Advanced Trauma Life Support®


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TENTH EDITION
ATLS®
Advanced Trauma Life Support®
Student Course Manual
New to this edition

ATLS®
Advanced Trauma Life Support®
Student Course Manual

Chair of Committee on Trauma: Ronald M. Stewart, MD, FACS Medical Director of Trauma Program: Michael F. Rotondo, MD, FACS ATLS Committee Chair: Sharon M. Henry, MD, FACS ATLS Program Manager: Monique Drago, MA, EdD Executive Editor: Claire Merrick Project Manager: Danielle S. Haskin Development Editor: Nancy Peterson Media Services: Steve Kidd and Alex Menendez, Delve Productions Designer: Rainer Flor Production Services: Joy Garcia Artist: Dragonfly Media Group
Tenth Edition
Copyright© 2018 American College of Surgeons 633 N. Saint Clair Street Chicago, IL 60611-3211
Previous editions copyrighted 1980, 1982, 1984, 1993, 1997, 2004, 2008, and 2012 by the American College of Surgeons.
Copyright enforceable internationally under the Bern Convention and the Uniform Copyright 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 information provided by the manufacturer of each drug to be administered to verify the recommended 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 Prehospital Trauma Life Support (PHTLS) standard in transporting patients with spine injury. If the collars and immobilization devices are to be removed in controlled hospital environments, this should be accomplished 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 10th edition of the ATLS Program.
Advanced Trauma Life Support® and the acronym ATLS® are marks 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: 2017907997 ISBN 78-0-9968262-3-5

DEDICATION
We dedicate the Tenth Edition of ATLS to the memory of Dr. Norman E. McSwain Jr. His dynamic, positive, warm, friendly, and uplifting approach to getting things done through his life’s work is a constant inspiration to those whose lives he touched. His tenure with the American College of Surgeons Committee on Trauma (COT) spanned almost exactly the same 40 years of the ATLS course.
Dr. McSwain’s time with the COT led him down a path where, without a doubt, he became the most important surgical advocate for prehospital patient care. He first worked to develop, and then led and championed, the Prehospital Trauma Life Support Course (PHTLS) as a vital and integral complement to ATLS. Combined, these two courses have taught more than 2 million students across the globe.
Dr. McSwain received every honor the COT could bestow, and as a last tribute, we are pleased to dedicate this edition of ATLS to his memory. The creators of this Tenth Edition have diligently worked to answer Dr. McSwain’s most common greeting: “What have you done for the good of mankind today?” by providing you with the Advanced Trauma Life Support Course, 10th Edition, along with our fervent hope that you will continue to use it to do good for all humankind. Thank you, Dr. McSwain.
Sharon Henry, MD Karen Brasel, MD Ronald M. Stewart, MD, FACS

FOREWORD

My first exposure to Advanced Trauma Life Support® (ATLS®) was in San Diego in 1980 while I was a resident. The instructor course was conducted by Paul E. “Skip” Collicott, MD, FACS, and fellow students included a young surgeon in San Diego, A. Brent Eastman, MD, FACS, and one from San Francisco, Donald D. Trunkey, MD, FACS. Over the next year or two, we trained everyone in San Diego, and that work became the language and glue for the San Diego Trauma System. The experience was enlightening, inspiring, and deeply personal. In a weekend, I was educated and had my confidence established: I was adept and skilled in something that had previously been a cause of anxiety and confusion. For the first time, I had been introduced to an “organized course,” standards for quality, validated education and skills training, and verification of these skills. It was a life-transforming experience, and I chose a career in trauma in part as a result. During that weekend, I also was introduced to the American College of Surgeons—at its very best.
The Tenth Edition of ATLS continues a tradition of innovation. It takes advantage of electronic delivery and by offering two forms of courses (traditional and electronic) to increase the reach and effectiveness of this landmark course. Just about to celebrate its 40th anniversary and currently used in over 60 countries, the ATLS program and its delivery through the Tenth Edition will continue to foster safe trauma practices for the world at large.
Under the leadership of Sharon Henry, MD, FACS, the ATLS Committee Chair, and Monique Drago, MA, EdD, the Trauma Education Program Manager, along with excellent college staff, we have been able to evolve the program, building on the foundation laid in the Ninth Edition by Karen Brasel, MD, FACS, and Will Chapleau, EMT-P, RN, TNS. The Tenth Edition of the ATLS program takes the finest achievements of the American College of Surgeons and its Fellows to the next level, and ultimately patient care is the greatest beneficiary.
David B. Hoyt, MD, FACS Executive Director American College of Surgeons Chicago, Illinois United States

The year 1976 was key for improving the care of the injured patient. In that year, orthopedic surgeon Dr. James Styner and his family were tragically involved in a plane crash in a Nebraska cornfield. The largely unprepared medical response by those caring for Dr. Styner and his family subsequently compelled him to action. Dr. Styner joined forces with his colleague, Dr. Paul “Skip” Collicott MD, FACS, and began a course entitled Advanced Trauma Life Support (ATLS). Today this initially small course has become a global movement. ATLS was quickly adopted and aggressively promulgated by the Committee on Trauma. The first course was held in 1980, and since that time ATLS has been diligently refined and improved year after year, decade after decade. More than a million students have been taught in more than 75 countries. From Nebraska to Haiti, more than 60% of ATLS courses are now taught outside North America.
It was also in 1976 that Don Trunkey, MD, FACS and the Committee on Trauma (COT) published Optimal Hospital Resources for Care of the Injured, the first document aimed at defining and developing trauma centers and trauma systems. This document led directly to the COT’s Verification Review and Consultation (VRC) program and its 450 verified trauma centers across the United States. These two programs have transformed the care of injured patients across the globe, resulting in hundreds of thousands of lives saved. In an interesting twist, ATLS was intended as an educational program, and the VRC was intended to be a set of standards. But in real ways, ATLS standardized the care of trauma patients, and the VRC educated the trauma community on how to provide optimal care for trauma patients.
Thus 1976 heralded radical and positive change in the care of trauma patients. The Tenth Edition of ATLS is the most innovative and creative update since the inception of the ATLS course. I believe this edition is a fitting testament to the memory of those pioneers who, in their mind’s eye, could see a path to a better future for the care of the injured. I congratulate the modern pioneers of this Tenth Edition. The development of this edition was led by a team with a similar commitment, zeal, and passion to improve. My hope is that all those taking and teaching ATLS will boldly continue this search to improve the care of the injured. In so doing, we may appropriately honor those pioneers of 1976.

Ronald M. Stewart, MD, FACS Chair of the ACS Committee on Trauma

v

PREFACE

Role of the A mer ic an College of Surgeons Commit tee on Traum a
The American College of Surgeons (ACS) was founded to improve the care of surgical patients, and it has long been a leader in establishing and maintaining the high quality of surgical practice in North America. In accordance with that role, the ACS Committee on Trauma (COT) has worked to establish guidelines for the care of injured patients.
Accordingly, the COT sponsors and contributes to continued development of the Advanced Trauma Life Support (ATLS) program. The ATLS Student Course does not present new concepts in the field of trauma care; rather, it teaches established treatment methods. A systematic, concise approach to the early care of trauma patients is the hallmark of the ATLS Program.
This Tenth Edition was developed for the ACS by members of the ATLS Committee and the ACS COT, other individual Fellows of the College, members of the international ATLS community, and nonsurgical consultants to the Committee who were selected for their special competence in trauma care and their expertise in medical education. (The Preface and Acknowledgments sections of this book contain the names and affiliations of these individuals.) The COT believes that the people who are responsible for caring for injured patients will find the information extremely valuable. The principles of patient care presented in this manual may also be beneficial to people engaged in the care of patients with nontrauma-related diseases.
Injured patients present a wide range of complex problems. The ATLS Student Course is a concise approach to assessing and managing multiply injured patients. The course supplies providers with comprehensive knowledge and techniques that are easily adapted to fit their needs. Students using this manual will learn one safe way to perform each technique. The ACS recognizes that there are other acceptable approaches. However, the knowledge and skills taught in the course are easily adapted to all venues for the care of these patients.
The ATLS Program is revised by the ATLS Committee approximately every four years to respond to changes

in available knowledge and incorporate newer and perhaps even safer skills. ATLS Committees in other countries and regions where the program has been introduced have participated in the revision process, and the ATLS Committee appreciates their outstanding contributions.
New to This Edition
This Tenth Edition of the Advanced Trauma Life Support Student Course Manual reflects several changes designed to enhance the educational content and its visual presentation.
Content Updates
All chapters were rewritten and revised to ensure clear coverage of the most up-to-date scientific content, which is also represented in updated references. New to this edition are:
•• Completely revised skills stations based on unfolding scenarios
•• Emphasis on the trauma team, including a new Teamwork section at the end of each chapter and a new appendix focusing on Team Resource Management in ATLS
•• Expanded Pitfalls features in each chapter to identify correlating preventive measures meant to avoid the pitfalls
•• Additional skills in local hemorrhage control, including wound packing and tourniquet application
•• Addition of the new Glasgow Coma Scale (GCS) •• An update of terminology regarding spinal
immobilization to emphasize restriction of spinal motion
•• Many new photographs and medical illustrations, as well as updated management algorithms, throughout the manual

vii

­viii

PREFACE

MyATLS Mobile Application
The course continues to make use of the MyATLS mobile application with both Universal iOS and Android compatibility. The app is full of useful reference content for retrieval at the hospital bedside and for review at your leisure. Content includes:

must be accompanied by the common law symbol of trademark ownership.
A mer ic an Colleg e of Surgeons Committee on Traum a

•• Interactive visuals, such as treatment algorithms and x-ray identification
•• Just in Time video segments capturing key skills
•• Calculators, such as pediatric burn calculator to determine fluid administration
•• Animations, such as airway management and surgical cricothyroidotomy

Ronald M. Stewart, MD, FACS Committee on Trauma, Chair Chair of the American College of Surgeons Committee on Trauma Witten B. Russ Professor and Chair of the Department of Surgery UT Health San Antonio San Antonio, Texas United States

Students, instructors, coordinators, and educators are encouraged to access and regularly use this important tool.
Skills Video
As part of the course, video is provided via the MyATLS. com website to show critical skills that providers should be familiar with before taking the course. Skill Stations during the course will allow providers the opportunity to fine-tune skill performance in preparation for the practical assessment. A review of the demonstrated skills before participating in the skills stations will enhance the learner’s experience.
Editorial Notes
The ACS Committee on Trauma is referred to as the ACS COT or the Committee, and the State/Provincial Chair(s) is referred to as S/P Chair(s).
The international nature of this edition of the ATLS Student Manual may necessitate changes in the commonly used terms to facilitate understanding by all students and teachers of the program.
Advanced Trauma Life Support® and ATLS® are proprietary trademarks and service marks owned by the American College of Surgeons and cannot be used by individuals or entities outside the ACS COT organization for their goods and services without ACS approval. Accordingly, any reproduction of either or both marks in direct conjunction with the ACS ATLS Program within the ACS Committee on Trauma organization

Michael F. Rotondo, MD, FACS Trauma Program, Medical Director CEO, University of Rochester Medical Faculty Group Vice Dean of Clinical Affairs–School of Medicine Professor of Surgery–Division of Acute Care Surgery Vice President of Administration–Strong Memorial Hospital President-Elect–American Association for the Surgery of Trauma University of Rochester Medical Center Rochester, New York United States
Commit tee on A dvanc ed Traum a Life Supp ort of the A mer ic an Colleg e of Surgeons Committee on Traum a
Sharon M. Henry, MD, FACS ATLS Committee Chair Anne Scalea Professor of Surgery University of Maryland School of Medicine University of Maryland Medical Center RA Cowley Shock Trauma Center Baltimore, Maryland United States
Saud A. Al Turki, MD, FACS Ministry of National Guard Health Affairs, King Abdulaziz Medical City King Saud Bin Abdulaziz University for Health Sciences

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PREFACE

Riyadh Saudi Arabia
Col. (Ret.) Mark W. Bowyer, MD, FACS Ben Eiseman Professor of Surgery Chief, Trauma and Combat Surgery Surgical Director of Simulation, Department of Surgery The Uniformed Services University Walter Reed National Military Medical Center Bethesda, Maryland United States
Kimberly A. Davis MD, MBA, FACS, FCCM Professor of Surgery, Trauma Vice Chairman for Clinical Affairs Yale School of Medicine Chief of General Surgery, Trauma and Surgical Critical Care Trauma Medical Director Yale New Haven Hospital New Haven, Connecticut United States
Julie A. Dunn, MD, MS, FACS Medical Director, Trauma Research and Education UC Health Northern Colorado Loveland, Colorado United States
Peter F. Ehrlich, MD, FACS Professor C S Mott Children’s Hospital Ann Arbor, Michigan United States
James R. Ficke, MD, FACS Professor of Orthopaedic Surgery Johns Hopkins Hospital Baltimore, Maryland United States

Martin S. Keller, MD, FACS, FAAP Associate Professor of Surgery St. Louis Children’s Hospital Washington University School of Medicine St. Louis, Missouri United States
Gilberto K. K. Leung, MBBS, FRCS, PhD Clinical Associate Professor The University of Hong Kong Queen Mary University Pok Fu Lam Hong Kong
R. Todd Maxson, MD, FACS Professor of Surgery University of Arkansas for Medical Sciences Trauma Medical Director Arkansas Children’s Hospital Little Rock, Arkansas United States
Daniel B. Michael, MD, PhD, FACS, FAANS Director of Neurosurgical Education William Beaumont Hospital Royal Oak Professor of Neurosurgery Oakland University William Beaumont School of Medicine Royal Oak, Michigan United States Director, Michigan Head and Spine Institute Southfield, Michigan United States
Neil G. Parry, MD, FACS, FRCSC Medical Director, Trauma Program Associate Professor of Surgery and Critical Care London Health Sciences Center Schulich School of Medicine, Western University London, Ontario Canada

Glen A. Franklin, MD FACS Professor University of Louisville School of Medicine Louisville, Kentucky United States

Bruce Potenza, MD, FACS Critical Care Surgeon, Trauma UCSD Medical Center San Diego, California United States

Maria Fernanda Jimenez, MD, FACS General Surgeon Hospital Universitario MEDERI Bogotá, Distrito Capital Colombia

Martin A. Schreiber MD, FACS Professor and Chief, Division of Trauma, Critical Care & Acute Surgery Oregon Health & Science University Portland, Oregon United States

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Advanced Trauma Life Support®