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Experience of implementation ofstandardized trauma treatment
methodology Advanced Trauma LifeSupport courses (ATLS) in Lithuania
Salvijus Milaius
Chief of Military Medical training Center
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Trauma
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Trauma
Leading cause of death < 44 years ofage
Third cause of death in all age groups
(in 2020 may be second cause ofdeath) 3.2 million deaths and 312 million
patients seek medical attention
worldwide (1990) Lost life years, disability Major socio-economic problem
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Lost life years
36
16
12
0
10
20
30
40
Trauma Cancer Cardio vascular
Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
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Treatment price
334
8851
0
100
200
300
400
Trauma Cancer Cardio vascular
Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
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0 50 100 150 200 250
2002Russian Federation2002CIS-12 average2003Belarus2002Kazakhstan2002Ukraine2002Latvia2002Lithuania2002Estonia2002Republic of Moldova2002EUROPE2002Kyrgyzstan
2001CARK-5 average 2002Hungary
2002EU-10 (MSs after 1.5.2004) average2002Finland2002Slovenia2002Romania2002Poland
1998Turkmenistan
2002Luxembourg2002Czech Republic2000France2002Slovakia2002Croatia1997Belgium2002Uzbekistan1999Denmark2002Bulgaria
2002Portugal2002Austria2001Albania2001Iceland2002EU-25 average2000Serbia and Montenegro
2001Ireland
2001Switzerland
2001Sweden
2001Norway
2001EU-15 (MSs prior 1.5.2004) average2000TFYR Macedonia1999Israel2002Armenia2001Greece2001Italy2001Germany2001Spain2001Tajikistan2000Netherlands2002Malta2002United Kingdom2001Georgia2002Azerbaijan2000San Marino
110102 +SDR, external cause injury and poison, all ages per 100000
Last available
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7/600 35 70 105 140 175 210 245
0
5
10
15
20
25
30
C
ountrynumber
AlbaniaArmeniaAustria
AzerbaijanBelarusBelgiumBosnia and HerzegovinaCroatiaCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceIsraelKazakhstanLatviaLithuaniaNetherlandsRomania
Russian FederationSloveniaTajikistanTurkeyUkraineUnited KingdomEUROPEEU-25 average
110102 +SDR, external cause injury andpoison, all ages per 100000, Last available
Estonia
Lithuania
Latvia
Ukraine
Netherlands
Belarus
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Trauma situation in
Lithuania
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Trauma situation in Lithuania
Nelaimingus atsitikimus,apsinuodijimus ir traumas
pagrstai galima vadinti Lietuvosnacionaline nelaime, nesmirtingumas nuo j, palyginti sukitomis Europos alimis, yra labai
didelis ir toliau spariai didjantis(Lietuvos sveikatos programa,1998)
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The need for standardized
training of medical personnel Severely injured patients must be
evacuated as quickly as possible
They are passing different levels of medicalcare, the same passing different medicaldoctors (and other personnel)
Managing of trauma patients often will be instressful environment
Trauma causes are different
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Trauma
In many countries reduction in traumamortality of 15-20 % have been achievedlargely as a result of improved health careinterventions and trauma care systems(Cales 1984, Lecky 2000)
Initiatives such as the Advanced TraumaLife Support training program in NorthAmerica succesfully reduced mortality(Kirsch 1998, Reines 1988)
Population based studies from NorthCarolina showed, that ATLS training isassociated with a low rate of deaths fromtrauma(Rutledge et al., 1994)
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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 ofcomplex definitive treatment
(Royal College of surgeons of England, 1988)
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0%
5%
10%
15%
20%
Prie PHTLS Po PHTLS
Bendrasmir
tingumas
Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
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Disease triangle
Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
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Haddon matrix
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Sample Haddons matrix for
motor vehicle accidentsprevention program creation
PREEVENT EVENT POSTEVENT
Host Avoid alcohol
consumption
Use of safety belts First aid by
bystanders
Vehicle Antilock brakes Air bags deploys
Environment Speed limits Impact-absorbing
barriers
Emergency medical
service (access
to trauma
system)
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Injury has become a majorcause of death and disabilityworldwide. Organized
approaches to its preventionand treatment are needed.These guidelines seek to setachievable standards fortrauma treatment serviceswhich could realistically be
made available to almostEvery injured person in theworld. They then seek todefine the resources thatwould be necessary to assuresuch care.
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ADVANCED TRAUMA LIFESUPPORT - ATLS
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ATLS
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ATLS intent
Originally, standard for doctors whodo not manage major trauma on their
daily basis but accepted to be a standard for
those, who provide care for traumapatients in first hours after injury
and standard for primary healthcare institutions and for moderntrauma care centers
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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 goals
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ATLS history
Plane crash in Nebraska,1976
1 killed, 4 injured
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ATLS
Injured orthopedic surgeon:
When I can provide better care in the
field with limited resources than mychildren and I received at the primarycare facility - there is something
wrong with the system and thesystem has to be changed
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ATLS
First course in USA in 1978
American college of surgeons
> 40 countries (Canada, Denmark, England,
Israel, Portugal, Italy, Sweden,etc.)
Hungary inaugural courses inFebruary 2005
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International dissemination
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Trimodal Death Distribution
0
50
100
150
200
250
300
350
400
Number
of Deaths
Time After Injury
0 1 2 3 4Hours Weeks
Immediate
DeathsEarly
Deaths
Late
Deaths
2 3 4 5
ACS
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ATLS philosophy
Treat the greatest threat to life first
Lack of definitive diagnosis should
never impede the application of anindicated treatment
A detailed history is not the essentialprerequisite to begin the evaluation of
an acutely injured patient
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ABCDE mnemonic
A irway with cervical spine
control B reathing
C irculation
D isability or neurological status E xposure with temperaturecontrol
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ACS
Injury
Resuscitation
ReevaluationReevaluation
Transfer
Optimize patient
status
Adjuncts
Secondary Survey
Primary Survey
Adjuncts
ATLS Teaches
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ATLSCourse structure and
organisation
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Duration2,5 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
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1 lecture room
4 practical skills training roomsAnimal lab
Course faculty room
Other facilities ..other support
ATLS course
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ATLS manual
Pretest
Lectures Demonstrations
Group discussions
Practical life saving skills Simulated patients scenarios
Final test
ATLS course
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ATLS
ATLS 400 pages manual
Sent to students 6 weeks inadvance
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Pretest before the course
ATLS
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Lectures
ATLS
Demonstrations
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Group discussions
ATLS
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Practical life saving skills
ATLS
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Simulated patients scenarios
ATLS
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Test
ATLS
40 questions,passing score
80%
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ATLS
Certificate valid for 4 years
After expiry resertification
1 day refreshment course
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ATCNAdvanced Trauma Care for Nurses
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PHTLS
Prehospital Basic andAdvanced Trauma Life Support
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ATLS
Advanced trauma life supportInternational promulgation
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International promulgation
The development of ACSATLS
Program within the requesting countryvia a recognized surgical organizationor an ACS Chapter in that country, and
outside the ACS COT network
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Implementation ofATLS
in Lithuania
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1. Request initiation request from TraumatologistOrthopaedic society approved for implementation ofATLS into Lithuania in August 2002
2. Introductory site (Military medical training center)visit by representatives from American college ofsurgeons ATLS committee 28 of FEB 2003
3. Development and equipping of site for conductingof ATLS courses in Lithuania
4. Initial training of instructorstraining of 8Lithuanian instructors in USA 07-17 of DEC 2003
5. Inaugural courses in Lithuania 15-20 NOV 20046. Continued promulgation
Implementation process
main steps
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Introductory site visit 28 of February 2003
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Representatives of variuos institutions signedthe letter of intent to implementATLS in
Lithuania
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Training of Lithuanian ATLSinstructors candidates in Fresno,
US 7-17 DEC 2003
ATLS i l
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ATLS inaugural courses15-20 NOV 2004
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InternationalATLS Faculty
ATLS inaugural courses15-20 NOV 2004
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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 healthcare institutions (GP) Surgeons Anesthesiologists ....others
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First aid - all
ATLS, ATCN, PHTLS
Prehospital care
DSTC
ATLS, ATCN
Emergency room,
Hospital
G
O
LD
E
N
H
OU
R
M
ED
E
V
AC
Trauma treatment chain
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ATLS courses in Lithuania
3 courses 48 doctorsparticipated in these courses
About 4-6 courses per year infuture
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Conclusions
ATLS courses provide standardizedinformation and skills for trauma patientstreatment.
After implementation of ATLS methodic inLithuania it will be build basement forcreation and development of trauma caresystem
Doctors will be proper trained forinternational missions
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Thank you for attention