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PHTLS_ Prehospital Trauma Life Support 8TH

PHTLS_ Prehospital Trauma Life Support 8TH

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for, the correctness, sufficiency, or completeness of such information or recommendations. Other or additional s afety measures may be required
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This textbook is intended solely as a guide to the appropriate procedures to be employed when rendering emergency care to the sick and i.Jtjured.
It is not intended as a statement of the standards of care required in any particular s ituation, because circumstances and the patient's physical
condition can vary widely from one emergency to another. Nor is it intended that this textbook shall in any way advise emergency personnel
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Library of Congress Cataloging-in-P u blication Data

PHTLS (1986)

PHTLS : prehospital trauma life support I Prehospital Trauma Life Support Committee ofThe National Association of Emergency Medical

Technicians in cooperation with the Committee on Trauma of the American College of Surgeons. - Eighth edition.

p. ;cm.

Prehospital trauma life support

Includes bibliographical references and index.

ISBN 978-1-284-04173-6

I. National Association of Emergency Medical Technicians (U.S.). Pre-Hospital Trauma Life Support Committee, author. II. American College of

Surgeons. Committee on Trauma, author. m. Title. IV. Title: Prehospital trauma life support.

[DNLM: 1. Wounds and Injuries-therapy. 2. Emergencies. 3. Emergency Medical Services. 4. First Aid- methods. 5. Traumatology. WO 700]

RC86.7

6 16.02'5--dc23 2014027414

6048

Printed in the United States ofAmerica
18 17 16 15 14 10 9 8 7 6 5 4 3 2 1

Brief Table of Contents

DIVISION 1 Introduction ............... 1 CHAPTER 15 Burn Injuries ....... 406

CHAPTER 1 PHTLS: Past, CHAPTER 16 Pediatric

Pres ent, and Future ...................... 1 Trauma ................................... 428

CHAPTER 2 Injury Prevention ...... 1 4 CHAPTER 17 Ger iatric
Trauma ................................... 456
DIVISION 2 Assessment and
Management .............................. 32 DIVISION 4 Summary ............... 475

CHAPTER 3 The Science, CHAPTER 1 B Golden P rincip les
Art, and Ethics of Prehospital of Prehospital Trauma Care........ 4 75
Care: Principles, Preferences,
and Critical Thinking .................... 32 DIVISION 5 Mass Casualt ies
and Terrorism ....................... . .. 487
CHAPTER 4 Phys iology of
Life and Death ............................ 48 CHAPTER 19 Disaster
Management ....................... . .... 487
CHAPTER 5 Kinematics of
Trauma ..................................... 70 CHAPTER 20 Explosions and
Weapons of Mass Destruction .... 508
CHAPTER 6 Scene Assessment 1 1 4

CHAPTER 7 Patient Assessment DIVISION 6 Special

and Management ...................... 1 36 Considerations ......................... 542

CHAPTER B Airway and CHAPTER 21 Env ironmenta l

Ventilation ............................... 1 63 Trauma I: Heat and Cold ......... . .. 542

CHAPTER 9 Shock .................. 21 7 CHAPTER 22 Env ironmenta l
Trauma II: Lightning, D r o w ning,
DIVISION 3 Specific Injuries....... 25B Diving , and Altitude ................ . .. 588
CHAPTER 10 Head Trauma ...... 25B
CHAPTER 11 Spinal Trauma ..... 288 CHAPTER 23 Wilderness
CHAPTER 12 Thoracic Trauma Care ......................... . .. 635
Trauma ...... . ................. . .......... 334
CHAPTER 24 Civi lian Tactical
Emergency Medical Support
CTEMSJ .......... . ......................... 655

CHAPTER 13 Abdominal Glossary .... . .. . .. .. . . . .. ... .. ..... .... ...... . 669
Trauma ...... . ................. . .......... 362 lndex....... . . . .. . .. .. . . . .. ... .. ..... .... ...... . 687

CHAPTER 14 Musculoskeletal
Trauma ...... . ................. . .......... 378

Table of Contents

DIVISION 1 Introduct ion . ....... .. ..... 1 Concepts of Injury Prevention.................................23

~ CHAPTER 1 PHTLS : Goal ....................................................................................... 23
.., ~,) Opportunities for Intervention .............................................. 23
Past, Present, and Potential Strategies ............................................................... 23
Strategy Implementation....................................................... 23
- Future ........ . ....... . .... . 1 Public Health Approach ......................................................... 26

Introduction ................................................................2 Evolving Role of EMS in Injury Prevention ............27

Philosophy of PHTLS...................................................2 One-on-One Interventions ..................................................... 27
Community-Wide Interventions............................................. 28
The Problem............................................................................. 2 Injury Prevention for EMS Providers ..................................... 28

The Phases of Trauma Care ........................................3 Summary ...................................................................29
Scenario Recap .........................................................30
Pre-event Phase ....................................................................... 4 Scenario Solution .....................................................30
Event Phase ............................................................................. 5 References.................................................................30
Postevent Phase....................................................................... 5 Suggested Reading ..................................................31

History of Trauma Care in Emergency DIVISION 2 Assessme n t a n d
Medical Services .........................................................7 Managem e n t ...... . ....... .. ........ .. .... 32

Ancient Period ......................................................................... 7 ~ CHAPTER 3 The
Larrey Period (Late 1700s to Approximately 1950) ................. 7
Farrington Era (Approximately 1950 to 1970)......................... 8 . , ~J Science, Art, and
Modern Era of Prehospital Care (Approximately
· · Ethics of Prehospital
1970 to Today) ..................................................................... 8 Care: Principles, Preferences,
and Critical Thinking ......... 32
PHTLS-Past, Present, Future ....................................9
Scenario .....................................................................33
Advanced Trauma Life Support................................................ 9 Introduction ..............................................................33
PHTLS ..................................................................................... 10 Principles and Preferences ......................................34
PHTLS in the Military ............................................................. 11
International PHTLS ............................................................... 11 Situation ................................................................................ 35
Vision for the Future.............................................................. 11 Condition of the Patient ........................................................ 36
Fund of Knowledge of the Prehospital
Summary ...................................................................12
Care Provider ..................................................................... 36
References .................................................................12 Equipment Available.............................................................. 36
Suggested Reading ..................................................13
Critical Thinking........................................................37
f i CHAPTER 2 Injury
Using Critical Thinking to Control Biases .............................. 39
. , J~, Prevention .. . ........... 1 4 Using Critical Thinking in Rapid Decision Making ................. 39
Using Critical Thinking in Data Analysis ................................ 39
Scenario .....................................................................15 Using Critical Thinking Throughout the Phases
Introduction ..............................................................15
Concepts of Injury ....................................................16 of Patient Care ................................................................... 40

Definition of Injury ................................................................ 16 Ethics .........................................................................40
Injury as a Disease ................................................................. 16
Haddon Matrix ....................................................................... 17 Ethical Principles ................................................................... 40
Swiss Cheese Model .............................................................. 18 Autonomy .............................................................................. 41
Classification of Injury........................................................... 19 Nonmaleficence ..................................................................... 42
Beneficence............................................................................ 42
Scope of the Problem...............................................19 Justice.................................................................................... 43

Injury to EMS Personnel......................................................... 22

Prevention as the Solution ......................................22

Research ....................................................................43 Scenario Recap .........................................................68

Reading the EMS Literature................................................... 43 Scenario Solution .....................................................68
Types of Evidence .................................................................. 43 References.................................................................69
Steps in Evaluation ................................................................ 44 Suggested Reading ..................................................69

Summary ...................................................................46 ~ CHAPTERS
Scenario Recap .........................................................46 ,, ~,) Kinematics of Trauma.. 70
Scenario Solution .....................................................47
Scenario .....................................................................71
References ................................................................. 47 Introduction ..............................................................71
Suggested Reading ..................................................48 General Principles.....................................................72

' f i,, ~,J CHAPTER 4 Physiology Pre-event ............................................................................... 72
of Life and Death ..... 49 Event...................................................................................... 72
Postevent............................................................................... 72
Scenario .....................................................................50
Energy ........................................................................72
Introduction ..............................................................50
Airway and Respiratory System..............................50 Laws of Energy and Motion................................................... 73
Energy Exchange Between a Solid Object and the
Oxygenation and Ventilation of the
Trauma Patient ................................................................... 51 Human Body....................................................................... 75

Pathophysiology .................................................................... 54 Blunt Trauma .............................................................79

Circulatory System ...................................................54 Mechanical Principles ............................................................ 79
Motor Vehicle Crashes ........................................................... 79
Circulation and Oxygenation ................................................. 54 Motorcycle Crashes................................................................ 88
Pathophysiology .................................................................... 54 Pedestrian Injuries................................................................. 90
Falls........................................................................................ 92
Shock .........................................................................54 Sports Injuries........................................................................ 93
Regional Effects of Blunt Trauma .......................................... 94
Definition of Shock ................................................................ 55
Penetrating Trauma ..................................................98
Physiology of Shock .................................................55
Physics of Penetrating Trauma............................................... 98
Metabolism: The Human Motor ............................................. 55 Damage and Energy Levels.................................................. 100
The Fick Principle................................................................... 56 Anatomy .............................................................................. 102
Cellular Perfusion and Shock ................................................. 57 Regional Effects of Penetrating Trauma .............................. 103
Shotgun Wounds .................................................................. 105
Anatomy and Pathophysiology of Shock ...............57
Blast Injuries ...........................................................107
Cardiovascular Response ....................................................... 57
Hemodynamic Response ........................................................ 59 Injury From Explosions ........................................................ 107
Endocrine Response............................................................... 61 Physics of Blast .................................................................... 108
Interaction of Blast Waves With
Types of Shock ..........................................................61
the Body........................................................................... 108
Hypovolemic Shock................................................................ 61 Explosion-Related Injuries ................................................... 108
Hemorrhagic Shock................................................................ 61 Injury From Fragments......................................................... 109
Distributive (Vasogenic) Shock .............................................. 63 Multi-etiology Injury............................................................ 110
Cardiogenic Shock ................................................................. 64
Using Kinematics in Assessment ...........................110
Complications of Shock ...........................................65 Summary ................................................................. 110

Acute Renal Failure ................................................................ 66 Blunt Trauma ........................................................................ 110
Acute Respiratory Distress Syndrome ................................... 66 Falls...................................................................................... 111
Hematologic Failure............................................................... 66 Penetrating Trauma.............................................................. 111
Hepatic Failure ....................................................................... 67 Blasts ................................................................................... 111
Overwhelming Infection ........................................................ 67
Multiple Organ Failure........................................................... 67 Table of Contents vii

Summary ...................................................................68

Scenario Recap .......................................................111 Establishing Priorities ............................................138
Scenario Solution ...................................................112 Primary Assessment ...............................................138
References...............................................................112
Suggested Reading ................................................113 General Impression.............................................................. 139
Step A-Airway Management and Cervical Spine
' ~ CHAPTER 6 Scene
Stabilization ..................................................................... 139
_ J~· ~ Assessment . ......... 1 1 4 Step B-Breathing (Ventilation) .......................................... 140
Step (-Circulation and Bleeding (Perfusion
Scenario ...................................................................115
Introduction ............................................................115 and Hemorrhage) ............................................................. 141
Scene Assessment...................................................115 Step D-Disability ............................................................... 143
Step E-Expose/Environment .............................................. 144
Safety................................................................................... 116 Simultaneous Evaluation and
Situation .............................................................................. 116
Management.................................................................... 145
Safety Issues ...........................................................116 Adjuncts to Primary Assessment ......................................... 145

Traffic Safety........................................................................ 116 Resuscitation...........................................................145
Mitigation Strategies........................................................... 117
Violence ............................................................................... 118 Transport.............................................................................. 146
Hazardous Materials............................................................ 119 Fluid Therapy ....................................................................... 146
Basic Versus Advanced Prehospital Care
Situation lssues.......................................................121
Provider Levels ................................................................ 146
Crime Scenes ....................................................................... 121
Weapons of Mass Destruction .................... ......................... 122 Secondary Assessment...........................................146
Scene Control Zones ............................................................ 123
Decontamination ................................................................. 123 Vital Signs ............................................................................ 149
Secondary Devices............................................................... 123 SAMPLE History ................................................................... 149
Command Structure ............................................................. 125 Assessing Anat omic Regions ............................................... 149
Incident Action Plans........................................................... 126 Neurologic Examination ...................................................... 152
Bloodborne Pathogens ............................... ......................... 128
Patient Assessment and Definitive Care in the Field....................................152

Triage ............................................................................... 130 Preparation for Transport .................................................... 153
Transport.............................................................................. 153
Summary .................................................................135 Field Triage of Injured Patients ............................................ 153
Scenario Recap .......................................................135 Duration of Transport .......................................................... 154
Scenario Solution ...................................................135 Method of Transport ............................................................ 154
References ...............................................................135
Suggested Reading ................................................135 Monitoring and Reassessment
{Ongoing Assessment) ...........................................156
-~ CHAPTER 7 Patient Communication ....................................................... 156
Assessment and Special Considerations...........................................156
~· _~J Management ....... . . 1 36
Traumatic Cardiopulmonary
Scenario ...................................................................137 Arrest ............................................................................... 156
Introduction ............................................................137
Pain Management ................................................................ 158
Abuse ................................................................................... 158

Prolonged Transport...............................................158

Patient Issues....................................................................... 159
Crew Issues.......................................................................... 159
Equipment Issues ................................................................. 159

Summary .................................................................160

Scenario Recap .......................................................160
Scenario Solution ...................................................161
References............................................................... 161

Suggested Reading ................................................162

viii Table of Contents

' f i CHAPTER B Airway References...............................................................194
Suggested Reading ................................................194
..,. ~;f'J and Ventilation ....... 1 63
~ CHAPTERS
Scenario ...................................................................164 .,. _~J Shock ................... 217
Introduction ............................................................164
Anatomy ..................................................................164 Scenario ...................................................................218
Introduction ............................................................218
Upper Airway ....................................................................... 164 Physiology of Shock ...............................................218
Lower Airway ....................................................................... 164
Metabolism .......................................................................... 218
Physiology ...............................................................166
Definition of Shock.................................................219
Oxygenation and Ventilation of the Trauma Patient............ 168 Classification of Traumatic Shock .........................219
Types of Traumatic Shock ......................................219
Pathophysiology .....................................................169
Hypovolemic Shock.............................................................. 219
Decreased Neurologic Function ........................................... 169 Distributive (Vasogenic) Shock ............................................ 221
Hyperventilation .................................................................. 170 Cardiogenic Shock ............................................................... 223

Assessment of the Airway and Ventilation ..........170 Assessment..............................................................224

Position of the Airway and Patient...................................... 170 Primary Assessment ............................................................. 225
Upper Airway Sounds .......................................................... 171 Secondary Assessment......................................................... 229
Examine the Airway for Obstructions .................................. 171 Musculoskeletal Injuries ...................................................... 230
Look for Chest Rise .............................................................. 171 Confounding Factors ............................................................ 230

Management ...........................................................171 Management ........................................................... 231

Airway Control ..................................................................... 171 Airway.................................................................................. 232
Essential Skills ..................................................................... 171 Breathing ............................................................................. 232
Circulation: Hemorrhage Control......................................... 232
Manual Clearing of the Airway .............................175 Disability.............................................................................. 237
Expose/Environment ............................................................ 237
Manual Maneuvers .............................................................. 175 Patient Transport.................................................................. 237
Suctioning ............................................................................ 175 Vascular Access .................................................................... 237
Volume Resuscitation .......................................................... 238
Selection of Adjunctive Device .............................176
Simple Adjuncts ......................................................177 Prolonged Transport...............................................244
Summary .................................................................245
Oropharyngeal Airway ......................................................... 177 Scenario Recap .......................................................246
Nasopharyngeal Airway....................................................... 177 Scenario Solution ...................................................246
References ............................................................... 246
Complex Airways ....................................................177 Suggested Reading ................................................247

Supraglottic Airways............................................................ 177 DIVISION 3 Specific Injur ies .... . .. 258
Endotracheal Intubation ...................................................... 178
~ CHAPTER ., 0
Continuous Quality lmprovement.........................188
Ventilatory Devices ................................................188 ., ~J Head Trauma ......... 258

Pocket Masks ....................................................................... 188 Scenario ...................................................................259
Bag-Mask Device ................................................................. 188 Introduction ............................................................259
Manually Triggered (Oxygen-Powered) Devices .................. 188
Positive-Pressure Ventilators ............................................... 189 Table of Contents ix

Evaluation ...............................................................190

Pulse Oximetry..................................................................... 190
Capnography........................................................................ 191

Prolonged Transport...............................................192
Summary .................................................................193

Scenario Recap .......................................................193
Scenario Solution ...................................................193

Anatomy ..................................................................259 Assessment..............................................................297

Physiology ...............................................................263 Neurologic Examination ...................................................... 297
Using Mechanism of Injury to Assess
Cerebral Blood Flow ............................................................ 263
Carbon Dioxide and Cerebral Blood Flow ........................... 264 Spinal Cord Injury ............................................................ 298
Indications for Spinal Immobilization ................................. 299
Pathophysiology .....................................................264
Management ........................................................... 301
Primary Brain Injury ............................................................. 264
Secondary Brain Injury......................................................... 264 General Method................................................................... 303
Manual In-line Stabilization of
Assessment..............................................................270
the Head .......................................................................... 303
Kinematics ........................................................................... 270 Rigid Cervical Col lars........................................................... 303
Primary Assessment ............................................................. 270 Immobilization of Torso to the Board Device ...................... 304
Secondary Assessment......................................................... 272 The Backboard Debate ........................................................ 305
Maintenance of Neutral In-line
Specific Head and Neck Injuries ............................273
Position of the Head ........................................................ 306
Scalp Injuries ....................................................................... 273 Completing Immobilization ................................................. 307
Skull Fractures ..................................................................... 273 Rapid Extrication Versus Short Device for the
Facial Injuries ....................................................................... 274
Laryngeal Injuries ................................................................ 276 Seated Patient.................................................................. 309
Injuries to Cervical Vessels .................................................. 276 Most Common Immobilization Mistakes ............................. 309
Brain Injuries........................................................................ 276 Obese Patients ..................................................................... 309
Pregnant Patients ................................................................ 31 O
Management ...........................................................280 Use of Steroids .................................................................... 31 O

Airway.................................................................................. 280 Prolonged Transport...............................................311
Breathing ............................................................................. 281 Summary .................................................................311
Circulation ........................................................................... 281 Scenario Recap .......................................................312
Disability.............................................................................. 282 Scenario Solution ...................................................312
Transport.............................................................................. 282 References ............................................................... 313
Suggested Reading ................................................314
Brain Death and Organ Donation .........................283
~ CHAPTER 12
Summary .................................................................285
Scenario Recap .......................................................285 ~, ~J Thoracic Trauma .... 334
Scenario Solution ...................................................286

References ...............................................................286
Suggested Reading ................................................288

~ CHAPTER 11 Scenario ...................................................................3 3 5
Introduction ............................................................335
i> _ ~J Spinal Trauma ...... .. 289 Anatomy ..................................................................335

Scenario ..................................................................290 Physiology ...............................................................3 3 6
Introduction ............................................................290
Anatomy and Physiology.......................................291 Ventilation ........................................................................... 336
Circulation ........................................................................... 338
Vertebral Anatomy............................................................... 291
Spinal Cord Anatomy ........................................................... 293 Pathophysiology ..................................................... 339

Pathophysiology .....................................................295 Penetrating Injury................................................................ 339
Blunt Force Injury................................................................. 340
Skeletal Injuries ................................................................... 295
Specific Mechanisms of Injury That Cause Spinal Trauma ... 296 Assessment..............................................................340
Spinal Cord Injuries ............................................................. 296 Asse~~me~t ~nd Management of
Spec1f1c lnJuries.......................................................341

x Table of Contents

Rib Fractures ........................................................................ 341 ~ CHAPTER 14
Flail Chest ............................................................................ 341
Pulmonary Contusion........................................................... 342 ~, ~,J Musculosk eletal
Pneumothorax ..................................................................... 342
Hemothorax ......................................................................... 349 - · Trauma ................. 379
Blunt Cardiac Injury ............................................................. 349
Cardiac Tamponade.............................................................. 350 Scenario...................................................................380
Commotio Cordis ................................................................. 351
Traumatic Aortic Disruption ................................................. 352 Introduction ............................................................380
Tracheobronchial Disruption ................................................ 354 Anatomy and Physiology.......................................381
Traumatic Asphyxia .............................................................. 355 Assessment..............................................................382
Diaphragmatic Rupture ....................................................... 355
Kinematics ........................................................................... 382
Prolonged Transport...............................................356 Primary and Secondary Assessment .................................... 383
Summary .................................................................357 Associated Injuries .............................................................. 385
Scenario Recap .......................................................357
Scenario Solution ...................................................358 Specific Musculoskeletal lnjuries ..........................386
References ............................................................... 358
Suggested Reading ................................................359 Hemorrhage ......................................................................... 386
Instability (Fractures and Dislocations) ............................... 387
-m CHAPTER 13
Special Considerations...........................................393
J-> ~' Abdominal Trauma ... 362
Critical Multisystem Trauma Patient.................................... 393
Scenario ...................................................................363 Pain Management................................................................ 393
Introduction ............................................................363 Relief of Anxiety (Anxiolysis) ............................................... 395
Anatomy ..................................................................363 Amputations ........................................................................ 395
Pathophysiology .....................................................364 Compartment Syndrome...................................................... 397
Assessment..............................................................367 Crush Syndrome................................................................... 398
Mangled Extremity .............................................................. 399
Kinematics ........................................................................... 367 Sprains ................................................................................. 399
History ................................................................................. 367 Management........................................................................ 399
Physical Examination ........................................................... 368
Special Examinations and Key Prolonged Transport...............................................400
Summary .................................................................400
Indicators ......................................................................... 370 Scenario Recap .......................................................401

Management ...........................................................372 Scenario Solution ...................................................401
Special Considerations...........................................372 References...............................................................401
Suggested Reading ................................................402
Impaled Objects................................................................... 372
Evisceration ......................................................................... 373 ~ CHAPTER 15
Trauma in the Obstetrical Patient ........................................ 373 ~, ~~)
Genitourinary Injuries.......................................................... 376 Burn Injuries .......... 406

Summary .................................................................376 Scenario ...................................................................407
Scenario Recap .......................................................377 Introduction ............................................................407
Scenario Solution ...................................................377 Anatomy of Skin .....................................................407
References ............................................................... 377
Suggested Reading ................................................378 Burn Characteristics ...............................................408

Burn Depth........................................................................... 409

Burn Assessment.....................................................411

Primary Assessment and
Resuscitation ................................................................... 411

Secondary Assessment......................................................... 413

Table of Contents xi

Management ...........................................................414 Circulation ........................................................................... 443
Pain Management................................................................ 445
Initial Burn Care ................................................................... 414 Transport.............................................................................. 445
Fluid Resuscitation .............................................................. 416
Analgesia ............................................................................. 418 Specific lnjuries.......................................................445

Special Considerations...........................................418 Traumatic Brain Injury.......................................................... 445
Spinal Trauma ...................................................................... 446
Electrical Burns .................................................................... 418 Thoracic Injuries................................................................... 447
Circumferential Burns .......................................................... 419 Abdominal Injuries .............................................................. 447
Smoke Inhalation lnjuries.................................................... 419 Extremity Trauma ................................................................. 448
Child Abuse .......................................................................... 421 Thermal Injuries ................................................................... 448
Radiation Burns ................................................................... 422
Chemical Burns .................................................................... 423 Motor Vehicle Injury Prevention ...........................449

Summary .................................................................426 Child Abuse and Neglect........................................450
Scenario Recap .......................................................426 Prolonged Transport...............................................450
Scenario Solution ...................................................427 Summary .................................................................453

References ...............................................................427 Scenario Recap .......................................................453
Scenario Solution ...................................................454
~ CHAPTER ., 6 References...............................................................454
Pediatric Trauma .. . . 429
"' ~-ii'J Suggested Reading ................................................455

Scenario ...................................................................430 ' CHAPTER ., 7
Introduction ............................................................430
The Child as Trauma Patient ..................................430 . , ~-ii'J Geriatric Trauma .... 456

Demographics of Pediatric Trauma ...................................... 430 Scenario ...................................................................457
Kinematics of Pediatric Trauma ........................................... 431 Introduction ............................................................457
Common Patterns of Injury.................................................. 431 Anatomy and Physiology of Aging .......................458
Thermal Homeostasis .......................................................... 431
Psychosocial Issues .............................................................. 431 Influence of Chronic Medical
Recovery and Rehabilitation ............................................... 432 Problems .......................................................................... 458

Pathophysiology.....................................................432 Ears, Nose, and Throat ......................................................... 459
Respiratory System .............................................................. 459
Hypoxia................................................................................ 433 Cardiovascular System......................................................... 460
Hemorrhage......................................................................... 433 Nervous System ................................................................... 461
Central Nervous System Injury ............................................ 434 Sensory Changes.................................................................. 461
Renal System ....................................................................... 462
Assessment..............................................................434 Musculoskeletal System ...................................................... 462
Skin ...................................................................................... 463
Primary Assessment ............................................................. 434 Nutrition and the Immune System ...................................... 463
Airway.................................................................................. 435
Breathing ............................................................................. 436 Assessment..............................................................463
Circulation ........................................................................... 437
Disability.............................................................................. 439 Kinematics ........................................................................... 463
Expose/Environment ............................................................ 439 Primary Assessment ............................................................. 464
Pediatric Trauma Score ........................................................ 439 Secondary Assessment (Detailed History and Physical
Secondary Assessment (Detailed
Examination) .................................................................... 465
Physical Examination) ...................................................... 441
Management...........................................................469
Management ...........................................................441
Airway.................................................................................. 469
Airway.................................................................................. 441 Breathing ............................................................................. 469
Breathing ............................................................................. 442 Circulation ........................................................................... 469

xii Table of Contents

Immobilization ..................................................................... 469 9. Maintain Manual Spinal Stabilization Until the Patient
Temperature Control............................................................ 469 Is Immobilized ............................................................. 482
Legal Considerations..............................................470
Reporting Elder Abuse......................................................... 470 10. For Critically Injured Trauma Patients,
Elder Maltreatment................................................470 Initiate Transport to the Closest Appropriate
Profile of the Abused ........................................................... 471 Facility as Soon as Possible After EMS Arrival
Profile of the Abuser............................................................ 471 on Scene .................................................................... 482
Categories of Maltreatment ................................................ 471
Important Points.................................................................. 472 11. Initiate Warmed Intravenous Fluid Replacement
Disposition ..............................................................472 En Route to the Receiving Facility............................. 483
Prolonged Transport...............................................472
Summary .................................................................473 12. Ascertain the Patient's Medical History and Perform a
Scenario Recap .......................................................473 Secondary Assessment When Life-Threatening
Scenario Solution ...................................................474 Problems Have Been Satisfactorily Managed or
References ...............................................................474 Have Been Ruled Out................................................. 484
Suggested Reading ................................................474
13. Provide Adequate Pain Relief ....................................... 484
DIVISION 4 Summary .... . .......... 4 75 14. Provide Thorough and Accurate

Communication Regarding the Patient and
the Circumstances of the Injury to the
Receiving Facility....................................................... 484
15. Above All, Do No Further Harm..................................... 484

Summary .................................................................486

References...............................................................486

~ CHAPTER 1 B Golden DIVISION 5 Mass Cas ualties
and Terrorism .... . ........ . ........ .. .. 487
._, ~,J Principles of Prehospital
., _"°~ CHAPTER 19 Disaster
Trauma Care ......... 475
J Management ......... 487
Scenario ...................................................................476
Scenario ...................................................................488
Introduction ............................................................476 Introduction ............................................................488
The Disaster Cycle ..................................................489
Why Trauma Patients Die .......................................476
Comprehensive Emergency Management ........................... 490
The Golden Principles of Prehospital Personal Preparedness......................................................... 490
Trauma Care ............................................................477
Mass-Casualty Incident Management ..................492
1. Ensure the Safety of the Prehospital Care Providers The National Incident Management System........................ 493
and the Patient............................................................ 477 Incident Command System .................................................. 493
Organization of the Incident Command System.................. 496
2. Assess the Scene Situation to Determine the Need for
Additional Resources .................................................. 478 Medical Response to Disasters .............................498
Initial Response ................................................................... 498
3. Recognize the Kinematics That Produced the Injuries.... 478 Search and Rescue ............................................................... 498
4. Use the Primary Assessment to Identify Life- Triage ................................................................................... 499
Treatment............................................................................. 500
Threatening Conditions............................................... 479 Transport.............................................................................. 501
5. Provide Appropriate Airway Management Medical AssistanceTeams .................................................... 501
Threat of Terrorism and Weapons of
While Maintaining Cervical Spine Stabilization Mass Destruction ............................................................. 502
as Indicated................................................................. 480 Decontamination ................................................................. 502
6. Support Ventilation and Deliver Oxygen to Maintain Treatment Area .................................................................... 503
an Sp0 Greater Than 95%.......................................... 480

2

7. Control Any Significant External Hemorrhage ................ 481
8. Provide Basic Shock Therapy, Including

Appropriately Splinting Musculoskeletal Injuries
and Restoring and Maintaining Normal Body
Temperature ................................................................ 481

Table of Contents xiii

Psychological Response to Disasters....................503 Chemical Agents .....................................................522

Characteristics of Disasters That Affect Mental Health....... 503 Physical Properties of Chemical Agents .............................. 522
Factors Impacting Psychological Response ......................... 503 Personal Protective Equipment ........................................... 523
Psychological Sequelae of Disasters ................................... 503 Evaluation and Management............................................... 523
Interventions ....................................................................... 503 Transport Considerations..................................................... 523
Emergency Responder Stress............................................... 503 Selected Specific Chemical Agents ...................................... 524

Disaster Education and Training ...........................504 Biologic Agents .......................................................527
Common Pitfalls of Disaster Response ................505
Concentrated Biohazard Agent Versus Infected
Preparedness ....................................................................... 505 Patient.............................................................................. 528
Communications .................................................................. 505
Scene Security ..................................................................... 506 Selected Agents................................................................... 529
Self-Dispatched Assistance.................................................. 506
Supply and Equipment Resources........................................ 506 Radiologic Disasters...............................................533
Failure to Notify Hospitals................................................... 506
Media................................................................................... 506 Medical Effects of Radiation
Catastrophes .................................................................... 534
Summary .................................................................507
Personal Protective Equipment ........................................... 537
Scenario Recap .......................................................507 Assessment and Management............................................. 537
Scenario Solution ...................................................507 Transport Considerations..................................................... 538
References ...............................................................508
Summary .................................................................538
Suggested Reading ................................................508 Scenario Recap .......................................................539
Scenario Solution ...................................................539

References...............................................................539
Suggested Reading ................................................541

~ CHAPTER20 DIVISION 6 Spe c ia l
C o nsider a t ions ... .. ..... . .. . . ....... . .. 5 4 2
J-> ~, Explosions and
~ CHAPTER 21
- Weapons of Mass
Destruction .. ....... . . 509 -> ~,J Environmental Trauma I:

Scenario ...................................................................510 Heat and Cold ....... 542
Introduction ............................................................510
General Considerations..........................................511 Scenario ................................................................... 543
Introduction ............................................................543
Scene Assessment................................................................ 511 Epidemiology ..........................................................543
Incident Command System .................................................. 511
Personal Protective Equipment ........................................... 512 Heat-Related Illness............................................................. 543
Control Zones ...................................................................... 514 Cold-Related Illness............................................................. 544
Patient Triage ....................................................................... 514
Principles of Decontamination ............................................ 514 Anatomy ..................................................................544

Explosions and Explosives .....................................515 The Skin ............................................................................... 544

Categories of Explosives ..................................................... 516 Physiology ............................................................... 545
Mechanisms of Injury........................................................... 517
Injury Patterns ..................................................................... 521 Thermoregulation and Temperature Balance ...................... 545
Evaluation and Management............................................... 521 Homeostasis ........................................................................ 546
Transport Considerations..................................................... 521
Risk Factors in Heat Illness ....................................546
Incendiary Agents...................................................522
Fitness and Body Mass Index............................................... 547
Thermite .............................................................................. 522 Age....................................................................................... 547
Magnesium .......................................................................... 522 Gender ................................................................................. 548
White Phosphorus................................................................ 522 Medical Conditions .............................................................. 548

xiv Table of Content s

Medications......................................................................... 548 Epidemiology....................................................................... 591
Dehydration ......................................................................... 548 Mechanism of Injury ............................................................ 591
Injuries From Lightning........................................................ 594
Injuries Caused by Heat .........................................549 Assessment .......................................................................... 595
Management........................................................................ 596
Minor Heat-Related Disorders............................................. 549 Prevention ........................................................................... 596
Major Heat-Related Disorders............................................. 551
D r o w n i n g ................................................................. 597
Prevention of Heat-Related lllness.......................556
Epidemiology....................................................................... 599
Environment ........................................................................ 560 Submersion Factors.............................................................. 600
Hydration ............................................................................. 560 Mechanism of Injury ............................................................ 601
Fitness.................................................................................. 561 Water Rescue ....................................................................... 602
Heat Acclimatization ............................................................ 561 Predicators of Survival ........................................................ 603
Emergency Incident Rehabilitation...................................... 562 Assessment .......................................................................... 604
Management........................................................................ 604
EMS Drug Storage in Thermal Extremes ..............564 Prevention of Submersion-Related Injuries ......................... 606
Injuries Produced by Cold ......................................566
Recreational Scuba-Related Injuries ....................608
Dehydration ......................................................................... 566
Minor Cold-Related Disorders ............................................. 566 Epidemiology....................................................................... 608
Major Cold-Related Disorders ............................................. 567 Mechanical Effects of Pressure ............................................ 609
Barotrauma .......................................................................... 610
2010 American Heart Association Guidelines for Assessment of AGE and DCS................................................ 614
Cardiopulmonary Resuscitation and Emergency Management........................................................................ 615
Cardiovascular Care Science..................................578 Prevention of Scuba-Related

Cardiac Arrest in Special Situations-Accidental Diving Injuries.................................................................. 615
Hypothermia .................................................................... 578
High Altitude Illness ...............................................622
Basic Life Support Guidelines for Treatment of Mild to
Severe Hypothermia ........................................................ 579 Epidemiology....................................................................... 622
Hypobaric Hypoxia............................................................... 622
Advanced Cardiac Life Support Guidelines for Treatment Factors Related to High-Altitude Illness .............................. 623
of Hypothermia ................................................................ 579 High-Altitude Illness............................................................ 624
Prevention ........................................................................... 628
Prevention of Cold-Related Injuries .....................579
Prolonged Transport...............................................629
Prolonged Transport...............................................582
Drowning ............................................................................. 629
Heat-Related Illness............................................................. 582 Lightning Injury ................................................................... 629
Cold-Related Illness ............................................................. 583 Recreational Scuba-Relat ed Diving Injuries ........................ 629
High-Altitude Illness ............................................................ 629
Summary .................................................................584
Summary .................................................................630
Scenario Recap .......................................................584
Scenario Solution ...................................................585 Scenario Recap .......................................................630
References ............................................................... 585 Scenario Solution ...................................................631
References...............................................................631
Suggested Reading ................................................588
Suggested Reading ................................................634
' ,'~i,f'J~ CHAPTER 22
.., Environmental

Trauma II: Lightning, ~
.., ~-:fj
Drowning, Diving, and CHAPTER23
Wilderness Trauma
Altitude ........................ 589

Scenario ...................................................................590 Care .................... 635
Introduction ............................................................590
Lightning-Related lnjuries .....................................590 Scenario ...................................................................636
Proper Care Depends on Context .........................636

Table of Contents xv

The Wilderness EMS Context .................................638 TEMS Practice Components ...................................657
Barriers to Traditional EMS Access........................657
Wilderness Injury Patterns................................................... 638 Zones of Operation.................................................658
Safety................................................................................... 638 Phases of Care ........................................................658
The Wilderness Is Everywhere ............................................. 639
Care Under Fire (Direct Threat Care) ................................... 659
EMS Decision Making: Balancing Risks Tactical Field Care (Indirect Threat Care)............................. 660
and Benefits ............................................................639 Tactical Evacuation Care (Evacuation Care)......................... 663

Improvised Evacuations....................................................... 640 Mass-Casualty Incidents ........................................664
Medical lntelligence ...............................................664
Patient Care in the Wilderness ..............................641 Summary .................................................................664
Scenario Recap .......................................................665
Elimination Needs................................................................ 641 Scenario Solution ...................................................665
Long Backboard Use ............................................................ 642 References...............................................................666
Food and Water Needs......................................................... 642 Suggested Reading ................................................666
Sun Protection ..................................................................... 642
Glossary. .. . . . . . .. .. . . . . .... .. . .. ... . . .. . . . . .. . . 668
Specifics of Wilderness EMS ..................................644
lndex ... . . ..... .. . . . .. . . . . . . . . ....... ... .. . . .. . ... 687
Wound Management ........................................................... 644
Dislocations ......................................................................... 646
Cardiopulmonary Resuscitation in the Wilderness.............. 646
Bites and Stings................................................................... 647

The Wilderness EMS Context Revisited ................651

Summary .................................................................651
Scenario Recap .......................................................651
Scenario Solution ...................................................652

References...............................................................652
Suggested Reading ................................................654

., J~ CHAPTER24
Civilian Tactical
~;(

· · Emergency Medical

Support CTEMSJ ... . . 655

Scenario ...................................................................656

History and Evolution of Tactical Emergency
Medical Support .....................................................656

xvi Table of Contents

Specific Skills Table of Contents

Trauma Jaw Thrust..................................................195 C-A-T Self-Application to a Lower
Alternate Trauma Jaw Thrust ................................196 Extremity.................................................................252
Trauma Chin Lift......................................................197
Wound Packing With Topical Hemostatic
Dressing or Plain Gauze .........................................254

Oropharyngeal Airway - Tongue Jaw Lift Pressure Dressing Using Israeli

Insertion Method ....................................................197 Trauma Bandage .....................................................256

Oropharyngeal Airway - Tongue Blade Logroll - Supine Patient.........................................316
Insertion Method....................................................199
Nasopharyngeal Airway.........................................200 Logroll - Prone or Semi-prone Patient..................318
Bag-Mask Ventilation - Two-Provider
Method....................................................................202 Sitting Immobilization (Vest-Type
Supraglottic Airway - Combitube.........................203 Extrication Device).................................................320

Rapid Extrication - Three or More
Prehospital Care Providers....................................324

Supraglottic Airway - King LT Airway...................206 Cervical Collar Sizing and Application..................325

Laryngeal Mask Airway..........................................208 Rapid Extrication - Two Prehospital
Care Providers........................................................ 327
Visualized Orotracheal Intubation of the Child Immobilization Device..................................328
Trauma Patient........................................................210

Face-to-Face Orotracheal Intubation....................212 Helmet Removal... ..................................................330

Needle Cricothyrotomy and Percutaneous vacuum Splint Application.....................................331
Transtracheal Ventilation.......................................214 Needle Decompression ..........................................361
Traction Splint for Femur Fractures ......................403
lntraosseous Vascular Access ................................248 Ruggedized Intravenous Line ................................668

C-A-T Self-Application to an Upper
Extremity.................................................................250

Acknowledgments

In 1624John Donne wrote, "No man is an island, entire of itself." composition of this book, and Nora Menzi for steering the pro-
In many ways, this insight describes the process of publishing duction of the ancillary program.
a book. Certainly, no editor is an island. Textbooks, such as
PHTLS: Prehospital Trauma Life Support; courses, especially The Editor and PHTLS Committee thank Michael Hunter,
those that involve audiovisual materials; and instructor manuals the paramedics, critical care 11.ight medics, and 11.ight nurses
cannot be published by editors in isolation. As a matter of fact, of the University of Massachusetts Memorial Medical Center
much, if not most, of the work involved in publishing a textbook Emergency Medical Services, Worcester EMS, and LifeFlight for
is accomplished not by the editors and the authors whose names their support and participation in preparing photos and videos
appear on the cover and on the inside of the book, but by the for this edition.
publisher's staff. The eighth edition of PHTLS is certainly no
exception. The Editor and PHTLS Committee thank Douglas Cotanche,
PhD, Director; Michael Doyle, Anatomy Labs Director; Dianne
From the American College of Surgeons Committee on Person, Associate Director; and the donors of the Anatomical
Trauma, Ronald M. Stewart, MD, FACS, the current Chairman of Gift Program at the University of Massachusetts Medical School
the Committee on Trauma, and Michael F. Rotondo, MD, FACS, for their support of this educational endeavor.
the ACS Medical Director of Trauma, have provided outstanding
support for this edition as well as for PHTLS. The editors also thank Kelly Lowery for her review and edit-
ing of the first draft chapter manuscripts.
Within Jones & Bartlett Learning, we must thank Christine
Emerton for her oversight of this effort, Jennifer Deforge-laing The spouses, children, and significant others of the editors
for her incredible work on the manuscript, Kirn Brophy for her and authors who have tolerated the long hours in the preparation
overarching support, Carol Guerrero for shepherding the art and of the material are obviously the backbone of any publication.
photo program for this book, Jessica deMartin for guiding the
Peter T. Pons, MD, FACEP, Editor
Norman McSwain, MD, FACS, NREMT-P, Editor-in-Chief

Contributors

Editor-in-Chief Center Assistant Professor, University UMass Memorial Medical Center-
Norman E . McSwain, J r., MD, FACS, of Colorado SOM University Campus
Denver, Colorado
NRE MT-P Worcester, Massachusetts
Medical Director, PHTLS
Professor of Surgery, Tulane University Augie Bamonti III, BA, EMT-P Craig H. J acobus, EMT-P, BA/BS, DC
Medical Officer EMS Faculty Metro Community College
Department of Surgery Chicago Heights Fire Dept. (Ret.) Fremont, Nebraska
Trauma Director, Spirit of Charity
Brad L. Bennett, PhD, NREMT-P, David A. Kappel, MD, FACS
Trauma Center, Interim LSU Hospital FAWM Clinical Professor of Surgery
Police Surgeon, New Orleans Police West Virginia University
Adjunct Assistant Professor Deputy State Medical Director
Department Military and Emergency Medicine West Virginia State Trauma System
New Orleans, Louisiana Rural Emergency I Trauma Institute
Department Wheeling, West Virginia
Editor-Eighth Edition F. Edward Hebert School of
Peter T. Pons , MD, FACEP Eduard Kompast
Associate Medical Director, PHTLS Medicine Deputy Officer
Emergency Medicine Uniformed Services University of the Vienna Ambulance
Denver, Colorado Instructor
Health Sciences Paramedic Academy
Associate Editors Bethesda, Maryland Vienna, Austria
Will Chaplean, EMT-P, RN, TNS
Chairperson, PHTLS Committee David W. Callaway, MD, MPA Mark Lueder, EMT-P
Director of Performance Improvement, CEO, Operational Medicine International, PHTLS Committee
Chicago Heights Fire Department
ATLS Program Inc. Chicago Heights, lllinois
American College of Surgeons Associate Professor of Emergency
Chicago, lllinois Norman E . McSwain , Jr., MD, FACS,
Medicine NREMT-P
Gregory Chapman, EMT-P, RRT Carolinas Medical Center
Vice-Chairperson, PHTLS Committee Charlotte, North Carolina Medical Director, PHTLS
Center for Prehospital Medicine Professor of Surgery, Tulane University
Department of Emergency Medicine Will Chaplean, EMT-P, RN, TNS
Carolinas Medical Center Chairperson, PHTLS Committee Department of Surgery
Charlotte, North Carolina Director of Performance Improvement, Trauma Director, Spirit of Charity

Editors-Military Edition ATLS Program Trauma Center, Interim LSU Hospital
Frank K. Butler, Jr., MD American College of Surgeons Police Surgeon, New Orleans Police
CAPT, MC, USN (Ret) Chicago, lllinois
Chairpe rson Department
Committee on Tactical Combat Casualty Gr egory Chapman, EMT-P, RRT New Orleans, Louisiana
Vice-Chairperson, PHTLS Committee
Care Center for Prehospital Medicine Jeffrey Mott, DHSc, PA-C
Joint Trauma System Department of Emergency Medicine Assistant Professor
Carolinas Medical Center Physician Assistant Studies
S. D. Giebner, MD, MPH Charlotte, North Carolina University of North Texas Health Science
CAPT, MC, USN (Ret)
Past Chairperson Blaine L. Ender son , MD, MBA, FACS, Center
Developmental Editor FCCM Fort Worth, Texas
Committee on Tactical Combat
Professor of Surgery J.C. Pitteloud, MD
Casualty Care University of Tennessee Medical Center Staff Anesthesiologist
Joint Trauma System Knoxville, Tennessee Hopital du Valais
Sion, Switzerland
Contributors J effrey S. Guy, MD, MSc, MMHC,
Katherine Bakes, MD FACS Peter T. Pons, MD, FACEP
Director of Denver Emergency Center Associate Medical Director, PHTLS
Chief Medical Officer Emergency Medicine
for Children Denver Health Medical TriStar Health System/HCA Denver, Colorado
Nashville, Tennessee

Michael J . Hunter, EMT-P
Deputy Chief, Worcester EMS

J effrey P. Salomone, MD, FACS, 1985-1988: J ames L. Paturas Lawrence Hatfield, MEd, NREMT-P
NREMT-P 1983-1985: Richard Vomacka, NREMT-Pt Lead Analyst, Instructor
National Nuclear Security
Chief, Division of 'frauma and Surgical t Deceased
Critical Care Administration
PHTLS-Medical Director Emergency Operations 'fraining
'frauma Medical Director 1983-present: Norman E. McSwain, J r.,
Maricopa Medical Center Academy
Phoenix, Arizona MD, FACS, NREMT-P Albuquerque, NM

Valerie Satkosk e, PhD PHTLS-Associate Medical Directors Michael J . Hunter, EMT-P
Ethicist, Wheeling Hospital 2010--present: Lance E. Stuke, MD, MPH, Deputy Chief, Worcester EMS
Wheeling, West Virginia UMass Memorial Medical Center-
Core Faculty FACS
Center for Bioethics and Health Law 2001-present: J effrey S. Guy, MD, FACS, University Campus
University of Pittsburgh Worcester, Massachusetts
Pittsburgh, Pennsylvania EMT-P
2000--present: Peter T. Pons, MD, FACEP Cr aig H. J acobus, E MT-P, BA/BS, DC
Lance E. Stuke, MD, MPH, FACS 1996-2010: Jeffrey Salomone, MD, FACS, EMS Faculty Metro Community College
Associate Medical Director, PHTLS Fremont, Nebraska
Assistant Professor of Surgery NREMT-P
Tulane University School of Medicine 1994-2001: Scott B. Frame, MD, FACS, Mark Lueder, EMT-P
New Orleans, Louisiana PHTLS Committee Chicago Heights Fire
FCCMt
National Association of Emergency Department
Medical Technicians 2014 Board of t Deceased Chicago Heights, Illinois
Directors
Officers PHTLS Committee No rman E . McSwain, Jr., MD, FACS,
President: Don Lundy Fra nk K. But ler, Jr., MD NREMT-P
President-Elect: C. T. Kearns CAPT, MC, USN (Ret)
Secretary: James A Judge, II Chairperson Medical Director, PHTLS
'freasurer. Dennis Rowe Committee on Tactical Combat Casualty Professor of Surgery, Tulane University
Immediate Past-President: Connie Meyer
Care Department of Surgery
Directors Scott Matin Joint 'frauma System 'frauma Director, Spirit of Charity
Rod Barrett Chad E. Mcintyre
Aimee Binning Cory Richter Will Cha plean , EMT-P, RN, TNS 'frauma Center, Interim LSU Hospital
Chris Cebollero J ames M. Slattery Chairperson, PHTLS Committee Police Surgeon, New Orleans Police
Ben Chlapek Matt Zavadsky Director of Performance Improvement,
Bruce Evans Department
Paul Hinchey, MD ATLS Program New Orleans, Louisiana
American College of Surgeons
PHTLS-Chairpersons Chicago, Illinois Peter T. Pon s, MD, FACEP
1996-present: Will Chapleau, EMT-P, RN, Associate Medical Director, PHTLS
Gr egory Ch a pman, EMT-P, RRT Emergency Medicine
TNS Vice-Chairperson, PHTLS Committee Denver, Colorado
1992-1996: Elizabeth M. Wertz, RN, BSN, Center for Prehospital Medicine
Department of Emergency Medicine De nnis Rowe, E MT-P
MPM Carolinas Medical Center Director of Operations
1991- 1992: J ames L. Paturas Charlotte, North Carolina Priority Ambulance
1990--1991: John Sinclair, EMT-P Knoxville, Tennessee
1988-1990: David Wuertz, EMT-P J effrey S. Guy, MD, MSc, MMHC,
FACS Lance E. St uke, MD, MPH, FACS
Associate Medical Director, PHTLS
Associate Medical Director, PHTLS Assistant Professor of Surgery
Chief Medical Officer Tulane University School ofMedicine
TriStar Health System I HCA New Orleans, Louisiana
Nashville, TN

xx Contributors

Reviewers

Linda M. Abraha mson, BA, ECRN, Ryan Batenhorst , BA, NREMT-P Lawrence D. Br ewer, BA, NRP
EMT-P, NCEE Southeast Community College Rogers State University
Lincoln, Nebraska Claremore, Oklahoma
Advocate Christ Medical Center-EMS
Academy John L. Beckman, AA, BS, Billie Brown, BS, EMT-I, NREMT-P
FF/Paramedic, EMS Instructor Southern Alleganies, EMS Council
Oak Lawn, Illinois Saxton , Pennsylvania
Ad dison Fire Protection District
J ohn Alexander, MS, NRP Addison , Illinois Robert K. Browning, AAS, NR-P, HMC
Maryland Fire & Rescue Institute (SCW) USN
University of Maryland De b Bell, MS, NREMT-P
College Park, Maryland Inspira He alth Network-EMS Medical Education and Training
Campus
Kristopher Ambro sia, FF, Paramedic, (previously Underwood-Memorial EMS)
NCEE Richland, New J ersey Department of Combat Medic
Training
Morton Fire Department Michael J . Berg, BSB/M, NREMT-P
Morton, Illinois Native Air/Air Methods Fort Sam Houston, Texas
Globe, Arizona
Paul Arens, BS, NREMT-P Cherylenn Buckley, AEMT, EMT-I
Iowa Central Community College Gerria Berryman, BS, EMT-P Hartford Hospital
Fort Dodge, Iowa Emergency Medical Training Hartford, Connecticut

William J . Armonait is, MS, NREMT-P, Professionals, LLC David Burdett, NREMT-P
NCEE Lexington, Kentucky Hamilton County EMS
Chattanooga, Tennessee
University Hospital EMS Robin E. Bishop, BA, MICP, CHS III,
Fairfield, New Jersey MEP Helen E . Burkhalter, BAS,
NREMT-P, RN
Daniel Armstrong, DPT, MS, EMT Crafton Hills College
Queensborough Community College Public Safety and E mergency Services Atlanta Technical College
Bayside , New York Atlanta, Georgia
Department
Robyn M. Asher, EMT-P, IC, CC Yucaipa, California Liza K. Burrill, AEMT
Rural Metro of Tennessee New Hampshire Bureau of EMS
Knoxville, Tennessee Tobby Bishop, BS, NREMT-P Concord, New Hampshire
Spartanburg EMS
Juan M. Atan, MS, EMT-P Spartanburg, South Carolina Kevin Carlis le, NREMT-P, Tactical
Orange County Fire Rescue Medic, 68W U.S. Army Reserves
Orange County, Florida Andy D. Boo th, NREMT-P
Lanier Technical College Medical Center Ambulance Services
Chuck Baird, MS, EFO, NREMT-P Oakwood, Georgia Madisonville, Kentucky
Cobb County Fire and Emergency
Nick Bourdeau, RN, EMT-P l/C Elliot Carh art, EdD, RRT, NRP
Services Huron Valley Ambulance J efferson College of Health Sciences
Powder Springs, Georgia Ann Arbor, Michigan Roanoke, Virginia

Mark Baisley, MA, NREMT-P Sharon D. Boyles, BS, MEd, EMT-I Greg Ceisn er, EMT-P
Gold Cross Ambulance Shippensburg Area Senior High School Raleigh Fire Department
Rochester, Minnesota Shippensburg, Pennsylvania Raleigh, North Carolina

Stanley W. Baldwin Trent R. Brass, BS, EMT-P, RRT Bernadette Cekuta, BS, EMT-P, CI C
Foothill College SwedishAmerican Health System Dutchess Community College
Los Altos Hills, California Rockford, Illinois Wappingers Falls, NY

Bruce Barry, RN, CEN, NREMT-P Barbara Brennan, RN, BSN, CCRN Stacey G. Ch a pman , NREMT-P
Peak Paramedicine, LLC Hawaii PHTLS State Coordinator Lancaster County E MS
Wilmington, New York Mililani, Hawaii Lancaster, South Carolina

Julie Ch ase, MSEd, FAWM FP-C Mark Deavers, Paramedic Gustavo E. Flores, MD, E MT-P
hnmersion EMS Academy Gouverneur Rescue Squad UCC School of Medicine
Berryville, Vrrginia Gouverneur, New York Bayam6n, Puerto Rico

Ted Chialtas, Fire Ca ptain, James D. Dinsch , MS, NREMT-P Do n F ortney, AS, NREMT-P,
Paramedic Indian River State College CCEMT-P
Fort Pierce, Florida
San Diego Fire-Rescue Department EMMCO East, Inc.
EMSTA College Robert L. Ditch, EdD, MSHS, CEM, Kersey, Pennsylvania
Santee, California NREMT-P
Fred e ric k E . Fowle r , BS , MPS,
Patrick L. Churchwell, EMS Arizona Academy of Emergency Services Param edic
Ins tructor, EMT-P Mesa, Arizona
EMS Solutions
Allen Fire Department Charles J . Dixon, NREMT-P, NCEE Schuylerville, New York
Allen, Texas Nucor Steel Berkeley EMS
Summerville, South Carolina Christophe r Gage, AS, NRP, FP-C
J ason L. Clark, NRP, CCEMT-P, FP-C, Davidson County Community
Stephanie Dorns ife, MS, RN,
CMTE NREMT-P, CCEMT-P, J/C College
Lexington, North Carolina
Erlanger Life Force Wentworth Douglass Hospital
Chattanooga, Tennessee Dover, New Hampshire Alan Ganapol, EMT-B, EMT-1/C,
BChE, MChE
J ohn C. Coo k , MBA, NREMT-P, Rommie L. Duc kworth, LP
CCEMT-P, NCEE New England Center for Rescue & objectiveQUEST
West Tisbury, Massachusetts
Jefferson College of Health Emergency Medicine
Sciences Shennan,Connecticut Scott A. Gano, BS, NRP, FP-C,
CCEMT-P
Roanoke, Virginia Michael J . Duna way, BHS, NRP, CCP
Greenville Technical College Columbus State Community College
Scott Cook, MS, CCEMT-P Columbus, Ohio
Southern Maine Community College EMT/Paramedic Department
South Portland, Maine Greenville, South Carolina Scott C. Garrett, AHS, EFO, NRP,
CCP
Patt Cope, MEd , NRP Ric hard Ellis, BSOE, NRP
Arkansas State University-Beebe Central Georgia Technical College Westview-Fairforest Fire Department
Searcy, Arkansas Macon, Georgia Spartanburg, South Carolina

Dennis L. Cosby, PM, CCP, EMS II Erik M. Eps kamp, P aramedic-IC, William Scott Gilmore, MD, EMT-P
Lee County EMS Ambulance, Inc. Instructor II Washington University School of
Donnellson, Iowa
Huron Valley Ambulance EMS Medicine
Dwayne Cottel, ACP, A-EMCA, Education St. Louis Fire Department
CQIA, NCEE Saint Louis, Missouri
Ann Arbor, Michigan
Southwest Ontario Regional Base David Gle nde nning, EMT-P
Hospital Program Shari E vans, RN, FP-C New Hanover Regional Medical
Air Evac EMS. Inc,
London Health Sciences Centre Mineral Wells, Texas Center-EMS
London , Ontario, Canada Wilmington, North Carolina
Ronald L. F eller , Sr., MBA, NRP
Sha wn Cr owley, MSN, RN, Oklahoma EMS for Children Kathleen D. Grote, EMT-P
CCEMT-P Oklahoma City Community College Anne Arundel County Fire
Moore, Oklahoma
Pee Dee Regional EMS Department
Florence, South Carolina Tom Fitts, RN, NREMT-P, MEd Millersville, Maryland
East Central College
lqndal M. Curry, MA, NRP Union, Missouri Anthony Gu e rne, BA, NREMT-P
Southern Union State Community Suffolk County Emergency Medical

College Services
Opelika, Alabama Suffolk County, New York

xxii Reviewers

James R. Hanley, MD, FAAP Dana Hunnewell, NREMT-P, David Kemper, EMT-P, FP-C, CMTE,
Ochsner Clinic Foundation Hospital CCEMT-P NAEMSE
Department of Emergency Medicine
New Orleans, Louisiana Chocowinity EMS University of Cincinnati Medical Center
Chocowinity, North Carolina Cincinnati, Ohio

Poul Anders Hansen, MD Scott A. Jaeggi, AS, EMT-P Michael Kennard, AS, Paramedic, I/C
Head of the Pre hospital Care Mt. San Antonio College EMT & New Hampshire Division of Fire

Organization , North Denmark Region Paramedic Program Standards and Training-EMS
Chair PHTLS Denmark Walnut, California Concord, New Hampshire
Aalborg, Denmark
Vanessa L. Jewett, RN, CEN, Alan F. Kicks, BE, EMT-Instructor
Anthony S. Harbour, BSN, MEd, RN, NREMT-P Bergen County EMS Training Center
NRP Paramus, New Jersey
EMSTAR Educational Facility
Southern Virginia Emergency Medical Elmira, New York Randall C. Kirby, BS/EMTP, PCC, I/C
SeIVices Tennessee Technological University
Micha el B. Johnson, MS, NRP Hartsville, Tennessee
Roanoke, Virginia Wallace State College
Hanceville, Alabama Melodie J. Kolmet z, PA-C, EMT-P
Randy Hardick, BA, NREMT-P Monroe Ambulance
Saddleback College Paramedic Program Vmcent J. Johnson, EMT-P Rochester, New York
Mission Viejo, California New York City Fire Department
New York, New York Edward "Ted" Lee, AAS, BS, MEd,
Richard Hayne, RN NREMT-P, CCEMT-P
Glendale Community College Karen Jones, EMT-P
Glendale, California Mason County EMS Trident Technical College
Point Pleasant, West Virginia Charleston South Carolina
Timothy M. Hellyer, MAT, EMT-P
Ivy Tech Community College Twilla Jones, NREMT William J. Leggio, Jr., EdD, MS, BS
South Bend, Indiana South Bossier Parish Fire EMS, NREMT-P

Greg P. Henington, L. Paramedic, District 1\vo Prince Sultan bin Abdul Aziz College
NREMT-P Elm Grove, Louisiana for EMS

Terlingua Fire & EMS Kevin F. Jura, NRP King Saud University
Terlingua, Texas State of Maryland Department of Riyadh, Kingdom of Saudi Arabia

Victor Robert Hernandez, BA, EMT-P Health & Mental Hygiene David C. Leisten, BA, CCEMT-P,
Emergency Training & Consultations Office of Preparedness & NREMT-P
Truckee, California
Response Rochester, New York
David A. Hiltbrunn, AGS, NRP, Baltimore, Maryland
CCTP Arthur J. Lewis II, NREMT-P
Greg J. Kapinos, EMT-P IIC, MPH, East Baton Rouge Parish
St. Mary Corwin Pre-Hospital Education SPHR Department of Emergency Medical
Pueblo, Colorado
Solutions in Human Resource SeIVices
Ed Hollowell, RN, CFRN, CEN, Management Baton Rouge, Louisiana
NREMT-P, CCP-C, FF
Scarborough, Maine Robert Loiselle, MA, NREMT-P,
Regional Fire & Rescue EMSIC
Estrella Mountain Community College Charmaine Kaptur, BSN, RN, NRP
Avondale, Arizona Tualatin Valley Fire & Rescue Education Training Connection
Sherwood, Oregon McLaren Bay Region E MS
Midland, Michigan
Cathryn A. Ho lstein, CCEMT-P, SEI Kevin Keen, AEMCA
Rural/Metro Ambulance Hamilton Fire Department Elizabeth Morgan Luter, NREMT-P
Seattle, Washington Hamilton, Ontario, Canada O'Fallon, Missouri

Review ers xxiii

Kevin M. lqnch, NYS-EMT/NYS-CLI Joseph R. McConomy, Jr., MICP, EMT-I Thomas W. Nichols, AAS,
Greenburgh Police/EMS Burlington County Emergency Services NREMT-P
Eastchester, New York
Training Center Tulsa Technology Center
Susan M. Macklin, BS, EMT-P Westampton, New Jersey Tulsa, Oklahoma
Central Carolina Community College
Olivia, North Carolina Michael McDonald, RN, NRP Keith Noble, Captain, MS, TX LP,
Loudoun County Department of Fire NREMT-P
Larry Macy, NREMT-P
Western Wyoming Community College Rescue and Emergency Management Austin Travis County EMS
Rock Springs, Wyoming Leesburg, V"rrginia Kyle, Texas

Jeanette S. Mann, RN, BSN, Gerard McEntee, MS, EMT-P Chris O'Connor, MSc, Dip EMT,
NREMT-P Union County College NREMT-P, NQEMT-AP
Plainfield, New Jersey
Dabney S. Lancaster Community College Medical Ambulance Service
Clifton Forge, Virginia Janis J. McManus, MS, NREMT-P Dublin, Ireland
Virtua Emergency Medical Services
Amy Marsh, BA, NREMT-P Mt Laurel, New Jersey Amiel B. Oliva, BSN, RN, R-EMT-B
Sioux Falls Fire Rescue EMR Healthcare & Safety Institute
Sioux Falls, South Dakota Matt McQuisten, BS, NRP Quezon City, Philippines
Avera Health
Scott Matin, MBA Sioux Falls, South Dakota Chris Ottolini, EMT-P
MONOC Coast Life Support District
Wall, New J ersey Darren S. Meador, NREMT-P Gualala, California
Valle Ambulance District Santa Rosa Junior College Public Safety
Nancy Mayeda-Brescia, MD, OTD, Desoto, Missouri
APRN, MBA, EMSI, NREMT-P Training Center
Wmdsor, California
Rocky Hill EMS
Rocky Hill, Connecticut Christopher Metsgar, MS, NRP, NCEE Norma Pancake, BS, MEP,
HealthONE EMS NREMT-P
David "Bernie" McBurnett, AAS, Englewood, Colorado
NREMT-PI/C Pierce County EMS Office
Kelly Miyashiro, EMT Tacoma, Washington
Chattanooga Fire Department American Medical Response
Chattanooga, Tennessee Seattle, Washington Sean F. Peck, MEd, EMT-P
WestMed College
Randall McCargar, NREMT-P Jerry D. Morris, BA, NREMT-P Chula Vista, California
Cherry Hill Fire Department Center for Prehospital Medicine
Cherry Hill, New Jersey Carolinas Medical Center Mark Pet erson, NREMT-P
Charlotte, North Carolina Hardin County EMS
Elizabethtown, Kentucky

Kevin McCarthy, MPA, NREMT-P Frederick Mueller, EMTP, NREMT-P, Rick Petrie, EMT-P
Adjunct Faculty-Department EMS I/C Atlantic Partners EMS
Wmslow, Maine
of Emergency Services Temple University Health System
Utah Valley University Deborah L. Petty, BS, CICP,
Orem, Utah Transport Team EMT-P I/C
Philadelphia, Pennsylvania
St. Charles County Ambulance
Candace McClain, MBA, BSN, RN, Daniel W. Murdock, AAS, District
NREMT-P, CEN, CCEMT-P NREMT-P, CLI
St. Peters, Missouri
Ray County Ambulance District SUNY Cobles kill Paramedic Program
Orrick, Missouri Cobleskill, New Yor k John C. Phelps II, MAM, BS,
NREMT-P
Cliff McCollum, Chief, EMT-B, Senior Ivan A. Mustafa, EMTIP, MSN,
EMS Instructor ARNP-C, CEMSO, EFO, CFO Sutton County EMS
UTHSCSA
Pierce County Fire District 13 Seminole County Fire Department Sonora, Texas
Tacoma, Washington
Sanford, Florida

xxiv Reviewers

Mark Podgwaite, NRAEMT, Thomas Russell, MS , Paramedic William D. Shelton, AAS, BS,
NECEMS I/C CT Training & Consulting Institute NREMT-P
Portland, Connecticut
Vermont EMS District 5 Fayetteville Technical Community
Danville, Vermont Christopher T. Ryth er, MS, NRP College
American River College
J ohn Eric P owell, PhD Sacramento, California Benson, North Carolina
Walters State Community College
Morristown, Tennessee Paul Salway, Lieuten ant, CCEMT-P, Sha drach Smith, BS Bio, NREMT-P,
NREMT-P LP
Alice J. Quiroz, BSN, CM
Past Affiliate Faculty South Portland Fire Department Paramedic Advantage
349th Medical Group, Travis Air Force South Portland, Maine Orange, California

Base (2001-2008) Ian T. T. Santee, MICT, MPA Bradley L. Spratt, BS, LP, NRP, EMS-I
Gold River, California City and County of Honolulu Salus Training Solutions
Honolulu Emergency Services The Woodlands, Texas
Stephen Rea, NREMT-P, BS/HCM
Thomas Jefferson EMS Council Department Tynell N. Stackhouse, MTh, NREMT-P
Charlottesville, Virginia Honolulu, Hawaii Pee Dee Regional EMS, Inc.
Floren ce, South Carolina
J ohn Reed , MPH, BSN, RN, J ason Sch eiderer, BA,
P a r am e d ic NREMT-P Robert Stakem, Jr., CCEMT-P
Harrisburg Area Community College
Birmingham Regional EMS System Wishard EMS Harrisburg, Pennsylvania
Birmingham, Alabama IUPUI
Indianapolis EMS Andrew W. Stern, NREMT-P,
Timothy J . Reit z, BS, NREMT-P, Indianapolis, Indiana CCEMT-P, MA, MPA
NCE E
Justin Schindler, Hudson Valley Community College
Conemaugh Memorial Medical Center NREMT-P Cardiorespiratory & Emergency Medicine
School of EMS
Johnstown, Pennsylvania Brighton Volunteer Ambulance Department
Rochester, New Yor k Troy, New Yor k
Les Remington , EMT-P, I/C, EMS
Educator J ar ed Schoenfeld, NREMT-P, CIC, R. E. Suarez, CCEMT-P, NCEE
AHATCF Suarez, Lepp ert, & Associates, LLC
Genesys Regional Medical Center Cap e Fear Tactical Medicine
Grand Blanc, Michigan Kingsboro Community College Clermont, Florida
Brooklyn, New York
Deborah Rich eal, NREMT-P, EMS Daniel A. Svenson, BA, NREMT-P
Educator Barry M. Schyma , BSc ( ho ns) Portland Fire Department
Biomed , MBChB, FRCA Westbrook, Maine
Cap ital Health System
Trenton , New Jersey Department of Anaesthetics, Critical David M. Tauber, BS, NR-P, CCEMT-P,
Care and Pain Medicine FP-C, NCEE
Paul Rich ard son , P aramedic, Lead
Ins tructo r Royal Infirmary of Edinburgh Yale New Haven Sponsor Hospital
United Kingdom New Haven, Connecticut
OSK St. Francis Medical Center Advanced Life Support Institute
Peoria, Illinois Anthony Scott, BA, NREMT-P Conway, New Hampshire
Montgomery County,
Katharine P. Rick ey, BS, Brent Thomas, Paramedic
NRParamedic, EMS I/C Maryland Division of Orillia Fire Department
Fire/Rescue Services Orillia, Ontario,Canada
EMS Educator Westminster, Maryland
Epsom, New Hampshire Candice Thompson, BS, LAT,
Christopher M. Seguin, NR-P, NREMT-P
Nicholas Russell, AAS, NREMT-P, E MS -1/C
E MS - I Centre for Emergency Health Sciences
Northwoods Center for Continuing Spring Branch, Texas
Edgewood Fire/EMS Education
Edgewood, Kentucky Review ers xxv
Campton, New Hampshire

Joshua 'Illton , FF-II, NR-P, CCEMT-P, Eric P. Victorin, MBA, EMT-I, J ackilyn E. Williams, RN, MSN,
EMS-I, FF-I NREMT-P NREMT-P

Malta-McConnelsville Fire Dutchess Community College Portland Community College Paramedic
Department Wappingers Falls, New York Program

Zanesville, Ohio Patricia A. Vmcent , NREMT-P, MICP, Portland, Oregon
BSOE
William F. Toon, EdD, Evelyn Wils on, MHS, NREMT-P
NREMT-P Anchorage Fire Department Western Carolina University
Anchorage, Alaska Cullowhee, North Carolina
Johnson County MED-ACT
Olathe, Kansas Carl Voskamp, LP, CCEMT-P Rich WISniewski, BS, NREMT-P
Victoria College South Carolina Department of Health and
William Torres, Jr., NREMT-P Victoria, Texas
Marcus Daley Hospital-EMS Environmental Control
Hamilton, Montana Gary S. Walter, BA, NREMT-P Division of EMS and Trauma
Union College Columbia, South Carolina
Patricia Tritt, RN, MA International Rescue and Relief Program
HealthONE EMS Lincoln, Nebraska Andrew L. Wood, MS, NREMT-P
Englewood, Colorado Emergency Medical Training

Brian J . Turner, NREMT-P, David Watson, NREMT-P, CCEMT-P Professionals, LLC
CCEMT-P,RN Pickens County EMS Lexington, Kentucky
Pickens, South Carolina
Clinton, Iowa Michael J. Yo ung, BS, MEd, NREMT-P,
CCEMT-P
Elsa Tuttle, RN, BSN, CCEMT-P Christopher Weaver, NRP, CCEMT-P
Central Jackson County Fire Protection Venture Crew 911 University of Maryland Fire and Rescue
St. Anthony Hospital Institute, ALS Division
District Lakewood, Colorado
Blue Springs, Missouri Oxford, Maryland

Rebecca Valentine, BS, EMT-P, l/C, Ernie Whitener, MS, LP Justin Yurong, BS, NRP
NCEE Texas A&M Engineering Extension Yakima County Department of EMS
Yakima, Washington
Clinical Education Specialist Service
Natick, Massachusetts Station, Texas Jeff Zuckernick , BS, MBA,
NREMT-P
Sara VanDusseldorp, NREMT-P, Charlie Williams, EMTP, EdS
CCEMT-P, NCEE Walters State Community College University of Hawaii-Kapiolani
Morristown, Tennessee Community College
Burlington, Wisconsin
Honolulu, Hawaii

xxvi Reviewers

PHTLS Honor Roll

PHTLS continues to prosper and promote high standards of trauma care all over the world. This success would not be possible without the
contributions ofmany dedicated and inspired individuals over the past three decades. Some of those mentioned below were instrumental in the
development ofour first textbook. Others were constantly "on the road" spreading the word. Still others "put out fires" and otherwise p roblem-solved
to keep PHTLS growing. The PHTLS Committee, along with the editors and contributors of this, our eighth edition, would like to express our thanks to

all of those listed below. PHTLS lives, breathes, and grows because ofthe efforts ofthose who volunteer their time to what they believe in.

Gregory H. Adkisson, MD Bret Gilliam Mark Reading
Melissa Alexander Jack Grandey Brian Reiselbara
Jameel Ali, MD Vincent A. Greco Lou Romig, MD
Stuart Alves NitaJ. Ham J effrey S. Salomone, MD
Augie Bamonti Donald Scelza
J.M. Barnes Mark C. Hodges John Sigafoos
Morris L. Beard Walter Idol Paul Silverston, MD
Ann Bellows Alex Isakov, MD David Skinner
Ernest Block, MD Lenworth Jacobs, MD Dale C. Smith
Chip Boehm Craig Jacobus Richard Sobieray
Don E. Boyle, MD Lou Jordan Sheila Spaid
Susan Brown Richard Judd Michael Spain
Susan Briggs, MD Jon A. King Don Stamper
Eduard Kompast Kenneth G. Swan, MD
Jonathan Busko Jon R. Krohmer, MD Kenneth G. Swan, Jr., MD
Alexander Butman Peter LeTarte, MD David M. Tauber
H. J eannie Butman Robert W. Letton, Jr. Joseph J. Tepas III, MD
Christain E. Callsen, Jr. Mark Lockhart Brian M. Tibbs
Steve Carden, MD Josh Vayer
Edward A. Casker DawnLoehn Richard Vomackat
Bud Caukin Robert Loftus Demetrios Vourvachakis, MDt
Hank Christen Greg C. Lord Robert K. Waddell, II
David Ciraulo Fernando Magallenes-Negrete, MD Michael Werdmann
Paul M. Maniscalco Carl Werntz
Victoria Cleary Scott W. Martin Elizabeth Wertz
Philip Coco Don Mauger Keith Wesley, MD
Frederick J . Cole William McConnell, DO David E. Wesson
Keith Conover Merry McSwain Roger D. White, MD
Arthur Cooper, MD Kenneth J. Wright
JelCoward John Mechtel David Wuertz
Michael D'Auito Claire Merrick Al Yellin, MD
Alice "Twink" Dalton Bill Metcalf Steven Yevich
Judith Demarest George Moerkirk Doug York
Joseph P Dineen, MD Stephen Murphy Alida Zamboni
Leon Dontigney, MD
Joan Drake-Olsen Lawrence D. Newell Ag;iin, thanks to all ofyou, andthanks to everyone
Mark Elcock, MD Jeanne O'Brien around the world for making PIITIB work
Blaine L. Endersen, MD Dawn Orgeron
Betsy Ewing Eric Ossmann PHTLS Co mmittee
Mary E. Fallat, MD Editors and Contributors of PHTLS
Milton R. Fields, III James Paturas
Scott B. Frame, MDt Joseph Pearce t Deceased
Sheryl G. A. Gabram Thomas Petrich
Valerie J. Phillips, MD
James Pierce

Brian Plaisier

Foreword

Prehospital personnel perform a unique service that cannot be developing prehospital care. In partnership with Will Chapleau
rendered by any other individual or group. Tirrough effective over the last 20 years, they have developed the PHTLS program
application of their lrnowledge and skills at the scene of an acci- to the point that it is the standard for prehospital care in trauma
dent or illness, they are in the enviable position to be able to save throughout the world.
lives and prevent or alleviate suffering.
Their partnership has been accompanied by the contributions
Patients in the prehospital setting do not get to choose their of many others, but their relationship and the professionalism
providers. These providers accept the responsibility to deliver they have engendered through their leadership have made the
patient care in some of the worst situations. The scene is often program what it is today. Prehospital care providers are proud
chaotic, accompanied by hazard and even inclement weather. individuals and carry their heads high with the utmost dedi-
The professionalism that defines prehospital personnel ensures cation. We would not see the amazing accomplishments that
that patients are cared for by someone who is well trained and have occurred in trauma care without their participation. Their
prepared, and who brings a passion and caring that is a unique professionalism is in part due to the leadership provided by
inspiration in medicine. Dr. McSwain and Mr. Chapleau.

All medical professionals ultimately have a bond with the On behalfofthe Eighth Edition contributors and through my
public, and the public's trust in us is based on our preparedness honor to write this foreword, I would like to dedicate the Eighth
and accountability. Prehospital Trauma Life Support (PHTLS) Edition of the PHTLS program textbook to the partnerships and
provides the basis for this trust in prehospital trauma care. By teamwork we see every day in prehospital care providers and the
design, it links to Advanced Trauma Life Support (ATLS) at the physicians and nurses they work with. This is exemplified by the
hospital level. The basic premise of PHTLS is that prehospital leadership model and by living the values of Dr. McSwain and
care providers think critically, particularly under stress, and use Mr. Chapleau. We are lucky to have the legacy created in the pre-
their technical skills to deliver excellent patient care, based on hospital community and the contributions that these two leaders
an excellent foundation of lrnowledge. have provided to make this possible.

Of all the advancements in trauma care in the last 50 years, David B. Hoyt, MD, FACS
the development of prehospital care, the training that estab- Executive Director
lishes readiness, and the development of trauma centers and American College of Surgeons
trauma systems have led to the greatest reductions in mortality. Chicago, Illinois
Dr. Norman McSwain, for over 40 years, has dedicated his life to

Preface

Providers of prehospital care must accept the responsibility to apply to the myriad of unique situations encountered in the
provide patient care that is as close to absolutely perfect as po&- prehospital setting.
sible. This cannot be achieved with insufficient lmowledge of the
subject. We must remember that the patient did not choose to be Up-to-Date Information
involved in a traumatic situation. On the other hand, the prehospi-
tal care provider has chosen to be there to take care of the patient. Development of the PHTLS program began in 1981, on the heels
The prehospital care provider is obligated to give 100% of his or of the inception of the Advanced Trauma Life Support (ATLS)
her effort during contact with every patient. The patient has had a program for physicians. As the ATLS course is revised every 4 to
bad day; the prehospital care provider cannot also have a bad day. 5 years, pertinent changes are incorporated into the next edition
The prehospital care provider must be sharp and capable in the of PHTLS. This eighth edition of the PHTLS program has been
competition between the patient and trauma and death. revised based on the 2012 ATLS course as well as subsequent
publications in the medical literature. Although following the
The patient is the most important person at the scene of an ATLS principles, PHTLS is specifically designed for the unique
emergency. There is no time to think about the order in which requirements ofcaring for trauma patients in the prehospital set-
the patient assessment is performed or what treatments should ting. A new chapter has been added, and other chapters have
take priority over others. There is no time to practice a skill been extensively revised. The new chapter includes information
before using it on a particular patient. There is no time to think on the physiology of life and death. Video clips of critical skills
about where equipment or supplies are housed within the jump and an eBook are available online.
kit. There is no time to think about where to transport the irtjured
patient. All of this information and more must be stored in the Scientific Base
prehospital care provider's mind, and all supplies and equipment
must be present in the jump kit when the provider arrives on the The authors and editors have adopted an "evidence-based"
scene. Without the proper lmowledge or equipment, the preho&- approach that includes references from medical literature sup-
pital care provider may neglect to do things that could increase porting the key principles, and additional position papers pub-
the patient's chance of survival. The responsibilities of a preho&- lished by national organizations are cited when applicable. Many
pital care provider are too great to make such mistakes. references have been added, allowing those prehospital care
providers with inquisitive minds to read the scientific data sup-
Those who deliver care in the prehospital setting are integral porting our recommendations.
members ofthe trauma patient care team, as are the nurses or phy-
sicians in the emergency department, operating room, intensive The PHTLS Family of Educational Offerings
care unit, ward, and rehabilitation unit. Prehospital care providers
must be practiced in their skills so that they can move the patient Since the introduction of the PHTLS course in 1981, PHTLS has
quickly and efficiently out ofthe environment ofthe emergency and continued to expand its educational offerings to encompass all
transport the patient quickly to the closest appropriate hospital. levels and types of prehospital trauma care providers.

Why PHTLS? • PHTLS: A 16--hour course for emergency medical
responders, emergency medical technicians, para-
Course Education Philosophy medics, nurses, physician assistants, and physicians.
The PHTLS provider course is offered in one of two
Prehospital Trauma Life Support (PHTLS) focuses on principles, formats: the traditional face-to-face format with lec-
not preferences. By focusing on the principles of good trauma tures and skill stations; or a hybrid format, where a
care, PHTLS promotes critical thinking. The PHTLS Committee portion of the course is taken online in an interactive,
of the National Association of Emergency Medical Technicians web-based format, followed by one day of face-to-face
(NAEMT) believes that emergency medical services (EMS) prac- classroom interaction for skill station instructions and
titioners make the best decisions on behalfoftheir patients when evaluations.
given a sound foundation of key principles and evidence-based
lmowledge. Rote memorization of mnemonics is discouraged. • PHTLS Refresher Course: An 8-hour course for indi-
Furthermore, there is no one "PHTLS way" of performing a viduals who have successfully completed a PHTLS pro-
specific skill. The principle of the skill is taught, and then one vider course or other approved trauma provider course
acceptable method of performing the skill that meets the prin- within the past 4 years.
ciple is presented. The authors realize that no one method can

• Trauma First Response (TFR): An 8-hour course • To provide a description of the physiology and kinemat-
that teaches the principles of PHTLS to non-EMS ics of injury
practitioners, including first responders (emergency
medical responders), police officers, fire fighters, res- • To provide an understanding of the need for rapid
cue personnel, and safety officers, to help them prepare assessment ofthe trauma patient
to care for trauma patients while serving as part of a
transport team or awaiting a transport provider. • To advance the participant's level of knowledge in
regard to examination and diagnostic skills
• Tactical Combat Casualty Care (TCCC): A 16--hour
course that introduces evidence-based, lifesaving tech- • To enhance the participant's performance in the assess-
niques and strategies for providing the best trauma ment and treatment of the trauma patient
care on the battlefield. TCCC courses are conducted
under the auspices of PHTLS. The course is designed • To advance the participant's level of competence in
for combat EMS/military personnel, including medics, regard to specific prehospital trauma intervention skills
corpsmen, and pararescue personnel deploying in sup-
p ort ofcombat operations. NAEMT's TCCC courses use • To provide an overview and establish a management
the PHTLS: Prehospital Trauma Life Support, Mili- method for the prehospital care of the multisystem
tary Edition, textbook and are fully compliant with trauma patient
the Department of Defense's Committee on Tactical
Combat Casualty Care (CoTCCC) guidelines. It is the • To promote a common approch for the initiation
only TCCC course endorsed by the American College and transition of care beginning with civilian first
of Surgeons. responders continuing up and through the levels
of care until the patient is delivered to definitive
• Tactical Emergency Casualty Care (TECC): medical care

A 16--hour course, derived from TCCC, that introduces It is also fitting to reprise our mission statement, which was
evidence-based, lifesaving techniques and strategies for written in a marathon session at the NAEMT conference in 1997:
providing the best trauma care in the civilian tactical
situation or hazardous environment. TECC courses are The Prehospital Trauma Life Support (PHTLS)
con ducted under the auspices of PHTLS. The course program of the National Association of Emergency
is designed for civilian EMS responders deploying in Medical Technicians (NAEMT) serves trauma vic-
support of tactical or other hazardous operations. tims through the global education of prehospital care
providers of all levels. With medical oversight from
• Law Enforcement and First Response Tactical the American College of Surgeons Committee on
Casualty Care (LEFR-TCC): An 8-hour course that Trauma (ACS-COT), the PHTLS programs develop
teaches public safety first responders including police, and disseminate educational materials and scientific
other Jaw enforcement officers, fire fighters, and other information, and promote excellence in trauma patient
first responders (emergency medical responders) the management by all providers involved in the delivery of
basic medical care interventions that will help save prehospital care.
an injured responder's life until EMS practitioners can
safely enter a tactical scene. It combines the principles The PHTLS mission also enhances the achievement of the
of PHTLS and TCCC, and meets the recommendations of NAEMT mission. The PHTLS program is committed to quality
the Hartford Consensus document and TECC guidelines. and performance improvement. As such, PHTLS is always atten-
tive to changes in technology and methods of delivering prehos-
• Bleeding Control for the Injured (BCon): A 2-hour pital trauma care that may be used to enhance the clinical and
service quality of this program.
course that teaches lay individuals the basic steps neces-
saryto stop external hemorrhage after a traumatic event. Support for NAEMT

PHTLS-Commitment and Mission NAEMT provides the administrative structure for the PHTLS
program. All profits from the PHTLS program are channeled
As we continue to pursue the potential of the PHTLS course and back into NAEMT to provide funding for issues and programs
the worldwide community of prehospital care providers, we that are of prime importance to EMS professionals, such as edu-
must remember the goals and objectives of the PHTLS program: cational conferences and advocacy efforts on behalf of prehos-
pital care providers.

xxx Preface

PHTLS Is a World Leader NAEMT strives to provide the highest quality continuing
education programs. All NAEMT continuing education programs
Because of the unprecedented success of the prior editions of are developed by highly experienced EMS educators, clinicians,
PHTLS, the program has continued to grow by leaps and bounds. and medical directors. Course content incorporates the latest
PHTLS courses continue to proliferate across the United States, research, newest techniques, and innovative approaches in EMS
and the U.S. military has adopted it, teaching the program to U.S. learning. All NAEMT continuing education programs promote
Armed Forces personnel at over 100 course sites worldwide. critical thinking as the foundation for providing quality care.
PHTLS has been taught in more than 66 nations, and many oth- This is based on the belief that EMS practitioners make the best
ers are expressing interest in bringing PHTLS to their countries decisions on behalf of their patients when given a sound founda-
in efforts to improve prehospital trauma care. tion of evidence-based knowledge and key principles.

Prehospital care providers have the responsibility to Once developed, continuing education programs are tested
assimilate this knowledge and these skills in order to use them and refined to ensure that course materials are clear, accurate,
for the benefit of the patients for whom they are responsible. and relevant to the needs of EMS practitioners. Finally, all con-
The editors and authors of this material and the PHTLS Com- tinuing education programs are regularly updated no less than
mittee of NAEMT hope that you will incorporate this infor- every 4 years to ensure that the content incorporates the most
mation into your practice and daily rededicate yourself to the up-to-date research and practices.
care of those persons who cannot care for themselves-the
trauma patients. NAEMT provides ongoing support to its instructors and the
EMS training sites that hold its courses. Over 1,800 training sites,
National Association of Emergency including colleges, EMS agencies, hospitals, and other training
Medical Technicians centers located in the United States and over 50 other countries,
offer NAEMT continuing education programs. NAEMT head-
The National Association of Emergency Medical Technicians quarters staff work with the networ k of continuing education
(NAEMT) was founded in 1975 to serve and represent the program volunteers from committee members; national,
professional interests of EMS practitioners, including para- regional, and state coordinators; and affiliate faculty to provide
medics, emergency medical technicians, and emergency medi- administrative and educational support.
cal responders. NAEMT members work in all sectors of EMS,
including government service agencies, fire departments, hospi- Peter T. Po ns, MD, FACEP
tal-based ambulance services, private companies, industrial and Editor
special operations settings, and the military.
Norman E. McSwain, Jr., MD, FACS, NREMT-P
One of NAEMT's principal activities is EMS continuing edu- Editor-in-Chief, PHTLS
cation. The mission of NAEMT continuing education programs
is to improve patient care through high-quality, cost-effective, Will Chaplean, EMT-P, RN, TNS
evidence-based education that strengthens and enhances the Gregory Chapman, EMT-P, RRT
knowledge and skills of EMS practitioners. Associate Editors

Preface xxxi

Dedication

This text is dedicated to all those individuals the world over who spend countless hours in the cold or the heat, during all hours of
the day or night, in the sun or the rain or the snow, in situations that are safe or dangerous, away from their family and loved ones,
to provide prehospital care to victims of trauma.

At the completion of this chapter, the reader will be able to do the following:

• Recognize the magnitude of the problem both in • Understand t he history and evolution of
human and financial terms caused by traumatic prehospital trauma care.
injury.

• Understand the three phases of trauma care.

2 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

them. We could have chosen another profes- than that of any other critically ill patient. The prehospital
sion, but we did not. We have accepted the care provider can lengthen the life span and productive years
responsibility for patient care in some of the worst situations: of the trauma patient and benefit society by virtue of the
when we are tired or cold; when it is rainy and dark; when we care provided. Through effective management of the trauma
cannot predict what conditions we will encounter. We must patient, the prehospital care provider has a significant influ-
either accept this responsibility or s urrender it. We must give to ence on society.
our patients the very best care that we can-not while we are
daydreaming, not with unchecked equipment, not with incom- Learning, understanding, and practicing the principles of
plete supplies, and not with yesterday's knowledge. We cannot PHTLS will prove more beneficial to your patients than will
know what medical information is current, we cannot purport completing any other educational program.1
to be ready to care for our patients if we do not read and learn
each day. The Prehospital Trauma Life Support (PHTLS) course The Problem
provides a part of that knowledge to the working EMT, but, more
important, it ultimately benefits the person who needs our all- Trauma is the leading cause of death in persons between 1 and
the patient. At the end of each run, we should feel that the patient 44 years of age.2 Over 70% of the deaths between the ages of
received nothing short of our very best. 15 and 24 years and over 40% of deaths between the ages
of 1and14 years are due to trauma Trauma continues to be the
Philosophy of PHTLS eighth leading cause of death in elderly persons. Almost three
times more Americans die of trauma each year than died in
PHTLS provides an understanding of anatomy and physiology, the entire Vietnam War and in the Iraq War through 2008.3 Every
the pathophysiology of trauma, the assessment and care of the 10 years, more Americans die of trauma than have died in all
trauma patient using the ABCDE approach, and the skills U.S. military conflicts combined. Only in the fifth decade of life
needed to provide that care-no more and no less . Patients who do cancer and heart disease compete with trauma as a leading
are bleeding or breathing inadequately have a limited amount cause of death. About 70 times as many Americans die yearly
of time before their condition results in severe disability or from blunt and penetrating trauma in the United States as died
becomes fatal. Prehospital care providers must possess and yearly in the Iraq War.
utilize critical thinking skills to make and carry out decisions
that will enhance the survival of the trauma patient. PHTLS Prehospital care providers can do little to increase the
does not train prehospital care providers to memorize a survival of a cancer patient; with trauma patients, however,
"one size fits all" approach. Rather, PHTLS teaches an under- prehospital care providers can often make the difference
standing of trauma care and critical thinking. Each prehospital between life and death, between temporary disability and serious
care provider-patient contact involves a unique set of circum- or permanent disability, or between a life of productivity and
stances. Ifthe prehospital care provider understands the basis a life of dependency. It is estimated that about 60 million inju-
of medical care and the specific needs of the individual patient ries occur each year in the United States. Of these, 40 million
given the circumstances at hand, then unique patient decisions will require emergency department care, 2.5 million will require
can be made that ensure the greatest chance of survival for hospitalization, and 9 million will be disabling. About 8.7 million
that patient. trauma patients will be temporarily disabled, and 300,000 will be
permanently disabled.4•5
The overarching tenets of PHTLS are that prehospital care
providers must have a good foundation of knowledge, must be The cost for care of trauma patients is staggering. Billions
critical thinkers, and must have appropriate technical skills to of dollars are spent on the management of trauma patients,
deliver excellent patient care, even in less-than-optimal circum- not including the dollars lost in wages, insurance admin-
stances. PHTLS neither proscribes nor prescribes specific istration costs, property damage, and employer costs. The
actions for the prehospital care provider, but instead supplies the National Safety Council estimated that the economic impact in
appropriate knowledge and skills to enable the prehospital care 2007 from both fatal and nonfatal trauma was approximately
provider to use critical thinking to arrive at the best management $684 billion.• Lost productivity from disabled trauma patients
of each patient. is the equivalent of 5.1 million years at a cost of more than $65
billion annually. For patien ts who die, 5.3 million years of life
The opportunity for a prehospital care provider to help a are lost (34 years per person) at a cost of more than $50 billion.
patient is greater in the management of trauma victims than Comparatively, the costs per patient (measured in dollars
in any other patient encounter. The chance for survival of the and in years lost) for cancer and heart disease are much less
trauma patient who receives excellent trauma care, in both (Figure 1-1). The prehospital care provider has an opportunity
the prehospital and the hospital setting, is probably greater to reduce the costs of trauma. For example, proper protection
of the fractured cervical spine by a prehospital care provider
may make the difference between lifelong quadriplegia and a
productive, healthy life of unrestricted activity. Prehospital
care providers encounter many more such examples almost
every day.

CHAPTER 1 PHTLS: Past, Present, and Future 3

...Ill 400 40 36
Trau ma
~ 334
0
0
300 'lii 30
0
0
...I
Ill
:sQ)
'cti 200 20 18
al
0 12
I::l:sl .I.l.l
0 fil E
~
.5 100 88 m 10 Cancer Cardiovascular

~G >
Cancer Cardiovascular
'lii
0
0 0 0

Trauma

AB

Figure 1-1 A . Comparative costs in thousands of dollars to U.S. victims of trauma, cancer, and cardiovascular disease each year.
B. Comparative number of years lost as a result of trauma, cancer, and cardiovascular disease.

Source: Data from the National Safety Council.

The following data come from the World Health Organization -30 29%
(WHO) Road Traffic Irtjuries Fact Sheet No. 358: 2,5_.6%

• Road traffic injuries are a huge public healt h 25
and developmen t problem. Road traffic crashes kill
1.24 million people a year worldwide or an average 20
of 3,242 people every day. They injure or disable
between 20 million and 50 million people a year. -15 13.9% -12.2% .1,0...3% 8.9%
Road traffic crashes rank as the ninth leading cause
of death overall and the number one cause of trauma 10 -~
deaths, accounting for 2.2% of all deaths globally. The
estimated cost of these injuries and deaths is $518 5
billion dollars annually.7 WHO predicts that without
improvements in prevention, 1.9 million people will I
be dyin g annually in motor vehicle crashes by the O ~--~--------~--~-------~
year 2020.
Africa Americas Eastern Europe Southeast Western
• The majority of roa d traffic injuries affect people
in low-income a nd middle-income countries, espe- Mediterranean Asia Pacific
cially young males and vulnera ble road users. Of
all road traffic deaths, over 90% occur in low-income Figure 1-2 Worldwide distribut ion of road traffic deaths.
and middle-income countries• (Figure 1-2).
Source: Data from World Healt h Organizat ion (WHO) Road Traffic Injuries Fact Sheet
• Worldwide, over 5.8 million people die annually No. 358.
from trauma , both unintentional and inten tional."
While road traffic incidents are the most common cause community decided to station an ambulance at the bottom of the
of death, suicide (844,000) and homicide (600,000) are cliff to care for the patients involved in these crashes. The better
the number two and three causes, respectively. 10 alternative would have been to place guardrails along the curve
to prevent the incident from occurring in the first place.
As these statistics clearly show, trauma is a worldwide
problem. Although the specific events that lead to injuries and The Phases of
deaths differ from country to country, the consequences do not. Trauma Care
The impact of preventable injuries is global.
Trauma is no accident, even though it is often referred to as such.
We who work in the trauma community have an obligation An accident is defined as either "an event occurring by chance
to our patients to prevent injuries, not just to treat them after or arising from unknown causes" or "an unfortunate occurrence
the injuries occur. An often-told story about emergency medical
services (EMS) best illustrates this point. On a long, winding
mountain road, there was a curve where cars would often slide
off the road and plummet 100 feet to the ground below. The

4 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

resulting from carelessness, unawareness, ignorance." Most MVC
trauma deaths and injuries fit the second definition but not the 19.6%
first and are preventable. Prevention has had a great deal of
success in developed countries but has a long way to go in devel- Falls Fi rearm
oping countries, with only 15% of the world's nations having 14.9% 17.5%
traffic safety laws. 11 Traumatic incidents fall into two catego-
ries: intentwnal and unintentwnal. Intentional injury results Poisoning
from an act carried out on purpose with the goal of harming, 23. 7%
injuring, or killing. Traumatic injury that occurs not as a result
of a deliberate action, but rather as an unintended or accidental
consequence, is considered unintentional.

Trauma care is divided into three phases: pre-event, event,
and postevent. The prehospital care provider has responsibilities
in each phase.

Pre-event Phase Figure 1-4 Motor vehicle trauma and firearms account for over
one-third of the deaths that result from traumatic injury.
The pre-event phase involves the circumstances leading up
to an injury. Efforts in this phase are primarily focused on Source: Data from the National Center for Injury Prevention and Control: WISQARS.
injury prevention. In working toward prevention of injuries, we Fatal Injury Reports 1999- 2010. Centers for Disease Control and Preventio n. http://
must educate the public to increase the use of vehicle occupant www.cdc.gov/injury/Wisqars/fatal_injury_reports.htm l. Accessed January 2, 2013.
restraintsystems, promote methodsto reduce the use ofweapons
in criminal activities, and promote nonviolent conflict resolu- Motorcycle helmet laws are one example of legislation that
tion. In addition to caring for the trauma patient, all members of has affected injury prevention. In 1966, the U.S. Congress gave
the health care delivery team have a responsibility to reduce the the Department of Transportation the authority to mandate that
number of trauma victims. Currently, violence and unintentional states pass legislation requiring the use of motorcycle helmets.
trauma cause more deaths annually in the United States than all The use of helmets subsequently increased to almost 100%, and
diseases combined. 12 Violence accounts for one-third of these the fatality rate from motorcycle crashes decreased draniatically.
deaths (Figure 1-3). Motor vehicles and firearms are involved The U.S. Congress rescinded this authority from the Department
in more than one-third of all trauma deaths, most of which are of Transportation in 1975. More than half the states repealed
preventable (Figure 1-4). or modified their existing legislation. As states reinstated or
repealed these laws, the mortality rates changed. Recently more
Other/u nknown states have repealed such laws, resulting in increased death rates
0.3% in 2006 and 2007.13

I Motorcycle deaths increased 11% in 2006. 14 The most
likely explanation for this draniatic increase in mortality is the
Suicide decreased use of helmets. Today, only 20 states have universal
21 % helmet laws. In states with such laws, helmet usage is 74%,
whereas in states without such laws, the usage rate is 42%.15 The
Homicide Unintentional decreased number ofstates with universal helmet laws has led to
9% 67% a drop in overall helmet usage from 71% in 2000 to 51% in 2006.
To illustrate the effects ofthese trends, in Florida, a 2002 change
Figure 1-3 Unintentional trauma accounts for more deaths than all in the law was followed by an increased death rate 24% greater
other causes of trauma death combined . than the increase in registrations would have predicted.

Source: Data from the National Center for Injury Prevention and Control: WISQARS. In August 2008, then U.S. Secretary of Transportation, Mary
Fatal Injury Reports 1999--2010. Centers for Disease Control and Prevention. httpJ/ Peters, reported a drop in highway fatalities in automobiles while
www.cdc.gov/inj ury/Wisqars/fatal_injury_reports.html. Accessed January 2, 2013. at the same time there was an increase in motorcycle fatalities.
There has been major improvement in all aspects of vehicular
safety except motorcycles. 16

Another example of preventable trauma deaths involves
driving while intoxicated with alcohol. 17 As a result of pressure
to change state laws regarding the level of intoxication while
driving and through the educational activities of such organiza-
tions as Mothers Against Drunk Driving (MADD), the number
of drunk drivers involved in fatal crashes has been consistently
decreasing since 1989.

CHAPTER 1 PHTLS: Past, Present, and Future 5

Another way to prevent trauma is through the use of child 80
safety seats. Many trauma centers, law enforcement organiza-
tions, and EMS gystems conduct programs to educate parents in -c 60 50%
the correct installation and use of child safety seats.
Q) 20%
The other component of the pre-event phase is prepara-
tion by prehospital care providers for the events that are not ~
prevented by the aforementioned efforts. Preparation includes
proper and complete education with updated information ~ 40
to provide the most current medical care. Just as you must
update your home computer or handheld device with the latest 20
software, you must update your lmowledge with current medical
practices and insights. In addition, you must review the equip- 0
ment on the response unit at the beginning of every shift and
review with your partner the individual responsibilities and Immediate Early Late
expectations of who will carry out what duties. It is just as (weeks)
important to review the conduct of the care when you arrive on (m inutes) (hours)
the scene as it is to decide who will drive and who will be in the
back with the patient. Time to death

Event Phase Figure 1-5 Immediate deaths can be prevented only by injury-
prevention education because some patients' only chance for
The event phase is the moment of the actual trauma. Steps survival is for the incident not to have occurred. Early deaths can be
performed in the pre-event phase can influence the outcome of prevented through timely, appropriate prehospital care to reduce
the event phase. This applies not only to our patients but also mortality and morbidity. Late deaths can be prevented only through
to ourselves. "Do no further harm" is the admonition for good prompt transport to a hospital appropriately staffed for trauma care.
patient care. Whether driving a personal vehicle or an emergency
vehicle, prehospital care providers need to protect themselves R Adams Cowley, MD, founder of the Maryland Institute of
and teach by example. You are responsible for yourself, your
partner, and the patients under your care while in your ambu- Emergency Medical Services (MIEMS), one of the first trauma
lance vehicle; therefore prevent irtjury by safe and attentive
driving. The same level of attention you give to your patient care centers in the United States, defined what he called the Golden
must be given to your driving. Always drive safely, follow traffic
laws, refrain from distracting activities such as cell phone use Hour. 1 Based on his research, Dr. Cowley believed that patients
or texting, and use the personal protective devices available, •
such as vehicle restraints, in the driving compartment and in the
passenger or patient care compartment. who received definitive care soon after an irtjury had a much

Postevent Phase higher survival rate than those whose care was delayed. One

The postevent phase deals with the outcome of the traumatic reason for this improvement in survival is prompt treatment of
event. Obviously, the worst possible outcome ofa traumatic event
is death ofthe patient. Trauma surgeon Donald Trunkey, MD, has hemorrhage and preservation of the body's ability to produce
described a trimodal distribution of trauma deaths. 18 The first
phase of deaths occurs within the first few minutes and up to an energy to maintain organ function. For the prehospital care
hour after an incident. These deaths would likely occur even with
prompt medical attention. The best way to combat these deaths provider, this translates into maintaining oxygenation and perfu-
is through irtjury prevention and safety strategies. The second
phase of deaths occurs within the first few hours of an incident. sion and providing rapid transport to a facility that is prepared
These deaths can often be prevented by good prehospital care
and hospital care. The third phase of deaths occurs several days to continue the process of resuscitation using blood and plasma
to several weeks after the incident. These deaths are generally
caused by multiple organ failure. Much more needs to be learned (Damage Control Resuscitation) and to not elevate the blood
about managing and preventing multiple organ failure; however,
early and aggressive management of shock in the prehospital pressure (over 90 mm Hg) by using large volumes of crystalloid.
setting can prevent some of these deaths (Figure 1-5).
In the United States, an average urban EMS gystem has a

response time (from the time of notification that the incident

occurred until arrival on the scene) of 6 to 8 minutes. A typical

transport time to the receiving facility is another 8 to 10 minutes.

Between 15 and 20 minutes of the magic Golden Hour are used

just to arrive at the scene and transport the patient. lfprehospital

care at the scene is not efficient and well organized, an additional

30 to 40 minutes can easily be spent on the scene. With this time

on the scene added to the transport time, the Golden Hour has

already passed before the patient arrives at the hospital where

the better resources of a well-prepared emergency department

and operating suite are available for the benefit of the patient.

Research data support this concept.20•21 One of these studies

showed that critically irtjured patients had a significantly lower

mortality rate (17.9% vs. 28.2%) when transported to the hospital

by a private vehicle rather than an ambulance.20 This unexpected

finding was most likely the result of prehospital care providers

spending too much time on the scene.

In the 1980s and 1990s, a trauma center documented that

EMS scene times averaged 20 to 30 minutes for patients irtjured

in motor vehicle crashes and for victims of penetrating trauma.

6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

This finding brings to light the questions that all prehospital care restoration of adequate perfusion by replacement of fluids as
providers need to ask when caring for a trauma victim: "Is what I near to whole blood as possible. Administration of reconstituted
am doing going to benefit the patient? Does that benefit outweigh whole blood (packed red blood cells and plasma, in a ratio of 1:1)
the risk of delaying transport?" to replace lost blood has produced impressive results by the mili-
tary in Iraq and Afghanistan and now in the civilian community.
One of the most important responsibilities of a prehos- These fluids replace the lost oxygen-carrying capacity, the clot-
pital care provider is to spend as little time on the scene as ting components, and the oncotic pressure to prevent fluid loss
possible and instead expedite the field care and transport of the from the vascular system. They are not currently available for
patient. In the first precious minutes after arrival to a scene, a use in the field and are an important reason for rapid transport
prehospital care provider rapidly assesses the patient, performs to the hospital. En route to the hospital, balanced resuscitation
lifesaving maneuvers, and prepares the patient for transport. (see the Shock chapter) has proven to be important. Hemostasis
In the 2000s, following the tenets of PHTLS, prehospital scene (hemorrhage control) cannot always be achieved in the field or
times have decreased by allowing all providers (fire, police, and in the emergency department (ED); it must often be achieved
EMS) to perform as a cohesive unit in a uniform style by having in the operating room (OR). Therefore, when determining an
a standard methodology across emergency services. As a result, appropriate facility to which a patient should be transported, it
patient survival has increased. is important that the prehospital care provider utilize the crit-
ical thinking process and consider the transport time to a given
A second responsibility is transporting the patient to an facility and the capabilities of that facility.
appropriate facility. The factor that is most critical to any
patient's survival is the length of time that elapses between A trauma center that has a surgeon available either before
the incident and the provision of definitive care. For a cardiac or shortly after the arrival of the patient, a well-trained and
arrest patient, definitive care is the restoration of a normal heart trauma-experienced emergency medicine team, and an OR team
rhythm and adequate perfusion. Cardiopulmonary resuscitation immediately available can often have a trauma patient with
(CPR) is merely a holding pattern. For a patient whose airway is life-threatening hemorrhage in the OR within 10 to 15 minutes
compromised, definitive care is the management of the airway ofthe patient's arrival (and often faster) and make the difference
and restoration of adequate ventilation. The re-establishment between life and death.
of either ventilation or normal cardiac rhythm by defibrillation
is usually easily achieved in the field. However, as critical care On the other hand, a hospital without such in-house surgical
hospitals develop ST-elevation myocardial infarction (STEM!) capabilities must await the arrival of the surgeon and the
programs, the amount of time from onset of cardiac symp- surgical team before transporting the patient from the ED to the
toms until balloon dilatation of the involved cardiac vessels is OR. Additional time may then elapse before the hemorrhage can
becoming more important."""25 be controlled, resulting in an associated increase in mortality
rate (Figure 1-6). There is a significant increase in survival if
While the management of trauma patients has changed, time nontrauma centers are bypassed and all severely injured patients
is just as critical as ever, perhaps more so. Definitive care for are taken to the trauma center.2'h<l
the trauma patient usually involves control of hemorrhage and

0 Time to OR/ definitive care 100
(in minutes)
D Ambulance response time
D Scenetime 25 50 75
D Transport time
D Surgeon response time Trauma
D OR team response time center

Closest
hospital

Figure 1-6 In locations in which trauma centers are available, bypassing hospitals not committed to the care of trauma patients can
significantly improve patient care. In severely injured trauma patients, definitive patient care generally occurs in the OR. An extra 10 to
20 minutes spent en route to a hospital with an in-house surgeon and in-house OR staff will significantly reduce the time to definitive care
in the OR. (Blue, EMS response time. Purple, on-scene time. Red, EMS transport time. Orange, surgical response from out of hospital. Yellow ,
OR team response from out of hospital.)

CHAPTER 1 PHTLS: Past, Present, and Future 7

Experience, in addition to the initial training in surgery and He developed hospitals that were close to the front lines
trauma, is important. Studies have demonstrated that the more (much like the military of today) and stressed the rapid move-
experienced surgeons in a busy trauma center have a better ment of patients from the field to medical care. Baron Larrey is
outcome than the less experienced trauma surgeons.34•35 now recognized as the father of EMS in the modern era.

History of Trauma Unfortunately, the type of care developed by Larrey was not
Care in Emergency used in the United States 60 years later at the beginning of the
Medical Services American Civil War by the Union Army. At the First Battle of Bull
Run in August 1861, the wounded lay in the field--3,000 for
The stages and development of the management of the trauma 3 days, 600 up to a week.36 Jonathan Letterman was appointed
p atient can be divided roughly into four time periods as described Surgeon General and created a separate medical corps with
by Norman McSwain, MD, in the Scudder Oration ofthe American better organized medical care. At the Second Battle of Bull Run a
College of Surgeons in 1999.36 These time periods are (1) the year later, there were 300 ambulances, and attendants collected
ancient period, (2) the Larrey period, (3) the Farrington era, and 10,000 wounded in 24 hours.38
(4) the modem era. This text, the entire PHTLS course, and care
of the trauma patient are based on the principles developed and In August 1864, the International Red Cross was created at
taught by the early pioneers ofprehospital care. The list of these the First Geneva Convention.32 The convention recognized the
innovators is long; however, a few especially deserve recognition. neutrality of hospitals, of the sick and wounded, of all involved
personnel, and of ambulances and guaranteed safe passage for
Ancient Period ambulances and medical personnel to move the wounded. It
also stressed the equality of medical care provided, regardless
All of the medical care that was accomplished in Egypt, Greece, of which side of the conflict the victim was on. This convention
and Rome, by the Israelites, and up to the time of Napoleon is marked the first step toward the Code of Conduct used by the
classified as premodem EMS. Most of the medical care was U.S. military today. This Code of Conduct is an important compo-
accomplished within some type of rudimentary medical facility; nent of the Tactical Combat Casualty Care Course (TCCC),
little was performed by prehospital care providers in the field. which is now an integral part of the PHTLS program.
The most significant contribution to our Imowledge of this period
is the Edwin Smith papyrus from approximately 4500 years ago, Hospitals, Military, and Mortuaries
which describes the medical care in a series of case reports.
In 1865, the first private ambulance service in the United States
Larrey Period (Late 1700s to was created in Cincinnati, Ohio, at Cincinnati General Hospital.38
Approximately 1950) Several EMS systems soon developed in the United States:
Bellevue Hospital Ambulance"" in New York in 1867; Grady
In the late 1700s, Baron Dominique Jean Larrey, Napoleon's chief Hospital Ambulance Service (the oldest continuously oper-
military physician, recognized the need for prompt prehospital ating hospital-based ambulance) in Atlanta in the 1880s; Charity
care. In 1797, he noted that". .. the remoteness of our ambulances Hospital Ambulance Services in New Orleans, created in 1885 by
deprive the wounded ofthe requisite attention. I was authorized a surgeon, Dr. A. B. Miles; and many other facilities in the United
to construct a carriage which I call flying ambulances."37 He devel- States. These ambulance services were run basically by hospi-
oped these horse-drawn "flying ambulances" for timely retrieval tals, the military, or mortuaries up until 1950.36
ofwarriors injured on the battlefield and introduced the premise
that individuals working in these "flying ambulances" should be In 1891, Nicholas Senn, MD, the founder of the Association
trained in medical care to provide on-scene and en-route care of Military Surgeons, said, "The fate of the wounded rests in the
for patients. hands of one who applies the first dressing." Although prehos-
pital care was rudimentary when Dr. Senn made his statement,
By the early 1800s, he had established the basic theory of the words still hold true as prehospital care providers address the
prehospital care that we continue to use to this day: specific needs of the trauma patient in the field.

• The "flying" ambulance Some changes in medical care occurred during the various
• Proper medical training of medical personnel wars up until the end of World War II, but generally the system
• Movement into the field during battle for patient care and the type of care rendered prior to arrival at the Battalion
Aid Station (Echelon II) in the military or at the back door of the
and retrieval civilian hospital remained unchanged until the mid-1950s.
• Field control of hemorrhage
• Transport to a nearby hospital During this period, many ambulancesin the major cities with
• Provision of care en route teaching hospitals were staffed by interns beginning their first
• Development of frontline hospitals year of training. The last ambulance service to require physicians
on the ambulance runs was Charity Hospital in New Orleans in
the 1960s. Despite the fact that physicians were present, most
of the trauma care was primitive. The equipment and supplies
were not changed from that used during the American Civil War.36

B PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

Farrington Era (Approximately of trained EMS personnel as advocated in the NAS/NRC white
1950 to 1970) paper. Rocco Morando was the leader of the NREMT for many
years and was associated with Drs. Fanington, Hampton,
The era of J. D. "Deke" Fanington, MD (1909 to 1982), began and Artz.
in 1950. Dr. Fanington, the father of EMS in t he United
States, stimulated the development of improved prehospitaJ Dr. Curry's call for specialized training of ambulance atten-
care with his landmark article, "Death in a Ditch."39 In the late dants for trauma was initially answered by using the educa-
1960s, Dr. Fanington and other early leaders, s uch as Oscar tional program developed by Drs. Fanington and Banks, by the
Hampton, MD, and Curtis Artz, MD, brought the United States publication of Emergency Care and Transpor tation of the Sick
into the modem era ofEMS and prehospitaJ care.36 Dr. Fanington and Injured (the "Orange Book") by the American Academy of
was actively involved in all aspects of ambulance care. His work Orthopaedic Surgeons (AAOS), by the EMT training programs
as chairman of the committees that produced three of the initial from the National Highway Traffic Safety Administration
documents establishing the basis of EMS-the essential equip- (NHTSA), and by the PHTLS training program during the past
ment list for ambulances of the American College of Surgeons,'° 25 years. The first training efforts were primitive but have
the KKK 1822 ambulance design specifications of the U.S. progressed significantly in a relatively brief time.
Department of Transportation,41 and the first emergency medical
technician (EMT) basic trainingprogram-also propelled the idea The first textbook of this era was Emergency Care and
and development of prehospitaJ care. In addition to the efforts of Transportation of the Sick and Injured. This was the brain-
Dr. Fanington, others actively helped promote the importance of child of Walter A. Hoyt Jr., MD, and was published in 1971 by the
prehospitaJ care for the trauma victim. Robert Kennedy, MD, was AAOS.36 This text is now in its 10th edition.
the author of Early Care of the Sick and Injured Patient.42 Sam
Banks, MD, along with Dr. Fanington, taught the first prehospitaJ During this same period, the Glasgow Coma Scale was
training course to the Chicago Fire Department in 1957, which developed in Glasgow, Scotland, by Dr. Graham Teasdale and
initiated proper care ofthe trauma patient. Dr. Bryan Jennett for research purposes. Dr. Howard Champion
brought it into the United States and incorporated it into the
A 1965 text edited and compiled by George J. Curry, MD, a care of the trauma patient for assessment of the continued
leader of the American College of Surgeons and its Committee neurologic status of the patient.44 The Glasgow Coma Scale is a
on Trauma, stated: very sensitive indicator of improvement or deterioration ofsuch
patients.
Iajuries sustained in accidents affect every part of the human
body. They range from simple abrasions and contusions to In 1973, federal EMS legislation was created to promote the
multiple complex iajuries involving many body tissues. This development of comprehensive EMS systems. The legislation
demands efficient and intelligent primary appraisal and care, identified 15 individual components that were needed to have
on an individual basis, before transport. It is obvious that the an integrated EMS system. Dr. David Boyd was placed in charge
services of trained ambulance attendants are essential. 1f we of implementing this legislation. One of these components was
are to expect maximum efficiency from ambulance attendants,
a special training program must be arranged." education. This became the basis for the development of training
curricula for EMT-Basic, EMT-Intermediate, and EMT-Paramedic
The landmark white paper, "Accidental Death and Disability: care throughout the United States. Today, these levels of training
The Neglected Disease of Modem Society," further acceler- are called Emergency Medical Technician (EMT), Advanced
ated the process in 1967.43 The National Academy of Sciences/ Emergency Medical Technician (AEMT) and Paramedic. The
National Research Council (NAS/NRC) issued this paperjust one curriculum was initially defined by the U.S. Department of
year after Dr. Curry's call to action. Transportation (DOT) in the NHTSA and became known as the
National Standard Curriculum or the DOT curriculum.
Modern Era of Prehospital Care
(Approximately 1970 to Today) Dr. Nancy Caroline defined the standards and the curric-
ulum for the first paramedic program and wrote the initial
1970s textbook, Emergency Care in the Streets, used in the training
of paramedics. This text is now in its seventh edition.
The modem era of prehospitaJ care began with the Dunlap and
Associates report to the U.S. Department of Transportation in The Blue Star of Life was designed by the American Medical
1968 defining the curriculum for EMT-Ambulance Training. This Association (AMA) as the symbol of the "Medic Alert" indica-
training became known as EMT-Basic, which is known as EMT tion that a patient had an important medical condition that EMS
today. should note. Itwas given to the NREMT by the AMA as the logo of
that registration and testing organization. Because the American
The National Registry of EMTs (NREMT) was established Red Cross would not allow the "Red Cross" logo to be used on
in 1970 and developed the standards for testing and registration ambulances as an emergency symbol, Lew Schwartz, the chief
of NHTSA's EMS branch, asked Dr. Fanington, the chairman of
the NREMT board, to allow NHTSA to use the emblem for ambu-
lances. Permission was granted by Dr. Fanington and Rocco
Morando, the executive director of NREMT. It has since become
an international symbol of EMS systems.36

CHAPTER 1 PHTLS: Past, Present, and Future 9

The National As.5ociation of EMTs (NAEMT) was developed PHTLS-Past,
in 1975 by Jeffrey Harris with the financial support of NREMT. Present, Future
NAEMT is the nation's only organization solely dedicated to
representing the professional interests of all EMS practitioners, Advanced Trauma Life Support
including paramedics, EMTs, emergency medical responders, and
other professionals working in prehospital emergency medicine. As happens so often in life, a personal experience brought about
the changes in emergency care that resulted in the birth of the
1980s Advanced Trauma Life Support (ATLS) course and eventually the
PHTLS program. ATLS started in 1978, two years after a private
In the mid-1980s it became apparent that the trauma patient was planecrashinarural areaof Nebraska TheATLS coursewas born
different from the cardiac patient. Trauma surgeons such as out of that mangled mass of metal, the ir\jured, and the dead. The
Frank Lewis, MD, and Donald Trunkey, MD, recognized the key pilot, an orthopedic surgeon, his wife, and his four children were
distinction between these two groups: For the cardiac patient, flying in their twin-engine airplane when it crashed. His wife was
all or most of the tools needed for reestablishment of cardiac killed instantly. The children were critically ir\jured. They waited
output (CPR, external defibrillation, and supportive medica- for help to arrive, but it never did. After approximately 8 hours,
tions) were available to the properly trained paramedic in the the orthopedic surgeon walked more than half a mile along a dirt
field. For the trauma patient, however, the most important tools road to a highway. After two trucks passed him by, he flagged
(surgical control of internal hemorrhage and replacement of down a car. Together, they drove to the accident site, loaded the
blood) were not available in the field. The importance of moving ir\jured children into the car, and drove to the closest hospital, a
the patient rapidly to the correct hospital became apparent to few miles south of the crash site.
both the prehospital care providers and the medical directors.
A well-prepared facility incorporated a well-trained trauma When they arrived at the emergency room door of the local
team comprised of emergency physicians, surgeons, trained rural hospital, they found it was locked. The on-duty nurse
nurses, and OR staff; a blood bank; registration and quality called the two general practitioners in the small farming commu-
assurance processes; and all of the components necessary for nity who were on call. After examining the children, one of the
the management of the trauma patient. All of these resources doctors carried one of the ir\jured children by the shoulders and
needed to be awaiting the arrival of the patient, with the surgical the knees to the x-ray room. Later, he returned and announced
team standing by to take the patient directly into the OR. Over that the x-rays showed no skull fracture. An ir\jury to the child's
time, these standards were modified to include such concepts cervical spine had not been considered. The doctor then began
as permissive hypotension (Dr. Ken Mattox) and a transfusion suturing a laceration the child had sustained. The orthopedic
ratio close to one part red blood cells for one part plasma (1:1) surgeon called his physician partner in Lincoln, Nebraska, and
(Ors. John Holcomb from the U.S. military and Juan Duchesne told him what had happened. His partner said that he would
in the civilian setting). However, the bottom line of rapid avail- arrange to get the surviving family to Lincoln as soon as possible.
ability of a well-equipped OR has not changed.
The doctors and staff in this little rural hospital had little or
Rapid treatment of the trauma patient depends on a prehos- no preparation for assessing and managing multiple patients with
pital care system that offers easy access to the system. This traumatic ir\juries. Unfortunately, there was a lack of training
access is aided by a single emergency phone number (e.g., 9-1-1 and experience on triage and on assessment and management
in the United States), a good communication system to dispatch of traumatic ir\juries. In the years that followed, the Nebraska
the emergency medical unit, and well-prepared and well-trained orthopedic surgeon and his colleagues recognized that some-
prehospital care providers. Many people have been taught that thing needed to be done about the general lack of a trauma care
early access and early CPR save the lives of those experiencing delivery system to treat acutely ir\jured patients in a rural setting.
cardiac arrest. Trauma can be approached the same way. The They decided that rural physicians needed to be trained in a
principles just listed are the basis for good patient care; to these systematic way on treating trauma patients. They chose to use a
basic principles has been added the importance of internal format similar to Advanced Cardiovascular Life Support (ACLS)
hemorrhage control, which cannot be accomplished outside and call it Advanced Trauma Life Support (ATLS).
of the trauma center and OR. Thus, rapid assessment, proper
packaging, and rapid delivery of the patient to a facility with OR A syllabus was created and organized into a logical
resources immediately available has become the additional prin- approach to manage trauma The "treat as you go" methodology
ciple that was not understood until the mid-1980s. These basic was developed as well as the ABCs of trauma (airway, breathing,
principles remain the bedrock of EMS care today. and circulation) to prioritize the order of assessment and treat-
ment. In 1978, the ATLS prototype was field tested in Auburn,
The accomplishments of these great physicians, prehospital Nebraska, with the help of many surgeons. Next, the course was
care providers, and organizations stand out; however, there are presented to the University of Nebraska and eventually to the
many more, too numerous to mention, who contributed to the American College of Surgeons Committee on Trauma
development of EMS. To all of them, we owe a great debt of
gratitude. Since that first ATLS course in Auburn, Nebraska, over three
decades have passed and ATLS keeps spreading and growing.
What was originally intended as a course for rural Nebraska has

1 0 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

become a course for the whole world, for all types of trauma original taskforce members to fine-tune the program. Mr. Vomacka
settings. It is this course that is the basis of PHTLS. was instrumental in forging a relationship between PHTLS and
the U.S. military. He also worked on the first international PHTLS
PHTLS course sites.

As Dr. Richard H. Carmona, former U.S. Surgeon General, stated National dissemination of PHTLS began with three inten-
in his foreword to the sixth edition of PHTLS: sive workshops taught in Denver, Colorado; Bethesda, Maryland;
and Orlando, Florida, between September 1984 and February
It has been said that we stand on the shoulders of giants in 1985. The graduates of these early PHTLS courses formed what
many apparent successes, and PHTLS is no different. With would be the "barnstormers." These individuals were PHTLS
great vision and passion, as well as challenges, a small group national and regional faculty members who traveled the country
of leaders persevered and developed PHTLS over a quarter of training additional faculty members, spreading the word on
a century ago. the core PHTLS principles. Alex Butman, NREMT-P, along with
Mr. Vomacka worked diligently, frequently using money out of
In 1958, Dr. Farrington convinced the Chicago Fire their own pockets, to bring the first two editions of the PHTLS
Department that fire fighters should be trained to manage emer- program to fruition.
gency patients. Working with Dr. Sam Banks, Dr. Farrington
started the Trauma Training Program in Chicago. Millions have Early courses focused on advanced life support (ALS)
been trained following the guidelines developed in this land- interventions for trauma patients in the field. In 1986, a course
mark program. Dr. Farrington continued to work at every level that encompassed basic life support (BLS) was developed. The
of EMS, from the field to education to legislation, to help expand course grew exponentially. Beginning with those first few enthu-
and improve EMS as a profession. The principles of trauma care siastic faculty members, first dozens, then hundreds, and now
set forth by Dr. Farrington's work form an important part of the thousands of prehospital care providers annually participate in
nucleus of PHTLS. PHTLS courses all over the world. Eventually, these two sepa-
rate courses were merged into one program that teaches the
The first chairman of the ATLS ad hoc committee for the complete approach to the management of the trauma victim in
American College of Surgeons and Chairman of the Prehospital the prehospital setting.
Care Subcommittee on Trauma for the American College of
Surgeons, Dr. Norman E. McSwain, Jr., FACS, knew that ATLS As the course grew, the PHTLS committee became a division
would have a profound effect on the outcome of trauma patients. of the NAEMT. Course demand and the need to maintain course
Moreover, he had a strong sense that an even greater effect could continuity and quality necessitated the building of networks of
come from bringing this type of critical training to prehospital affiliate state, regional, and national faculty members. There
care providers. are national coordinators for every country where PHTLS is
taught. In each country, there are regional and state coordinators
Dr. McSwain, a founding member of the board of directors along with affiliate faculty members to make sure information
of the National Association of Emergency Medical Technicians is disseminated and courses are consistent, whether a prehos-
(NAEMT), gained the support of the Association's president, pital care provider participates in a program in Chicago Heights,
Gary LaBeau, and began to lay plans for a prehospital version Illinois, or in Buenos Aires, Argentina.
of ATLS.44 President LaBeau directed Dr. McSwain and Robert
Nelson, NREMT-P, to determine the feasibility of an ATLS-type Throughout the growth process, medical oversight has been
program for prehospital care providers. provided through the American College of Surgeons Committee
on Trauma. For nearly 20 years, the partnership between the
As a professor of surgery at Tulane University School of American College of Surgeons and the NAEMT has ensured that
Medicine in New Orleans, Louisiana, Dr. McSwain gained the PHTLS course participants receive the opportunity to help give
university's support in putting together the draft curriculum of trauma patients their best chance at survival.
what was to become Prehospital Trauma Life Support (PHTLS).
With this draft in place, a PHTLS committee was established in More recently, Dr. Scott B. Frame, FACS, FCCM (1952-
1983. This committee continued to refine the curriculum, and 2001), was the Associate Medical Director for the PHTLS
later that same year, pilot courses were conducted in Lafayette program. His major emphasis was in the development of the
and New Orleans, Louisiana, the Marian Health Center in Sioux audiovisuals for PHTLS and its promulgation internationally. At
City, Iowa, the Yale University School of Medicine in New Haven, the time of his untimely death, he had assumed the responsibility
Connecticut, and the Norwalk Hospital in Norwalk, Connecticut. of putting together the fifth edition of the PHTLS course. This
included the revision not only of the textbook but also of the
Richard W. Vomacka (1946-2001) was a part of the task instructor's manual and all of the associated teaching materials.
force that developed the initial PHTLS course. PHTLS became his He accepted the appointment to become Medical Director of the
passion as the course came together, and he traveled around the PHTLS course when the fifth edition was published. The PHTLS
country in the early 1980s conducting pilot courses and regional program grew tremendously under Dr. Frame's leadership, and
faculty workshops. He worked with Dr. McSwain and the other its continuation into the future is owing to his efforts and the
part of his life that he lent to PHTLS and to his patients.

CHAPTER 1 PHTLS: Past, Present, and Future 11

It is on the shoulders of these, and many more individuals Brunei, Canada, Chile, China and Hong Kong, Colombia, Costa
too numerous to mention, that PHTLS stands and continues Rica, Cyprus, Denmark, the Dominican Republic, Ecuador, Egypt,
to grow. France, Georgia, Germany, Greece, Grenada, Haiti, India, Ireland,
Israel, Italy, Japan, Kenya, Lebanon, Lithuania, Luxembourg,
PHTLS in the Military Mexico, the Netherlands, North Mariana Islands, Norway, Oman,
Paraguay, Peru, Philippines, Poland, Portugal, Puerto Rico, Saudi
Beginning in 1988, the U.S. military aggressively set out to train its Arabia, Serbia and Montenegro, Singapore, South Africa, Spain,
combat medics in PHTLS. Coordinated by the Defense Medical Sweden, Switzerland, Trinidad and Tobago, the United Arab
Readiness Training lnstitute (DMRTI) at Fort Sam Houston in Emirates, the United Kingdom, the United States, and Uruguay.
Texas, PHTLS was taught to combat medics in the United States Demonstration courses have been held in Bulgaria, Croatia,
and stationed overseas. In 2001, the Anny's 91WB program stan- Macedonia, New Zealand, Panama, and Venezuela, and hopefully
dardized the training of over 58,000 combat medics to include these countries will be added to the PHTLS family in the very
PHTLS. near future.

In the fourth edition of PHTLS, a military chapter was Translations
added to better address the needs of military providers treating
combat-related irtjuries. Afterthe fifth edition was first published, Our growing international family has spawned translations of
a strong relationship was forged between the PHTLS committee the PHTLS text, which is currently available in English, Spanish,
and the newly established Committee on Tactical Combat German, Greek, Portuguese, Fren ch, Dutch, Georgian, Chinese,
Casualty Care of the Defense Health Board in the Department and Italian. Negotiations are ongoing to have the text published
of Defense. As a result of this relationship, a military version of in a number of additional languages.
PHTLS, with an extensively revised military chapter, for a revised
fifth edition was published in 2005. This collaboration between Vision for the Future
the PHTLS committee and the Committee on Tactical Combat
Casualty Care Jed to the creation of multiple military chapters The vision for the future of PHTLS is family. The father of
for the military edition of the sixth edition of PHTLS. PHTLS, Dr. McSwain, remains the foundation for the growing
family that provides vital training and contributes knowledge
PHTLS has been taught numerous times "in theater" during and experience to the world. The inaugural international
the Afghanistan and Iraq Wars and has contributed to the lowest PHTLS Trauma Symposium was held near Chicago, Illinois, in
mortality rate from any armed conflict in U.S. history. the year 2000. In 2010, the first Pan-European PHTLS meeting
was held. These programs bring the work of practitioners and
International PHTLS researchers around the globe together to determine the stan-
dards of trauma care for the new millennium. The support of
The sound principles ofprehospital trauma management empha- the PHTLS family worldwide, all volunteering countless hours
sized in the PHTLS course have led prehospital care providers of their lives, allows the PHTLS leadership to keep PHTLS
and physicians outside the United States to request the impor- growing.
tation of the program to their various countries. ATLS faculty
members presenting ATLS courses worldwide have assisted in As we continue to pursue the potential of the PHTLS course
this effort. This network of trauma surgeons provides medical and the worldwide community of prehospital care providers,
direction and course continuity. we must remember our commitment to the patient by accom-
plishing the following:
As PHTLS has moved across the United States and around
the globe, the PHTLS committee members have been struck by • Rapid and accurate assessment
the differences in our cultures and climates and also by the simi- • Identification of shock and hypoxemia
larities of the people who devote their lives to caring for the sick • Initiation ofthe right interventions at the right time
and irtjured. All of us who have been blessed with the opportu- • Timely transport to the right place
nity to teach overseas have experienced the fellowship with our
international partners and know that we are all one people in the It is also fitting to reprise our mission. The PHTLS mission
pursuit of caring for those who need care the most. continues to be to provide the highest quality prehospital trauma
education to all who wish to avail themselves ofthis opportunity.
The PHTLS family continues to grow with over 700,000 The PHTLS program is committed to quality and performance
prehospital care providers educated in 66 countries and terri- improvement. As such, PHTLS is always attentive to changes in
tories since the program's inception (as of the publication of technology and methods of delivering prehospital trauma care
this edition). Annually, we are offering more than 3,700 courses, that may be used to enhance the clinical and service quality of
training approximately 43,000 students. this program.

As of the publication of this edition, the nations and terri-
tories in the ever-growing PHTLS family include Argentina,
Aruba, Australia, Austria, Barbados, Belgium, Bolivia, Brazil,

12 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

The prehospital care ofthe trauma victim has undergone a profound evolution over the past 60 years and can
essentially be divided into four approaches36:
• Grab and run. No care----either in the field or en route, with rapid transport to the hospital, frequently

without anyone in the patient care compartment-was the system prior to the 1950s.
• Fief,d management and care. This period began with the publication of the National Standard

Curriculum and continued until the late 1970s.
• Stay and ptay. From the mid- to late 1970s until the mid-1980s, the trauma patient and the cardiac

patient were treated exactly alike; that is, attempts were made to stabilize the patient in the field, often
for prolonged amounts of time.
• No-detay trauma care. Beginning in the mid- to late 1980s, it was recognized that the critical trauma
patient could not be "stabilized" in the field but rather required rapid assessment and intervention in an
OR to control hemorrhage. This realization led to the change in prehospital management of the trauma
patient of minimizing the on-scene time and rapid extrication and transport to an appropriate trauma
center with most, if not all, interventions performed while en route.
• Traumais the leading cause of death in patients younger than 44 years of age. Our efforts to provide prehos-
pital care to trauma victims and limit death and disability have a direct effect on the future of our communi-
ties by returning young productive people to their families and their work.
• Even in older populations, people can expect to have many more productive years if they survive trauma
with the least disability possible through the best care available.
• An organized, systematic approach to the care ofthese patients can improve patient survival. This organized
approach begins initially with efforts to prevent irtjury from occurring. When irtjury does occur, the orga-
nized and systematic response of the entire health care delivery team, beginning in the prehospital setting,
will help decrease the morbidity and mortality of traumatic irtjury.

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At the completion of this chapter, the reader will be able to do the following:

• Describe the concept of energy as a cause • Describe and advocat e for the role of EMS in
of injury. injury prevention, to include:

• Build a Haddon Matrix for a type of injury • Individual
of interest. • Family
• Community
• Relate the importance of accurate, attentive • Professional
scene observations and documentation of data by • Organizational
prehospital care providers to the success of injury • Coalitions of organizations
prevention initiatives.
• Identify strategies t hat prehospital care providers
• Assist in the development, implementation, and can implement that will reduce the risk of injury.
evaluation of injury prevention programs in his
or her community or emergency medical services

(EMS) organization.

CHAPTER 2 Injury Prevention 1 5

You and your partner are on the scene of a motor vehicle collision and are working to rapidly extricate a heavy patient from the driver's
seat of his vehicle. He was unrestrained in the vehicle during the collision. You and your partner are both wearing approved safety vests
over your work gear since you are near the roadway. Law enforcement is on the scene to provide traffic control, and t he ambulance is
parked to maximize your protection from oncoming vehicles. The patient is packaged properly and secured onto your motorized cot,
which is being used due to the patient's weight. The motorized cot allows you and your partner to lift the patient safely into the ambu-
lance without putting excess strain on your bodies.

Once inside the ambu lance, you secure yourself in the rear-facing chair and continue care of the patient while your partner operates
the siren and the strobe-flashing lights of the ambulance to attract other drivers' attention. She maneuvers safely into her lane and drives
to the hospital. The ambulance arrives safely at the hospital, and you transfer the patient to the care of the emergency department staff.

While completing paperwork after the call, you consider the overall national injury and death statistics for prehospital care providers.
You realize that thanks to the careful attention to all aspects of injury prevention that you and your partner demonstrated, the call was
concluded safely for everyone involved.

• Is accident prevention a realistic approach in preventing injury and death in motor vehicle collisions and other causes of
traumatic injury?

• Is there evidence that compliance with seat belt and safety seats has an impad in preventing injury and death?
• As prehospital care providers, what can we do to prevent deaths and inj uries from motor vehicle collisions?

.~" -"'/ Introduction patients will always exist. However, the most efficient and
effective method to combat injury is to p revent it from happen-
A major impetus in the development of mod- ing in the first place. Health care providers at all levels play an
active role in injury prevention to achieve the best results for not
ern emergency medical services (EMS) sys- only the community at large but also for themselves.

tems was the p ublication ofthe 1966 white paper by the National In 1966, the authors of the NAS/NRC white paper recognized
the importance of injury prevention when they wrote:
Academy of Sciences/National Research Council (NAS/NRC),
The long-term solution to the injury problem is prevention .. ..
Accidental Death and Disability: the Neglected Disease of Prevention of accidents involves training in the home, in the
school, and at work, augmented by frequent pleas for safety
Modern Society. The paper spotlighted shortcomings in injury in the news media; first aid courses and public m eetings; and
inspection and surveillance by regulatory agencies.1
management in the United States and h elped launch a formal
Prevention of some diseases, such as rabies or measles,
system of on-scene care and rapid transport for patients injured has been so effective that the occurrence of a single case makes
front-page news. Public health officials recognize that preven-
as a result of "accidents." This educational initiative was instru- tion res ults in the greatest reward toward the amelioration of
disease. Curricula for prehospital care providers have long
mental in the creation of a more efficient system to deliver pre- included formal instruction in scene safety and personal pro-
tective equipment as a means of self-injury prevention for the
hospital care to sick and injured patients.1 emergency medical technician (EMT). To spur EMS systems
to take a more active role in community prevention strategies,
The incidence of death and disability from injury in the the EMS Agenda for the Future, developed by and fo r the EMS
community, lists prevention as 1 of 14 attributes to develop fur-
United States has fallen since the publication of the white paper.2 ther in order to "improve community health and result in more
appropriate use of acute health resources."7 To this end, the
Despite this progress, however, injury remains a major public National EMS Education Standards include community injury
pr evention.
health problem. More than 182,000 Americans die from inju-

ries annually, and millions more are adversely affected to some

degree.3•4 Injuries remain a leading cause of death for all age

groups.5•6 For some age groups, particularly children , teenagers,

and young adults, injury is the leading cause of death.

Injury is a global problem as well. Over five million people

worldwide died from injuries in 2010.5 Globally, nine p eople die

from injuries per minute.

The desire to care for patients stricken by injury draws

many into the field of EMS. The Prehospital Trauma Life

Support (PHTLS) course teaches p rehospital care providers

to be efficient and effective in injury management. The need

for well-trained p rehosp ital care providers to care for injured

1 6 PREHOSPITAL TRAUMA LIFE SUPPORT, EIGHTH EDITION

EMS systems are transforming themselves from a solely Energy Out of Control
reactionary discipline to a broader, more effective discipline
that includes more emphasis on prevention. This chapter intro- People harness and use all five forms of energy in many produc-
duces key concepts of irtjury prevention to the prehospital care tive endeavors every day. In these situations, energy is under con-
provider. trol and is not allowed to affect the body adversely. A person's
ability to maintain control of energy depends on two factors: task
Concepts of Injury performance and task demand.9 As long as a person's ability to
perform a task exceeds the demands of a task, energy is released
Definition of Injury in a controlled, usable manner.

A discussion of irtjury prevention should begin with a definition In the following three situations, however, demand may
of the term injury. lrtjury is now commonly defined as a harm- exceed performance, leading to an uncontrolled release of
ful event that arises from the release of specific forms of phys- energy:
ical energy or barriers to the normal flow of energy.• The wide
variability of the causes of irtjury initially represented a major 1. When the difficulty of the task suddenly exceeds the
hurdle in its study and prevention. For example, what does a individual's performance ability. For example, a pre-
fractured hip caused by an elderly person's fall have in common hospital care provider may operate an ambulance safely
with a self-inflicted gunshot wound to the head of a young adult? during normal driving conditions but loses control
Furthermore, how does one compare a femur fracture from a when the vehicle hits a sheet of black ice. The sudden
fall in an elderly female to a femur fracture in a young male who increase in the demands ofthe task exceeds the prehos-
crashed his motorcycle? All possible causes of irtjury-from pital care provider's performance capabilities and leads
vehicle crash, to stabbing, to suicide, to drowning-have one to a crash.
factor in common: the transfer of energy to the victim.
2. When the individual's performance level falls below
Energy exists in five physical forms: mechanical, chemical, the demands of the task. A person who falls asleep at
thermal, radiation, or electrical. the wheel of a vehicle while driving down a country
road experiences a sudden drop in performance with
• Mechanical energy is the energy that an object con- no change in task demand, leading to a crash.
tains when it is in motion. For example, mechanical
energy, the most common cause ofirtjury, is transferred 3. When both factors change simultaneously. Talking on
from a vehicle when an unrestrained driver collides a cellular phone while driving may reduce a driver's
with the winds hield during a vehicle crash. concentration on the road. If an animal darts in front
of the vehicle, task demand suddenly rises. Under nor-
• Chemical energy is the energy that results from the mal circumstances, the driver may be able to handle the
interaction of a chemical with exposed human tissue. increased demands of the task. A drop in concentration
For instance, chemical energy results in a burn from at the very moment when additional skill is required
exposure to an acid or base. may lead to a crash.

• Thermal energy is the energy associated with Thus, irtjury may result when there is a release of energy in
increased temperature and heat. For example, thermal an uncontrolled manner in proximity to victims.
energy causes irtjury when a cook sprays lighter fluid
on actively burning charcoal in an outdoor grill, which Injury as a Disease
then flashes in his face.
The disease process has been studied for years. It is now under-
• Radiation energy is any electromagnetic wave that stood that three factors must be present and interact simultane-
travels in rays (such as x-rays) and has no physical ously for an illness to occur: (1) an agent that causes the illness,
mass to it. Radiation energy p roduces sunburn in the (2) a host in which the agent can reside, and (3) a suitable envi-
teenager searching for a golden tan for the summer. ronment in which the agent and host can come together. Once
public health professionals recognized this "epidemiological
• Electrical energy results from the movement of elec- triad," they discovered how to combat disease (Figure 2-1).
trons between two points. It is associated with direct Eradication of certain infectious diseases has been possible
irtjury as well as thermal irtjury and, for example, dam- by vaccinating the host, destroying the agent with antibiotics,
ages the skin, nerves, and blood vessels of a prehospital reducing environmental transmission through improved sanita-
care providerwho fails to do a proper scene assessment tion, or a combination of all three.
before touching a vehicle that hit a utility pole.
Only since the late 1940s has significant exploration of the
Any form of physical energy in sufficient quantity can cause injury process occurred. Pioneers in the study of irtjury demon-
tissue damage. The body can tolerate energy transfer within strated that despite the obviously different results, illness and
certain limits; however, an irtjury results if this threshold is irtjury are remarkably similar. Both require the presence of the
exceeded.

CHAPTER 2 Injury Prevention 1 7

filled with water with a beach ball floating just beyond the edge;
the environment might be a pool gate left open while the babysit-
ter runs inside to answer the telephone. With the host, agent, and
environment all coming together at the same time, an uninten-
tional injury- in this case, drowning-ean occur.

Haddon Matrix

Figure 2-1 Epidemiological triad. Dr. William J. Haddon, Jr., is considered the father of the science
of injury prevention. Working within the concept of the epidemi-
three elements of the epidemiological triad, and therefore, both ological triad, in the mid-1960s, he recognized that an injury can
are treated as a disease: be broken down into the following three temporal phases:

1. Pre-event: Before the injury.
2. Event: The point when harmful energy is released.
3. Postevent: The aftermath of the injury (see also the

PHTLS: Past, Present, and Future chapter).

1. For an injury to occur, a host (i.e., the human) must By examining the three factors of the epidemiological
exist. As with illness, susceptibility ofthe host does not triad during each temporal phase, Haddon created a nine-cell
remain constant from individual to individual; it varies "phase-factor" matrix (Figure 2-2). This grid has become known
as a result of internal and external factors. Internal as the Haddon Matrix. It provides a means to depict graphically
factors include intelligence, gender, and reaction time. the events or actions that increase or decrease the odds that an
External factors include intoxication, anger, and social injury will occur. It can also be used to identify prevention strate-
beliefs. Susceptibility also varies over time within the gies. The Haddon Matrix demonstrates that multiple factors can
same person. lead to an injury, and therefore, multiple opportunities exist to
prevent or reduce its severity. The matrix played a major role in
2. As described previously, the agent of injury is energy. dispelling the myth that injury is the res ult of a single cause, bad
Velocity, shape, material, and time of exposure to the luck, or fate.
object that releases the energy all play a role in whether
the host's tolerance level is overwhelmed. Figure 2-2 depicts a Haddon Matrix for an ambulance crash.
The components in each cell of the matrix are different depend-
3. The host and agent must come together in an envi- ing on the injury being examined. The pre-event phase includes
ronment that allows the two to interact. Typically, the factors that can contribute to the likelihood of a crash; however,
environment is divided into physical and social compo- energy is still under control. This phase may last from a few
nents. Physical environmental factors can be seen and seconds to several years. The event phase depicts the factors that
touched. Social environmental factors include attitudes, influence the severity ofthe injury. During this time, uncontrolled
beliefs, andjudgments. For example, teenagers are more energy is released and injury occurs if energy transfer exceeds
likely to participate in risk-taking behavior (the physical the body's tolerance. The event phase is typically very brief; it
component) because they have more of a sense of invin- may last only a fraction of a second and rarely lasts more than a
cibility (the social component) than other age groups. few minutes. Factors in the postevent phase affect the outcome
once an injury has occurred. Depending on the type of event, it
The characteristics of the host, agent, and environment may last from a few seconds to the remaining life span of the
change with time and circumstance. Public health profession- host. (See also the PHTLS: Past, Present, and Future chapter.)
als Tom Christoffel and Susan Scavo Gallagher describe this
dynamic as follows: Public health programs have adopted the terminology ofpri-
mary, secondary, and tertiary prevention.
To illustrate, think of the components of the Epidemiological
Triad as constantly turning wheels. Inside each wheel are • Primarypreventionis aimed atavoiding theinjury before
pie-shaped sections, one for each possible circumstantial it occurs. This type of prevention activity involves edu-
variable--good and bad. The three wheels tum at different cation programs to help minimize risk-taking behaviors
rates, so different characteristics interact (meet) at different and the use of protective equipment such as helmets,
times and in different combinations. Some combinations pre- child-safety seats, and vehicle restraint systems.
dict that no i.ajury will occur; some predict disaster.10
• Secondary prevention refers to those actions taken to
In the case of injury, the host might be a curious, mobile prevent the progression of an acute injury once it has
2-year-old child; the agent of injury might be a swimming pool occurred-for example, avoiding the occurrence of
hypoxia or hypotension after a traumatic brain injury


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