Objective For the early recognition and management of hypovolaemic shock, ATLS suggests four shock classes based upon an estimated blood loss in percent. The aim of this study was to assess the confidence and acceptance of the ATLS classification of hypovolaemic shock among ATLS course directors and instructors in daily trauma care.
Methods During a 2-month period, ATLS course directors and instructors from the ATLS region XV (Europe) were invited to participate in an online survey comprising 15 questions.
Results A total of 383 responses were received. Ninety-eight percent declared that they would follow the ‘A, B, C, D, E’ approach by ATLS in daily trauma care. However, only 48% assessed ‘C-Circulation’ according to the ATLS classification of hypovolaemic shock. One out of four respondents estimated that in daily clinical routine, less than 50% of all trauma patients can be classified according to the current ATLS classification of hypovolaemic shock. Additionally, only 10.9% considered the ATLS classification of hypovolaemic shock as a ‘good guide’ for fluid resuscitation and blood product transfusion, whereas 45.1% stated that this classification only ‘may help’ or has ‘no impact’ to guide resuscitation strategies.
Conclusions Although the ‘A, B, C, D, E’ approach according to ATLS is widely implemented in daily trauma care, the use of the ATLS classification of hypovolaemic shock in daily practice is limited. Together with previous analyses, this study supports the need for a critical reassessment of the current ATLS classification of hypovolaemic shock.
- emergency department management
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The ATLS course presents a concise approach to assess and manage multiply injured patients in the emergency department (ED).1 The course aims to provide knowledge and techniques that are comprehensive and easily adapted to daily trauma care. To date, ATLS has been taught to more than one million doctors in over 50 countries. It has become the foundation of care of the severely injured patient by teaching a common language and a common systematic approach. One key aspect of ATLS is to early recognise and treat hypovolaemic shock. For this purpose, ATLS suggests four classes of hypovolaemic shock (classes I–IV) based upon an estimated blood loss in percent and corresponding vital signs (table 1). For each class, ATLS allocates therapeutic recommendations, for example, the replacement of fluids and the administration of blood products.1 ,2
Haemorrhage is the most common cause of shock after trauma, and the ATLS classification of hypovolaemic shock has been presented as a useful tool for adequately estimating acute blood loss and to guide resuscitation. However, the clinical applicability and validity of the ATLS classification of hypovolaemic shock has recently been questioned by the results of two large-scale analyses of the TARN (Trauma Audit and Research Network) registry and the TraumaRegister DGU database, comprising more than 140 000 datasets of severely injured patients.3–5 As a result, 90.7% of all trauma patients could not be classified according to the criteria suggested by ATLS when a combination of the vital signs of heart rate (HR), systolic blood pressure (SBP) and GCS were considered.3 ATLS seemed (1) to overestimate the degree of tachycardia associated with hypotension and (2) to underestimate mental disability in the presence of hypovolaemic shock.3–5
In consequence, we aimed to assess the acceptance and user confidence in this classification by conducting a survey among ATLS course directors and instructors across the ATLS region XV (Europe).
An online questionnaire was developed (SurveyMonkey, Palo Alto, USA; http://www.surveymonkey.com) which contained 15 questions combined with a list of possible and preformulated answers. The individual qualification (ATLS course director or instructor), country of work and professional man-years of each respondent were asked via open-ended questions.
The online survey was addressed to ATLS instructors and course directors affiliated to the ATLS region XV (Europe) including the following countries: Denmark, France, Greece and Cyprus, Germany, Hungary, Ireland, Israel, Italy, Lithuania, Norway, Portugal, Slovenia, South Africa, Spain, Sweden, Switzerland, The Netherlands and the UK. In order to protect the privacy of the participants, the initial invitation email, including background information as well as a link to access the online survey, was distributed only to the national board committee of each of the 18 countries of the ATLS region XV. The further distribution of the questionnaire to the national ATLS instructors and course directors was performed solely by each national board.
Data acquisition was conducted between October and December 2012, and one reminder was sent to all participants in between. Data were downloaded from the online database, and data analyses were performed using Microsoft Excel 2007.
As this investigation was a voluntary survey among medical professionals, ethical approval was not required.
From October to December 2012, 383 responses were received of which 81.4% (312/383) were obtained from Ireland, Germany, The Netherlands and the UK (table 2). In the remaining countries, participation was either marginal (<15 responses) or the national board committee did not support this initiative. Among the participants, 19.7% (75/383) were ATLS course directors, and 80.3% (306/383) ALTS course instructors with mean professional man-years of 20.9 (±8.1) and 13.2 (±7.6), respectively. The majority of respondents practiced in either level 1 (43.5%) or level 2 (31.9%) trauma centres.
The role of the ATLS classification of hypovolaemic shock in assessing ‘C-Circulation’
When respondents were asked if the general ‘A, B, C, D, E’ approach of ATLS is followed in daily trauma care, 98.1% (366/373) acknowledged its use ‘always’ or in ‘most of the times’ (table 3).
Although, 83.6% (296/354) of the respondents declared that they are confident with the current ATLS classification of hypovolaemic shock, only 48% (170/354) assessed ‘C-Circulation’ according to its given criteria and definitions. By contrast, half the respondents (49.2%; 174/354) relied rather on their clinical experience, physical examination and laboratory tests in assessing ‘C-Circulation’ in daily clinical trauma care (figure 1).
Number of accurately classified patients according to the ATLS classification of hypovolaemic shock
When respondents were asked how many patients they could adequately classify according to the ATLS classification of hypovolaemic shock in daily trauma care, one-third (33.9%; 121/357) stated that more than 75% of all trauma patients can be allocated correctly into one of the suggested shock classes. By contrast, one out of four (26.6%; 95/357) estimated that less than 50% of all patients can be classified correctly (table 4A). In the group of respondents not using the ATLS classification of hypovolaemic shock primarily (table 4B), this percentage was even higher (37.7%; 64/170).
The ATLS classification as a guide for fluid resuscitation and blood product transfusion
Only 10.9% (39/359) of the ATLS instructors and course directors considered the ATLS classification of hypovoalemic shock is a ‘good guide’ for fluid resuscitation and transfusion of blood products (table 5A). In the group of responders who were not using the ATLS classification of shock primarily, almost 70% declared that this classification only ‘may help’ or even has ‘no impact’ to guide resuscitation strategies (table 5B).
The aim of the present study was to evaluate the use of the ATLS classification of hypovolaemic shock in daily trauma care among European ATLS course directors and instructors.
As expected, the vast majority of all responders declared that the ‘A, B, C, D, E’ approach is used in their daily trauma care, indicating that the ATLS philosophy is actively practiced. The beneficial role of a standardised approach in the ED, such as ATLS, has been shown previously: Among ATLS providers, >96% stated that ATLS improves clinical skills,6 as well as increases confidence, trauma capability and improves communication.7 A significantly lower number of inadequately managed patients has been described after implementation of ATLS.8 ,9 However, the question whether this translates directly into a better patient outcome remains controversial.8 ,10–13
Despite the general use of the ‘A, B, C, D, E’ approach for the initial assessment and care of trauma patients, only 48% of the respondents used the ATLS classification of hypovolaemic shock to assess circulatory depletion. The other half of the respondents tended to rely more on their clinical experience, physical examination and laboratory findings. A possible explanation for the limited use of the ATLS classification may be found in the high percentage of respondents who stated that according to their experiences less than 50% of all patients can be classified using the ATLS classification of hypovolaemic shock. This is substantiated by a previous analysis on 36 504 severely injured patients from the TraumaRegister DGU.3 In this analysis, only 3411 (9.3%) patients could be classified according to ATLS. By contrast, 33 093(90.7%) did not match the criteria suggested by ATLS, if a combination of HR, SBP and GCS was considered. Similar results have been also observed in the prehospital setting.14 In conclusion, ATLS seemed to overestimate the degree of tachycardia associated with hypotension and to underestimate mental disability in the presence of hypovolaemic shock. This assumption is shared by previous analyses demonstrating that the association between increased HR and decreased SBP is far less pronounced as presented in the ATLS courses.4 ,5 ,15–17 Consequently, these results suggest that the current ATLS classification of hypovolaemic shock, as a part of the otherwise clinically useful ‘A, B, C, D, E’ concept, displays substantial deficits in adequately risk-stratifying trauma patients.3–5 However, it is important to note that the initial assessment of trauma patients does not rely on the ATLS classification of hypovolaemic shock only. If in doubt of any blood loss, an immediate identification of the bleeding source is essential and the basic management principle is to stop the bleeding and to replace the volume loss.1
Regarding the role of the ATLS classification of hypovolaemic shock in guiding fluid resuscitation and transfusion of blood products, only 10.9% of the respondents declared that the classification is a ‘good guide’. By contrast, a remarkable number of respondents affirmed that the classification has ‘no impact’ or only ‘may help’ to guide resuscitation strategies. These observations are consistent with a previous analysis by our group demonstrating that the ATLS classification of hypovolaemic shock seems to dramatically underestimate the need for blood product transfusion.18
Certain limitations to this investigation have to be acknowledged. As stated above, the initial invitation email was distributed solely by each national board in order to protect the privacy of each participant. Consequently, the number of persons who were invited to participate in the questionnaire remains unknown and prevents calculation of response rates. Furthermore, previous studies have questioned the validity of the current ATLS classification of hypovolaemic shock by demonstrating that this classification displays substantial deficits.3–5 Therefore, it cannot be excluded that this data have influenced and triangulated the respondents’ views on this classification. Moreover, not all European national board committees supported the current survey, and forwarded the request to their national course directors and course instructors. Overall, the vast majority of responses was obtained from four European countries. Therefore, the survey is subject to response bias and may not accurately reflect the opinion of the entire ATLS members across Europe. However, this was not the intention of the current survey. Furthermore, the study population was addressed to course directors and instructors only. Therefore, the applicability of the results to the larger cohort of ATLS providers in general is questionable. But in spite of these restrictions, the current investigation displays an interesting insight into the use of the ATLS classification of shock in daily trauma care.
The results of this questionnaire among 383 ATLS course directors and instructors indicated that although the general ‘A, B, C, D, E’ approach is broadly used in clinical trauma care, half the respondents do not assess circulatory depletion by using the ATLS classification of hypovolaemic shock. A remarkable number of respondents stated that <50% of all trauma patients can be classified according to ATLS, and that the current classification has no impact or only may help to guide fluid resuscitation and blood product transfusion. Together with previous analyses, the results presented here may suggest that a critical revision of the current ATLS classification of hypovolaemic shock is warranted.
Contributors M Mutschler and M Maegele conceived the study, designed the questionnaire, analysed the data and drafted the manuscript. MH, M Muenzberg and CW conducted to the design of the questionnaire and undertook data analysis. IS, TP and BB supervised data collection, analysed the data and contributed to manuscript preparation. All authors contributed substantially to the revision of the manuscript. M Mutschler takes responsibility for the paper and its content as a whole.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.