Experience of implementation of

standardized trauma treatment

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

Salvijus Milašius
Chief of Military Medical training Center
 E
D Trauma
C
B
A
 E
D Trauma
C
B • Leading
A age
cause of death < 44 years of

• 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
 E
D Lost life years
C
B
A
40

30

20
36

10
16
12

0
Trauma Cancer Cardio vascular

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
 E
D Treatment price
C
B
A
400

300

200
334

100

88
51
0
Trauma Cancer Cardio vascular

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
 110102 +SDR, external cause injury and poison, all ages per 100000
Russian Federation2002

E
CIS-12 average 2002
Belarus2003
Kazakhstan2002
Ukraine2002

D
Latvia2002
Lithuania2002
Estonia2002

C
Republic of Moldova 2002
EUROPE2002
Kyrgyzstan 2002

B
CARK-5 average 2001
Hungary 2002
EU-10 (MSs after 1.5.2004) average 2002

A
Finland2002
Slovenia2002
Romania2002
Poland 2002
Turkmenistan 1998
Luxembourg 2002
Czech Republic2002
France2000
Slovakia 2002
Croatia2002
Belgium1997
Uzbekistan 2002
Denmark1999
Bulgaria 2002
Portugal 2002
Austria2002
Albania2001
Iceland 2001
EU-25 average2002
Serbia and Montenegro 2000
Ireland 2001
Switzerland 2001
Sweden 2001
Norway 2001
EU-15 (MSs prior 1.5.2004) average 2001
TFYR Macedonia 2000
Israel1999
Armenia2002
Greece2001
Italy 2001
Germany2001
Spain 2001
Tajikistan2001
Netherlands2000
Malta 2002
United Kingdom2002
Georgia2001
Azerbaijan2002
San Marino 2000

0 50 100 150 200 250

Last available
 110102 +SDR, external cause injury and

E
poison, all ages per 100000, Last available

D
30

Albania

C
Armenia
Austria

B
Azerbaijan
25 Belarus

A
Belgium
Bosnia and Herzegovina
Croatia
Czech Republic
20 Denmark
Estonia
Finland
Country number

France
Georgia
Estonia Germany
15 Greece
Lithuania
Israel
Latvia Kazakhstan
Ukraine Latvia
Lithuania
Netherlands
10 Netherlands
Belarus Romania
Russian Federation
Slovenia
Tajikistan
Turkey
5 Ukraine
United Kingdom
EUROPE
EU-25 average

0
0 35 70 105 140 175 210 245
 E Trauma situation in
D Lithuania
C
B
A
 E
DTrauma situation in Lithuania
C
B • Nelaimingus atsitikimus,
A 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)
 Eneed for standardized
D
The
C
training of medical personnel
B• Severely injured patients must be
A 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
 E
D Trauma
C
B
A • 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)
 E
D Trauma
C
B
A • 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)
 E
D
C
B
A

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
 E
D Disease triangle
C
B
A

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

E
D
C
B
A

Claire Merrick et. al. Prehospital Trauma Life Support, Mosby, 2003
 ESample Haddon’s matrix for
D motor vehicle accidents
C
B prevention program creation
A PREEVENT EVENT POSTEVENT

Host Avoid alcohol Use of safety belts First aid by

consumption bystanders

Vehicle Antilock brakes Air bags deploys

Environment Speed limits Impact-absorbing Emergency medical

barriers service (access
to trauma
system)
 E
D
C
B
A
 E Injury has become a major

D
cause of death and disability

C
worldwide. Organized
approaches to its prevention

B and treatment are needed.

A
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®
 E
D ATLS® intent
C
B • Originally, standard for doctors who
A 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
 E
D ATLS® goals
C
BTo provide basic knowledge necessary to:
A • 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
 E
D ATLS® history
C
B
A
• Plane crash in Nebraska,
1976
• 1 killed, 4 injured
 E
D ATLS®
C
B• Injured orthopedic surgeon:
A ” 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”
 E
D ATLS®
C
B • First course in USA in 1978
A • American college of surgeons
• > 40 countries
• (Canada, Denmark, England,
Israel, Portugal, Italy, Sweden,
etc.)
• Hungary – inaugural courses in
February 2005
 E
DInternational dissemination
C
B
A
 E
D
Trimodal Death Distribution
C
B
A
Number Immediate
of Deaths
Deaths
Early Late
Deaths Deaths

0 1 2 3 4 2 3 4 5
Hours Weeks
Time After Injury
ACS
 E ATLS® philosophy
D
C
B • Treat the greatest threat to life first
A • 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
 EABCDE mnemonic
D
C
B
A
– A irway with cervical spine
control
– B reathing
– C irculation
– D isability or neurological status
– E xposure with temperature
control
 E
D ATLS Teaches
C
B
ATransfer Injury

Optimize patient Primary Survey

status Adjuncts
Resuscitation
Reevaluation
Reevaluation
Secondary Survey
Adjuncts
ACS
 E
D
A
B
C
ATLS ®
Course structure and
organisation
 E
D ATLS® course
C
B• Duration –2,5 days
A • 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)
 E
D ATLS® course
C
B
A • 1 lecture room
• 4 practical skills training rooms
• Animal lab
• Course faculty room
• Other facilities
• …..other support
 E
D ATLS course
®
C
B• ATLS manual
A • Pretest
• Lectures
• Demonstrations
• Group discussions
• Practical life saving skills
• Simulated patients scenarios
• Final test
 E
D ATLS®
C
B • ATLS 400 pages manual
A

• Sent to students 6 weeks in

advance
 E
D ATLS
C
B
A • Pretest before the course
 E
D ATLS
®
C
B • Lectures
A • Demonstrations
 E
D ATLS ®
C
B • Group discussions
A
 E
D ATLS ®
C
B • Practical life saving skills
A
 E
D ATLS ®
C
B • Simulated patients scenarios
A
 E
D ATLS
®
C
B • Test
A

40 questions,
passing score
80%
 E
D ATLS®
C
B • Certificate valid for 4 years
A • After expiry – resertification
• 1 day refreshment course
 E
C
D ATCN
B Advanced Trauma Care for Nurses
A
 E
D
C
B
A

®
PHTLS
Prehospital Basic and
Advanced Trauma Life Support
 E
D
C
B
A
ATLS ®
Advanced trauma life support
International promulgation
 E
DInternational promulgation
C
B
A • ”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”
 E
D
C
B
A
 E
D
C
B
A
Implementation of ATLS
®

in Lithuania
 E
Implementation process –
D
C main steps
B Request
A
1. 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
 E
D site visit 28 of February 2003
Introductory
C
B
A
 E
D
C
B
A
 E
D
C
B
A

Representatives of variuos institutions signed

the letter of intent to implement ATLS® in
Lithuania
 ETraining of Lithuanian ATLS®
D
instructors candidates in Fresno,
C US 7-17 DEC 2003
B
A
 ATLS® inaugural courses
E
D 15-20 NOV 2004
C
B
A
 E
DInternational ATLS ®
Faculty
C
B
A

ATLS® inaugural courses

15-20 NOV 2004
 E
A TLS®
course possible
D
C students in Lithuania
B
A • 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
 ETrauma treatment chain
D
C
B
A M
DSTC
ATLS, ATCN –
G
O
Emergency room,
E Hospital L
D
D E
E ATLS, ATCN, PHTLS – N
Prehospital care
V H
A O
First aid - all U
C R
 E ATLS
D ®
courses in Lithuania
C
B • 3 courses – 48 doctors
A participated in these courses
• About 4-6 courses per year in
future
 E
D Conclusions
C
B• ATLS courses provide standardized
A
®

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