SPECIAL REPORT
Advanced trauma life support (ATLS\): The ninth edition
Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX
1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/15/2024
The ATLS Subcommittee, American College of Surgeons’ Committee on Trauma,
and the International ATLS working group, Chicago, Illinois
T
he Advanced Trauma Life Support (ATLS) course was
introduced in 1978 and is currently taught in more than
60 countries. It continues to be a widely accepted standard for
the initial care of the trauma patient. Begun as a consensus view
of recognized experts on safe initial management of a trauma
patient, it combines didactic information with procedural skills,
culminating with management of simulated patients. Evidence
of its effectiveness includes ascertainment and retention of both
knowledge and skills as well as reduced morbidity and mortality
after introduction of the ATLS program.1Y3
The ATLS course undergoes revision approximately every
4 years, with early editions primarily revising old and incorporating new content. The eight edition, published in 2008, established a new process for incorporating change.4 All content
changes in that edition and all subsequent editions required evidence rather than opinion for change. Suggestions for change
are submitted directly to the ATLS revision Web site, with the
opportunity to provide references and the level of evidence.
The ninth edition continues to rely on evidence to support
changes in ATLS content.5 However, the major changes in the
ninth edition are format and delivery changes rather than content changes. The drivers for format changes come primarily
from the increasing understanding of adult education along
with the educational preferences of the next generations.
In both content and format, two principles in addition to
level of evidence continue to guide any changes to the ATLS
course. The course continues to emphasize one safe way to
care for the trauma patient during initial assessment; it is not
meant to incorporate the most advanced, cutting edge information or technology. In addition, with the increasing penetrance
of ATLS around the world, there is increasing variation in local
resources and practice. The ATLS vision is to embrace those
differences that do not affect the ultimate delivery of safe care
and allow flexibility for course directors to choose safe options
that reflect their local practice.
evidence based, with a review of the levels of evidence in the
accompanying references provided in Table 1.
Team Training
ATLS began as a means to provide education to individual practitioners who cared for trauma patients. Although
this concept is still important and there are many areas of the
world in which a single provider does render care, there are
many other areas where a provider leads a team of health care
practitioners who care for a single trauma patient. Preparation of the team, along with team dynamics and debriefing, are
important parts of team-based care that are highlighted in the
Initial Assessment chapter.6Y12
Airway
The use of additional advanced airway techniques is
highlighted, along with the use of videolaryngoscopy.13Y20
For pediatric patients, the use of cuffed endotracheal tubes
for all children (with the exception of infants G1 year of age)
is suggested.21Y23
Balanced Resuscitation
The concept of balanced resuscitation is further emphasized, and the term aggressive resuscitation has been eliminated.
The standard use of 2 L of crystalloid resuscitation as the starting point for all resuscitation has been modified to initiation of
1 L of crystalloid.
Early use of blood and blood products for patients in
shock is also emphasized, without mandating or suggesting any
specific ratio of plasma and platelets.24Y45
Heat Injury
There is optional expanded content on heat injury provided
for those courses that are taught in areas where heat injury is
either a primary problem or has the potential to significantly
compromise the care of injured patients.46Y50
CONTENT CHANGES
FORMAT CHANGES
Consistent with the precedent established during the revision process for the eighth edition, all content changes are
Pelvis
KEY WORDS: ATLS; app; elearning; trauma; initial assessment.
Although there is no new content related to the pelvis,
more emphasis is placed on the pelvis as a source of blood loss.
This has been done by moving all of the content to the abdomen
and pelvis chapter and the shock and surgical skills stations.
Submitted: January 28, 2013, Accepted: February 4, 2013.
From the American College of Surgeons, Chicago, Illinois.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text, and links to the digital files are provided in the HTML text of
this article on the journal’s Web site (www.jtrauma.com).
Address for reprints: Karen J. Brasel, MD, MPH, Surgery, Bioethics and Medical
Humanities Medical College of Wisconsin 9200 W. Wisconsin Ave, Milwaukee,
WI 53226; email: kbrasel@mcw.edu.
DOI: 10.1097/TA.0b013e31828b82f5
Skills Stations
Both diagnostic peritoneal lavage and pericardiocentesis
have been made optional skill stations.60Y68 If the course
director chooses not to teach diagnostic peritoneal lavage, the
new Focused Assessment with Sonography for Trauma (FAST)
skill station must be taught; one way of assessing the abdomen as
J Trauma Acute Care Surg
Volume 74, Number 5
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1363
J Trauma Acute Care Surg
Volume 74, Number 5
Brasel
TABLE 1. Levels of Evidence for Content Changes in the Ninth Edition
Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX
1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/15/2024
Chapter
Subject
Eighth Edition
Initial assessment
Team training
No mention
Airway
Videolaryngoscopy
No mention
Airway, Pediatric
Cuffed endotracheal
tubes for children
Balanced
resuscitation
Uncuffed tubes should
be used
Aggressive resuscitation,
initial 2 L of crystalloid
Initial assessment, shock,
pediatric, initial
assessment
scenarios
Thermal injuries,
appendix
Heat injury
a source of potential blood loss remains mandatory. The new
FAST skill station uses the same case scenarios as the diagnostic
peritoneal lavage portion of the surgical skills station and provides examples of positive and negative FAST views. It is not
possible to teach ATLS students to perform a FAST examination
during the allotted time during ATLS; this skill station is only to
introduce the concept of the use of FAST to evaluate the abdomen
and to provide example images for the student to recognize.
Initial Assessment Scenarios
There are several new initial assessment scenarios, emphasizing geriatric patients, blunt trauma, rib fracture treatment,
and pelvic fractures. The initial assessment scenarios, in addition
to the skills stations and text, contain multiple new images.
INSTRUCTOR COURSE
The instructor course has been revised, with a greater
emphasis on the importance of providing feedback along with
more opportunities for instructor candidates to practice their
teaching and receive feedback. The philosophy of the instructor
course is clearly articulated in the goal that an ATLS instructor
will ‘‘Stand behind the ATLS concepts, Walk with the learner
and Support the Team Teaching process.’’ An evidence-based
approach to the instructor course has been adopted with the
experiences and expertise of an international education faculty
influencing the final course resources. The instructor course
has been developed to provide flexibility with both 1.5- and
2-day program options. The ATLS instructor course continues
to rely on faculty role modeling of best educational principles
and a team approach to developing high quality new instructors.
Level(s) of
Evidence, References
Ninth Edition
Preparation of the team in addition to team debriefing are
important aspects of trauma care in instances where a
team, rather than an individual health care practitioner
provides care.
Videolaryngoscopy is a useful adjunct in patients with
potentially difficult airways.
Cuffed tubes appropriate for all children except infants
G1 y of age.
The phrase aggressive resuscitation has been eliminated.
Balanced resuscitation covers permissive hypotension
before control of bleeding, less crystalloid (1 L instead
of 2), and early use of plasma and platelets in patients
requiring massive transfusion or with significant
anticipated blood loss.
Expanded content on heat injury provided for areas where
heat injury is a primary problem or has the potential to
significantly compromise care of injured patients.
2Y56Y12
1Y313Y20
1,221Y23
1Y424Y45
2Y446Y50
psychometric analysis focused on the difficulty index (p value)
and the discriminative quality (rpbi-value) per question and for
the overall three tests of 40 MCQs. Difficulty of the individual
questions, both new and revised questions, and discriminative
capacity were sufficient and similar for different topics. The
three tests had a comparable level of difficulty.
As of November 2012, a new set of three validated MCQ
tests is available, testing the content of the ninth edition of
the ATLS.
MYATLS
One of the biggest changes in the ninth edition is the
incorporation of electronic media into the ATLS course.75Y77
A multidisciplinary team was assembled, and the defining
criteria of the were app established, mobile, practical, and on
demand. MyATLS is a native app compatible for both iOS
and Android devices. As of November 2012, there have been
more than 7,000 downloads in more than 100 countries, many
of which do not have established ATLS courses.
A favorites feature allows the user to bookmark and personalize the app specific to their speciality requirements. A built-in
robust search engine including voice recognition facilitates easy
navigation through the app content. Concise, high-definition
‘‘just in time’’ videos are included, which effectively communicate practical procedures without the need for Internet streaming, and a useful collection of resources and calculators serve as
a to-hand aid when, for example, calculating fluid resuscitation
for burns patients and recalling dermatomes.
REFERENCES
MCQ REVISION
Following a scientifically substantiated procedure, an international working group of content and educational experts
carefully reviewed the currently used multiple choice questions
(MCQs) with the eighth edition. Several new questions were
developed.69Y74 In the preimplementation beta-testing phase,
1364
The reference list has been updated, with new references
supporting the content and format changes as well as content
and format present in the eighth edition. The updates have attempted to include relevant recent references (published in the
last 10 years) as well as keeping classic references that support
basic ATLS principles.78Y163
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg
Volume 74, Number 5
Brasel
A complete list of authors and contributors to this article
and to the ATLS ninth edition can be found in Supplemental
Digital Content 1, http://links.lww.com/TA/A244.
Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX
1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/15/2024
DISCLOSURE
The author declares no conflict of interest.
REFERENCES
1. Ali J, Adam R, Stedman M, Howard M, Williams JL. Advanced trauma life
support program increases emergency room application of trauma resuscitative procedures in a developing country. J Trauma. 1994;36:391Y394.
2. Ali J, Cohen R, Adam R, et al. Attrition of cognitive and trauma management skills after the Advanced Trauma Life Support course. J Trauma.
1996;40:860.
3. Van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Advanced
trauma life support study: quality of diagnostic and therapeutic procedures.
J Trauma. 2004;57:381Y384.
4. Kortbeek J, et al. Advanced trauma life support, 8th edition, the evidence
for change. J Trauma. 2008;64:1638Y1650.
5. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85:1Y3.
6. Lubbert PH, Kaasschieter EG, Hoorntje LE, et al. Video registration
of trauma team performance in the emergency department: the results
of a 2-year analysis in a Level 1 trauma center. J Trauma. 2009;67:
1412Y1420.
7. Holcomb JB, Dumire RD, Crommett JW, et al. Evaluation of trauma
team performance using an advanced human patient simulator for resuscitation training. J Trauma. 2002;52:1078Y1086.
8. Manser T. Teamwork and patient safety in dynamic domains of healthcare:
a review of the literature. Acta Anaesthesiol Scand. 2009;53:143Y151.
9. Turner L, Kenward G, Hodgetts T. Preparing to receive patients with
trauma. Nurs Times. 2002;98:34Y36.
10. Horne S, Smith JE. Preparation of the resuscitation room and patient
reception. J R Army Med Corps. 2011;157(Suppl 1):S267YS272.
11. Sakran JV, Finneman B, Maxwell C, et al. Trauma leadership: does
perception drive reality? J Surg Educ. 2012;69:236Y240.
12. Georgiou A, Lockey DJ. The performance and assessment of hospital
trauma teams. Scand J Trauma Resusc Emerg Med. 2010;18:66.
13. Aoi Y, Inagawa G, Hashimoto K, Tashima H, Tsuboi S, Takahata T,
Nakamura K, Goto T. Airway scope laryngoscopy under manual inline
stabilization and cervical collar immobilization: a crossover in vivo
cinefluoroscopic study. J Trauma. 2010;69:838Y842.
14. Arslan ZI, Yildiz T, Baykara ZN, Solak M, Toker K. Tracheal intubation
in patients with rigid collar immobilization of the cervical spine: a comparison of Airtraq and LMA CTrach devices. Anaesthesia. 2009;64:
1332Y1336.
15. Bathory I, Frascarolo P, Kern C, Schoettker P. Evaluation of the GlideScope
for tracheal intubation in patients with cervical spine immobilisation by a
semi-rigid collar. Anaesthesia. 2009;64:1337Y1341.
16. Liu EH, Goy RW, Tan BH, Asai T. Tracheal intubation with videolaryngoscopes in patients with cervical spine immobilization: a randomized trial of
the Airway Scope and the GlideScope. Br J Anaesth. 2009;103:446Y451.
17. Ayoub CM, Kanazi GE, Al Alami A, et al. Tracheal intubation following
training with the GlideScope compared to direct laryngoscopy. Anaesthesia. 2010;65:674Y678.
18. Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis
of 2,004 Glidescope intubations, complications, and failures from two
institutions. Anesthesiology. 2011;114:34Y41.
19. Martin LD, Mhyre JM, Shanks AM, et al. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications.
Anesthesiology. 2011;114:42Y48.
20. de Oliveira GS, Fitzgerald PC, Beckerly R, et al. A randomized comparison of the use of an optical compared with a rigid laryngoscope on the
success rate of novices performing tracheal intubation. Anesth Analg.
2011;112:615Y618.
21. Tollefsen WW, Chapman J, Frakes M, et al. Endotracheal tube cuff
pressures in pediatric patients intubated before aeromedical transport.
Pediatr Emerg Care. 2010;26:361Y363.
22. Weiss M, Dullenkopf A, Fischer JE, et al. European Paediatric Endotracheal
Intubation Study Group. Prospective randomized controlled multi-centre trial
of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth.
2009;103:867Y873.
23. Clements RS, Steel AG, Bates AT, et al. Cuffed endotracheal tube use
in paediatric prehospital intubation: challenging the doctrine? Emerg Med
J. 2007;24:57Y58.
24. Brohi K, Cohen MJ, Ganter MT, et al. Acute coagulopathy of trauma:
hypoperfusion induces systemic anticoagulation and hyperfibrinolysis.
J Trauma. 2008;64:1211Y1217.
25. Bruns B, Lindsey M, Rowe K, Brown S, Minei JP, Gentilello LM, Shafi S.
Hemoglobin drops within minutes of injuries and predicts need for an
intervention to stop hemorrhage. J Trauma. 2007;63:312Y315.
26. Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP.
Predefined massive transfusion protocols are associated with a reduction in
organ failure and postinjury complications. J Trauma. 2009;66:41Y49.
27. Dzik WH, Kirkley SA. Citrate toxicity during massive blood transfusion.
Transfus Med Rev. 1988;2:76Y94.
28. Eastridge BJ, Salinas J, McManus JG, Blackburn L, Bugler EM, Cooke
WH, Convertino VA, Wade CE, Holcomb JB. Hypotension begins at 110
mm Hg: redefining ‘‘hypotension’’ with data. J Trauma. 2007;63:291Y299.
29. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA,
Schreiber MA, Gonzalez EA, Pomper GJ, Perkins JG, Spinella PC, et al.
Increased plasma and platelet to red blood cell ratios improves outcome
in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:
447Y458.
30. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb
JB. Survival with emergency tourniquet use to stop bleeding in major limb
trauma. Ann Surg. 2009;249:1Y7.
31. McManus J, Yershov AL, Ludwig D, Holcomb JB, Salinas J, Dubick MA,
Convertino VA, Hinds D, David W, Flanagan T, et al. Radial pulse
character relationships to systolic blood pressure and trauma outcomes.
Prehosp Emerg Care. 2005;9:423Y428.
32. Nunez TC, Young PP, Holcomb JB, Cotton BA. Creation, implementation,
and maturation of a massive transfusion protocol for the exsanguinating
trauma patient. J Trauma. 2010;68:1498Y1505.
33. Riskin DJ, Tsai TC, Riskin L, Hernandez-Boussard T, Purtill M, Maggio
PM, Spain DA, Brundage SI. Massive transfusion protocols: the role of
aggressive resuscitation versus product ratio in mortality reduction. J Am
Coll Surg. 2009;209:198Y205.
34. Roback JD, Caldwell S, Carson J, Davenport R, Drew MJ, Eder A, Fung M,
Hamilton M, Hess JR, et al. Evidence-based practice guidelines for plasma
transfusion. Transfusion. 2010;50:1227Y1239.
35. Brown JB, Cohen MJ, Minei JP, et al. Debunking the survival bias myth:
characterization of mortality during the initial 24 hours for patients requiring massive transfusion. J Trauma Acute Care Surg. 2012;73:358Y364.
36. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation
is associated with a reduction in resuscitation volumes and improvement
in survival in 390 damage control laparotomy patients. Ann Surg. 2011;
254:598Y605.
37. Dente CJ, Shaz BH, Nicholas JM, et al. Improvements in early mortality
and coagulopathy are sustained better in patients with blunt trauma after
institution of a massive transfusion protocol in a civilian Level I trauma
center. J Trauma. 2009;66:1616Y1624.
38. Duchesne JC, Kimonis K, Marr AB, et al. Damage control resuscitation
in combination with damage control laparotomy: a survival advantage.
J Trauma. 2010;69:46Y52.
39. Dzik WH, Blajchman MA, Fergusson D, et al. Clinical review: Canadian
National Advisory Committee on Blood and Blood ProductsVmassive
transfusion consensus conference 2011: report of the panel. Crit Care.
2011;15:242.
40. Holcomb JB, Del Junco DJ, Fox EE, et al. The Prospective, Observational,
Multicenter, Major Trauma Transfusion (PROMMTT) Study: Comparative Effectiveness of a Time-Varying Treatment With Competing Risks.
Arch Surg. 2012;1Y10.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1365
J Trauma Acute Care Surg
Volume 74, Number 5
Brasel
Downloaded from http://journals.lww.com/jtrauma by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX
1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/15/2024
41. Holcomb JB, Zarzabal LA, Michalek JE, et al. Increased platelet:RBC
ratios are associated with improved survival after massive transfusion.
J Trauma. 2011;71(Suppl 3):S318YS328.
42. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly
addressing the early coagulopathy of trauma. J Trauma. 2007;62:307Y310.
43. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative
coagulopathy in trauma patients with hemorrhagic shock: preliminary
results of a randomized controlled trial. J Trauma. 2011;70:652Y663.
44. Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66:346Y352.
45. Rowell SE, Barbosa RR, Diggs BS, et al. Effect of high product ratio
massive transfusion on mortality in blunt and penetrating trauma patients.
J Trauma. 2011;71(Suppl 3):S353YS357.
1366
46. Glazer JL. Management of heatstroke and heat exhaustion. Am Fam
Physician. 2005;71:2133Y2140.
47. Yeo TP. Heat stroke: a comprehensive review. AACN Clin Issues.
2004;15:280Y293.
48. Armstrong LE, Crago AE, Adams R, et al. Whole-body cooling of hyperthermic runners: comparison of two field therapies. Am J Emerg Med.
1996;14:355Y358.
49. McDermott BP, Casa DJ, Ganio MS, et al. Acute whole-body cooling for
exercise-induced hyperthermia: a systematic review. J Athl Train. 2009;44:
84Y93.
50. Hee-Nee P, Rupeng M, Lee VJ, et al. Treatment of exertional heat injuries
with portable body cooling unit in a mass endurance event. Am J Emerg
Med. 2010;28:246Y248.
Additional references can be found in Supplemental Digital Content 2,
http://links.lww.com/TA/A245
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.