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Original article
1
Department of Trauma and
Orthopedic Surgery, Institute
for Research in Operative
Medicine (IFOM), Cologne-
Merheim Medical Center
(CMMC), University of Witten/
Herdecke, Cologne, Germany
2
University of Witten/Herdecke,
Witten, Germany
3
Department of Trauma and
Orthopedic Surgery, BG
Hospital Ludwigshafen,
Ludwigshafen, Germany
4
Department of Trauma
Surgery, Leiden University
Medical Center, Leiden,
Netherlands
5
Department of Trauma and
Orthopedic Surgery,
Cologne-Merheim Medical
Center (CMMC), University of
Witten/Herdecke, Cologne,
Germany
Correspondence to
Dr Manuel Mutschler,
Department of Trauma and
Orthopedic Surgery,
Cologne-Merheim Medical
Center (CMMC), University of
Witten/Herdecke, Ostmerheimer
Str. 200, Cologne D-51109,
Germany;
manuelmutschler@web.de
Received 10 April 2013
Accepted 12 September 2013
Published Online First
26 September 2013
To cite: Mutschler M,
Hoffmann M, Wölfl C, et al.
Emerg Med J 2015;32:
134–137.
134
Is the ATLS classification of hypovolaemic shock
appreciated in daily trauma care? An online-survey
among 383 ATLS course directors and instructors
Manuel Mutschler,1 Marzellus Hoffmann,2 Christoph Wölfl,3 Matthias Münzberg,3
Inger Schipper,4 Thomas Paffrath,5 Bertil Bouillon,5 Marc Maegele5
ABSTRACT
Objective For the early recognition and management
of hypovolaemic shock, ATLS suggests four shock classes
based upon an estimated blood loss in percent. The aim
of this study was to assess the confidence and
acceptance of the ATLS classification of hypovolaemic
shock among ATLS course directors and instructors in
daily trauma care.
Methods During a 2-month period, ATLS course
directors and instructors from the ATLS region XV
(Europe) were invited to participate in an online survey
comprising 15 questions.
Results A total of 383 responses were received.
Ninety-eight percent declared that they would follow the
‘A, B, C, D, E’ approach by ATLS in daily trauma care.
However, only 48% assessed ‘C-Circulation’ according to
the ATLS classification of hypovolaemic shock. One out
of four respondents estimated that in daily clinical
routine, less than 50% of all trauma patients can be
classified according to the current ATLS classification of
hypovolaemic shock. Additionally, only 10.9%
considered the ATLS classification of hypovolaemic shock
as a ‘good guide’ for fluid resuscitation and blood
product transfusion, whereas 45.1% stated that this
classification only ‘may help’ or has ‘no impact’ to guide
resuscitation strategies.
Conclusions Although the ‘A, B, C, D, E’ approach
according to ATLS is widely implemented in daily trauma
care, the use of the ATLS classification of hypovolaemic
shock in daily practice is limited. Together with previous
analyses, this study supports the need for a critical
reassessment of the current ATLS classification of
hypovolaemic shock.
INTRODUCTION
The ATLS course presents a concise approach to
assess and manage multiply injured patients in the
emergency department (ED).1 The course aims to
provide knowledge and techniques that are compre-
hensive and easily adapted to daily trauma care. To
date, ATLS has been taught to more than one
million doctors in over 50 countries. It has become
the foundation of care of the severely injured
patient by teaching a common language and a
common systematic approach. One key aspect of
ATLS is to early recognise and treat hypovolaemic
shock. For this purpose, ATLS suggests four classes
of hypovolaemic shock (classes I–IV) based upon
an estimated blood loss in percent and correspond-
ing vital signs (table 1). For each class, ATLS allo-
cates therapeutic recommendations, for example,
Mutschler M, et al. Emerg Med J 2015;32:134–137. doi:10.1136/emermed-2013-202727
the replacement of fluids and the administration of
blood products.1 2
Haemorrhage is the most common cause of shock
after trauma, and the ATLS classification of hypovol-
aemic shock has been presented as a useful tool
for adequately estimating acute blood loss and to
guide resuscitation. However, the clinical applicabil-
ity and validity of the ATLS classification of hypo-
volaemic shock has recently been questioned by the
results of two large-scale analyses of the TARN
(Trauma Audit and Research Network) registry and
the TraumaRegister DGU database, comprising
more than 140 000 datasets of severely injured
patients.3–5 As a result, 90.7% of all trauma patients
could not be classified according to the criteria sug-
gested by ATLS when a combination of the vital
signs of heart rate (HR), systolic blood pressure
(SBP) and GCS were considered.3 ATLS seemed (1)
to overestimate the degree of tachycardia associated
with hypotension and (2) to underestimate mental
disability in the presence of hypovolaemic shock.3–5
In consequence, we aimed to assess the acceptance
and user confidence in this classification by conduct-
ing a survey among ATLS course directors and instruc-
tors across the ATLS region XV (Europe).
METHODS
An online questionnaire was developed (SurveyMonkey,
Palo Alto, USA; http://www.surveymonkey.com) which
contained 15 questions combined with a list of possible
and preformulated answers. The individual qualification
(ATLS course director or instructor), country of work
and professional man-years of each respondent were
asked via open-ended questions.
The online survey was addressed to ATLS instruc-
tors and course directors affiliated to the ATLS region
XV (Europe) including the following countries:
Denmark, France, Greece and Cyprus, Germany,
Hungary, Ireland, Israel, Italy, Lithuania, Norway,
Portugal, Slovenia, South Africa, Spain, Sweden,
Switzerland, The Netherlands and the UK. In order
to protect the privacy of the participants, the initial
invitation email, including background information as
well as a link to access the online survey, was distribu-
ted only to the national board committee of each of
the 18 countries of the ATLS region XV. The further
distribution of the questionnaire to the national ATLS
instructors and course directors was performed solely
by each national board.
Data acquisition was conducted between October
and December 2012, and one reminder was sent to
all participants in between. Data were downloaded
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Original article

Table 1 The ATLS classification of hypovolaemic shock1

Class I Class II Class III Class IV

Blood loss in % <15 15–30 30–40 >40

Pulse rate <100 100–120 120–140 >140
Systolic blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or increased Decreased Decreased Decreased
Respiratory rate 14–20 20–30 30–40 >35
Mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Urine output (mL/h) >30 20–30 5–15 Negligible
Fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood

from the online database, and data analyses were performed hypovolaemic shock in daily trauma care, one-third (33.9%;
using Microsoft Excel 2007. 121/357) stated that more than 75% of all trauma patients can
As this investigation was a voluntary survey among medical be allocated correctly into one of the suggested shock classes.
professionals, ethical approval was not required. By contrast, one out of four (26.6%; 95/357) estimated that less
than 50% of all patients can be classified correctly (table 4A). In
RESULTS the group of respondents not using the ATLS classification of
Respondent characteristics hypovolaemic shock primarily (table 4B), this percentage was
From October to December 2012, 383 responses were received even higher (37.7%; 64/170).
of which 81.4% (312/383) were obtained from Ireland,
Germany, The Netherlands and the UK (table 2). In the remain- The ATLS classification as a guide for fluid resuscitation and
ing countries, participation was either marginal (<15 responses) blood product transfusion
or the national board committee did not support this initiative. Only 10.9% (39/359) of the ATLS instructors and course direc-
Among the participants, 19.7% (75/383) were ATLS course tors considered the ATLS classification of hypovoalemic shock is
directors, and 80.3% (306/383) ALTS course instructors with a ‘good guide’ for fluid resuscitation and transfusion of blood
mean professional man-years of 20.9 (±8.1) and 13.2 (±7.6), products (table 5A). In the group of responders who were not
respectively. The majority of respondents practiced in either using the ATLS classification of shock primarily, almost 70%
level 1 (43.5%) or level 2 (31.9%) trauma centres. declared that this classification only ‘may help’ or even has ‘no
impact’ to guide resuscitation strategies (table 5B).
The role of the ATLS classification of hypovolaemic shock in
assessing ‘C-Circulation’
DISCUSSION
When respondents were asked if the general ‘A, B, C, D, E’
The aim of the present study was to evaluate the use of the
approach of ATLS is followed in daily trauma care, 98.1% (366/
ATLS classification of hypovolaemic shock in daily trauma care
373) acknowledged its use ‘always’ or in ‘most of the times’
among European ATLS course directors and instructors.
(table 3).
As expected, the vast majority of all responders declared that
Although, 83.6% (296/354) of the respondents declared that
the ‘A, B, C, D, E’ approach is used in their daily trauma care,
they are confident with the current ATLS classification of hypo-
indicating that the ATLS philosophy is actively practiced. The
volaemic shock, only 48% (170/354) assessed ‘C-Circulation’
beneficial role of a standardised approach in the ED, such as
according to its given criteria and definitions. By contrast, half
ATLS, has been shown previously: Among ATLS providers,
the respondents (49.2%; 174/354) relied rather on their clinical
>96% stated that ATLS improves clinical skills,6 as well as
experience, physical examination and laboratory tests in asses-
increases confidence, trauma capability and improves communi-
sing ‘C-Circulation’ in daily clinical trauma care (figure 1).
cation.7 A significantly lower number of inadequately managed
patients has been described after implementation of ATLS.8 9
Number of accurately classified patients according to the
However, the question whether this translates directly into a
ATLS classification of hypovolaemic shock
better patient outcome remains controversial.8 10–13
When respondents were asked how many patients they could
Despite the general use of the ‘A, B, C, D, E’ approach for
adequately classify according to the ATLS classification of
the initial assessment and care of trauma patients, only 48% of
the respondents used the ATLS classification of hypovolaemic
Table 2 Number of respondents from each participating country shock to assess circulatory depletion. The other half of the
Country Number of respondents respondents tended to rely more on their clinical experience,
physical examination and laboratory findings. A possible
The Netherlands 126
UK 86
Germany 64
Table 3 Percent of respondents who follow the general ‘A, B, C, D, E’
Ireland 40 approach in daily trauma care
Norway 15
All ATLS directors ATLS instructors
France 11
Slovenia 11 Always (%; n) 75.9 (282) 82.4 (61) 74.1 (223)
Greece 10 Most of the times (%; n) 22.5 (84) 16.2 (12) 23.9 (72)
Others 20 Sometimes (%; n) 1.6 (6) 1.4 (1) 1.7 (5)
Total 383 Never (%; n) 0.3 (1) 0 (0) 0.3 (1)

Mutschler M, et al. Emerg Med J 2015;32:134–137. doi:10.1136/emermed-2013-202727 135

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Original article

Figure 1 Percentage of respondents

who assess the severity of
hypovolaemia either according to the
ATLS classification of hypovolaemic
shock (dark grey) or rely upon their
clinical experience, physical
examination and laboratory findings
(grey). (A) All respondents; (B) ATLS
course directors; (C) ATLS course
instructors.

explanation for the limited use of the ATLS classification may
be found in the high percentage of respondents who stated that
according to their experiences less than 50% of all patients can
be classified using the ATLS classification of hypovolaemic
shock. This is substantiated by a previous analysis on 36 504
severely injured patients from the TraumaRegister DGU.3 In this
analysis, only 3411 (9.3%) patients could be classified according
to ATLS. By contrast, 33 093(90.7%) did not match the criteria
suggested by ATLS, if a combination of HR, SBP and GCS was
considered. Similar results have been also observed in the pre-
hospital setting.14 In conclusion, ATLS seemed to overestimate
the degree of tachycardia associated with hypotension and to
underestimate mental disability in the presence of hypovolaemic
shock. This assumption is shared by previous analyses
demonstrating that the association between increased HR and
decreased SBP is far less pronounced as presented in the ATLS
courses.4 5 15–17 Consequently, these results suggest that the
current ATLS classification of hypovolaemic shock, as a part of
the otherwise clinically useful ‘A, B, C, D, E’ concept, displays
substantial deficits in adequately risk-stratifying trauma
patients.3–5 However, it is important to note that the initial
assessment of trauma patients does not rely on the ATLS classifi-
cation of hypovolaemic shock only. If in doubt of any blood
loss, an immediate identification of the bleeding source is essen-
tial and the basic management principle is to stop the bleeding
and to replace the volume loss.1
Regarding the role of the ATLS classification of hypovolaemic
shock in guiding fluid resuscitation and transfusion of blood

Table 4 Percentage of patients who can be classified into a respective shock Table 5 The ATLS classification of hypovolaemic shock as a guide for fluid
class according to the ATLS classification of hypovolaemic shock in the opinion resuscitation and blood product transfusion in the opinion of (A) ATLS course
of (A) ATLS course directors and instructors; (B) ATLS classification users and directors and instructors; (B) ATLS classification users and non-ATLS classification
non-ATLS classification users users
A all ATLS directors ATLS instructors A All ATLS directors ATLS instructors

>75% (%; n) 33.9 (121) 36.6 (26) 33.3 (96) Good guide (%; n) 10.9 (39) 9.9 (7) 11.4 (33)
50–75% (%; n) 39.5 (141) 32.4 (23) 41.3 (119) Rough guide (%; n) 44 (158) 42.3 (30) 44.8 (130)
25–50% (%; n) 18.5 (66) 23.9 (17) 17 (49) May help (%; n) 38.4 (138) 42.3 (30) 36.9 (107)
<25% (%; n) 8.1 (29) 7 (5) 8.3 (24) No impact (%; n) 6.7 (24) 5.6 (4) 6.9 (20)

B ATLS classification user non ATLS classification user B ATLS classification user non ATLS classification user

>75% (%; n) 41.3 (71) 25.3 (43) Good guide (%; n) 19.8 (34) 2.3 (4)
50–75% (%; n) 43 (74) 37.1 (63) Rough guide (%; n) 61 (105) 29.5 (51)
25–50% (%; n) 9.9 (17) 26.5 (45) May help (%; n) 15.1 (26) 59.5 (103)
<25% (%; n) 5.8 (10) 11.2 (19) No impact (%; n) 4.1 (7) 8.7 (15)

136 Mutschler M, et al. Emerg Med J 2015;32:134–137. doi:10.1136/emermed-2013-202727

 Downloaded from http://emj.bmj.com/ on October 18, 2015 - Published by group.bmj.com
products, only 10.9% of the respondents declared that the clas-
sification is a ‘good guide’. By contrast, a remarkable number of
respondents affirmed that the classification has ‘no impact’ or
only ‘may help’ to guide resuscitation strategies. These observa-
tions are consistent with a previous analysis by our group dem-
onstrating that the ATLS classification of hypovolaemic shock
seems to dramatically underestimate the need for blood product
transfusion.18
Certain limitations to this investigation have to be acknowl-
edged. As stated above, the initial invitation email was distributed
solely by each national board in order to protect the privacy of
each participant. Consequently, the number of persons who were
invited to participate in the questionnaire remains unknown and
prevents calculation of response rates. Furthermore, previous
studies have questioned the validity of the current ATLS classifi-
cation of hypovolaemic shock by demonstrating that this classifi-
cation displays substantial deficits.3–5 Therefore, it cannot be
excluded that this data have influenced and triangulated the
respondents’ views on this classification. Moreover, not all
European national board committees supported the current
survey, and forwarded the request to their national course direc-
tors and course instructors. Overall, the vast majority of
responses was obtained from four European countries.
Therefore, the survey is subject to response bias and may not
accurately reflect the opinion of the entire ATLS members across
Europe. However, this was not the intention of the current
survey. Furthermore, the study population was addressed to
course directors and instructors only. Therefore, the applicability
of the results to the larger cohort of ATLS providers in general is
questionable. But in spite of these restrictions, the current investi-
gation displays an interesting insight into the use of the ATLS
classification of shock in daily trauma care.
CONCLUSION
The results of this questionnaire among 383 ATLS course direc-
tors and instructors indicated that although the general ‘A, B, C,
D, E’ approach is broadly used in clinical trauma care, half the
respondents do not assess circulatory depletion by using the
ATLS classification of hypovolaemic shock. A remarkable number
of respondents stated that <50% of all trauma patients can be
classified according to ATLS, and that the current classification
has no impact or only may help to guide fluid resuscitation and
blood product transfusion. Together with previous analyses, the
results presented here may suggest that a critical revision of the
current ATLS classification of hypovolaemic shock is warranted.
Mutschler M, et al. Emerg Med J 2015;32:134–137. doi:10.1136/emermed-2013-202727
Original article
Contributors M Mutschler and M Maegele conceived the study, designed the
questionnaire, analysed the data and drafted the manuscript. MH, M Muenzberg and
CW conducted to the design of the questionnaire and undertook data analysis. IS, TP
and BB supervised data collection, analysed the data and contributed to manuscript
preparation. All authors contributed substantially to the revision of the manuscript.
M Mutschler takes responsibility for the paper and its content as a whole.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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137
 Downloaded from http://emj.bmj.com/ on October 18, 2015 - Published by group.bmj.com

Is the ATLS classification of hypovolaemic

shock appreciated in daily trauma care? An
online-survey among 383 ATLS course
directors and instructors
Manuel Mutschler, Marzellus Hoffmann, Christoph Wölfl, Matthias
Münzberg, Inger Schipper, Thomas Paffrath, Bertil Bouillon and Marc
Maegele

Emerg Med J 2015 32: 134-137 originally published online September 26,
2013
doi: 10.1136/emermed-2013-202727

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