ATLS: Advanced Trauma Life Suport Student Course Manual

421 Pages·2012·33.39 MB·English

Chair of Committee on Trauma: Michael F. Rotondo, MD, FACS
Medical Director of Trauma Program: John Fildes, MD, FACS
ATLS Committee Chair: Karen J. Brasel, MD, MPH, FACS
ATLS Program Manager: Will Chapleau, EMT-P, RN, TNS
Project Manager: Claire Merrick
Development Editor: Nancy Peterson
Production Services: Anne Seitz and Laura Horowitz, Hearthside Publishing Services
Media Services: Steve Kidd and Alex Menendez, Delve Productions
Designer: Terri Wright Design
Artist: Dragonfly Media Group
Book Layout and Composition: Greg Johnson/Textbook Perfect
Ninth Edition
Copyright © 2012 American College of Surgeons
633 N. Saint Clair Street
Chicago, IL 60611-3211
Previous editions copyrighted 1980, 1982, 1984, 1993, 1997, 2004, and 2008 by the
American College of Surgeons.
Copyright enforceable internationally under the Bern Convention and the Uniform
Copy right Convention. All rights reserved. This manual is protected by copyright. No
part of it may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without
written permission from the American College of Surgeons.
The American College of Surgeons, its Committee on Trauma, and contributing authors
have taken care that the doses of drugs and recommendations for treatment contained
herein are correct and compatible with the standards generally accepted at the time of
publication. However, as new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy may become necessary or appropriate. Readers
and participants of this course are advised to check the most current product informa-
tion provided by the manufacturer of each drug to be administered to verify the recom-
mended dose, the method and duration of administration, and contraindications. It is
the responsibility of the licensed practitioner to be informed in all aspects of patient care
and determine the best treatment for each individual patient. Note that cervical collars
and spinal immobilization remain the current PHTLS standard in transporting spine
injury patients. If the collars and immobilization devices are to be removed in control-
led hospital environments, they should be removed only when the stability of the injury
is assured. Cervical collars and immobilization devices have been removed in some of
the photos and videos to provide clarity for specific skill demonstrations. The American
College of Surgeons, its Committee on Trauma, and contributing authors disclaim any
liability, loss, or damage incurred as a consequence, directly or indirectly, of the use and
application of any of the content of this Ninth Edition of the ATLS Program.
Advanced Trauma Life Support® and the acronym ATLS® are registered trademarks of
the American College of Surgeons.
Printed in the United States of America.
Advanced Trauma Life Support® Student Course Manual
Library of Congress Control Number: 2012941519
ISBN 13: 978-1-880696-02-6
Dedication
To Paul “Skip” Collicott, MD, FACS
We all leave tracks in the sand as we pass through life. Occasionally we pause and
look back at those tracks. This Ninth Edition of the ATLS® manual is truly the sum
of the contributions of many who have made tracks, directly and indirectly. But
there are no tracks wider or more firmly planted than those made by Paul E. “Skip”
Collicott, MD, FACS.
It’s hard to remember the “bad ol’ days” when an injured patient was evalu-
ated in the Emergency Department by an intern or medical student. The evaluation
started with a complete history and physical. Unless the patient was crashing, the
ABCs were not given any particular priority. Imagine an intern questioning the
family of a patient with a gunshot wound to the chest about childhood illnesses as
the patient was in significant respiratory distress! Yet, it happened. How differently
such a patient is managed today.
Today, as the news media broadcasts various conflicts and other traumatic
events from around the world, one thing that becomes obvious is that first respond-
ers and physicians caring for the injured are using the principles and methods of
ATLS. Why? Because the principles and methods work.
We and the injured patients we treat owe you a debt of gratitude, Skip — you
and your small group of original authors. If we were to be so lucky to have the
opportunity to touch as many lives around the world as your vision and effort have
through the birth, adolescence and now maturity of ATLS®, then we could feel jus-
tifiably proud of our accomplishments. It seems inadequate to say but . . . thank you
for your vision. ATLS works!
This tribute to Skip and the legacy he will leave goes far beyond the dedication
of this edition of the manual to him. Well done, my Friend.
Max L. Ramenofsky, MD, FACS
Professor of Surgery
Robert Wood Johnson College of Medicine
New Brunswick, NJ
Richard M. Bell, MD, FACS
Professor, Department of Surgery
University of South Carolina
Columbia, SC

Brief Contents
CHAPTER 1 Initial Assessment and Management 2
 SKILL STATION I: Initial Assessment and Management 23
CHAPTER 2 Airway and Ventilatory Management 30
 SKILL STATION II: Airway and Ventilatory Management 50
 SKILL STATION III: Cricothyroidotomy 58
CHAPTER 3 Shock 62
 SKILL STATION IV: Shock Assessment and Management 82
 SKILL STATION V: Venous Cutdown (Optional Station) 92
CHAPTER 4 Thoracic Trauma 94
 SKILL STATION VI: X-Ray Identification of Thoracic Injuries 113
 SKILL STATION VII: Chest Trauma Management 118
CHAPTER 5 Abdominal and Pelvic Trauma 122
 SKILL STATION VIII: Focused Assessment Sonography in Trauma (FAST) 141
 SKILL STATION IX: Diagnostic Peritoneal Lavage (Optional) 145
CHAPTER 6 Head Trauma 148
 SKILL STATION X: Head and Neck Trauma: Assessment and Management 170
CHAPTER 7 Spine and Spinal Cord Trauma 174
 SKILL STATION XI: X-Ray Identification of Spine Injuries 194
 SKILL STATION XII: Spinal Cord Injury Assessment and Management 199
CHAPTER 8 Musculoskeletal Trauma 206
 SKILL STATION XIII: Musculoskeletal Trauma: Assessment and Management 224
CHAPTER 9 Thermal Injuries 230
CHAPTER 10 Pediatric Trauma 246
CHAPTER 11 Geriatric Trauma 272
CHAPTER 12 Trauma in Pregnancy and Intimate Partner Violence 286
CHAPTER 13 Transfer to Definitive Care 298
APPENDICES 309
INDEX 355
v

Foreword
My first exposure with ATLS was in San Diego in 1980 Remember and Celebrate!
while I was a resident. The instructor course was con-
ducted by Paul E. “Skip” Collicott, MD, FACS, and fel- The Advanced Trauma Life Support (ATLS) Course
low students included a young surgeon in San Diego, arose from the zeal and passion of a small group of sur-
A. Brent Eastman, MD, FACS, and one from San Fran- geons intent on improving patient care. In 1976, when
cisco, Donald D. Trunkey, MD, FACS. Over the next orthopedic surgeon Dr. James Styner encountered a
year or two, we trained everyone in San Diego, and woefully inadequate response to the needs of his chil-
this became the language and glue for the San Diego dren injured in a light plane crash in rural Nebraska,
Trauma System. The experience was enlightening, in- he was compelled to take action. He spurred the de-
spiring, and deeply personal. In a weekend, I was edu- velopment of an organized systematic approach to the
cated and had my confidence established: I was adept evaluation and care of the injured patient. Recently
and skilled in something that had previously been a retired Director of Member Services for the American
cause of anxiety and confusion. For the first time, I had College of Surgeons, Paul “Skip” Collicott MD, FACS,
been introduced to an “organized course,” standards joined forces with his then-colleague Dr. Styner and
for quality, validated education and skills training, and the movement called “Advanced Trauma Life Sup-
verification of these skills. It was a life-transforming port” was born. In short order, it was adopted by the
experience and I chose a career in trauma in part as a Committee on Trauma and since then, the course has
result. During that weekend, I also was introduced to been developed and refined year after year, decade af-
the American College of Surgeons — at its very best. ter decade, in that same spirit of dedication kindled
The tradition of ATLS and the newest course — the by its founders. Since its inception, ATLS has trained
Ninth Edition — carry on this powerful tradition. This more than one million physicians in 63 countries and
type of education fulfills our responsibility with our no doubt has saved countless lives. In recent years,
patients and the public at large — we are committed several individuals central to the development and
to consistency in practice and excellence in delivery promulgation of ATLS have been lost. While we miss
above all else. them, their spirit lives on as we celebrate the launch of
The fellow creators of the Ninth Edition under the Ninth Edition of ATLS.
the leadership of Dr. Karen Brasel, MD, FACS, Will The Ninth Edition represents the latest in evi-
Chapleau, EMT-P, RN, TNS, and the wonderful Col- dence-based care for the injured. The course materi-
lege staff have furthered the tradition, the experience, als were thoroughly vetted by a group of international
and broadened the global impact. ATLS has been and experts and the content was vigorously debated for both
remains one of the finest achievements of the Ameri- its scientific merit and practical application. The result
can College of Surgeons and its Fellows. The Ninth is a vibrant offering for health care providers across the
Edition takes this achievement to an even higher level. world who seek an easily remembered framework to
care for patients with complex injures. The new edition
David B. Hoyt, MD, FACS has many changes including the latest techniques in ini-
Executive Director tial assessment, a balanced strategy for resuscitation,
American College of Surgeons
and an interactive approach to learning.
Chicago, Illinois
So then, on the occasion of this, the Ninth Edi-
United States
tion of ATLS, we remember the spirit in which it was
founded and we celebrate our work as we carry out the
mission of the Committee on Trauma. We hope you
will find the course stimulating and interesting. Above
all, we hope it will help you save a life.
Michael F. Rotondo, MD, FACS
Chair, Committee on Trauma
American College of Surgeons
Chicago, Illinois
United States
vii

Preface
educators review the educational materials to ensure
Role of the American College of

that the course is conducted in a manner that facili-
Surgeons Committee on Trauma
tates learning. All of the course content is available
in other resources, such as textbooks and journals.
The American College of Surgeons (ACS) was founded However, the ATLS Course is a specific entity, and
to improve the care of surgical patients, and it has long the manuals, slide presentations, skill procedures, and
been a leader in establishing and maintaining the high other resources are used for the entire course only and
quality of surgical practice in North America. In ac- cannot be fragmented into separate, freestanding lec-
cordance with that role, the ACS Committee on Trau- tures or practical sessions. Members of the ACS COT
ma (COT) has worked to establish guidelines for the and the ACS Regional and State/Provincial Commit-
care of injured patients. tees, as well as the ACS ATLS Program Office staff
Accordingly, the COT sponsors and contributes to members, are responsible for maintaining the high
the continued development of the Advanced Trauma Life quality of the program. By introducing this course and
Support (ATLS) Program. The ATLS Student Course maintaining its high quality, the COT hopes to provide
does not present new concepts in the field of trauma another instrument by which to reduce the mortality
care; rather, it teaches established treatment methods. A and morbidity related to trauma. The COT recom-
systematic, concise approach to the early care of trauma mends that providers participating in the ATLS Stu-
patients is the hallmark of the ATLS Program. dent Course reverify their status every four years to
This Ninth Edition was developed for the ACS by maintain both their current status in the program and
members of the ATLS Committee and the ACS COT, their knowledge of current ATLS core content.
other individual Fellows of the College, members of the
international ATLS community, and nonsurgical con-
sultants to the Committee who were selected for their New to this Edition
special competence in trauma care and their expertise
in medical education. (Please see the listing at the end
This Ninth Edition of the Advanced Trauma Life Sup-
of the Preface and the Acknowledgements section for
port Student Course Manual reflects several changes
names and affiliations of these individuals.) The COT
designed to enhance the educational content and its
believes that those individuals who are responsible for
visual presentation.
caring for injured patients will find the information
extremely valuable. The principles of patient care pre-
Content Updates
sented in this manual may also be beneficial for the
care of patients with nontrauma-related diseases.
All chapters were rewritten and revised to ensure clear
Injured patients present a wide range of complex
coverage of the most up-to-date technical content,
problems. The ATLS Student Course presents a con-
which is also represented in updated references. New
cise approach to assessing and managing multiply
to this edition are:
injured patients. The course presents providers with

knowledge and techniques that are comprehensive and Concept of balanced resuscitation

easily adapted to fit their needs. The skills described Emphasis on the pelvis as a source of blood loss
in this manual represent one safe way to perform each  Use of more advanced airway techniques for the
technique. The ACS recognizes that there are other difficult airway

acceptable approaches. However, the knowledge and Optional DPL and pericardiocentesis
skills taught in the course are easily adapted to all ven-  New FAST Skill Station
ues for the care of these patients. 
New multiple-choice questions for pre-test and
The ATLS Program is revised by the ATLS Com- post-test
mittee approximately every four years to respond to 
Optional expanded content on heat injury
changes in available knowledge and incorporate newer 
New initial assessment scenarios
and perhaps even safer skills. ATLS Committees in

Many new images
other countries and regions where the Program has

been introduced have participated in the revision proc- New Instructor Course Content

ess, and the ATLS Committee appreciates their out- New Skills Videos
standing contributions. National and international  New ATLS App
ix
x PREFACE
Mobile Application in preparation for the practical assessment. Review of
the demonstrated skills prior to participating in the
We are pleased to offer a mobile application
skills stations will enhance the learner’s experience.
with both Universal iOS and Android compat-
ibility that is full of useful reference content
for retrieval at the bedside and for review at your lei-
sure. Content includes: Editorial Notes
■■Interactive visuals, such as treatment algorithms
and x-ray identification The ACS Committee on Trauma is referred to as the
ACS COT or the Committee, and the State/Provincial
■■Just in Time video segments capturing key skills
Chair(s) is referred to as S/P Chair(s).
■■Calculators, such as pediatric burn calculator
The international nature of this edition of the
and the Parkland Formula to determine fluid
ATLS Student Manual may necessitate changes in
administration
commonly used terms to facilitate understanding by
■■Animations, such as airway management and all students and teachers of the Program.
surgical cricothyroidotomy Advanced Trauma Life Support® and ATLS® are
proprietary trademarks and service marks owned
Students, instructors, coordinators, and educators can
by the American College of Surgeons and cannot be
access the app through the MyATLS.com website.
used by individuals or entities outside the ACS COT
organization for their goods and services without ACS
Skills Video
approval. Accordingly, any reproduction of either or
As part of the course, video is provided via the both marks in direct conjunction with the ACS ATLS
MyATLS.com website to show critical skills that Program within the ACS Committee on Trauma
pro viders should be familiar with before taking the organization must be accompanied by the common law
course. Skill Stations during the course will allow pro- symbol of trademark ownership.
viders the opportunity to fine tune skill performance
Textbook Features
The pedagogical features of the textbook help to improve student compre-
hension and knowledge retention. Look for the following features:
Chapter Chapter Outline Links
Statement Outline See Skill Station IV: Shock Assess-
New to this edition, ment and Management.
This feature provides a “road map” to
the Chapter State- Cross-references to other chapters,
the chapter content.
ment capsulizes the overall learning Skill Stations, and additional resources
goal of the chapter. help to pull all of the information to-
Key Questions gether. These cross-references are hot-
Scenario ? These questions are aligned with links in the interactive textbook PDF,
the instructor’s PowerPoint pre- which is available at MyATLS.com.
sentations to prepare students for
key discussions during lectures.
Summary
Also new to this edition, each chapter
opens with a Scenario that progresses Key Points Chapter Summary
throughout the chapter and concludes Sentences appear in red font to attract
at the end. Follow the initial assess- the reader’s attention to key points of Chapter summaries tie back to the
ment and treatment of each patient, information. Chapter Objectives to ensure under-
and learn the final outcome. This fea- standing of the most pertinent chapter
ture showcases the practical applica- content.
tion of chapter content. Pitfalls
PITFALLS
These boxes highlight critical pitfalls to
avoid while caring for trauma patients.