EDITION International Trauma Life Support for Emergency Care Providers NINTH EDITION Roy L. Alson, PhD, MD, FACEP, FAEMS Kyee H. Han, MBBS, FRCS, FRCEM John E. Campbell, MD, FACEP
Global Edition INTERNATIONAL Trauma Life Support for Emergency Care Providers ROY L. ALSON, PhD, MD, FACEP, FAEMS K YEE H. HAN, MBBS, FRCS, FRCEM JOHN E. C AMPBELL, MD, FACEP Harlow, England • London • New York • Boston • San Francisco • Toronto • Sydney • Dubai • Singapore • Hong Kong Tokyo • Seoul • Taipei • New Delhi • Cape Town • São Paulo • Mexico City • Madrid • Amsterdam • Munich • Paris • Milan
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ISBN 10: 1-292-35767-3 ISBN 13: 978-1-292-35767-6 uPDF ISBN 13: 978-1-292-35768-3 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library 1 21 Typeset in Palatino LT Pro 10/12 by SPi Global Notice on Care Procedures It is the intent of the authors and publisher that this textbook be used as part of an education program taught by qualified instructors and supervised by a licensed physician, in compliance with rules and regulations of the jurisdiction where the course is being offered. The procedures described in this textbook are based upon consultation with emergency care providers including EMTs, paramedics, nurses, and physicians, who are actively involved in prehospital care. As a field, prehospital medicine is constantly evolving. The authors and publisher have taken care to make certain that these procedures reflect currently accepted clinical practice; however, the procedures cannot be considered absolute recommendations, nor do they supersede applicable local laws or rules and the medical supervision of the prehospital provider. The material in this textbook contains the most current information available at the time of publication. However, international, national, federal, state, provincial, and local guidelines concerning clinical practices, including, without limitation, those governing infection control and universal precautions, change rapidly. The reader should note, therefore, that new regulations may require changes in some procedures. The references to products in this text do not represent an official endorsement by ITLS. Efforts have been made to include multiple types of devices, for illustrative purposes, when possible. It is impossible to include in this text an example of every type of device. As in other areas of medicine, there is ongoing development of equipment for use in the care of the prehospital trauma patient, which the authors and editors believe is good. It remains the responsibility of the ITLS provider in conjunction with local medical direction to determine which specific devices are applicable in their specific practice setting. It is the responsibility of the reader to familiarize himself or herself with the policies and procedures set by federal, state, provincial, and local agencies as well as the institution or agency where the reader is employed. The authors and the publisher of this textbook and the supplements written to accompany it disclaim any liability, loss, or risk resulting directly or indirectly from the suggested procedures and theory, from any undetected errors, or from the reader’s misunderstanding of the text. It is the reader’s responsibility to stay informed of any new changes or recommendations made by any national, federal, state, provincial, and local agency as well as by his or her employing institution or agency. Notice on Gender Usage The English language has historically given preference to the male gender. Among many words, the pronouns, he and his are commonly used to describe both genders. Society evolves faster than language, and the male pronouns still predominate our speech. The authors have made great effort to treat the two genders equally, recognizing that a significant percentage of EMS providers are female. However, in some instances, male pronouns may be used to describe both males and females solely for the purpose of brevity. This is not intended to offend any readers of the female gender. Notice on Prehospital Personnel Designation Around the world, the credentialing and training of personnel who provide prehospital care vary greatly. In some jurisdictions, physicians and nurses respond as part of the EMS crew, whereas in other areas, those responding may only be trained to a basic life support (BLS) level. As the principles of care of the multiple trauma patient are the same regardless of the level of training of the persons providing care, the authors and publisher have attempted to describe those care providers in generic terms throughout the book. Common terms in English such as medic or emergency medical responder are, in some jurisdictions, actual certification levels of personnel. The term emergency care provider is used in this text to describe all levels of personnel who provide care in the prehospital setting. When other common terms are used to refer to persons providing care, it is intended to represent all persons who provide prehospital care and not to exclude or offend any care provider.
Dedication Dr. John Campbell 1943–2018 Founder, President and Patriarch, Philanthropist and Altruist, Teacher and Mentor, Friend Known worldwide for his ground-breaking work in developing prehospital trauma education, Dr. Campbell founded the Basic Trauma Life Support (BTLS) program in 1982. It was the first course and curriculum dedicated to prehospital trauma assessment and trauma care worldwide. Dr. Campbell conducted the first BTLS course at Southeast Alabama EMS System on August 23, 1982. The goal of the first BTLS course was to provide the student the knowledge and experience to recognize, assess, and care for critical trauma patients and ensure timely transport to the emergency department. Students were taught to identify conditions requiring “load and go.” From its beginning, patient assessment has been the core of the BTLS/ITLS curriculum. ITLS had humble beginnings in Alabama as a local course developed by Dr. Campbell for paramedics to learn the principles of Advanced Trauma Life Support (ATLS) to improve the care provided to trauma patients. ITLS is now a worldwide organization offering 15 types of trauma courses and teaching more than 30,000 students annually in more than 40 countries across the globe. Dr. Campbell’s work has touched more than 800,000 trauma care providers worldwide since the program began and the millions of patients they care for. From its very beginning, Dr. Campbell’s program was based on current research while maintaining a conservative and noncontroversial approach. He wanted the course to be simple, practical, and short enough to be taught in 2 days. Dr. Campbell also recognized the importance of allowing the course to be adapted for regional differences among local EMS systems. “I’m speechless to think of this and I can’t believe that this little course has come this far,” Dr. Campbell once said about the growth of ITLS worldwide. “It’s just an idea whose time had come, and I just happened to be, by accident, the one who was there when it started. It's still as important now as it was then.” Dr. Campbell leaves behind a legacy of unfailing dedication and excellence in trauma care. He will be missed by the thousands of students, instructors, colleagues, and friends whose lives he touched, personally and professionally, through the reach of ITLS training and education. International Trauma Life Support will continue to advance Dr. Campbell’s mission of improving trauma care worldwide by continuing to develop innovative curricula, programs, and services that are evidence based, flexible, and assessment focused for trauma care providers and the patients they serve. The ITLS Board of Directors and Editorial Board will continue under the leadership of Board Chair Jonathan L. Epstein, MEMS, NRP, of Massachusetts, and Editor-in-Chief Roy L. Alson, PhD, MD, FACEP, FAEMS, of North Carolina. International Trauma Life Support (ITLS) announced the passing of our Founder and President, John Emory Campbell, MD, FACEP of Alabama, in August 2018. Dr. Campbell passed away in his home after a long illness. He was 75 years old.
SECTION 1 Essential Information CHAPTER 1 Introduction to Traumatic Disease Chapter Overview 22 Situational Awareness 22 Case Presentation 23 Scene Size-up 24 Standard Precautions 24 Scene Safety 24 Total Number of Patients 26 Essential Equipment and Additional Resources Mechanism of Injury 27 Blunt Trauma 27 Penetrating Trauma 33 Priorities of Trauma Care 36 Trauma Triage Decisions 37 Prevention and Public Education 37 CHAPTER 2 21 CHAPTER 4 26 Trauma Assessment and Management 4 CHAPTER 6 72 78 Shock and Hemorrhage Control Skills Cannulation of the External Jugular Vein 98 Intraosseous Infusion 98 Indications 99 Contraindications 99 Recommended Sites 99 Potential Complications 99 FAST Responder™ Intraosseous Device 104 Length-Based Resuscitation Tapes 106 Control of Life-Threatening Hemorrhage 107 Application of Tourniquets 110 Use of Hemostatic Agents 112 Assessment Skills 63 ITLS Primary Survey—Critical Information 64 Scene Size-up 64 Initial Assessment 64 Rapid Trauma Survey 69 ITLS Reassessment Exam—Critical Information Subjective Changes 72 Mental Status 72 Reassess ABCs 72 43 Hemorrhage Control and Shock Chapter Overview 79 Case Presentation 79 Pathophysiology of Shock 80 Evaluation of Tachycardia 81 The Shock Syndromes 82 Management 83 Special Situations in Hypovolemic Shock 85 Obstructive Shock 86 Cardiogenic Shock 88 Current Thinking in the Treatment of Shock 90 CHAPTER 5 Chapter Overview 44 Case Presentation 44 ITLS Primary Survey 46 Scene Size-up 46 Initial Assessment 49 Rapid Trauma Survey or Focused Exam 51 ITLS Reassessment Exam 55 ITLS Secondary Survey 56 Adjuncts for Trauma Patient Assessment 59 Transfer of Care 59 CHAPTER 3 ITLS Secondary Survey—Critical Information 74 SAMPLE History 74 Vital Signs and Repeat Initial Assessment 74 Neurological Exam 74 Detailed Exam 76 Ground Rules for Teaching and Evaluation 77 Airway Management 116 Chapter Overview 117 Case Presentation 117 Anatomy and Physiology 118 Nasopharynx 118 Oropharynx 118 Hypopharynx 119 97
TA B L E O F C O N T E N T S Larynx 119 Trachea and Bronchi 121 The Lungs 121 The Patent Airway 121 Observation 123 Suction 123 Airway Adjuncts 124 Supplemental Oxygen 128 Ventilation 128 Normal Ventilation 128 Positive-Pressure (Artificial) Ventilation Compliance 130 Ventilation Techniques 131 Airway Equipment 133 CHAPTER 7 Diaphragmatic Tears 188 Pulmonary Contusion 189 Blast Injuries 189 Other Chest Injuries 190 Impaled Objects 190 Traumatic Asphyxia 190 Simple Pneumothorax 190 Sternal Fractures 190 Simple Rib Fracture 190 CHAPTER 9 129 Airway Skills 136 Chapter Overview 137 Basic Airway Management 137 The Pulse Oximeter 141 Supraglottic Airways 143 Advanced Airway Management 151 Preparation for Intubation 151 Face-to-Face Intubation 156 Confirmation of Tube Placement 158 Drug-Assisted Intubation 165 Fiberoptic and Video Intubation 169 SECTION 2 Foundational Knowledge CHAPTER 8 Thoracic Trauma 172 Chapter Overview 173 Case Presentation 173 The Thorax 173 Anatomy 173 Pathophysiology 175 Emergency Care of Chest Injuries 175 Airway Obstruction 177 Flail Chest 177 Open Pneumothorax 179 Massive Hemothorax 181 Tension Pneumothorax 182 Cardiac Tamponade 184 Myocardial Contusion 186 Traumatic Aortic Rupture 187 Tracheal or Bronchial Tree Injury 188 Thoracic Trauma Skills 193 Chapter Overview 194 Chest Decompression 194 Indications to Perform Chest Decompression 194 Performing a Chest Decompression by the Anterior Approach 195 Performing a Chest Decompression by the Lateral Approach 197 Management of Open Pneumothorax 199 CHAPTER 10 Spinal Trauma and Spinal Motion Restriction 202 Chapter Overview 203 Case Presentation 203 Evolution of Spinal Motion Restriction 204 Relationship to Patient Safety 204 Patient-Specific and Appropriate Spinal Motion Restriction 204 Summary of Patient-Centered Spinal Motion Restriction 206 The Normal Spinal Column and Cord 206 Spinal Column 206 Spinal Cord 207 Spinal Injury 208 Mechanisms of Blunt Spinal Column Injury 210 Pathophysiology of Spinal Cord Injury 210 Neurogenic Shock 210 Assessment of the Trauma Patient 211 Assessing for Possible Spinal Injury 211 Focused Evaluation of the Spinal Cord 212 Management of the Trauma Patient 212 Minimizing Spinal Movement 212 Spinal Motion Restriction in the Trauma Patient 215 The Log Roll 215
TA B L E O F C O N T E N T S Spinal Motion Restriction Devices 217 Complications of Spinal Motion Restriction 219 Airway Intervention 219 Special Spinal Motion Restriction Situations 219 CHAPTER 11 Spine Management Skills 229 Essential Components of Spinal Motion Restriction 230 Principles of SMR 230 Applying SMR 233 Patients Requiring SMR 233 SMR with a Short Extrication Device 236 Emergency Rescue and Rapid Extrication 236 SMR with the Long Backboard 238 CHAPTER 12 Head Trauma and Traumatic Brain Injury 249 Chapter Overview 250 Case Presentation 250 Anatomy of the Head 251 Pathophysiology of Head Trauma 252 Primary and Secondary Brain Injuries 252 Intracranial Pressure 253 Cerebral Herniation Syndrome 254 Head Injuries 255 Facial Injuries 255 Scalp Wounds 255 Skull Injuries 256 Brain Injuries 256 Evaluation of the Patient with Traumatic Brain Injury ITLS Primary Survey 260 ITLS Secondary Survey 265 ITLS Reassessment Exam 265 Management of the Patient with TBI 265 CHAPTER 13 Abdominal Trauma 269 Chapter Overview 270 Case Presentation 270 Anatomy of the Abdomen 271 Types of Abdominal Injuries 271 Assessment and Stabilization 272 Scene Size-up 272 Patient Assessment 273 Stabilization 274 New Trends in Managing Abdominal Trauma CHAPTER 14 Extremity Trauma Chapter Overview 281 Case Presentation 282 280 Injuries to Extremities 282 Fractures 282 Dislocations 284 Open Wounds 284 Amputations 285 Neurovascular Injuries 286 Sprains and Strains 286 Impaled Objects 287 Compartment Syndrome 287 Crush Injury and Crush Syndrome Assessment and Management 288 Scene Size-up and History 288 Assessment 288 Management of Extremity Injuries Management of Specific Injuries 288 295 CHAPTER 15 Extremity Trauma Skills Traction Splints 306 Pelvic Stabilization Techniques CHAPTER 16 Trauma Arrest 260 305 312 314 Chapter Overview 315 Case Presentation 315 The Unsalvageable Patient 315 Airway and Breathing Problems 316 Circulatory Problems 318 Approach to Trauma Patients in Cardiac Arrest 319 General Plan of Action 320 Considerations in Traumatic Cardiac Arrest Management 323 SECTION 3 Special Populations CHAPTER 17 Burns 275 287 327 Chapter Overview 328 Case Presentation 328 Anatomy and Pathophysiology 328 The Skin 328 Classifying Burns by Depth 330 Determining the Severity of Burns 330 Patient Assessment and Management 332 ITLS Primary Survey 333 ITLS Secondary Survey 335 Patient Management 335 Special Problems in Burn Management 336
TA B L E O F C O N T E N T S CHAPTER 18 Pediatric Trauma 351 Chapter Overview 352 Case Presentation 352 Communication with the Child and Family 353 Parental Consent 354 Assessment and Care 355 Pediatric Equipment 355 Common Mechanisms of Injury 355 General Assessment 358 Rapid Trauma Survey or Focused Exam 365 Critical Trauma Situation 365 ITLS Secondary Survey 366 Potentially Life-Threatening Injuries 367 Hemorrhagic Shock 367 Fluid Resuscitation 368 Head Trauma 368 Chest Injury 369 Abdominal Injury 370 Spine Injury 370 Child Restraint Seats 371 CHAPTER 19 Geriatric Trauma CHAPTER 20 Trauma in Pregnancy 388 Chapter Overview 389 Case Presentation 389 Pregnancy 390 Fetal Development 390 Physiologic Changes During Pregnancy Responses to Hypovolemia 393 Assessment and Management 393 Special Considerations 393 Types of Trauma 395 Trauma Prevention in Pregnancy 397 391 CHAPTER 21 The Impaired Patient 399 Chapter Overview 400 Case Presentation 400 Substance Abuse 400 Assessment and Management 402 The Uncooperative Patient 404 Excited Delirium 404 GLOSSARY 409 376 Chapter Overview 377 Case Presentation 378 Pathophysiology of Aging 378 The Aging Body 378 Medications 381 Aging and Injury 381 Assessment and Management 381 ITLS Primary Survey 382 Reassessment Exams 385 INDEX 417 APPENDICES APPENDIX A Standard Precautions A-1 APPENDIX B Analgesia and Pain Control for the Trauma Patient B-1 APPENDIX C Multicasualty Incidents and Triage C-1
Roy L. Alson, PhD, MD, FACEP, FAEMS Dr. Roy L. Alson is a Professor Emeritus of Emergency Medicine at Wake Forest University School of Medicine and the former Director of the Office of Prehospital and Disaster Medicine, also at Wake Forest. He is also an Associate Professor at the Childress Institute for Pediatric Trauma at Wake Forest University and an Adjunct Associate Professor in the Department of Military Medicine at Rocky Vista University College of Osteopathic Medicine, in Parker, Colorado. Dr. Alson received his bachelor’s degree from the University of Virginia in 1974 and both his PhD and MD from the Bowman Gray School of Medicine of Wake Forest University (1982, 1985). He completed his residency in emergency medicine at Allegheny General Hospital in Pittsburgh, Pennsylvania, and is board certified in both emergency medicine and emergency medical services by the American Board of Emergency Medicine. Dr. Alson’s EMS career began in the early 1970s as an EMT in New York City. As a graduate student, he became a member of the Winston-Salem Rescue Squad and began working for the Forsyth County EMS as an EMT. Upon completion of his residency, Dr. Alson returned to Wake Forest University and the Forsyth County EMS system, serving as Assistant Medical Director for 14 years and Medical Director from 2003 to 2019. He remains actively involved in the education of EMS personnel. Dr. Alson’s involvement with ITLS dates to the 1980s. He served as the North Carolina Chapter Medical Director for 15 years. Since the early 1990s, Dr. Alson has been a member of the editorial board for ITLS as well as a contributing author. He was the co-Editor-in-Chief for the eighth edition of this textbook. Along with EMS, disaster medicine is an area of interest. Dr. Alson served as the Medical Director for the North Carolina State Medical Response System (NC SMAT) program. He has served as the Chairman of the Disaster Preparedness and Response Committee for the American College of Emergency Physicians from 2011 until 2016, a member of the EMS Committee for ACEP, and as a member of the EMS Committee for the American Academy of Emergency Physicians. Dr. Alson was the Chairman for the NAEMSP Disaster Preparedness Committee in 2014–2016. Dr. Alson served with the National Disaster Medical System (NDMS) for 28 years, most recently as a member of the International Medical Surgical Response Team East (IMSURT-E). He previously served as the Commander and Deputy Commander for the North Carolina Disaster Medical Assistance Team (NC-DMAT-1) and Deputy Commander of the NMRT-E Dr. Alson has responded to numerous nationally declared disasters. He continues to teach about the delivery of care in austere and surge-type conditions and has lectured nationally and internationally on prehospital trauma care and disaster medicine. He and his wife, Rebecca, reside in Winston-Salem, North Carolina. Kyee H. Han, MBBS, FRCS, FRCEM Dr. Kyee H. Han is a Consultant in Trauma and Emergency Medicine at the James Cook University Hospital, in Middlesbrough, which is a Regional Major Trauma Centre in the North East of England. He is also Honorary Medical Director to the North East Ambulance Service NHS Foundation Trust. Dr. Han 8 completed his undergraduate medical training at the Institute of Medicine in Rangoon, Burma, in 1976. Following his internship and Senior House Officer surgical rotational training in Birmingham, UK, he worked as a Surgical Registrar and was awarded the FRCS in 1981. After gaining cardiothoracic surgical experience in Leicester, Dr. Han decided to pursue a career in an up-and-coming specialty then known as Accident and Emergency Medicine (A&E) in the UK. He entered the Northern Deanery residency/ specialist training program at the Royal Victoria Infirmary (RVI) in Newcastle upon Tyne and Middlesbrough General
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