Mutschler M, Paffrath T, Wölfl C, Probst C, Nienaber U, Schipper I B, Bouillon B, Maegele M
Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany.
Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany.
Injury. 2014 Oct;45 Suppl 3:S35-8. doi: 10.1016/j.injury.2014.08.015.
Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS(®) suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU(®) indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS(®) shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS(®) classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS(®) may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS(®) classification of hypovolaemic shock, an online survey among 383 European ATLS(®) course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS(®) classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS(®) classification of hypovolaemic seems warranted.
未控制的出血是创伤患者休克的主要原因，而识别和治疗的延迟与不良后果相关。为了及时检测和处理低血容量性休克，高级创伤生命支持（ATLS®）根据生命体征和估计的失血百分比提出了四级休克分类。尽管在过去几十年中这种分类方法已被广泛应用，但仍没有明确的前瞻性证据来充分支持这一分类。相反，最近有研究表明这种分类可能存在重大缺陷。一项对创伤注册数据库DGU®数据的回顾性分析表明，当评估心率、收缩压和格拉斯哥昏迷量表这三项生命体征时，所有创伤患者中只有9.3%能够被归入ATLS®休克分类中的某一类。因此，超过90%的创伤患者无法按照ATLS®的低血容量性休克分类进行归类。进一步分析包括来自英国创伤审计与研究网络（TARN）注册库的数据表明，ATLS®可能高估了与低血压相关的心动过速程度，而低估了存在低血容量性休克时的精神障碍。这一发现与院前治疗无关，也与是否存在严重创伤性脑损伤无关。有趣的是，即使潜在的创伤机制（钝性或穿透性）对能够被正确归类的患者数量也没有影响。考虑到与ATLS®低血容量性休克分类相关的这些潜在缺陷，对383名欧洲ATLS®课程教员和主任进行了一项在线调查，以评估在日常临床创伤护理中对该工具的实际认可度和信心。有趣的是，所有受访者中不到一半（48%）表示他们会根据ATLS®的低血容量性休克分类在初级评估中评估潜在的循环血容量耗竭情况。基于这些观察结果，对当前ATLS®低血容量性休克分类进行批判性重新评估似乎是必要的。
