Advanced trauma life support

Last updated
Advanced trauma life support
Atencion Prehospitalaria por estudiantes.jpg
General information
NamesAdvanced trauma life support
AbbreviationATLS
Field
Medicine
History
Inventor James K. Styner, Paul 'Skip' Collicott
Invention date1978
Description
Organizer American College of Surgeons
Participants emergency physicians, paramedics and other advanced practitioners
Duration3 days (for hybrid course) [1]
Frequency1 week – 1 month
Additionally
Related courses
Advanced cardiac life support
Pediatric advanced life support
Fundamental critical care support

Advanced trauma life support (ATLS) is a training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons. Similar programs exist for immediate care providers such as paramedics. The program has been adopted worldwide in over 60 countries, [2] sometimes under the name of Early Management of Severe Trauma, especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers. The premise of the ATLS program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. [2]

Contents

The American College of Surgeons Committee on Trauma has taught the ATLS course to over 1 million doctors in more than 80 countries. ATLS has become the foundation of care for injured patients by teaching a common language and a common approach. [3] However, there is no high-quality evidence to show that ATLS improves patient outcomes as it has not been studied. If it were studied, this would be known. [4] [5]

Primary survey

The first and key part of the assessment of patients presenting with trauma is called the primary survey. During this time, life-threatening injuries are identified and simultaneously resuscitation is begun. A simple mnemonic, ABCDE, is used as a mnemonic for the order in which problems should be addressed.

Airway maintenance

Cervical spine stabilization is the first step, after that follow ABCD. The first stage of the primary survey is to assess the airway. If the patient is able to talk, the airway is likely to be clear. If the patient is unconscious, he/she may not be able to maintain his/her own airway. The airway can be opened using a chin lift or jaw thrust. Airway adjuncts may be required. If the airway is blocked (e.g., by blood or vomit), the fluid must be cleaned out of the patient's mouth by the help of suctioning instruments. In the case of obstruction, pass an endotracheal tube.[ citation needed ]

Breathing and ventilation

The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment with Pulmonary Contusion and Cardiac Tamponade. Flail chest, tracheal deviation, penetrating injuries and bruising can be recognized by inspection. Subcutaneous emphysema can be recognized by palpation. Tension Pneumothorax and Haemothorax can be recognized by percussion and auscultation.

Circulation with bleeding control

Hemorrhage is the predominant cause of preventable post-injury deaths. Hypovolemic shock is caused by significant blood loss. Two large-bore intravenous lines are established and crystalloid solution may be given. If the person does not respond to this, type-specific blood, or O-negative if this is not available, should be given. External bleeding is controlled by direct pressure. Occult blood loss may be into the chest, abdomen, pelvis or from the long bones.[ citation needed ]

Disability/Neurologic assessment

During the primary survey a basic neurological assessment is made, known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive). A more detailed and rapid neurological evaluation is performed at the end of the primary survey. This establishes the patient's level of consciousness, pupil size and reaction, lateralizing signs, and spinal cord injury level.

The Glasgow Coma Scale is a quick method to determine the level of consciousness, and is predictive of patient outcome. If not done in the primary survey, it should be performed as part of the more detailed neurologic examination in the secondary survey. An altered level of consciousness indicates the need for immediate reevaluation of the patient's oxygenation, ventilation, and perfusion status. Hypoglycemia and drugs, including alcohol, may influence the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise.

Exposure and environmental control

The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermia in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.

Secondary survey

When the primary survey is completed, resuscitation efforts are well established, and the vital signs are normalizing, the secondary survey can begin. The secondary survey is a head-to-toe evaluation of the trauma patient, including a complete history and physical examination, including the reassessment of all vital signs. Each region of the body must be fully examined. X-rays indicated by examination are obtained. If at any time during the secondary survey the patient deteriorates, another primary survey is carried out as a potential life threat may be present. The person should be removed from the hard spine board and placed on a firm mattress as soon as reasonably feasible as the spine board can rapidly cause skin breakdown and pain while a firm mattress provides equivalent stability for potential spinal fractures. [6]

Tertiary survey

A careful and complete examination followed by serial assessments help recognize missed injuries and related problems, allowing a definitive care management. The rate of delayed diagnosis may be as high as 10%. [7]

Alternatives

Mannequin surgical simulators are widely used in the United States as alternatives to the use of live animals in ATLS courses. In 2014, PETA announced that it was donating surgical simulators to ATLS training centers in 9 countries that agreed to switch from animal use to training on the simulators. [8]

Additionally, Anaesthesia Trauma and Critical Care (ATACC) is an international trauma course based in the United Kingdom that teaches an advanced trauma course and represents the next level for trauma care and trauma patient management post ATLS certification. Accredited by two Royal Colleges and numerous emergency services, the course runs numerous times per year for candidates drawn from all areas of medicine and trauma care. [9] Specific injuries, such as major burn injury, may be better managed by other more programs.

In military medicine, the ATLS protocol has been modified to the Battlefield Advanced Trauma Life Support (BATLS) protocol. The treatment procedure is cABCDE. Added c = Catastrophic bleeding (massive external bleeding). [10]

History

James Styner with three of his children who all received severe head trauma in the crash James K Styner.jpg
James Styner with three of his children who all received severe head trauma in the crash
Styner's Beechcraft Baron after the crash The Styner Plane after the crash.jpg
Styner's Beechcraft Baron after the crash

ATLS has its origins in the United States in 1976, when James K. Styner, an orthopedic surgeon piloting a light aircraft, crashed his plane into a field in Nebraska. His wife Charlene was killed instantly and three of his four children, Ken, Randy, and Kim sustained critical injuries. His son Chris suffered a broken arm. He carried out the initial triage of his children at the crash site. Styner had to flag down a car to transport him to the nearest hospital in Hebron; upon arrival, he found it closed. Even once the hospital was opened and a doctor called in, he found that the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate. [11] Upon returning to Lincoln, Styner declared: "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed." [12]

Upon returning to work, he set about developing a system for saving lives in medical trauma situations. Styner and his colleague Paul 'Skip' Collicott, with assistance from advanced cardiac life support personnel and the Lincoln Medical Education Foundation, produced the initial ATLS course which was held in 1978. In 1980, the American College of Surgeons Committee on Trauma adopted ATLS and began US and international dissemination of the course. Styner himself recently recertified as an ATLS instructor, teaching his Instructor Candidate course in Nottingham in the UK, July 2007, [13] and then in the Netherlands. [12]

Since its inception, ATLS has become the standard for trauma care in American emergency departments and advanced paramedical services. Since emergency physicians, paramedics and other advanced practitioners use ATLS as their model for trauma care it makes sense that programs for other providers caring for trauma would be designed to interface well with ATLS. The Society of Trauma Nurses has developed the Advanced Trauma Care for Nurses (ATCN) course for registered nurses. ATCN meets concurrently with ATLS and shares some of the lecture portions. This approach allows for medical and nursing care to be well-coordinated with one another as both the medical and nursing care providers have been trained in essentially the same model of care. Similarly, the National Association of Emergency Medical Technicians has developed the Prehospital Trauma Life Support (PHTLS) course for basic Emergency Medical Technicians (EMT)s and a more advanced level class for Paramedics. The International Trauma Life Support committee publishes the ITLS-Basic and ITLS-Advanced courses for prehospital professionals as well. This course is based around ATLS and allows the PHTLS-trained EMTs to work alongside paramedics and to transition smoothly into the care provided by the ATLS and ATCN-trained providers in the hospital. On March 22, 2013, the American College of Surgeons Committee on Trauma renamed their annual Award for Meritorious Service in ATLS to the James K. Styner Award for Meritorious Service in honor of Styner's contributions to trauma care. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Emergency medicine</span> Medical specialty concerned with care for patients who require immediate medical attention

Emergency medicine is the medical specialty concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency medicine physicians specialize in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency medical physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.

<span class="mw-page-title-main">Emergency medical services</span> Services providing acute medical care

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as EMAS or EMARS.

<span class="mw-page-title-main">Emergency medical technician</span> Health care provider of emergency medical services

An emergency medical technician is a medical professional that provides emergency medical services. EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to at least be EMT certified.

<span class="mw-page-title-main">Golden hour (medicine)</span> Concept in medicine regarding immediate treatment

In emergency medicine, the golden hour is the period of time immediately after a traumatic injury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death. While initially defined as an hour, the exact time period depends on the nature of the injury and can be more than or less than this duration. It is well established that the person's chances of survival are greatest if they receive care within a short period of time after a severe injury; however, there is no evidence to suggest that survival rates drop off after 60 minutes. Some have come to use the term to refer to the core principle of rapid intervention in trauma cases, rather than the narrow meaning of a critical one-hour time period.

<span class="mw-page-title-main">Battlefield medicine</span> Medical treatment in or near combat

Battlefield medicine, also called field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. With the advent of advanced procedures and medical technology, even polytrauma can be survivable in modern wars. Battlefield medicine is a category of military medicine.

<span class="mw-page-title-main">Internal bleeding</span> Leakage of blood within the body

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Advanced life support</span> Life-saving protocols

Advanced Life Support (ALS) is a set of life saving protocols and skills that extend basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing).

<span class="mw-page-title-main">Paramedics in Canada</span> Overview of paramedics in Canada

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<span class="mw-page-title-main">Trauma team</span> Team of healthcare workers treating severe injury

A trauma team is a multidisciplinary group of healthcare workers under the direction of a team leader that works together to assess and treat the severely injured. This team typically meets before the patient reaches the trauma center. Upon arrival, the team does an initial assessment and necessary resuscitation, adhering to a defined protocol.

<span class="mw-page-title-main">ABC (medicine)</span> Mnemonic for Airway, Breathing, and Circulation

ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons when dealing with a patient. In its original form it stands for Airway, Breathing, and Circulation. The protocol was originally developed as a memory aid for rescuers performing cardiopulmonary resuscitation, and the most widely known use of the initialism is in the care of the unconscious or unresponsive patient, although it is also used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations, from first-aid to hospital medical treatment. Airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective: a viable Airway is necessary for Breathing to provide oxygenated blood for Circulation. Since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters or adding other letters.

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<span class="mw-page-title-main">Paramedics in the United States</span> Overview of paramedics in the United States of America

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<span class="mw-page-title-main">James K. Styner</span> American surgeon

James Kenneth Styner was an American orthopedic surgeon who practiced in Lawndale, California. He was instrumental in the development of the advanced trauma life support (ATLS) program after his experiences in a private airplane crash in rural Nebraska.

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<span class="mw-page-title-main">Tactical emergency medical services</span>

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References

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  3. Rotondo, Michael. "About ATLS". The American College of Surgeons. Retrieved 1 September 2020.
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  6. Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes. Malden, Mass: Blackwell Pub./BMJ Books. p. 60. ISBN   978-1-4051-4166-6.
  7. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI.The tertiary trauma survey: a prospective study of missed injury.J Trauma. 1990 Jun;30(6):666-9
  8. McNeil, Donald (13 January 2014). "PETA's Donation to Help Save Lives, Animal and Human". The New York Times. New York Times. Retrieved 9 March 2015.
  9. "Anaesthesia Trauma and Critical Care". Archived from the original on 2014-03-29. Retrieved 2018-10-03.
  10. Hodgetts, TJ; Mahoney, PF; Russell, MQ; Byers, M (Oct 2006). "ABC to <C>ABC: redefining the military trauma paradigm". Emergency Medicine Journal. 23 (10): 745–746. doi:10.1136/emj.2006.039610. PMC   2579588 . PMID   16988297.
  11. Carmont MR (2005). "The Advanced Trauma Life Support course: a history of its development and review of related literature". Postgraduate Medical Journal. 81 (952): 87–91. doi:10.1136/pgmj.2004.021543. PMC   1743195 . PMID   15701739.
  12. 1 2 Styner, Randy (2012). The Light of the Moon - Life, Death and the Birth of Advanced Trauma Life Support. Kindle Books: Kindle Books. p. 267.
  13. Nottingham Evening Post-July 5, 2007
  14. Croce, Martin; Livingston, David; Luchette, Frederick; Mackersie, Robert (Sep 13, 2013). American Association for the Surgery of Trauma 75th Anniversary 1938-2013. The American Association for the Surgery of Trauma. p. 164. ISBN   978-0989892803 . Retrieved 2 September 2020.

Further reading