Advanced trauma life support

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Advanced Trauma Life Support (ATLS) is a training program for medical providers (MD/DO/DPM/PA/NP/CO) in the management of acute trauma cases, developed by the American College of Surgeons. Similar programs exist for nurses (ATCN) and paramedics (PHTLS). The program has been adopted worldwide in over 60 countries,[1] sometimes under the name of Early Management of Severe Trauma (EMST), 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. However, there is no high quality evidence to show that ATLS improves patient outcomes as it has not been studied.[2][3]

Primary survey[edit]

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 memory aid for the order in which problems should be addressed.

Airway maintenance with cervical spine protection[edit]

Main article: airway management

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 case of obstruction, pass an endotracheal tube.

Breathing and ventilation[edit]

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 hemorrhage control[edit]

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]

As of 2012, use of rFVIIa is not supported by evidence.[4] While it may help control bleeding, there is a risk of arterial thrombosis, and other than in those with factor VII deficiency, its use should be limited to clinical trials.[4]

Disability/Neurologic assessment[edit]

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[edit]

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[edit]

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.[5]

Tertiary survey[edit]

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%.[6]

Alternatives[edit]

Anaesthesia Trauma and Critical Care (ATACC) is an international trauma course based in the United Kingdom. It is 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.[7] Specific injuries, such as major burn injury, may be better managed by modified ATLS protocols such as EMSB (Emergency Management of Severe Burns: a training course and protocols developed by the Australian and New Zealand Burn Association (ANZBA) and also adopted by the British Burn Association).[1][2]

History[edit]

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, Richard, 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. Dr. Styner had to flag down a car to transport him to the nearest hospital; 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.[8] Upon returning to Lincoln, Dr. 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”[9]

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 the UK and then in the Netherlands.[citation needed]

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 Dr. Styner's contributions to trauma care.

See also[edit]

References[edit]

  1. ^ Bouillon B, Kanz KG, Lackner CK, Mutschler W, Sturm J (October 2004). "[The importance of Advanced Trauma Life Support (ATLS) in the emergency room]". Unfallchirurg (in German) 107 (10): 844–50. doi:10.1007/s00113-004-0847-2. PMID 15452655. 
  2. ^ Jayaraman, S; Sethi, D; Chinnock, P; Wong, R (Aug 22, 2014). "Advanced trauma life support training for hospital staff.". The Cochrane database of systematic reviews 8: CD004173. PMID 25146524. 
  3. ^ Jayaraman, S; Sethi, D; Wong, R (Aug 21, 2014). "Advanced training in trauma life support for ambulance crews.". The Cochrane database of systematic reviews 8: CD003109. PMID 25144654. 
  4. ^ a b Simpson, E; Lin, Y; Stanworth, S; Birchall, J; Doree, C; Hyde, C (Mar 14, 2012). Stanworth, Simon, ed. "Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia". Cochrane Database of Systematic Reviews 3: CD005011. doi:10.1002/14651858.CD005011.pub4. PMID 22419303. 
  5. ^ 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 1-4051-4166-2. 
  6. ^ Template: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
  7. ^ Anaesthesia Trauma and Critical Care
  8. ^ 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. 
  9. ^ Styner, Randy (2012). The Light of the Moon - Life, Death and the Birth of Advanced Trauma Life Support. Kindle Books: Kindle Books. p. 267. 

Further reading[edit]

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