ATLS® Advanced Trauma Life Support® Student Course Manual 10th Edition PDF

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. R...

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 n TO TABLE OF CONTENTS  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 n TO TABLE OF CONTENTS  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 n TO TABLE OF CONTENTS v  PREFACE Role of the A mer ic an in available knowledge and incorporate newer and perhaps even safer skills. ATLS Committees in Colleg e of Surg eons other countries and regions where the program has Commit tee on Traum a 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 Ne w 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 medical education. (The Preface and Acknowledgments Emphasis on the trauma team, including a new sections of this book contain the names and affiliations Teamwork section at the end of each chapter 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 n TO TABLE OF CONTENTS 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 A mer ic an Colleg e of compatibility. The app is full of useful reference content for retrieval at Surg eons Commit tee the hospital bedside and for review at your leisure. on Traum a 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 enhance the learner’s experience. Commit tee on A dvanc ed Traum a Life Supp ort of the A mer ic an Colleg e Editor i a l Note s of Surg eons Commit tee on Traum a 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 n TO TABLE OF CONTENTS ­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 n TO TABLE OF CONTENTS ­x PREFACE Gary A. Vercruysse, MD, FACS Lewis E. Jacobson, MD, FACS Director of Burn Services Chair, Department of Surgery Associate Professor of Surgery, Division of Trauma, Burns, Director, Trauma and Surgical Critical Care Acute Care Surgery and Surgical Critical Care St. Vincent Indianapolis Hospital University of Arizona School of Medicine Indianapolis, Indiana Tucson, Arizona United States United States Newton Djin Mori, MD, PhD, FACS Robert J. Winchell, MD, FACS General and Trauma Surgeon Chief, Division of Trauma, Burn, Acute and Critical Care Hospital das Clinicas–University of São Paulo Director of the Trauma Center São Paulo, São Paulo Weill Cornell Medicine Brazil New York–Presbyterian Weill Cornell Medical Center New York, New York John P. Sutyak, EdM, MD, FACS United States Director, Southern Illinois Trauma Center Associate Professor of Surgery Southern Illinois University School of Medicine Springfield, Illinois A s so c i ate Members to the United States Commit tee on A dvanc ed Traum a Life Supp ort of the A mer ic an Colleg e Li a isons to the of Surg eons Commit tee Commit tee on A dvanc ed on Traum a Traum a Life Supp ort of the A mer ic an Colleg e Mary-Margaret Brandt, MD, MHSA, FACS of Surg eons Commit tee Trauma Director on Traum a St. Joseph Mercy Health System Ann Arbor, Michigan United States Michael Murray, MD General Surgery Megan L. Brenner, MD FACS Banner Churchill Community Hospital Assistant Professor of Surgery Sparks, Nevada University of Maryland Medical Center United States Baltimore, Maryland United States Clark West, MD FACR Co-Course Director Frederic J. Cole, Jr., MD, FACS The University of Texas Health Science Associate Medical Director, Trauma Clinic and Patient Houston Medical School Outcomes Houston, Texas Legacy Emanuel Medical Center United States Portland, Oregon United States Oscar D. Guillamondegui, MD, MPH, FACS Professor of Surgery Trauma Medical Director Vanderbilt University Medical Center Nashville, Tennessee United States n TO TABLE OF CONTENTS ­xi PREFACE International Liaison Americ an College of to the Committee on Emergenc y Physicians Advanced Trauma Life Liaisons to the Commit tee Support of the American on Advanced Trauma Life College of Surgeons Support of the Americ an Committee on Trauma College of Surgeons Commit tee on Trauma Karen J. Brasel, MD, FACS Professor and Program Director Christopher Cribari, MD Oregon Health and Science University Medical Director, Acute Care Surgery, Medical Center of Portland, Oregon the Rockies, University of Colorado Health United States Loveland, CO United States Christopher S. Kang, MD, FACEP American Society of Attending Physician, Emergency Medicine, Madigan Army Anesthesiologists Liaison Medicine Center to the Committee on Tacoma, Washington United States Advanced Trauma Life Support of the American College of Surgeons A dvanc ed Traum a Life Committee on Trauma Supp ort Senior Educ ator A dv isory Boar d Richard P. Dutton, MD, MBA Debbie Paltridge, MHlthSc (ED) Michael Murray, MD Senior Educator Advisory Board, Chair General Surgery Principal Educator Banner Churchill Community Hospital Royal Australasian College of Surgeons Sparks, Nevada Melbourne, Victoria United States Australia Joe Acker, EMT-P, MPH Executive Director, Birmingham Regional EMS System A dvanc ed Traum a Car e University of Alabama at Birmingham for Nurse s Li a ison to the Birmingham, Alabama Commit tee on A dvanc ed United States Traum a Life Supp ort of Wesam Abuznadah, MD, MEd, FRCS(C ), FACS, RPVI the A mer ic an Colleg e of Assistant Professor, Consultant Vascular and Endovascular Surg eons Commit tee on Surgery Traum a Associate Dean, Academic and Student Affairs, College of Medicine King Saud Bin Abdulaziz University for Health Sciences Jan Howard, MSN, RN, Chair, ATCN Committee Jeddah South Bend, Indiana Saudi Arabia United States n TO TABLE OF CONTENTS ­xii PREFACE Jacqueline Bustraan, MSc A dvanc ed Traum a Life Educational Advisor, Trainer and Researcher Leiden University Medical Center/BOAT (Bustraan Supp ort Coor dinator Organisation, Advice and Training) Commit tee Leiden The Netherlands Lesley Dunstall, RN ATLS Coordinator Committee, Chair Marzellus Hofmann, MD, MME National Coordinator, EMST/ATLS Australasia Dean of Medical Education and Student Affairs Royal Australasian College of Surgeons Witten/Herdecke University, Faculty of Health North Adelaide, South Australia Witten, NRW Australia Germany Catherine Wilson, MSN, ACNP-BC, CEN Elizabeth Vallejo de Solezio ATLS Coordinator Committee, Vice Chair National Education, COT Ecuador Trauma Outreach Coordinator Quito Vanderbilt University Medical Center Ecuador Nashville, Tennessee United States Claus Dieter Stobaus, ME, ED Postgraduate Program in Education Mary Asselstine, RN Pontifical Catholic University of Rio Grande do Sul Sunnybrook Health Sciences Centre Porto Alegre, Rio Grande do Sul Toronto, Ontario Brazil Canada John P. Sutyak, EdM, MD, FACS Ryan Bales, RN Director, Southern Illinois Trauma Center ATLS Coordinator Associate Professor of Surgery CNIII Trauma Program Southern Illinois University School of Medicine Sacramento, California Springfield, Illinois United States United States Vilma Cabading Prof. Heba Youssef Mohamed Sayed, MD Trauma Courses Office, Deanship of Postgraduate Education Professor and Head of Forensic Medicine and Clinical King Saud Bin Abdulaziz University for Health Sciences Toxicology Department Riyadh Port Said University Saudi Arabia Port Said, Egypt Arab Republic of Egypt Sally Campbell, RN, BA ATLS Course Coordinator Kum Ying Tham, MBBS, FRCSE, EDD Kaiser Medical Center, Vacaville, California Senior Consultant David Grant Medical Center, Travis Air Force Base, Tan Tock Seng Hospital California Singapore United States Cristiane de Alencar Domingues, RN, MSN, PhD Professor Faculdade das Américas (FAM) São Paulo, São Paulo Brazil Agienszka Gizzi Regional and International Programmes Coordinator The Royal College of Surgeons of England London United Kingdom n TO TABLE OF CONTENTS ­xiii PREFACE Betty Jean Hancock, MD, FRCSC, FACS Associate Professor, Pediatric Surgery and Critical Care University of Manitoba Children's Hospital of Winnipeg/Health Sciences Centre Winnipeg, Manitoba Canada Sherri Marley, BSN, RN, CEN, TCRN Clinical Educator for Trauma Services Eskenazi Health Indianapolis, Indiana United States Martha Romero ATLS Coordinator AMDA-Bolivia Santa Cruz de la Sierra Bolivia n TO TABLE OF CONTENTS  ACKNOWLEDGMENTS It is clear that many people are responsible for Marlena Libman development of the Tenth Edition, but the outstanding Trauma Education Program Coordinator staff in the ATLS Program Office deserves special The American College of Surgeons mention. Their dedication and hard work not only Chicago, Illinois produced the new edition while ensuring that each United States one is better than the last but also facilitates its use in hundreds of courses around the world each year. Freddie Scruggs Trauma Education Program Coordinator Monique Drago, MA, EdD The American College of Surgeons Trauma Education Programs Manager Chicago, Illinois The American College of Surgeons United States Chicago, Illinois United States Germaine Suiza Program Coordinator, Trauma Education Programs (LMS) Ryan Hieronymus, MBA, PMP The American College of Surgeons Trauma Education Projects Manager Chicago, Illinois The American College of Surgeons United States Chicago, Illinois United States Pascale Leblanc Contributors Trauma Education Projects Manager The American College of Surgeons While developing this revision, we received a great deal Chicago, Illinois of assistance from many individuals—whether they United States were reviewing information at meetings, submitting images, or evaluating research. ATLS thanks the Kathryn Strong following contributors for their time and effort in Program Manager, Trauma Education Programs (LMS) development of the Tenth Edition. The American College of Surgeons Chicago, Illinois Wesam Abuznadah, MD, MEd, FRCS(C), FACS, RPVI United States Assistant Professor, Consultant Vascular and Endovascular Surgery; Associate Dean, Academic and Student Affairs, Autumn Zarlengo College of Medicine Program Manager, Trauma Education Programs (CME/CE) King Saud Bin Abdulaziz University for Health Sciences The American College of Surgeons Jeddah Chicago, Illinois Saudi Arabia United States Joe Acker, EMT-P, MPH Executive Director, Birmingham Regional EMS System Emily Ladislas University of Alabama at Birmingham Program Coordinator, Trauma Education Programs (CME/CE) Birmingham, Alabama The American College of Surgeons United States Chicago, Illinois United States n TO TABLE OF CONTENTS xv ­xvi ACKNOWLEDGMENTS Suresh Agarwal, MD, FACS Ryan Bales, RN Professor of Surgery ATLS Coordinator University of Wisconsin CNIII Trauma Program Madison, Wisconsin Sacramento, California United States United States Jameel Ali, MD, MMedEd, FRCSC, FACS Raphael Bonvin, MD, MME Professor of Surgery Head of Educational Unit University of Toronto Faculty of Biology and Medicine Toronto, Ontario Lausanne Canada Switzerland Hayley Allan, BA(hons), Dip Ed, MEd, MRes Bertil Bouillon, MD National Educator, ATLS UK Professor and Chairman Department of Trauma and The Royal College of Surgeons of England Orthopaedic Surgery London University of Witten/Herdecke, Cologne Merheim England Medical Center Cologne Saud Al Turki, MD, FACS Germany Ministry of National Guard Health Affairs, King Abdulaziz Medical City Mark W. Bowyer, MD, FACS King Saud Bin Abdulaziz University for Health Sciences ATLS Board Member Germany Col. (Ret.) Riyadh Ben Eiseman Professor of Surgery; Chief, Trauma and Combat Kingdom of Saudi Arabia Surgery; Surgical Director of Simulation Department of Surgery Mary Asselstine, RN The Uniformed Services University; Walter Reed Sunnybrook Health Sciences Centre National Military Medical Center Toronto, Ontario Bethesda, Maryland Canada United States Mahmood Ayyaz, MBBS, FCPS, FRCS, FACS Mary-Margaret Brandt, MD, MHSA, FACS Professor of Surgery, Services Institute of Medical Sciences; Trauma Director Councillor and Director, National Residency Programme; St. Joseph Mercy Health System National Course Director, ATLS Pakistan Ann Arbor, Michigan Services Hospital United States College of Physicians and Surgeons Pakistan Lehore Frank Branicki, MB, BS, DM, FRCS, FRCS(Glasg), Pakistan FRACS, FCSHK, FHKAM, FCSECSA, FACS Professor and Chair, Department of Surgery Mark Bagnall, BMedSc(Hons), MBChB(Hons), MSc, United Arab Emirates University PhD, MRCS(Eng) Al Ain Specialist Registrar in General Surgery; General Surgery United Arab Emirates Representative ATLS UK Steering Group Susan Briggs, MD, MPH, FACS United Kingdom Director, International Trauma and Disaster Institute Massachusetts General Hospital Andrew Baker, MBChB, FRCS(Orth), FCS(Orth), SA Boston, Massachusetts Senior Consultant United States Entabeni Hospital Durban George Brighton, MBBS, BSc Honors, MSc, PGCE South Africa Med Ed. Clinical Entrepreneur Fellow NHS England Royal Devon and Exeter NHS Foundation Trust Exeter England n TO TABLE OF CONTENTS ­xvii ACKNOWLEDGMENTS Bertil Bouillon, MD Juan Carlos Puyana, MD, FACS Professor and Chairman Department of Trauma and Professor of Surgery, Critical Care Medicine and Clinical Orthopaedic Surgery Translational Medicine University of Witten/Herdecke, Cologne Merheim University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Cologne United States Germany Narain Chotirosniramit, MD, FACS, FICS, FRCST Guy Brisseau, MD, MEd, FACS Chief, Trauma and Critical Care Unit; Department of Director, Pediatric Trauma; Director, Surgical Education Surgery, Faculty of Medicine Sidra Medical and Research Center Chiangmai University Doha Chiangmai Qatar Thailand Troy Browne, MBChB, FCA(SA), FANZCA, FCICM Ian Civil, MBChB, FRACS, FACS Medical Leader—Anaesthesia, Radiology and Surgical Director of Trauma Services Services; Director of Intensive Care/High Dependency Unit Auckland City Hospital Bay of Plenty District Health Board Auckland Tauranga New Zealand New Zealand Keith Clancy, MD, MBA, FACS Shane Brun, MD, M.Trauma, M.Ed, FFSEM(UK), Trauma Medical Director FACRRM, FRACGP Geisinger Wyoming Valley Medical Center Associate Professor Wilkes-Barre, Pennsylvania James Cook University United States Queensland Australia Peter Clements Stephen Bush, MA(Oxon), FRCS, FRCEM Frederic J. Cole, Jr., MD, FACS Consultant in Emergency Medicine Legacy Emanuel Medical Center Leeds Teaching Hospitals Portland, Oregon Trust Leeds, West Yorkshire United States United Kingdom Jaime Cortes-Ojeda, MD, FACS Jacqueline Bustraan, MSc Chief Department of Surgery Educational Advisor, Trainer, and Researcher Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera" Leiden University Medical Center/BOAT (Bustraan San José Organisation, Advice and Training) Costa Rica Leiden The Netherlands Renn J. Crichlow, MD MBA Orthopaedic Trauma Surgeon Vilma Cabading St. Vincent Indianapolis Trauma Center Trauma Courses Office, Deanship of Postgraduate Education OrthoIndy Hospital King Saud Bin Abdulaziz University for Health Sciences Indianapolis, Indiana Riyadh United States Kingdom of Saudi Arabia Scott D’Amours, MD, FRCS(C), FRACS, FRCS(Glasg) Sally Campbell, RN, BA Trauma Surgeon, Director of Trauma ATLS Course Director Liverpool Hospital Kaiser Medical Center/David Grant Medical Center Sydney, New South Wales Vacaville/Travis Air Force Base, California Australia United States n TO TABLE OF CONTENTS ­xviii ACKNOWLEDGMENTS Marc DeMoya, MD, FACS Esteban Foianini, MD, FACS Associate Professor of Surgery Medical Director Massachusetts General Hospital/Harvard Medical School Clinica Foianini Boston, Massachusetts Santa Cruz de la Sierra United States Bolivia Newton Djin Mori, MD, PhD, FACS Adam Fox, DPM, DO, FACS General and Trauma Surgeon Assistant Professor of Surgery and Section Chief, Trauma Hospital das Clinicas–University of São Paulo Division of Trauma Surgery and Critical Care, Rutgers NJMS; São Paulo, São Paulo Associate Trauma Medical Director, NJ Trauma Center Brazil Newark, New Jersey United States Cristiane de Alencar Domingues, RN, MSN, PhD Professor Robert Michael Galler, DO, FACS, FACOS Faculdade das Américas (FAM) Associate Professor, Neurosurgery and Orthopedics; São Paulo, São Paulo Co-Director, Comprehensive Spine Center, Institute for Brazil Advanced Neurosciences Stony Brook University Medical Center Jay Doucet, MD, FRCSC, FACS Long Island, New York Professor of Surgery United States University of California, San Diego San Diego, California Raj Gandi, MD United States Trauma Medical Director JPS Health Network Julia A. Dunn, MD, MS, FACS Fort Worth, Texas Medical Director, Trauma Research and Education United States UC Health Northern Colorado Loveland, Colorado Naisan Garraway, CD, FRCSC, FACS United States Medical Director, Trauma Program Vancouver General Hospital Lesley Dunstall, RN Vancouver, British Columbia National Coordinator; EMST/ATLS Australasia Canada Royal Australasian College of Surgeons North Adelaide, South Australia Subash Gautam, MB, FRCS(Eng, Edn, and Glasg), FACS Australia Head of Department Fujairah Hospital David Efron, MD, FACS Fujairah Professor of Surgery; Chief, Division of Acute Care Surgery; United Arab Emirates Director of Adult Trauma The Johns Hopkins University School of Medicine Julie Gebhart, PA-C Baltimore, Maryland Lead Orthopedic Trauma Physician; Assistant Manager, United States Orthopedic Advanced Practice Providers OrthoIndy Hospital Froilan Fernandez, MD, FACS Indianapolis, Indiana Chair, ACS-COT Chile; Associate Senior Surgical Staff United States Hospital Del Trabajador Santiago Agienszka Gizzi Chile Regional and International Programmes Coordinator The Royal College of Surgeons of England John Fildes, MD, FACS London Foundation Professor; Chair, Surgery; Chief, Division of Acute United Kingdom Care Surgery; Program Director, Acute Care Surgery Fellowship University of Nevada, Reno School of Medicine Las Vegas, Nevada United States n TO TABLE OF CONTENTS ­xix ACKNOWLEDGMENTS Oscar Guillamondegui, MD, MPH, FACS Roxolana Horbowyj, MD, MSChE, FACS Professor of Surgery, Trauma Medical Director Assistant Professor of Surgery, Department of Surgery Vanderbilt University Medical Center Uniformed Services University of the Health Sciences/ Nashville, Tennessee Walter Reed National Military Medical Center United States Bethesda, Maryland United States Betty Jean (B. J.) Hancock, MD, FRCSC, FACS Associate Professor, Pediatric Surgery and Critical Care David B. Hoyt, MD, FACS University of Manitoba; Children’s Hospital of Executive Director Winnipeg/Health Sciences Centre American College of Surgeons Winnipeg, Manitoba Chicago, Illinois Canada United States Paul Harrison, MD, FACS Eliesa Ing, MD Trauma Medical Director HCA Continental Division; Staff Ophthalmologist, Portland VA HSC Associate Medical Director, Clinical Professor of Surgery Assistant Professor, Casey Eye Institute/OHSU Wesley Medical Center/KU School of Medicine Portland, Oregon Wichita, Kansas United States United States Lewis Jacobson, MD, FACS Col. (Ret.) Walter Henny, MD Chair, Department of Surgery; Director, Trauma and University Hospital and Medical School Surgical Critical Care Rotterdam St. Vincent Indianapolis Hospital The Netherlands Indianapolis, Indiana United States Sharon M. Henry, MD, FACS Anne Scalea Professor of Surgery Randeep Jawa, MD, FACS University of Maryland School of Medicine; University Clinical Professor of Surgery of Maryland Medical Center RA Cowley Shock Trauma Stony Brook University School of Medicine Center Stony Brook, New York Baltimore, Maryland United States United States Maria Fernanda Jimenez, MD, FACS Fergal Hickey, FRCS, FRCSEd, DA(UK), FRCEM, FIFEM General Surgeon National Director, ATLS Ireland; Consultant in Emergency Hospital Universitario MEDERI Medicine Bogotá, Distrito Capital Sligo University Hospital Colombia Sligo Ireland Aaron Joffe, DO, FCCM Associate Professor of Anesthesiology Marzellus Hofmann, MD, MME University of Washington, Harborview Medical Center Dean of Medical Education and Student Affairs Seattle, Washington Witten/Herdecke University, Faculty of Health United States Witten, NRW Germany Kimberly Joseph, MD, FACS, FCCM Division Chair, Trauma Critical Care and Prevention Annette Holian Department, Department of Trauma and Burns Clinical Director-Surgery and Perioperative Services John H. Stoger Hospital of Cook County Royal Australian Air Force Chicago, Illinois United States n TO TABLE OF CONTENTS ­xx ACKNOWLEDGMENTS Haytham Kaafarani, MD, MPH, FACS Sarvesh Logsetty, MD, FACS, FRCS(C) Patient Safety and Quality Director; Director of Clinical Associate Professor, Director, Manitoba Firefighters Burn Unit Research, Trauma, Emergency Surgery and Surgical Critical University of Manitoba Care Winnipeg, Manitoba Massachusetts General Hospital and Harvard Medical Canada School Boston, Massachusetts Siew Kheong Lum, MBBS, FRCSEd, FACS, FRACS United States (Hon), FAMM, FAMS Professor of Surgery and ATLS Program Director Martin Keller, MD, FACS, FAAP Sungai Buloh Hospital Associate Professor of Surgery Kuala Lumpur St. Louis Children’s Hospital; Washington University Malaysia School of Medicine St. Louis, Missouri Patrizio Mao, MD, FACS United States Azienda Ospedaliero–Universitaria San Luigi Gonzaga John Kortbeek, MD, FRCSC, FACS Orbassano, Torino Professor, Department of Surgery, Critical Care and Italy Anaesthesia Cumming School of Medicine, University of Calgary Sherri Marley, BSN, RN, CEN, TCRN Calgary, Alberta Clinical Educator for Trauma Services Canada Eskenazi Hospital Indianapolis, Indiana Deborah A. Kuhls, MD, FACS United States Professor of Surgery University of Nevada School of Medicine Katherine Martin, MBBS, FRACS Las Vegas, Nevada Trauma Surgeon United States Alfred Hospital Melbourne, Victoria Sunir Kumar, MD Australia Cleveland Clinic Cleveland, Ohio Sean P. McCully, MD, MS United States Surgical Critical Care Fellow Department of Surgery Eric Kuncir, MD, MS, FACS Oregon Health and Science University Chief, Division of Emergency General Surgery; Clinical Portland, Oregon Professor of Surgery United States University of California, Irvine Orange, California Chad McIntyre, BS, NRP, FP-C United States Manager, Trauma and Flight Services UF Health Jacksonville Claus Falck Larsen, DMSc,MPA Jacksonville, Florida consultant, United States Clinic at TraumaCentre Rigshospitalet Daniel B. Michael, MD, PhD, FACS, FAANS University of Southern Denmark Director of Neurosurgical Education Copenhagen William Beaumont Hospital Royal Oak Denmark Professor of Neurosurgery Oakland University William Beaumont School of Gilberto K. K. Leung, MBBS, FRCS, PhD Medicine Clinical Associate Professor Royal Oak, Michigan The University of Hong Kong Queen Mary University United States Pok Fu Lam Director, Michigan Head and Spine Institute Hong Kong Southfield, Michigan United States n TO TABLE OF CONTENTS ­xxi ACKNOWLEDGMENTS Mahesh Misra, MD, FACS Debbie Paltridge, MHlthSc (ED) Director Principal Educator All India Institute of Medical Sciences Royal Australasian College of Surgeons New Delhi Melbourne, Victoria India Australia Soledad Monton Neil Parry, MD, FACS, FRCSC Médico en Servicio Navarro de Salud Medical Director, Trauma Program; Associate Professor of Servicio Navarro de Salud Surgery and Critical Care Pamplona London Health Sciences Center; Schulich School of Spain Medicine, Western University London, Ontario Hunter Moore, MD Canada Trauma Research Fellow University of Colorado Albert Pierce Denver, Colorado United States Hermanus Jacobus Christoffel Du Plessis, MB, ChB, MMed(Surg), FCS(SA), FACS John Ng, MD, MS, FACS Chief, Division of Oculofacial Plastics, Orbital and Travis Polk, MD, FACS Reconstructive Surgery; Professor, Departments of Commander, Medical Corps, U.S. Navy; Surgical Director, Ophthalmology and Otolaryngology/Head and Neck Surgery Healthcare Simulation and Bioskills Training Center Casey Eye Institute–Oregon Health and Science Naval Medical Center Portsmouth University Portsmouth, Virginia Portland, Oregon United States United States Bruce Potenza, MD, FACS Nnamdi Nwauwa, MSCEM, MPH, MBBS Critical Care Surgeon, Trauma Director, Training and Clinical Services UCSD Medical Center Emergency Response International San Diego, California Port Harcourt, Nigeria United States James V. O’Connor MD, FACS Tarek Razek, MD, FRCSC, FACS Professor of Surgery, University of Maryland School of Chief, Division of Trauma Surgery Medicine McGill University Health Centre Chief, Thoracic and Vascular Trauma Montreal, Quebec R Adams Cowley Shock Trauma Center Canada Baltimore, Maryland United States Martin Richardson, MBBS, MS, FRACS Associate Clinical Dean Roddy O’Donnell, MBBS, MA, PhD, FRCPCH, MRCP, Epworth Hospital, University of Melbourne FFICM Melbourne, Victoria Consultant Paediatrician and Director of PICU Australia Addenbrookes Hospital Cambridge Avraham Rivkind, MD, FACS United Kingdom Head, Division of Emergency Medicine and Shock Trauma Unit Giorgio Olivero, MD, FACS Hadassah Medical Center ATLS Program Director; Professor of Surgery Jerusalem Department of Surgical Sciences, University of Torino Israel Torino Italy n TO TABLE OF CONTENTS ­xxii ACKNOWLEDGMENTS Rosalind Roden, BA(Cambridge), FRCEM Elizabeth Vallejo de Solezio Consultant in Emergency Medicine National Education, Committee on Trauma Ecuador Leeds Teaching Hospitals Quito, Ecuador Trust Leeds, West Yorkshire United Kingdom Ronald Stewart, MD, FACS Chair, American College of Surgeons Committee on Trauma Jakob Roed, MD, MPA, DLS Witten B. Russ Professor and Chair of the Department Chief Anesthetist, Department of Anesthesiology and of Surgery Intensive Care UT Health San Antonio Zealand University Hospital San Antonio, Texas Roskilde United States Denmark Claus Stobaus, ME, ED Dan Rutigliano, DO Postgraduate Program in Education Assistant Professor of Surgery Pontifical Catholic University of Rio Grande do Sul Stony Brook University School of Medicine Porto Alegre, Rio Grande do Sul Stony Brook, New York Brazil United States John Sutyak, EdM, MD, FACS Kennith Sartorelli, MD, FACS Director, Southern Illinois Trauma Center Department of Surgery Associate Professor of Surgery University of Vermont College of Medicine Southern Illinois University School of Medicine Burlington, Vermont Springfield, Illinois United States United States Patrick Schoettker, MD Gonzalo Tamayo Professor of Anesthesiology University Hospital CHUV Kum-Ying Tham, MBBS, FRCSE, EDD Lausanne, VD Senior Consultant Switzerland Tan Tock Seng Hospital Singapore David Schultz, MD, FACS Thedacare Regional Medical Center Neenah Phil Truskett Neenah, Wisconsin Surgeon at SESIH United States SESIH Sydney, Australia Kristen C. Sihler, MD, MS, FACS Maine Medical Center Gary Vercruysse, MD, FACS Portland, Maine Director of Burns Services; Associate Professor of Surgery, United States Division of Trauma, Burns, Acute Care Surgery and Surgical Critical Care Preecha Siritongtaworn, FRCST,FACS. University of Arizona School of Medicine Department of Surgery Tucson, Arizona Faculty of Medicine United States Siriraj Hospital Bangkok, Thailand Eric Voiglio, MD, FACS Emergency Surgery Unit David Skarupa, MD, FACS University Hospitals of Lyon Assistant Professor of Surgery, Department of Surgery/ Pierre-Bénite Division of Acute Care Surgery France University of Florida College of Medicine–Jacksonville Jacksonville, Florida United States n TO TABLE OF CONTENTS ­xxiii ACKNOWLEDGMENTS James Vosswinkel, MD, FACS Jay A. Yelon, DO, FACS, FCCM Chief, Division of Trauma Professor of Surgery; Medical Director of Surgical Services Stony Brook University School of Medicine Hofstra Northwell School of Medicine; Southside Stony Brook, New York Hospital/Northwell Health United States Bay Shore, New York United States Bob Yellowe, MD, MSc Sport Medicine Consultant Orthopedic and Trauma Surgeon Heba Youssef Mohamed Sayed, MD University of Port Harcourt Teaching Hospital Professor and Head of Forensic Medicine and Clinical Port Harcourt Toxicology Department Nigeria Faculty of Medicine–Port Said University Port Said Dany Westerband, MD, FACS Arab Republic of Egypt Medical Director of Trauma Services; Chief, Section of Trauma and Emergency Surgery; Chairman, Department Laura Zibners, MD of Surgery Honorary Consultant, Pediatric Emergency Medicine Suburban Hospital–Johns Hopkins Medicine Imperial College, St. Mary’s Hospital Bethesda, Maryland London United States United Kingdom Garry Wilkes, MBBS, FACEM Director, Emergency Medicine Honor Roll Monash Medical Centre Melbourne, Victoria Over the past 30 years, ATLS has grown from a local Australia course training of Nebraska doctors to care for trauma patients to a family of trauma specialists from more Catherine Wilson, MSN, ACNP-BC, CEN than 60 countries who volunteer their time to ensure Trauma Outreach Coordinator that our materials reflect the most current research and Vanderbilt University Medical Center that our course is designed to improve patient outcomes. Nashville, Tennessee The Tenth Edition of ATLS reflects the efforts of the United States individuals who contributed to the first nine editions, and we honor them here: Robert Winchell, MD, FACS Chief, Division of Trauma, Burn, Acute Care and Critical Georges Abi Saad Care, Director of Trauma Center Sabas F. Abuabara, MD, FACS Weill Cornell Medicine; New York–Presbyterian Weill Joe E. Acker, II, MS, MPH, EMT Cornell Medical Center Fatimah Albarracin, RN New York, New York Celia Aldana United States Raymond H. Alexander, MD, FACS Omar Al Ghanimi Bob Winter, FRCP, FRCA, FFICM, DM Abdullah Al-Harthy Medical Director, East Midlands Ambulance Services Jameel Ali, MD, MMed Ed, FRCS(C), FACS Horizon Place Saud Al-Turki, MD, FRCS, ODTS, FACA, FACS Nottingham Donna Allerton, RN United Kingdom Heri Aminuddin, MD John A. Androulakis, MD, FACS Christoph Wöelfl, MD, PhD Charles Aprahamian, MD, FACS Head of Departement, Departement of Orthopedic and Guillermo Arana, MD, FACS Trauma Surgery Marjorie J. Arca, MD, FACS Krankenhaus Hetzelstift Ana Luisa Argomedo Manrique Neustadt a. d. Weinstrasse John H. Armstrong, MD, FACS Germany John L.D. Atkinson, MD, FACS Ivar Austlid Gonzalo Avilés Mahmood Ayyaz, MD n TO TABLE OF CONTENTS ­xxiv ACKNOWLEDGMENTS Richard Baillot, MD Raul Coimbra, MD, PhD, FACS Andrew Baker, MD Francisco Collet e Silva, MD, FACS, PhD(Med) Barbara A. Barlow, MA, MD, FACS Paul E. Collicott, MD, FACS James Barone, MD, FACS Arthur Cooper, MD, FACS John Barrett, MD, FACS Jaime Cortes Ojeda, MD Pierre Beaumont, MD Clay Cothren Burlew, MD, FACS Margareta Behrbohm Fallsberg, PhD, BSc Ronald D. Craig, MD Richard M. Bell, MD, FACS Doug Davey, MD Eugene E. Berg, MD, FACS Kimberly A. Davis, MD, FACS Richard Bergeron, MD Cristiane de Alencar Domingues, RN, MSN, PhD François Bertrand, MD Subrato J. Deb, MD Renato Bessa de Melo, MD Alejandro De Gracia, MD, FACS, MAAC Mike Betzner, MD Laura Lee Demmons, RN, MBA Emidio Bianco, MD, JD Ronald Denis, MD David P. Blake, MD, FACS Elizabeth de Solezio, PhD Ken Boffard, MB BCh, FRCS, FRCS(Ed), FACS Jesus Díaz Portocarrero, MD, FACS Mark W. Bowyer, MD, FACS, DMCC Mauricio Di Silvio-Lopez, MD, FACS Don E. Boyle, MD, FACS Frank X. Doto, MS Marianne Brandt Jay J. Doucet, MD, FACS Mary-Margaret Brandt, MD, FACS Anne-Michéle Droux Frank J. Branicki, MBBS, DM, FRCS, FRACS, FCS(HK), Julia A. Dunn, MD, FACS FHKAM(Surg) Hermanus Jacobus Christoffel Du Plessis, MB, ChB, Karen Brasel, MPH, MD, FACS MMed(Surg), FCS(SA), FACS Fred Brenneman, MD, FRCSC, FACS Marguerite Dupré, MD George Brighton, MD Candida Durão Åse Brinchmann-Hansen, PhD Ruth Dyson, BA(Hons) Peter Brink, MD, PhD Martin Eason, MD, JD Karim Brohi, MD A. Brent Eastman, MD, FACS James Brown, MA Frank E. Ehrlich, MD, FACS Rea Brown, MD, FACS Martin R. Eichelberger, MD, FACS Allen F. Browne, MD, FACS Abdelhakim Talaat Elkholy, MBBCh Laura Bruna, RN David Eduardo Eskenazi, MD, FACS Gerry Bunting, MD Vagn Norgaard Eskesen, MD Andrew R. Burgess, MD, FACS Denis Evoy, MCH, FRCSI Richard E. Burney, MD, FACS William F. Fallon, Jr., MD, FACS David Burris, MD, FACS David V. Feliciano, MD, FACS Reginald A. Burton, MD, FACS Froilan Fernandez, MD Jacqueline Bustraan, MSc Carlos Fernandez-Bueno, MD Vilma Cabading John Fildes, MD, FACS Sylvia Campbell, MD, FACS Ronald P. Fischer, MD, FACS C. James Carrico, MD, FACS Stevenson Flanigan, MD, FACS Carlos Carvajal Hafemann, MD, FACS Lewis M. Flint, Jr, MD, FACS Gustavo H. Castagneto, MD, FACS Cornelia Rita Maria Getruda Fluit, MD, MedSci Candice L. Castro, MD, FACS Joan Foerster C. Gene Cayten, MD, FACS Esteban Foianini, MD, FACS June Sau-Hung Chan Jorge E. Foianini, MD, FACS Zafar Ullah Chaudhry, MD, FRCS, FCPS, FACS Heidi Frankel, MD, FACS Peggy Chehardy, EdD, CHES Knut Fredriksen, MD, PhD Regina Sutton Chennault, MD, FACS Susanne Fristeen, RN Robert A. Cherry, MD, FACS Richard Fuehling, MD Diane Chetty Christine Gaarder, MD Wei Chong Chua, MD Sylvain Gagnon, MD Emmanuel Chrysos, MD, PhD, FACS Richard Gamelli, MD, FACS Chin-Hung Chung, MB BS, FACS Subash C. Gautam, MD, MBBS, FRCS, FACS David E. Clark, MD, FACS Paul Gebhard n TO TABLE OF CONTENTS ­xxv ACKNOWLEDGMENTS James A. Geiling, MD, FCCP Amy Koestner, RN, MSN Thomas A. Gennarelli, MD, FACS Radko Komadina, MD, PhD John H. George, MD Digna R. Kool, MD Aggelos Geranios, MD John B. Kortbeek, MD, FACS Michael Gerazounis, MD Roman Kosir, MD Roger Gilbertson, MD Brent Krantz, MD, FACS Robert W. Gillespie, MD, FACS Jon R. Krohmer, MD, FACEP Marc Giroux, MD Eric J. Kuncir, MD, FACS Gerardo A. Gomez, MD, FACS Roslyn Ladner Hugo Alfredo Gomez Fernandez, MD, FACS Ada Lai Yin Kwok Khalid Masood Gondal Maria Lampi, BSc, RN Javier González-Uriarte, MD, PhD, EBSQ, FSpCS Katherine Lane, PhD John Greenwood Francis G. Lapiana, MD, FACS Russell L. Gruen, MBBS, PhD, FRACS Pedro Larios Aznar Niels Gudmundsen-Vestre Claus Falck Larsen, MD, PhD(Med), MPA, FACS Oscar D. Guillamondegui, MD, FACS Anna M. Ledgerwood, MD, FACS Enrique A. Guzman Cottallat, MD, FACS Dennis G. Leland, MD, FACS J. Alex Haller, Jr., MD, FACS Frank Lewis, MD, FACS Betty Jean (B. J.) Hancock, MD, FACS Wilson Li, MD Burton H. Harris, MD, FACS Helen Livanios, RN Michael L. Hawkins, MD, FACS Chong-Jeh Lo, MD, FACS Ian Haywood, FRCS(Eng), MRCS, LRCP Sarvesh Logsetty, MD, FACS James D. Heckman, MD, FACS Nur Rachmat Lubis, MD June E. Heilman, MD, FACS Edward B. Lucci, MD, FACEP David M. Heimbach, MD, FACS Eduardo Luck, MD, FACS Richard Henn, RN, BSN, M.ED Thomas G. Luerssen, MD, FACS Walter Henny, MD Ka Ka Lui Sharon M. Henry, MD, FACS J.S.K. Luitse, MD David N. Herndon, MD, FACS Siew-Kheong Lum Grace Herrera-Fernandez Douglas W. Lundy, MD, FACS Fergal Hickey, FRCS, FRCS Ed(A&E), DA(UK), FCEM Arnold Luterman, MD, FACS Erwin F. Hirsch, MD, FACS Fernando Machado, MD Francisco Holguin, MD Fernando Magallanes Negrete, MD Michael Hollands, MB BS, FRACS, FACS Jaime Manzano, MD, FACS Scott Holmes Patrizio Mao, MD, FACS Roxolana Horbowyj, MD, FACS Donald W. Marion, MD, FACS David B. Hoyt, MD, FACS Michael R. Marohn, DO, FACS Arthur Hsieh, MA, NREMT-P Barry D. Martin, MD Irvene K. Hughes, RN Salvador Martín Mandujano, MD, FACS Christopher M. Hults, MD, FACS, CDR, USN Kimball I. Maull, MD, FACS Richard C. Hunt, MD, FACEP R. Todd Maxson, MD, FACS John E. Hutton, Jr, MD, FACS Mary C. McCarthy, MD, FACS Miles H. Irving, FRCS(Ed), FRCS(Eng) Gerald McCullough, MD, FACS Randeep S. Jawa, MD, FACS John E. McDermott, MD, FACS José María Jover Navalon, MD, FACS James A. McGehee, DVM, MS Richard Judd, PhD, EMSI Chad McIntyre, NREMT-P, FP-C Gregory J. Jurkovich, MD, FACS William F. McManus, MD, FACS Aage W. Karlsen Norman E. McSwain, Jr., MD, FACS Christoph R. Kaufmann, MD, FACS Philip S. Metz, MD, FACS Howard B. Keith, MD, FACS Cynthia L. Meyer, MD James F. Kellam, MD, FRCS, FACS Daniel B. Michael, MD, PhD, FACS Steven J. Kilkenny, MD, FACS Salvijus Milasˇius, MD Darren Kilroy, FRCS(Ed), FCEM, M.Ed Frank B. Miller, MD, FACS Lena Klarin, RN Sidney F. Miller, MD, FACS Peggy Knudson, MD, FACS n TO TABLE OF CONTENTS ­xxvi ACKNOWLEDGMENTS LEO Pien Ming, MBBS, MRCS (Edin), M.Med Jesper Ravn, MD (Orthopaedics) Tarek S. A. Razek, MD, FACS Mahesh C. Misra, MD, FACS Marcelo Recalde Hidrobo, MD, FACS Soledad Monton, MD John Reed, MD Ernest E. Moore, MD, FACS Marleta Reynolds, MD, FACS Forrest O. Moore, MD, FACS Stuart A. Reynolds, MD, FACS Newton Djin Mori, MD Peter Rhee, MD, MPH, FACS, FCCM, DMCC Johanne Morin, MD Bo Richter Charles E. Morrow, Jr., MD, FACS Bernard Riley, FFARCS David Mulder, MD, FACS Charles Rinker, MD, FACS Stephen G. Murphy, MD Avraham Rivkind, MD Kimberly K. Nagy, MD, FACS Rosalind Roden, FFAEM Raj K. Narayan, MD, FACS Diego Rodriguez, MD James B. Nichols, DVM, MS Vicente Rodriguez, MD Nicolaos Nicolau, MD, FACS Jakob Roed, MD Martín Odriozola, MD, FACS Olav Røise, MD, PhD Han Boon Oh Martha Romero Giorgio Olivero, MD, FACS Ronald E. Rosenthal, MD, FACS Franklin C. Olson, EdD Michael F. Rotondo, MD, FACS Steve A. Olson, MD, FACS Grace Rozycki, MD, FACS Osama Ali Omari, MD Daniel Ruiz, MD, FACS Hock Soo Ong, MD, FACS J. Octavio Ruiz Speare, MD, MS, FACS Gonzalo Ostria P., MD, FACS James M. Ryan, MCh, FRCS(Eng), RAMC Arthur Pagé, MD Majid Sabahi, MD José Paiz Tejada James M. Salander, MD, FACS Rattaplee Pak-Art, MD Gueider Salas, MD Fatima Pardo, MD Jeffrey P. Salomone, MD, FACS Steven N. Parks, MD, FACS Rocio Sanchez-Aedo Linares, RN BiPinchandra R. Patel, MD, FACS Mårtin Sandberg, MD, PhD Chester (Chet) Paul, MD Thomas G. Saul, MD, FACS Jasmeet S. Paul, MD Nicole Schaapveld, RN Andrew Pearce, BScHons, MBBS, FACEM PG Cert Domenic Scharplatz, MD, FACS Aeromed retrieval William P. Schecter, MD, FACS Mark D. Pearlman, MD Inger B. Schipper, MD, PhD, FACS Andrew B. Peitzman, MD, FACS Patrick Schoettker, MD, M.E.R. Nicolas Peloponissios, MD Martin A. Schreiber, MD, FACS Jean Péloquin, MD Kari Schrøder Hansen, MD Philip W. Perdue, MD, FACS Thomas E. Scott, MD, FACS Pedro Moniz Pereira, MD Stuart R. Seiff, MD, FACS Neil G. Perry, MD, FRCSC, FACS Estrellita C. Serafico J.W. Rodney Peyton, FRCS(Ed), MRCP Bolivar Serrano, MD, FACS Lawrence H. Pitts, MD, FACS Juan Carlos Serrano, MD, FACS Renato Sergio Poggetti, MD, FACS Steven R. Shackford, MD, FACS Alex Poole, MD, FACS Marc J. Shapiro, MD, FACS Galen V. Poole, MD, FACS Thomas E. Shaver, MD, FACS Danielle Poretti, RN Mark Sheridan, MBBS, MMedSc, FRACS Ernest Prégent, MD Brian Siegel, MD, FACS Raymond R. Price, MD, FACS Richard C. Simmonds, DVM, MS Richard R. Price, MD, FACS Richard K. Simons, MB, BChir, FRCS, FRCSC, FACS Sonia Primeau Preecha Siritongtaworn, MD, FACS Herbert Proctor, MD, FACS Diana Skaff Jacques Provost, MD Nils Oddvar Skaga, MD Paul Pudimat, MD David V. Skinner, FRCS(Ed), FRCS(Eng) Cristina Quintana Peter Skippen, MBBS, FRCPC, FJFICM, MHA Max L. Ramenofsky, MD, FACS Arnold Sladen, MD, FACS n TO TABLE OF CONTENTS ­xxvii ACKNOWLEDGMENTS Tone Slåke Endre Varga, MD, PhD R. Stephen Smith, MD, RDMS, FACS Edina Värkonyi Birgitte Soehus Panteleimon Vassiliu, MD, PhD Ricardo Sonneborn, MD, FACS Eugenia Vassilopoulou, MD Anne Sorvari Antigoni Vavarouta Michael Stavropoulos, MD, FACS Allan Vennike Spyridon Stergiopoulos, MD Antonio Vera Bolea Gerald O. Strauch, MD, FACS Alan Verdant, MD Luther M. Strayer, III, MD Tore Vikström, MD, PhD James K. Styner, MD J. Leonel Villavicencio, MD, FACS LAM Suk-Ching, BN, MHM Eric Voiglio, MD, PhD, FACS, FRCS Paul-Martin Sutter, MD Franklin C. Wagner, MD, FACS John Sutyak, MD, FACS Raymond L. Warpeha, MD, FACS Lars Bo Svendsen, MD, DMSci Clark Watts, MD, FACS Vasso Tagkalakis John A. Weigelt, MD, FACS Wael S. Taha, MD Leonard J. Weireter Jr., MD, FACS Kathryn Tchorz, MD, FACS John West, MD, FACS Joseph J. Tepas, III, MD, FACS Nicholas M. Wetjen, MD Stéphane Tétraeault, MD Robert J. White, MD, FACS Gregory A. Timberlake, MD, FACS Richard L. Wigle, MD, FACS Wei Ting Lee Stephen Wilkinson, MBBS, MD, FRACS Gustavo Tisminetzky, MD, FACS, MAAC Daryl Williams, MBBS, FANZCA,GDipBusAd, GdipCR Peter G. Trafton, MD, FACS Robert J. Winchell, MD, FACS Stanley Trooksin, MD, FACS Robert Winter, FRCP, FRCA, DM Julio L. Trostchansky, MD, FACS Fremont P. Wirth, MD, FACS Philip Truskett, MB BS, FRACS Bradley D. Wong, MD, FACS David Tuggle, MD, FACS Nopadol Wora-Urai, MD, FACS Wolfgang Ummenhofer, MD, DEAA Peter H. Worlock, DM, FRCS(Ed), FRCS(Eng) Jeffrey Upperman, MD, FACS Jay A. Yelon, MD, FACS Jay Upright Bang Wai-Key Yuen, MB BS, FRCS, FRACS, FACS Yvonne van den Ende Ahmad M. Zarour, MD, FACS Armand Robert van Kanten, MD n TO TABLE OF CONTENTS  COURSE OVERVIEW: PURPOSE, HISTORY, AND CONCEPTS OF THE ATLS PROGRAM Pro g ra m Goa l s Upon completing the ATLS student course, the participant will be able to: The Advanced Trauma Life Support (ATLS) course 1. Demonstrate the concepts and principles of the supplies its participants with a safe and reliable method primary and secondary patient assessments. for the immediate treatment of injured patients and the 2. Establish management priorities in a trauma basic knowledge necessary to: situation. 1. Assess a patient’s condition rapidly and accurately. 3. Initiate primary and secondary management neces- sary for the emergency management of acute life- 2. Resuscitate and stabilize patients according to threatening conditions in a timely manner. priority. 4. In a given simulation, demonstrate the following 3. Determine whether a patient’s needs exceed the skills, which are often required during initial resources of a facility and/or the capability of a assessment and treatment of patients with provider. multiple injuries: 4. Arrange appropriately for a patient’s interhospital or intrahospital transfer. a. Primary and secondary assessment of a patient with simulated, multiple injuries 5. Ensure that optimal care is provided and that the level of care does not deteriorate at any point during b. Establishment of a patent airway and initiation the evaluation, resuscitation, or transfer process. of assisted ventilations c. Orotracheal intubation on adult and infant manikins Course Ob jec ti v e s d. Pulse oximetry and carbon dioxide detection in exhaled gas e. Cricothyroidotomy The content and skills presented in this course are designed to assist doctors in providing emergency f. Assessment and treatment of a patient care for trauma patients. The concept of the “golden in shock, particularly recognition of life- hour” emphasizes the urgency necessary for successful threatening hemorrhage treatment of injured patients and is not intended to g. Intraosseous access represent a fixed time period of 60 minutes. Rather, h. Pleural decompression via needle or finger and it is the window of opportunity during which doctors chest tube insertion can have a positive impact on the morbidity and mortality associated with injury. The ATLS course i. Recognition of cardiac tamponade and provides the essential information and skills for appropriate treatment doctors to identify and treat life-threatening and j. Clinical and radiographic identification of potentially life-threatening injuries under the thoracic injuries extreme pressures associated with the care of these k. Use of peritoneal lavage, ultrasound (FAST), patients in the fast-paced environment and anxiety and computed tomography (CT) in abdominal of a trauma room. The ATLS course is applicable to evaluation clinicians in a variety of situations. It is just as relevant to providers in a large teaching facility in North l. Evaluation and treatment of a patient with America or Europe as it is in a developing nation with brain injury, including use of the new Glasgow rudimentary facilities. Coma Scale score and CT of the brain n TO TABLE OF CONTENTS xxix ­xxx COURSE OVERVIEW m. Protection of the spinal cord and radiographic Other* Road traffic 21% and clinical evaluation of spine injuries n. Musculoskeletal trauma assessment and management 23% Poisoning War The Need 6% 3% Falls Homicide According to the most current information from the 8% World Health Organization (WHO) and the Centers for Disease Control (CDC), more than nine people die