International Trauma Life Support for
Emergency Care Providers 9th Edition
, Table of Contents
SECTION 1 Essential Information ITLS Secondary Survey—Critical Information 54
SAMPLE History 54
CHAPTER 1 Introduction to Traumatic Disease 1
Vital Signs and Repeat Initial Assessment 54
Chapter Overview 2
Neurological Exam 54
Situational Awareness 2
Detailed Exam 56
Case Presentation 3
Ground Rules for Teaching and Evaluation 57
Scene Size-up 4
Standard Precautions 4 CHAPTER 4 Hemorrhage Control and Shock 58
Scene Safety 4 Chapter Overview 59
Total Number of Patients 6 Case Presentation 59
Essential Equipment and Additional Resources 6 Pathophysiology of Shock 60
Mechanism of Injury 7 Evaluation of Tachycardia 61
Blunt Trauma 7 The Shock Syndromes 62
Penetrating Trauma 13 Management 63
Priorities of Trauma Care 16 Special Situations in Hypovolemic Shock 65
Trauma Triage Decisions 17 Obstructive Shock 66
Prevention and Public Education 17 Cardiogenic Shock 68
CHAPTER 2 Trauma Assessment and Management 23 Current Thinking in the Treatment of Shock 70
Chapter Overview 24 CHAPTER 5 Shock and Hemorrhage Control Skills 77
Case Presentation 24 Cannulation of the External Jugular Vein 78
ITLS Primary Survey 26 Intraosseous Infusion 78
Scene Size-up 26 Indications 79
Initial Assessment 29 Contraindications 79
Rapid Trauma Survey or Focused Exam 31 Recommended Sites 79
ITLS Reassessment Exam 35 Potential Complications 79
ITLS Secondary Survey 36 FAST Responder™ Intraosseous Device 84
Adjuncts for Trauma Patient Assessment 39 Length-Based Resuscitation Tapes 86
Transfer of Care 39 Control of Life-Threatening Hemorrhage 87
CHAPTER 3 Assessment Skills 43 Application of Tourniquets 90
ITLS Primary Survey—Critical Information 44 Use of Hemostatic Agents 92
Scene Size-up 44 CHAPTER 6 Airway Management 96
Initial Assessment 44 Chapter Overview 97
Rapid Trauma Survey 49 Case Presentation 97
ITLS Reassessment Exam—Critical Information 52 Anatomy and Physiology 98
Subjective Changes 52 Nasopharynx 98
Mental Status 52 Oropharynx 98
Reassess ABCs 52 Hypopharynx 99
iv
, CO NTR IBUT O R S
Patrick J. Maloney, MD S. Robert Seitz, MEd, RN, NRP
Staff Physician, Denver Health Medical Center and Denver Assistant Professor, School of Health and Rehabilitation
Emergency, Center for Children; Clinical Instructor, Univer- Sciences, Emergency Medicine Program, University of
sity of Colorado School of Medicine, Denver, CO Pittsburgh, Pittsburgh, PA; Assistant Program Director,
Office of Education and International Emergency Medi-
David Manthey, MD, FACEP, FAAEM cine, University of Pittsburgh Center for Emergency Med-
Professor of Emergency Medicine and Vice Chair of icine; Continuing Education Editor, Journal of Emergency
Education, Wake Forest University School of Medicine, Medical Services; Editorial Board, International Trauma Life
Winston-Salem, NC
Support
Leslie K. Mihalov, MD
Chief, Emergency Medicine, and Medical Director, Emer-
Nicholas Sowers, MD, FRCPC
gency Services, Nationwide Children’s Hospital; Associate Associate Professor of Emergency Medicine, Dalhou-
Professor of Pediatrics at The Ohio State University College sie University School of Medicine, Halifax, Nova Scotia,
of Medicine, Columbus, OH Canada
Richard N. Nelson, MD, FACEP J. T. Stevens, NRP (ret.)
Professor and Vice Chair, Department of Emergency Med- Sun City, SC
icine, The Ohio State University College of Medicine,
Columbus, OH
Shin Tsuruoka, MD
Vice Director and Chief of Neurosurgical Department, JA
Jonathan Newman, MD, MMM, FACEP Toride Medical Center, Toride, Japan; ITLS Japan Chapter
Assistant Medical Director, United Hospital Center, Medical Director
Bridgeport, WV
Howard A. Werman, MD, FACEP
Bob Page, MEd, NRP, CCP, NCEE Professor of Clinical Emergency Medicine, The Ohio State
Edutainment Consulting and Seminars, LLC, Spring- University, Columbus, OH; Medical Director, MedFlight of
field, MO Ohio
William Bruce Patterson, Platoon Chief/EMT-P
Katherine West, BSN, MSEd, CIC
Strathcona County Emergency Services, Alberta, Canada
Infection Control Consultant, Manassas, VA; Editorial
Andrew B. Peitzman, MD Board, Journal of Emergency Medical Services
Distinguished Professor of Surgery, Mark M. Ravitch Chair
in Surgery, Chief in the Division of General Surgery, and
Melissa White, MD, MPH
Vice-President for Trauma and Surgical Services, University Associate Professor and Assistant Residency Director,
of Pittsburgh Medical Center, Pittsburgh, PA Department of Emergency Medicine, Emory University
School of Medicine, Atlanta, GA; Medical Director, John’s
William F. Pfeifer, MD, FACS Creek Fire Department; Medical Director, Emory Emer-
Professor of Surgery, Department of Specialty Medicine, gency Medical Services; Associate Medical Director, AirLife
Rocky Vista University College of Osteopathic Medicine; Georgia
Mile High Surgical Specialists, Littleton, CO; Colonel MC
USAR (ret) Janet M. Williams, MD
Professor of Emergency Medicine, University of Rochester
Art Proust, MD, FACEP Medical Center, Rochester, New York
Associate Medical Director, Southern Fox Valley EMS Sys-
tem, Geneva, IL E. John Wipfler, III, MD, FACEP
Attending Emergency Physician, OSF Saint Francis Med-
Mario Luis Ramirez, MD, MPP ical Center Residency Program; Medical Director, STATT
Tactical and Prehospital EMS Fellow and Clinical Instructor TacMed Unit, Tactical Medicine; Sheriff’s Physician, Peoria
in Emergency Medicine, Department of Emergency Medi- County Sheriff’s Office; Clinical Associate Professor of Sur-
cine, Vanderbilt University Medical Center, Nashville, TN gery, University of Illinois College of Medicine, Peoria, IL
Alexandra Rowe, NRP
Arthur H. Yancey II, MD, MPH, FACEP
CE Solutions, Burnett, TX
Medical Director, Grady EMS Emergency Communications
Jonathan M. Rubin, MD, FAAEM Center; Medical Director, College Park Fire Department;
Associate Professor of Emergency Medicine, Medical Associate Professor, Department of Emergency Medicine,
College of Wisconsin, Milwaukee, Wisconsin Emory University School of Medicine, Atlanta, GA
, Organization of This Book
The ninth edition of International Trauma Life Support for Also new to this edition is the editorial assistance of
Emergency Care Providers has been reorganized to reflect a Dr. Kyee Han, Consultant in Accident and Emergency Med-
more functional approach to the assessment and manage- icine, who has joined Dr. Alson as the Associate Editor of
ment of the trauma patient in the prehospital environment. the text. Dr. Han has extensive experience in EMS care and
The book is divided into four sections. education and has been a contributor to the ITLS text and
Section I, “Essential Information,” includes Chapters 1–7. course for over 20 years.
These topics are core to the care of the trauma patient and The text again conforms to the American Heart Associa-
include mechanism of injury, assessment of the trauma tion/International Liaison Committee of Resuscitation
patient, hemorrhage control, and shock and airway man- (AHA/ILCOR) guidelines, as well as those put forth by
agement. Following each didactic chapter on a clinical topic the Committee on Trauma of the American College of Sur-
is a chapter that reviews the essential skills needed to man- geons, as well as position statements from the National
age the clinical situation. Association of EMS Physicians, the Committee for Tactical
Emergency Casualty Care, the American College of Emer-
Section II, “Foundational Knowledge,” includes Chap-
ters 8–16. Topics include assessment and management gency Physicians, and other international advisory groups.
of injuries to specific body areas: chest trauma, abdomi- Some of the chapter-by-chapter key components and
nal trauma, spinal injuries and spinal motion restriction, changes are:
extremity trauma, and traumatic cardiac arrest. Chapters • The Introduction explains the concept of the “Golden
covering specific skills follow the didactic material. Period” and why it remains important to what we do as
The chapters in Section III, “Special Populations,” include emergency care providers.
burn patients, older adults, pediatric and pregnant patients, • Chapter 1 continues to emphasize scene safety and the
and patients under the influence of intoxicating substances. concept that trauma care as a team effort involving
The final section, available online or in text, covers other many disciplines as central components. The chapter
important areas: standard precautions, pain control, multi- now includes a discussion of the changes in response
casualty triage, trauma scoring, air medical, drowning, heat put forth by the Hartford Consensus.
and cold injuries, advanced skills, and overview of tactical • Chapter 2 includes minor changes in the assessment
medical care. sequence based on feedback from ITLS instructors and
providers. It also reinforces the importance of identify-
ing and controlling hemorrhage at the start of the assess-
What’s New in This Edition ment. As the leader performs the assessment, he or she
will delegate responses to abnormalities found in the
The ninth edition of International Trauma Life Support for initial assessment. This is to reinforce the rule that the
Emergency Care Providers has been updated to provide the leader must not interrupt the assessment to deal with
emergency care provider with information on the latest and problems but must delegate the needed actions to team
most effective approaches in the care of the trauma patient. members. This emphasizes the team concept and keeps
The science of trauma is constantly evolving, and the on-scene time at a minimum. The order of presentation of
authors, in collaboration with the research working group the three assessments (ITLS–Primary Survey, ITLS Reas-
at ITLS, have updated the text with the latest information sessment Exam, and ITLS Secondary Survey) has been
that is pertinent to the initial care of the trauma patient. changed. The ITLS Reassessment Exam is performed
This is the first edition without the presence of Dr. John before the ITLS Secondary Survey, a more common situ-
Campbell, FACEP, the founder of ITLS and the first Editor ation, and may replace it. The chapter also mentions the
in Chief. Dr. Campbell passed away in 2018 after a long and use of fingerstick serum lactate levels and prehospital
valiant battle with cancer. This text strives to continue his abdominal ultrasound exams as ways to better identify
focus on providing the emergency care provider with the patients who may be in early shock.
knowledge and skills to render to trauma patients the best • The assessment skills in Chapter 3 reflect the changes in
possible care. Chapter 2.
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