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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