Experience of implementation of standardized trauma treatment

Experience of implementation of standardized trauma treatment

methodology Advanced Trauma Life Support® courses (ATLS®) in

Lithuania

Salvijus MilašiusChief of Military Medical training Center

ABCDE Trauma

ABCDE 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

ABCDE Lost life years

36

1612

0

10

20

30

40

Trauma Cancer Cardio vascular

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

ABCDE Treatment price

334

8851

0

100

200

300

400

Trauma Cancer Cardio vascular


ABCDE

0 50 100 150 200 250

2002Russian Federation2002CIS-12 average2003Belarus2002Kazakhstan2002Ukraine2002Latvia2002Lithuania2002Estonia2002Republic of Moldova2002EUROPE2002Kyrgyzstan2001CARK-5 average 2002Hungary2002EU-10 (MSs after 1.5.2004) average2002Finland2002Slovenia2002Romania2002Poland1998Turkmenistan2002Luxembourg2002Czech Republic2000France2002Slovakia2002Croatia1997Belgium2002Uzbekistan1999Denmark2002Bulgaria2002Portugal2002Austria2001Albania2001Iceland2002EU-25 average2000Serbia and Montenegro2001Ireland2001Switzerland2001Sweden2001Norway2001EU-15 (MSs prior 1.5.2004) average2000TFYR Macedonia1999Israel2002Armenia2001Greece2001Italy2001Germany2001Spain2001Tajikistan2000Netherlands2002Malta2002United Kingdom2001Georgia2002Azerbaijan2000San Marino

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

Last available

ABCDE

0 35 70 105 140 175 210 2450

5

10

15

20

25

30

Country num

ber

AlbaniaArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaCroatiaCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceIsraelKazakhstanLatviaLithuaniaNetherlandsRomaniaRussian FederationSloveniaTajikistanTurkeyUkraineUnited KingdomEUROPEEU-25 average

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

Estonia

Lithuania

Latvia

Ukraine

Netherlands

Belarus

ABCDE Trauma situation in Lithuania

ABCDE Trauma situation in Lithuania

• Nelaimingus atsitikimus, apsinuodijimus ir traumas pagrįstai galima vadinti Lietuvos nacionaline nelaime, nes mirtingumas nuo jų, palyginti su kitomis Europos šalimis, yra labai didelis ir toliau sparčiai didėjantis (Lietuvos sveikatos programa, 1998)

ABCDEThe 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

ABCDE 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)

ABCDE 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)

ABCDE

0%

5%

10%

15%

20%

Prieš PHTLS Po PHTLS

Ben

dras

mirt

ingu

mas


ABCDE Disease triangle


ABCDE


Haddon matrix

ABCDESample Haddon’s matrix for motor vehicle accidents

prevention 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)

ABCDE

ABCDE Injury has become a major cause of death and

disabilityworldwide. Organized approaches to its

preventionand treatment are needed.These guidelines seek to

set achievable standards fortrauma treatment services which could realistically be made available to almost Every injured person in the world. They then seek todefine the resources that would be necessary to

assuresuch care.

ADVANCED TRAUMA LIFE SUPPORT - ATLS®

ATLS®

ABCDE 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

ABCDETo provide basic knowledge necessary to: • Rapid and accurate assesment of the

patient condition• Resucitation and stabilisation IAW priority• Determination of the patient´s needs• Arrangement for the patient´s transfer

(medical evacuation) • Assure that optimum care is provided

ATLS® goals

ABCDE ATLS® history

• Plane crash in Nebraska, 1976

• 1 killed, 4 injured

ABCDE 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”

ABCDE 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

ABCDE International dissemination

ABCDE Trimodal Death Distribution

0

50

100

150

200

250

300

350

400

Numberof Deaths

Time After Injury0 1 2 3 4

Hours Weeks

ImmediateDeaths

EarlyDeaths

LateDeaths

2 3 4 5

ACS

ABCDEATLS® 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

ABCDEABCDE mnemonic

– A irway with cervical spine control

– B reathing– C irculation– D isability or neurological

status– E xposure with temperature

control

ABCDE

ACS

Injury

Resuscitation

ReevaluationReevaluation

Transfer

Optimize patient status

AdjunctsSecondary Survey

Primary SurveyAdjuncts

ATLS Teaches

ABCDEATLS®

Course structure and organisation

ABCDE• 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

ABCDE• 1 lecture room• 4 practical skills training rooms• Animal lab• Course faculty room• Other facilities• …..other support

ATLS® course

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

ATLS® course

ABCDE ATLS®

• ATLS 400 pages manual

• Sent to students 6 weeks in advance

ABCDE• Pretest before the

course

ATLS

ABCDE• Lectures

ATLS®

• Demonstrations

ABCDE• Group discussions

ATLS®

ABCDE• Practical life saving skills

ATLS®

ABCDE• Simulated patients scenarios

ATLS®

ABCDE• Test

ATLS®

40 questions, passing score 80%

ABCDE ATLS®

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

ABCDE ATCNAdvanced Trauma Care for

Nurses

ABCDE

PHTLS® Prehospital Basic and

Advanced Trauma Life Support

ABCDE

ATLS® Advanced trauma life

supportInternational promulgation

ABCDE 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”

ABCDE

ABCDE

Implementation of ATLS® in Lithuania

ABCDE1. Request initiation – request from Traumatologist

Orthopaedic society approved for implementation of ATLS into Lithuania in August 2002

2. Introductory site (Military medical training center) visit by representatives from American college of surgeons ATLS committee – 28 of FEB 2003

3. Development and equipping of site for conducting of ATLS courses in Lithuania

4. Initial training of instructors –training of 8 Lithuanian instructors in USA – 07-17 of DEC 2003

5. Inaugural courses in Lithuania 15-20 NOV 2004 6. Continued promulgation

Implementation process – main steps

ABCDEIntroductory site visit 28 of February 2003

ABCDE

ABCDE

Representatives of variuos institutions signed the letter of intent to implement

ATLS® in Lithuania

ABCDETraining of Lithuanian ATLS® instructors candidates in

Fresno, US 7-17 DEC 2003

ABCDEATLS® inaugural

courses 15-20 NOV 2004

ABCDE International ATLS® Faculty

ATLS® inaugural courses 15-20 NOV

2004

ABCDEATLS® 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

ABCDE

First aid - all

ATLS, ATCN, PHTLS – Prehospital care

DSTC

ATLS, ATCN – Emergency room,

Hospital

GOLDEN

HOUR

MEDEVAC

Trauma treatment chain

ABCDEATLS® courses in Lithuania

• 3 courses – 48 doctors participated in these courses

• About 4-6 courses per year in future

ABCDE 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

Documents

Experience of implementation of standardized trauma treatment