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® The year 1976 was key for improving the care of the (ATLS®) was in San Diego in 1980 while I was a resident. injured patient. In that year, orthopedic surgeon Dr. The instructor course was conducted by Paul E. “Skip” James Styner and his family were tragically involved Collicott, MD, FACS, and fellow students included a in a plane crash in a Nebraska cornfield. The largely young surgeon in San Diego, A. Brent Eastman, MD, unprepared medical response by those caring for Dr. FACS, and one from San Francisco, Donald D. Trunkey, Styner and his family subsequently compelled him to MD, FACS. Over the next year or two, we trained everyone action. Dr. Styner joined forces with his colleague, Dr. in San Diego, and that work became the language and Paul “Skip” Collicott MD, FACS, and began a course glue for the San Diego Trauma System. The experience entitled Advanced Trauma Life Support (ATLS). Today was enlightening, inspiring, and deeply personal. In this initially small course has become a global movement. a weekend, I was educated and had my confidence ATLS was quickly adopted and aggressively promulgated established: I was adept and skilled in something that by the Committee on Trauma. The first course was held in had previously been a cause of anxiety and confusion. 1980, and since that time ATLS has been diligently refined For the first time, I had been introduced to an “organized and improved year after year, decade after decade. More course,” standards for quality, validated education and than a million students have been taught in more than skills training, and verification of these skills. It was a 75 countries. From Nebraska to Haiti, more than 60% of life-transforming experience, and I chose a career in ATLS courses are now taught outside North America. trauma in part as a result. During that weekend, I also It was also in 1976 that Don Trunkey, MD, FACS and the was introduced to the American College of Surgeons—at Committee on Trauma (COT) published Optimal Hospital its very best. Resources for Care of the Injured, the first document The Tenth Edition of ATLS continues a tradition of aimed at defining and developing trauma centers and innovation. It takes advantage of electronic delivery trauma systems. This document led directly to the COT’s and by offering two forms of courses (traditional and Verification Review and Consultation (VRC) program electronic) to increase the reach and effectiveness of and its 450 verified trauma centers across the United this landmark course. Just about to celebrate its 40th States. These two programs have transformed the care of anniversary and currently used in over 60 countries, injured patients across the globe, resulting in hundreds the ATLS program and its delivery through the Tenth of thousands of lives saved. In an interesting twist, ATLS Edition will continue to foster safe trauma practices for was intended as an educational program, and the VRC the world at large. was intended to be a set of standards. But in real ways, Under the leadership of Sharon Henry, MD, FACS, the ATLS standardized the care of trauma patients, and ATLS Committee Chair, and Monique Drago, MA, EdD, the VRC educated the trauma community on how to the Trauma Education Program Manager, along with provide optimal care for trauma patients. excellent college staff, we have been able to evolve the Thus 1976 heralded radical and positive change in program, building on the foundation laid in the Ninth the care of trauma patients. The Tenth Edition of ATLS Edition by Karen Brasel, MD, FACS, and Will Chapleau, is the most innovative and creative update since the EMT-P, RN, TNS. The Tenth Edition of the ATLS program inception of the ATLS course. I believe this edition is a takes the finest achievements of the American College of fitting testament to the memory of those pioneers who, Surgeons and its Fellows to the next level, and ultimately in their mind’s eye, could see a path to a better future patient care is the greatest beneficiary. for the care of the injured. I congratulate the modern pioneers of this Tenth Edition. The development of this David B. Hoyt, MD, FACS edition was led by a team with a similar commitment, Executive Director zeal, and passion to improve. My hope is that all those American College of Surgeons taking and teaching ATLS will boldly continue this Chicago, Illinois search to improve the care of the injured. In so doing, United States 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 AmeRicAN in available knowledge and incorporate newer and perhaps even safer skills. ATLS Committees in college of suRgeoNs other countries and regions where the program has committee oN tRAumA been introduced have participated in the revision process, and the ATLS Committee appreciates their outstanding contributions. 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 New to this editioN 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 This Tenth Edition of the Advanced Trauma Life the care of injured patients. Support Student Course Manual reflects several changes Accordingly, the COT sponsors and contributes to designed to enhance the educational content and its continued development of the Advanced Trauma visual presentation. Life Support (ATLS) program. The ATLS Student Course does not present new concepts in the field of trauma care; rather, it teaches established treatment Content Updates methods. A systematic, concise approach to the early care of trauma patients is the hallmark of the All chapters were rewritten and revised to ensure clear ATLS Program. coverage of the most up-to-date scientific content, which This Tenth Edition was developed for the ACS by is also represented in updated references. New to this members of the ATLS Committee and the ACS COT, edition are: other individual Fellows of the College, members of the international ATLS community, and nonsurgical • Completely revised skills stations based on consultants to the Committee who were selected for their unfolding scenarios special competence in trauma care and their expertise in • Emphasis on the trauma team, including a new medical education. (The Preface and Acknowledgments Teamwork section at the end of each chapter sections of this book contain the names and affiliations of these individuals.) The COT believes that the people and a new appendix focusing on Team Resource who are responsible for caring for injured patients will Management in ATLS find the information extremely valuable. The principles • Expanded Pitfalls features in each chapter to of patient care presented in this manual may also be identify correlating preventive measures meant beneficial to people engaged in the care of patients with to avoid the pitfalls nontrauma-related diseases. Injured patients present a wide range of complex • Additional skills in local hemorrhage control, problems. The ATLS Student Course is a concise approach including wound packing and tourniquet to assessing and managing multiply injured patients. application The course supplies providers with comprehensive • Addition of the new Glasgow Coma Scale (GCS) knowledge and techniques that are easily adapted to fit their needs. Students using this manual will learn one • An update of terminology regarding spinal safe way to perform each technique. The ACS recognizes immobilization to emphasize restriction of that there are other acceptable approaches. However, spinal motion the knowledge and skills taught in the course are easily adapted to all venues for the care of these patients. • Many new photographs and medical The ATLS Program is revised by the ATLS Committee illustrations, as well as updated management approximately every four years to respond to changes algorithms, throughout the manual vii viii PREFACE MyatLs MobiLe appLiCation must be accompanied by the common law symbol of trademark ownership. The course continues to make use of the MyATLS mobile application with both Universal iOS and Android AmeRic AN college of compatibility. The app is full of useful suRgeoNs committee reference content for retrieval at oN tRAumA the hospital bedside and for review at your leisure. Content includes: • Interactive visuals, such as treatment Ronald M. Stewart, MD, FACS algorithms and x-ray identification Committee on Trauma, Chair Chair of the American College of Surgeons Committee on • Just in Time video segments capturing key skills Trauma • Calculators, such as pediatric burn calculator to Witten B. Russ Professor and Chair of the Department of determine fluid administration Surgery UT Health San Antonio • Animations, such as airway management and San Antonio, Texas surgical cricothyroidotomy United States Students, instructors, coordinators, and educators Michael F. Rotondo, MD, FACS are encouraged to access and regularly use this Trauma Program, Medical Director important tool. CEO, University of Rochester Medical Faculty Group Vice Dean of Clinical Affairs–School of Medicine Professor of Surgery–Division of Acute Care Surgery skiLLs Video Vice President of Administration–Strong Memorial Hospital President-Elect–American Association for the Surgery of As part of the course, video is provided via the MyATLS. Trauma com website to show critical skills that providers should University of Rochester Medical Center be familiar with before taking the course. Skill Stations Rochester, New York during the course will allow providers the opportunity United States to fine-tune skill performance in preparation for the practical assessment. A review of the demonstrated skills before participating in the skills stations will committee oN AdvANced enhance the learner’s experience. tRAumA life suppoRt of the AmeRicAN college editoRiAl Notes of suRgeoNs committee oN tRAumA 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). Sharon M. Henry, MD, FACS The international nature of this edition of the ATLS ATLS Committee Chair Student Manual may necessitate changes in the Anne Scalea Professor of Surgery commonly used terms to facilitate understanding by University of Maryland School of Medicine all students and teachers of the program. University of Maryland Medical Center RA Advanced Trauma Life Support® and ATLS® are Cowley Shock Trauma Center proprietary trademarks and service marks owned by Baltimore, Maryland the American College of Surgeons and cannot be used by United States individuals or entities outside the ACS COT organization for their goods and services without ACS approval. Saud A. Al Turki, MD, FACS Accordingly, any reproduction of either or both marks Ministry of National Guard Health Affairs, King Abdulaziz in direct conjunction with the ACS ATLS Program Medical City within the ACS Committee on Trauma organization King Saud Bin Abdulaziz University for Health Sciences ix PREFACE Riyadh Martin S. Keller, MD, FACS, FAAP Saudi Arabia Associate Professor of Surgery St. Louis Children’s Hospital Col. (Ret.) Mark W. Bowyer, MD, FACS Washington University School of Medicine Ben Eiseman Professor of Surgery St. Louis, Missouri Chief, Trauma and Combat Surgery United States Surgical Director of Simulation, Department of Surgery The Uniformed Services University Gilberto K. K. Leung, MBBS, FRCS, PhD Walter Reed National Military Medical Center Clinical Associate Professor Bethesda, Maryland The University of Hong Kong Queen Mary University United States Pok Fu Lam Hong Kong Kimberly A. Davis MD, MBA, FACS, FCCM Professor of Surgery, Trauma R. Todd Maxson, MD, FACS Vice Chairman for Clinical Affairs Professor of Surgery Yale School of Medicine University of Arkansas for Medical Sciences Chief of General Surgery, Trauma and Surgical Critical Trauma Medical Director Care Arkansas Children’s Hospital Trauma Medical Director Little Rock, Arkansas Yale New Haven Hospital United States New Haven, Connecticut United States Daniel B. Michael, MD, PhD, FACS, FAANS Director of Neurosurgical Education Julie A. Dunn, MD, MS, FACS William Beaumont Hospital Royal Oak Medical Director, Trauma Research and Education Professor of Neurosurgery UC Health Northern Colorado Oakland University William Beaumont School of Loveland, Colorado Medicine United States Royal Oak, Michigan United States Peter F. Ehrlich, MD, FACS Director, Michigan Head and Spine Institute Professor Southfield, Michigan C S Mott Children’s Hospital United States Ann Arbor, Michigan United States Neil G. Parry, MD, FACS, FRCSC Medical Director, Trauma Program James R. Ficke, MD, FACS Associate Professor of Surgery and Critical Care Professor of Orthopaedic Surgery London Health Sciences Center Johns Hopkins Hospital Schulich School of Medicine, Western University Baltimore, Maryland London, Ontario United States Canada Glen A. Franklin, MD FACS Bruce Potenza, MD, FACS Professor Critical Care Surgeon, Trauma University of Louisville School of Medicine UCSD Medical Center Louisville, Kentucky San Diego, California United States United States Maria Fernanda Jimenez, MD, FACS Martin A. Schreiber MD, FACS General Surgeon Professor and Chief, Division of Trauma, Critical Care & Hospital Universitario MEDERI Acute Surgery Bogotá, Distrito Capital Oregon Health & Science University Colombia Portland, Oregon United States