Clinical paperA critical reappraisal of the ATLS classification of hypovolaemic shock: Does it really reflect clinical reality?☆
Introduction
Advanced Trauma Life Support (ATLS) is a training programme for the initial assessment and management of multiply injured patients in the emergency department.1 One key aspect of ATLS is the early recognition and management of 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
Although ATLS has become widely accepted over the last decade and is currently educated in more than 50 countries worldwide, validation of the ATLS classification of hypovolaemic shock in the literature is still limited.2, 3 Recently, Guly et al. have questioned its validity when applying it onto emergency department data from injured patients derived from the Trauma Audit and Research Network (TARN) database. These authors demonstrated an association between increased heart and respiratory rate and decreased systolic blood pressure, but by far less pronounced as claimed by the ATLS classification. Furthermore, they discussed the reciprocal association between hypotension and tachycardia, commonly considered as a compensatory mechanism for maintaining cardiac output, as a too simple view of the altered physiology in states of shock.3, 4
In the present study, we undertook another attempt to validate the ATLS classification of hypovolaemic shock by applying it onto datasets of severely injured patients derived from the TraumaRegister DGU® database (Trauma registry of the German Society for Trauma Surgery). In contrast to the TARN registry, the TraumaRegister DGU® database, by strict inclusion criteria, comprises a higher percentage of patients with major trauma and thus higher Injury Severity Scores (ISS) and therefore focuses more on patients with a higher risk to develop hypovolaemic shock.
Section snippets
The TraumaRegister DGU® of the German Society for Trauma Surgery
The TraumaRegister DGU® (Trauma Registry of the German Society for Trauma Surgery) was founded in 1993.5 The aim of this multi-centre database is an anonymous and standardized documentation of severely injured patients. To date, more than 450 hospitals, mainly in Germany but also in other European and near Eastern countries have entered data from about 70,000 patients into the database (http://www.traumaregister.de). For the years 2002–2010, the registry comprises approximately 15–20% of all
Allocation of patients into the ATLS classes of hypovolaemic shock by a combination of all three parameters
A total of 36,504 patients were identified for further analyses. Out of these patients, only 3411 patients (9.3%) could be adequately classified according to ATLS by matching the combination of all three parameters (HR, GCS and SBP). The vast majority of these patients (n = 3114) was allocated to group I, presenting with a combined heart rate of <100/min together with a SBP >110 mmHg and a GCS = 15 upon ED admission. In contrast, 90.7% (n = 33,093) of all trauma patients recorded in the TraumaRegister
Discussion
The aim of this study was to validate the commonly used ATLS classification of hypovolaemic shock on the TraumaRegister DGU® database. This database currently compiles datasets of more than 70,000 trauma patients and is thus one of the largest of its kind worldwide. In contrast to other trauma databases, the TraumaRegister DGU®, by inclusion criteria, comprises a higher percentage of patients with major trauma reflected by higher Injury Severity Score (ISS) and therefore focuses more precisely
Conclusion
The results presented here together with the previous analysis by Guly and co-workers, may suggest a critical reassessment of the current ATLS classification of hypovolaemic shock.
Conflicts of interest
There are no conflicts of interest associated with this article.
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.07.012.
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Working Group on Polytrauma of the German Society for Trauma Surgery (DGU).