Clinical paperTesting the validity of the ATLS classification of hypovolaemic shock☆
Introduction
Unrecognised hypovolaemic shock is the commonest cause of preventable death following trauma.1 In the early stages of trauma resuscitation, the recognition of hypovolaemia is usually based on an estimation of volume of blood loss from injuries sustained and/or from traditional vital signs.
The Advanced Trauma Life Support (ATLS) system2 has been devised for the initial management of patients with major trauma and has become internationally accepted. Its manual classifies the degree of hypovolaemic shock in adults. A simplified version is shown in Table 1.
While ATLS offer this as a guide only, their classification is widely used in practice and has been reproduced (sometimes with minor variations) in many other articles and guidelines on the management of trauma.3, 4, 5, 6
This classification is unreferenced and we found no evidence to fully support it. In addition there are other influences on vital signs. Heart rate and blood pressure may be affected by age, anxiety, pain, medication, raised intracranial pressure, core temperature, and spinal cord injury. Respiratory rate may be raised in chest injury and conscious level may be reduced in patients with brain injury.
Our research question was to test the validity of the ATLS classification of shock by comparing it with the initial ED physiological data recordings of injured patients held in the Trauma Audit and Research Network (TARN) database.
Section snippets
Data and inclusion criteria
Cases included were adults aged 16 or over presenting between 1989 and 2007, and submitted by participating hospitals to TARN. Eligible patients are those who sustain injury resulting in immediate admission to hospital for three days or longer, admission to an intensive care or a high dependency unit, transfer for specialist care or death within 93 days. TARN excludes patients over 65 years with isolated fracture of the femoral neck or pubic ramus and those with single uncomplicated limb
Results
107,649 adult patients injured by blunt trauma were entered into the TARN database between 1989 and 2007.
Times from incident to arrival in the ED are only available for 40% of the patients. The median time is 1.08 h (IQR 0.72–1.83)
Discussion
In this trauma registry there is an association between raised HR, lowered SBP and raised RR but not to the degree indicated by ATLS. The values given in the ATLS classification of shock (Table 1) do not appear accurate from this analysis.
It is clear that tachycardia is an indicator of severity as shown by increasing ISS and increasing mortality with an increasing HR, especially in blunt trauma. However, although the SBP decreased and the RR increased with increasing HR, this was not to the
Conclusion
In a large trauma registry there is an association between raised HR, lowered SBP and raised RR but not to the degree indicated by the ATLS classification of shock.
A tachycardia after injury is associated with increased mortality but the absence of tachycardia does not exclude shock as significant blood loss can be associated with a bradycardia.
The diagnosis of shock in the emergency department is a complex clinical diagnosis that should be based on physiological measurements, the injuries
Conflict of interest statement
None.
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Hypovolaemic shock
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A Spanish translated version of the abstract of this article appears as Appendix in the online version at doi:10.1016/j.resuscitation.2010.04.007.
- 1
On behalf of the Trauma Audit and Research Network (TARN).
- 2
Current address: Tigh-Fraoich, Dervaig, Tobermory, Isle of Mull, PA75 6QW, UK.