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