Assessment of hypovolaemic shock at scene: is the PHTLS classification of hypovolaemic shock really valid?

Objective Validation of the classification of hypovolaemic shock suggested by the prehospital trauma life support (PHTLS) in its sixth student course manual. Methods Adults, entered into the TraumaRegister DGU((R)) database between 2002 and 2011, were classified into reference ranges for heart rate (HR), systolic blood pressure (SBP) and Glasgow coma scale (GCS) according to the PHTLS classification of hypovolaemic shock. First, patients were grouped by a combination of all three parameters (HR, SBP and GCS) as suggested by PHTLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to PHTLS and alterations in the remaining two parameters were assessed. Furthermore, subgroup analysis for trauma mechanism and traumatic brain injury (TBI) were performed. Results Out of 46689 patients, only 12432 (26.5%) could be adequately classified according to PHTLS if a combination of all three criteria was assessed. In TBI patients, only 12.2% could be classified adequately, whereas trauma mechanism had no significant influence. When patients were grouped by HR, there was only a slight reduction in SBP. When grouped by SBP, GCS dropped from 14 to 8, while no significant tachycardia was observed in any group. In patients with a GCS less than 12, HR was unaltered whereas SBP was slightly reduced to 114 (42)mmHg. On average, GCS in TBI patients was lower within all shock groups. In penetrating trauma patients, changes in HR and SBP were more distinct, but still less than predicted by PHTLS. Conclusions The PHTLS classification of hypovolaemic shock displays substantial deficits in adequately risk-stratifying trauma patients

Level of Evidence Analysis for the Latest German National Guideline on Treatment of Patients with Severe and Multiple Injuries and ATLS

Advanced Trauma Life Support (ATLS(A (R))) is one of the world's best-known training programs for medical providers. Revisions of the ATLS manual have been evidence based for a number of years. In 2011, a level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published in Germany. The scope of this study was the systematic comparison of the educational content of the ATLS concept and the interdisciplinary S3 polytrauma guideline. A total of 123 key recommendations of the guideline were compared with the content of the ATLS manual (9th edition). Depending on the level of agreement, the recommendations were classed in the following categories: (1) Agreement. (2) Minor variation. (3) Major variation. An overall 86 % conformity was found between the key recommendations of the guideline and the ATLS(A (R)) manual. The ATLS(A (R)) primary survey (ABCDE) showed an 85 % conformity. The degree of conformity for the individual priorities was as follows: A (Airway) 79 %, B (Breathing) 79 %, C (Circulation) 86 %, D (Disability) 93 %, E (Exposure) 100 %. The ATLS(A (R)) secondary survey showed a 94 % conformity. The main differences were in the areas of anesthetic induction, fluid administration, and coagulation therapy. According to our comparison, the educational content and manual of the ATLS are largely compatible with a high level of evidence S3 guideline. However, subsequent editions of both the ATLS(A (R)) and the S3 guideline should re-examine and reassess a number of aspects