Experience of implementation of standardized trauma treatment methodology Advanced Trauma Life Support ® courses (ATLS ® ) in Lithuania Salvijus Milašius Chief 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 Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003

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

ABCDE

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)

ABCDE The 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 % 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 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

ABCDE Sample Haddon’s matrix for motor vehicle accidents prevention program creation PREEVENTEVENTPOSTEVENT HostAvoid alcohol consumption Use of safety beltsFirst aid by bystanders VehicleAntilock brakesAir bags deploys EnvironmentSpeed limitsImpact-absorbing barriers Emergency medical service (access to trauma system)

ABCDE

Injury has become a major cause of death and disability worldwide. Organized approaches to its prevention and treatment are needed. These guidelines seek to set achievable standards for trauma treatment services which could realistically be made available to almost Every injured person in the world. They then seek to define the resources that would be necessary to assure such 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

ABCDE To 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, 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 Number of Deaths Time After Injury Hours Weeks Immediate Deaths Early Deaths Early Deaths Late Deaths  ACS

ABCDE ATLS ® 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

ABCDE ABCDE 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 Reevaluation Transfer Optimize patient status Optimize patient status Adjuncts Secondary Survey Primary Survey Adjuncts ATLS Teaches

ABCDE ATLS ® 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 ATCN Advanced Trauma Care for Nurses

ABCDE PHTLS ® Prehospital Basic and Advanced Trauma Life Support

ABCDE ATLS ® Advanced trauma life support International 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

Implementation of ATLS ® in Lithuania

ABCDE 1.Request initiation – request from Traumatologist Orthopaedic society approved for implementation of ATLS into Lithuania in August Introductory site (Military medical training center) visit by representatives from American college of surgeons ATLS committee – 28 of FEB Development and equipping of site for conducting of ATLS courses in Lithuania 4.Initial training of instructors –training of 8 Lithuanian instructors in USA – of DEC Inaugural courses in Lithuania NOV Continued promulgation Implementation process – main steps

ABCDE Introductory site visit 28 of February 2003

ABCDE

Representatives of variuos institutions signed the letter of intent to implement ATLS ® in Lithuania

ABCDE Training of Lithuanian ATLS ® instructors candidates in Fresno, US 7-17 DEC 2003

ABCDE ATLS ® inaugural courses NOV 2004

ABCDE International ATLS ® Faculty ATLS ® inaugural courses NOV 2004

ABCDE ATLS ® 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 HOURGOLDEN HOUR MEDEVACMEDEVAC Trauma treatment chain

ABCDE ATLS ® 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