MILITARY MEDICINE, 182, 3/4:e1588, 2017

Advanced Trauma Life Support Time Standards

Maj Andrew B. Hall, USAF MC*; Maj Felix S. Boecker, USAF MC*;
Lt Col Joseph M. Shipp, USAF BSC*; Dennis Hanseman, PhD†

ABSTRACT Introduction: Trauma readiness is critical to military medicine. Without medical centers that include persis-
tent volumes of trauma, simulation has become the means to maintain and practice those skills. To create those simulations,
standards for both design and metrics to evaluate practitioners are required. Materials and Methods: Forty-four traumas were
monitored and times to completion of the various steps of Advanced Trauma Life Support were recorded and tabulated.
The times recorded for level 1 and level 2 traumas were compared without statistical differences identified. Results:
Normative times for various portions of the Advanced Trauma Life Support protocol were provided. These include time
to airway assessment, breathing assessment, circulation assessment, establishment of intravenous, completion of pri-
mary survey, chest X-ray, first set of vitals, and focused assessment with sonography for trauma scan. Conclusions: Using
these mean times, simulations can be created to best replicate traumas and evaluate the capabilities of practitioners.

INTRODUCTION to first complete vitals, time to establish initial or addi-

Advanced Trauma Life Support (ATLS) methods have become
the standard for the initial evaluation and treatment for trauma
in both civilian and military trauma practices. We in the mili-
tary have to maintain our proficiency and readiness to be
ready to utilize ATLS methods at a moment’s notice. At the
Centers for the Sustainment of Trauma and Readiness Skills,
we teach and reinforce these skills for the military medical
professionals; however, continued practice and reinforcement
are required at all military medical centers for continued read-
iness. Trauma simulations can be difficult to accurately con-
duct without a recent understanding of trauma situations and
standards on which to assess and train. The purpose of this
article is to provide ATLS performance standards to help both
design and possibly assess the practitioner to improve trauma
readiness at military institutions throughout the military.
MATERIALS AND METHODS
ATLS times for both civilian and military personnel were
assessed on an ongoing basis as part of a quality improve-
ment project at Saint Louis University Hospital. A Center for
the Sustainment of Trauma and Readiness Skills provider
not involved in the care of the trauma patient observed the
trauma and recorded times to completion of various ATLS
steps. Timing was started the moment the patient was trans-
ferred from the emergency medical team’s gurney to the
hospital bed in the trauma room. Points of measurement
were as follows: time to assess airway, time to assess breath
sounds, time to assess circulation by measuring pulses, time
*Center for the Sustainment of Trauma and Readiness Skills, 3635 Vista
Avenue, St. Louis, MO 63110.
†Center for the Sustainment of Trauma and Readiness Skills, 231 Albert
Sabin Way, Cincinnati, OH 45267.
The views expressed in this article are those of the authors and do not
necessarily reflect the official policy or position of the Air Force, the
Department of Defense, or the U.S. Government.
doi: 10.7205/MILMED-D-16-00172
tional intravascular access, time to complete primary survey
(log roll, identify external sources of bleeding, etc.), time to
chest X-ray, time to focused assessment with sonography for
trauma (FAST) exam, and time to first fluid/blood transfu-
sion. FAST exam, intravenous (IV) fluids, and whether the
patient came into the emergency department with IV access
or required an additional IV access were on a case-by-case
basis. In all cases, an IV was established. In addition,
descriptions of the various trauma scenarios were obtained
including level, mechanism, whether the patient allowed for
performance of part or all of the ATLS steps, and whether
lifesaving procedures before completion of the initial ATLS
steps such as central lines, intubation, chest tubes, compres-
sion, and so on were required.
The times from gurney transfer to completion for each
portion of ATLS were compared between both level 1 and
level 2 traumas. The elapsed times, measured in seconds,
were compared between trauma levels using independent
sample t tests.
RESULTS
Both level 1 and level 2 trauma data were aggregated and
reported with a comparison between the two trauma levels
(Tables I–II). The criteria and descriptors for trauma levels
can have some variation by state. At our institution, the
trauma activation level descriptions can be found at http://
health.mo.gov. In general, level 1 traumas are higher acuity
and more likely to have unstable vital signs compared to
level 2. The ATLS trauma times for level 1 and level 2
traumas were compared to ensure aggregated means could
apply to both levels. There were no statistically significant
differences between trauma levels (Table II).
DISCUSSION
Readiness is key to all military matters, and with the even-
tual loss of hands-on experience from recent conflicts, simu-
lations in trauma assessment and mass casualties will be

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 Trauma Simulation Standards

TABLE I. Aggregated Data Describing Included Traumas
Item n Percentile
Trauma Activation Level
Level 1 20
Level 2 24
Mechanism
Blunt 37
Penetrating 7 16.00
Cooperation of Patient
Cooperative 41
Uncooperative 3 7.00
Lifesaving Measures Required 2 11.76
required to maintain some element of proficiency. To make
a good simulation, the actual steps that are done should be
replicated as closely as possible (functional fidelity), and to
a much lesser degree the appearance and tactile senses (engi-
neering fidelity).1,2 This can be a good thing, because it is
much simpler to replicate the required steps than it is to cre-
ate realistic appearing traumas, but also challenging in some
regard because the simulation tends to focus on recreating
the emotional impact of gore, screaming, and so on. In rec-
reating the functional fidelity, information such as how long
it takes to do ATLS steps can help best design a scenario. It
is easy to create scenarios where practitioners simply declare
the steps of ATLS from memory, such as “would do com-
plete survey” or “checked vitals,” and have a proctor record
the information. However, creating barriers to performing
various steps, such as requiring students to cut away cloth-
ing to reveal injuries, placing blood pressure cuffs, mimick-
ing fractured limbs, and placing backboards that inhibit log
rolling, and so on, can better reflect actual traumas and the
time it takes to perform the various steps and allow for
improvement in processes.
At our institution, initial trauma management uses a hori-
zontal approach, with multiple practitioners having a role
and with an overall trauma surgeon as the hub of informa-
tion and decision-making. In a more austere situation, a ver-
tical approach, with 1 practitioner performing all steps, may
be required with elapsed times likely higher. These results
are the average of a set number of cases and include a variety
45.00
55.00
of trauma scenarios. If a patient requires extensive lifesaving
maneuvers (i.e., chest tubes, intubation), an individual trauma
84.00 assessment will increase accordingly. These data only serve
as a baseline, not necessarily to determine if someone is pro-
ficient, but to roughly determine how long an individual sce-
93.00
nario should take.
Using these data as a means to pass or fail students on the
basis of simulations would be dangerous. There are many
variables that can determine how long a trauma scenario
takes, such as intubation or insertion of a chest tube. These
procedures can substantially increase the time it takes to
complete all portions of the ATLS protocol, if included in a
simulation before ATLS would be completed. To use these
means and assess a practitioner’s ability to perform lifesav-
ing procedures, it would probably be best to have the simu-
lated patient require the procedures after the initial steps of
ATLS are completed.
While the study exists to provide military centers with
normative times, the most notable limitation if used for
research is sample size. Although a group of 44 is a small
number in the hundreds of patients our institution sees may
seem small, the number collected does represent a diverse
sample of patients with multiple mechanisms and 44 does
create a reasonable set of average times that can be used to
assess simulations and roughly assess simulation teams.
Other average times for ATLS steps have been collected and
reported in the past, and while times seem superficially simi-
lar to ours other studies tend to break down the ATLS algo-
rithm into different subparts or have limitations in patient
selection making comparisons impossible.3–5
As wars wind down and institutional memory is lost, simu-
lations will play a more important role over time. Once edu-
cation and performance standards are set, future studies will
aim to assess readiness and on performance improvement.

TABLE II. Average Times With Ranges and Comparison Between Level Times

Level 1a Level 2a
Mean Range
Variable (Minute:Second) (Minute:Second) Median IQR Median IQR p Value
Airway Assessment 00:16 00:01–01:53 9.0 4.0–26.5 4.5 1.0–18.5 0.13
Breathing Assessment 00:39 00:08–04:59 27.5 21.5–44.0 26.5 19.5–35.0 0.49
Circulation Assessment 01:14 00:24–10:32 59.0 44.5–76.5 40.5 34.5–57.0 0.07
Establish IV Access (Field or ED) — — 168.0 127.0–375.0 198.0 153.0–299.0 0.42
Establish Initial IV Access 04:50 01:47–19:22 — — — — —
Establish Additional IV in ED 04:29 02:06–18:00 — — — — —
Complete Primary Survey 06:44 02:33–36:10 308.0 258.0–452.5 362.5 284.0–400.0 0.43
Chest X-ray 09:14 05:10–17:58 520.0 395.0–605.0 524.0 461.0–688.0 0.32
FAST Scan 07:33 02:03–15:44 424.0 256.0–826.0 411.0 236.0–536.0 0.74
First Full Set of Vitals 02:57 01:05–07:53 155.0 122.5–189.5 149.0 120.0–241.5 0.95

IQR, interquartile range. aTimes are in elapsed seconds from gurney transfer.

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 Trauma Simulation Standards

CONCLUSION Performance. Washington, DC, National Academy Press, 1994. Available

Trauma scenario creation requires a baseline standard to deter-
mine accuracy to real life and to determine how well practi-
tioners are doing. The ATLS standards within this article can
be used at both military and civilian institutions for their own
trauma scenario creation and evaluation.
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