED.
Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system
Resuscitation. 2009 Nov;80(11):1270-4

Plasma:red cell transfusion ratio in trauma

In major trauma patients who require blood transfusion, fresh frozen plasma (FFP) to packed red blood cell (RBC) ratios of up to 1:1 have been associated with reduced mortality in retrospective studies, which may be in part due to survival bias (some patients die before they can be given as much FFP as the survivors).

To eliminate this bias, Australian researchers reviewed 331 trauma patients receiving at least 5 units of red cells in the first 4 hours, with a median Injury Severity Score of 36. When deaths in the first 24 hours were excluded, FFP:RBC ratio had no association with mortality. They conclude that prospective randomised controlled trials are needed.
Fresh frozen plasma (FFP) use during massive blood transfusion in trauma resuscitation
Injury. 2010 Jan;41(1):35-9