History and future of ATLS in 21st century trauma management

Dr Matt WilesSheffield Teaching Hospitals NHS Trust

@STHJournalClubhttp://sthjournalclub.wordpress.com

Major William Barnsley AllenVC, DSO, MC and Bar

Objectives

To examine how the Advance Trauma Life Support (ATLS) course meets the challenges of modern trauma management, with a focus on: The background to the development of ATLS The impact of ATLS training on trauma related

morbidity & mortality The weaknesses of ATLS, especially in the

context of UK trauma management To look at how training in trauma

management in the UK could be developed in the future

History of ATLS

"When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed.“

James K. Styner

The ATLS Machine

“With great power comes great responsibility....”

Dogma

“So let it be written, so let it be done..”

Dogma

“The greater the ignorance, the greater the dogmatism”

William Osler

Psuedoaxioms

“False principles or rules handed down through generations of medical providers and accepted without serious challenge or investigation”[Newman. J Emerg Med 2007; 50: 476-77]

Rapid Sequence Induction [Can J Anesth 2007; 54: 748-764]

Psuedoaxioms in Trauma Anaesthesia

Manual in-line stabilisation[Br J Anaesth 2000; 84: 705-709]Trauma nasopharyngeal airways[Emerg Med J 2005; 22: 394-396]

Permissive hypotension[Anaes 2013; 68: 445-452]

GCS as a trigger for intubation[Trauma 2003; 54: 671-680]

[Emerg Med J 2007; 24: 139-141]

Psuedoaxioms in Trauma Anaesthesia

Cervical Collars[J Neurotrauma 2014; 31: 531-540]

ATLS Myths: Classes of Shock

[Guly et al. Resuscitation 2011; 82: 556-559]

ATLS Myths: Classes of Shock

[Mutschler et al. Resuscitation 2013; 84: 309-313]

ATLS Myths: Triphasic Deaths

[Demetriades et al. J Am Coll Surgeons 2005; 201: 343-348]

[De Knegt et al. Injury 2008; 39: 993-1000]

ATLS: Guidelines or Rules?

“Rules are for the obedience of fools and the guidance of wise men”

Douglas Bader

Do we use ATLS in UK Trauma?

Sequential assessment

Permissive hypotension

Haemostatic resuscitation

Etomidate Importance of CT

Doughnut of death...

ATLS Effect on Trauma Outcomes

Impact in Developing World

Advanced Trauma Life Support program increases emergency room application of trauma resuscitative procedures in a developing country.Ali et al. Trauma 1994; 36: 391-394

Trauma outcome improves following the Advanced Trauma Life Support Program in a developing country.Ali et al. Trauma 1993; 34: 890-899

Clinical Impact of Advanced Trauma Life Support.Van Olden et al. Am J Emerg Med 2004; 22: 522-525

Solution to a rural problem?

Horses for Courses…

ATLS is a dogmatic approach to trauma resuscitation in the civilian hospital setting. It would be naïve to apply the same model to each echelon of care within the conventional military evacuation chain. BATLS 2008 is a stepwise approach to trauma resuscitation that acknowledges the tactical constraints at point of wounding, together with the incremental enhancement of interventional skills, diagnostic equipment, experience-based judgement and trauma team sophistication at successive echelons of care.

The future of trauma training

“If I had an hour to solve a problem I'd spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.”

Albert Einstein

Team Training

“Everything is awesome.Everything is cool when you’re part of a team”

President Business

Crew Resource Management (CRM)

Essential Trauma CRM Skills

[Trauma Team Performance. Barach & Weimger; http://www.academia.edu/5270549/ITTACS_Team_Performance]

Team Training

Trauma Team Training

[Capella et al. J Surg 2010; 67: 439-443]

Trauma Team Training

[Capella et al. J Surg 2010; 67: 439-443]

BEST: Better & Systematic Trauma Care

28 hospitals, 2860 trauma team members

1 day course

[Wisborg et al. Educ Health 2006; 19: 85-95]

The future of trauma training

Treat ATLS as BTLSStop routine recertificationFocus on non-technical skillsInstitution specific training

ProtocolsTeam workingDebriefs

In summary…

All trauma team training should take place as a multidisciplinary team and should be undertaken within the usual working environment of that team

Train as a team in order to perform and deliver as a team