Elsevier

Resuscitation

Volume 84, Issue 3, March 2013, Pages 309-313
Resuscitation

Clinical paper
A critical reappraisal of the ATLS classification of hypovolaemic shock: Does it really reflect clinical reality?

https://doi.org/10.1016/j.resuscitation.2012.07.012Get rights and content

Abstract

Aim

The aim of this study was to validate the classification of hypovolaemic shock given by the Advanced Trauma Life Support (ATLS).

Methods

Patients derived from the TraumaRegister DGU® database between 2002 and 2010 were analyzed. First, patients were allocated into the four classes of hypovolaemic shock by matching the combination of heart rate (HR), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) according to ATLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to the ATLS classification and the corresponding changes of the remaining two parameters were assessed within these four groups. Analyses of demographic, injury and therapy characteristics were performed as well.

Results

36,504 patients were identified for further analysis. Only 3411 patients (9.3%) could be adequately classified according to ATLS, whereas 33,093 did not match the combination of all three criteria given by ATLS. When patients were grouped by HR, there was only a slight reduction of SBP associated with tachycardia. The median GCS declined from 12 to 3. When grouped by SBP, GCS dropped from 13 to 3 while there was no relevant tachycardia observed in any group. Patients with a GCS = 15 presented normotensive and with a HR of 88/min, whereas patients with a GCS < 12 showed a slight reduced SBP of 117 mmHg and HR was unaltered.

Conclusion

This study indicates that the ATLS classification of hypovolaemic shock does not seem to reflect clinical reality accurately.

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.

References (13)

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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.

d

Working Group on Polytrauma of the German Society for Trauma Surgery (DGU).

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