Experience of implementation of standardized trauma treatment methodology Advanced Trauma Life Support courses (ATLS) in Lithuania

Salvijus Milaius Chief of Military Medical training Center

Trauma

Trauma
Leading cause of death < 44 years of age Third cause of death in all age groups (in 2020 may be second cause of death) 3.2 million deaths and 312 million patients seek medical attention worldwide (1990) Lost life years, disability Major socio-economic problem

Lost life years

40

30

20 36

10

16 12

0 Trauma Cancer Cardio vascular

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

Treatment price
400

300

200 334 100 88 0 Trauma Cancer Cardio vascular

51

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

110102 +SDR, external cause injury and poison, all ages per 100000
Russian Federation2002
CIS-12 average 2002

Belarus2003 Kazakhstan2002 Ukraine2002 Latvia2002 Lithuania2002 Estonia2002

Republic of Moldova 2002

EUROPE2002
Kyrgyzstan 2002 CARK-5 average 2001 Hungary 2002 EU-10 (MSs after 1.5.2004) average 2002

Finland2002 Slovenia2002 Romania2002

Poland 2002 Turkmenistan 1998 Luxembourg 2002

Czech Republic2002 France2000

Slovakia 2002

Croatia2002 Belgium1997
Uzbekistan 2002

Denmark1999
Bulgaria 2002 Portugal 2002

Austria2002 Albania2001
Iceland 2001

EU-25 average2002
Serbia and Montenegro 2000 Ireland 2001 Switzerland 2001 Sweden 2001 Norway 2001 EU-15 (MSs prior 1.5.2004) average 2001 TFYR Macedonia 2000

Israel1999 Armenia2002 Greece2001

Italy 2001

Germany2001
Spain 2001

Tajikistan2001 Netherlands2000
Malta 2002

United Kingdom2002 Georgia2001 Azerbaijan2002

San Marino 2000 0 50 100 150 Last available 200 250

110102 +SDR, external cause injury and poison, all ages per 100000, Last available
30

25

20

15

Estonia Lithuania Latvia Ukraine Netherlands

10

Belarus

Albania Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Croatia Czech Republic Denmark Estonia Finland France Georgia Germany Greece Israel Kazakhstan Latvia Lithuania Netherlands Romania Russian Federation Slovenia Tajikistan Turkey Ukraine United Kingdom EUROPE EU-25 average

Country number

0 0 35 70 105 140 175 210 245

Trauma situation in Lithuania

Trauma situation in Lithuania

Nelaimingus atsitikimus, apsinuodijimus ir traumas pagrstai galima vadinti Lietuvos nacionaline nelaime, nes mirtingumas nuo j, palyginti su kitomis Europos alimis, yra labai didelis ir toliau spariai didjantis (Lietuvos sveikatos programa, 1998)

The need for standardized training of medical personnel

Severely injured patients must be evacuated as quickly as possible They are passing different levels of medical care, the same passing different medical doctors (and other personnel) Managing of trauma patients often will be in stressful environment Trauma causes are different

Trauma
In many countries reduction in trauma mortality of 15-20 % have been achieved largely as a result of improved health care interventions and trauma care systems (Cales 1984, Lecky 2000) Initiatives such as the Advanced Trauma Life Support training program in North America succesfully reduced mortality (Kirsch 1998, Reines 1988) Population based studies from North Carolina showed, that ATLS training is associated with a low rate of deaths from trauma (Rutledge et al., 1994)

Trauma
One of three deaths occurred in hospital as a result of injury could be prevented Often avoidable factors include simple management errors in the early stages (golden hour), rather than a failure of complex definitive treatment (Royal College of surgeons of England, 1988)

20%

Bendras mirtingumas

15%

10%

5%

0% Prie PHTLS Po PHTLS

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

Disease triangle

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

Haddon matrix

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

Sample Haddons matrix for motor vehicle accidents prevention program creation
PREEVENT Host Avoid alcohol consumption Antilock brakes EVENT Use of safety belts POSTEVENT First aid by bystanders

Vehicle

Air bags deploys

Environment

Speed limits

Impact-absorbing barriers

Emergency medical service (access to trauma system)

Injury has become a major cause of death and disability worldwide. Organized approaches to its prevention and treatment are needed. These guidelines seek to set achievable standards for trauma treatment services which could realistically be made available to almost Every injured person in the world. They then seek to define the resources that would be necessary to assure such care.

ADVANCED TRAUMA LIFE SUPPORT - ATLS

ATLS

ATLS intent
Originally, standard for doctors who do not manage major trauma on their daily basis but accepted to be a standard for those, who provide care for trauma patients in first hours after injury and standard for primary health care institutions and for modern trauma care centers

ATLS goals
To provide basic knowledge necessary to: Rapid and accurate assesment of the patient condition Resucitation and stabilisation IAW priority Determination of the patients needs Arrangement for the patients transfer (medical evacuation) Assure that optimum care is provided

ATLS history
Plane crash in Nebraska, 1976 1 killed, 4 injured

ATLS
Injured orthopedic surgeon: When I can provide better care in the field with limited resources than my children and I received at the primary care facility - there is something wrong with the system and the system has to be changed

ATLS
First course in USA in 1978 American college of surgeons > 40 countries (Canada, Denmark, England, Israel, Portugal, Italy, Sweden, etc.) Hungary inaugural courses in February 2005

International dissemination

Trimodal Death Distribution

400 350 300

Number 250 of Deaths

200 150 100 50 0
0

Immediate Deaths

Early Deaths
1 2 3 4 2

Late Deaths
3 4 5

Hours

Weeks

Time After Injury

ACS

ATLS philosophy
Treat the greatest threat to life first Lack of definitive diagnosis should never impede the application of an indicated treatment A detailed history is not the essential prerequisite to begin the evaluation of an acutely injured patient

ABCDE mnemonic
A irway with cervical spine control B reathing C irculation D isability or neurological status E xposure with temperature control

ATLS Teaches
Transfer Optimize patient status Reevaluation Secondary Survey
Adjuncts

Injury Primary Survey

Adjuncts

Resuscitation Reevaluation
ACS

Course structure and organisation

ATLS

ATLS course
Duration 2,5 days 16 physicians (and 8 nurses) 1 Course Director 1 Course Coordinator At least 5 instructors 4 instructor assistant - nurses Veterinarian Anesthesiologist

At least 4 patients models (make-ups)

ATLS course
1 lecture room 4 practical skills training rooms Animal lab Course faculty room Other facilities ..other support

 ATLS

course

ATLS manual Pretest Lectures Demonstrations Group discussions Practical life saving skills Simulated patients scenarios Final test

ATLS
ATLS 400 pages manual

Sent to students 6 weeks in advance

ATLS
Pretest before the course

 ATLS

Lectures

Demonstrations

 ATLS

Group discussions

 ATLS

Practical life saving skills

 ATLS

Simulated patients scenarios

 ATLS

Test

40 questions, passing score 80%

ATLS
Certificate valid for 4 years After expiry resertification 1 day refreshment course

Advanced Trauma Care for Nurses

ATCN

PHTLS

Prehospital Basic and Advanced Trauma Life Support

Advanced trauma life support International promulgation

ATLS

International promulgation
The development of ACS ATLS Program within the requesting country via a recognized surgical organization or an ACS Chapter in that country, and outside the ACS COT network

Implementation of in Lithuania

ATLS

Implementation process main steps

1.
2. 3. 4. 5. 6.

Request initiation request from Traumatologist Orthopaedic society approved for implementation of ATLS into Lithuania in August 2002 Introductory site (Military medical training center) visit by representatives from American college of surgeons ATLS committee 28 of FEB 2003 Development and equipping of site for conducting of ATLS courses in Lithuania Initial training of instructors training of 8 Lithuanian instructors in USA 07-17 of DEC 2003 Inaugural courses in Lithuania 15-20 NOV 2004 Continued promulgation

Introductory site visit 28 of February 2003

Representatives of variuos institutions signed the letter of intent to implement ATLS in Lithuania

Training of Lithuanian ATLS instructors candidates in Fresno, US 7-17 DEC 2003

ATLS inaugural courses 15-20 NOV 2004

International ATLS Faculty

ATLS inaugural courses 15-20 NOV 2004

ATLS course possible

students in Lithuania
Ambulance service doctors Fire and rescue service doctors Emergency room (patients admitting room) physicians Search and rescue doctors (SAR) Military medical doctors Physicians, functioning at primary health care institutions (GP) Surgeons Anesthesiologists ....others

Trauma treatment chain

DSTC
G O L D E N H O U R

M E D E V A C

ATLS, ATCN Emergency room, Hospital

ATLS, ATCN, PHTLS Prehospital care

First aid - all

ATLS courses in Lithuania

3 courses 48 doctors participated in these courses About 4-6 courses per year in future

Conclusions
ATLS courses provide standardized information and skills for trauma patients treatment. After implementation of ATLS methodic in Lithuania it will be build basement for creation and development of trauma care system Doctors will be proper trained for international missions

Thank you for attention