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Advanced trauma life support

1996; Lippincott Williams & Wilkins; Volume: 13; Issue: 2 Linguagem: Inglês

10.1097/00003643-199603000-00002

1365-2346

Carl Gwinnutt, Peter Driscoll,

Trauma Management and Diagnosis

February 1996 was the 20th anniversary of the tragic events in Nebraska USA, which led to the development of the Advanced Trauma Life Support (ATLS) Course, and changed the face of trauma care worldwide. Dr. J. Styner was piloting his private plane when it crashed, killing his wife and seriously injuring himself and his four children. For 10 hours, Dr Styner cared for his family with limited resources until they reached hospital. Concerned at the inadequate treatment that he and his children subsequently received at the medical facility, he is reputed to have said "When you get better care in the field, as my children and I did, than in hospital, something is wrong with the system and the system has to be changed." To achieve this, he urged local physicians, familiar with the Advanced Cardiac Life Support (ACLS) program, to set up a similar standardized approach to managing a victim of trauma in the first hour after injury. Within the same year, this group developed the first trauma training program under the auspices of the Lincoln Medical Education Foundation and the Southeast Nebraska Medical Services. Advanced Trauma Life Support was born, its name chosen to reflect its association with the ACLS program [1,2]. It would therefore seem an opportune moment to consider if the original aims have been met, what is the current state of play and what the future holds in store for the ATLS program on this side of the Atlantic. Since its creation, the ATLS Course has maintained its original aims, namely for a clinician to acquire the knowledge and skills to: assess an injured patient rapidly and accurately; resuscitate and stabilize the patient on a priority basis; determine if the patient's needs exceed the hospital's capabilities; arrange appropriate and safe transfer if required; ensure that optimal care is provided continually. The ATLS Course aims to achieve this by concentrating on teaching one safe system of assessing and managing victims of trauma in the first hour. The system is based upon three fundamental concepts; the first and most important of which is to treat the greatest threat to life first. Second, the lack of a definitive diagnosis should not impede the start of appropriate treatment. Finally, a detailed history is not a prerequisite for the commencement of the patient's assessment [3]. From these concepts, ATLS has developed a three-phase approach to be followed in all injured patients, consisting of: Primary survey with resuscitation; secondary survey; definitive care. The primary survey and resuscitation phase entails looking for, and treating, any immediately life threatening conditions as soon as they are identified. This is conducted using an 'ABCDE' mnemonic to ensure that the most time critical conditions are dealt with first (Table 1).Table 1: The primary survey and resuscitation phase Each part of the primary survey must be completed before progressing-even if this requires emergency surgery. Examples of this include uncontrollable haemorrhage or the presence of an extradural haematoma. The secondary survey consists of a detailed head to toe assessment of the patient to identify all other injuries and concurrent medical problems. Definitive care of each condition can then commence depending on its priority. Course structure The basic ATLS Course is referred to as a 'Provider Course'. Four to six weeks before attending such a course, candidates are sent the manual containing the core material and a multiple-choice question (MCQ) paper to allow self assessment. The course consists of a combination of lectures, practical skill stations and discussion groups. Over 2 1/2 days these are used to teach the specific order of trauma management, with the emphasis placed on clinical assessment, aggressive resuscitation and reassessment. Currently each course is limited to 16 candidates with a minimum faculty of six instructors. Assessment of the candidates consists of an ongoing appraisal of their abilities in the practical skill stations, a 20-question MCQ and finally an opportunity to demonstrate their knowledge and skills in a simulated resuscitation or 'moulage'. In these, people are made up with realistic life and limb threatening injuries and coached to act out the role of a trauma victim. To assist the student there is one 'neutral' nurse whose actions are limited to assisting upon request but not acting independently. If all three assessments are satisfactory, the candidate becomes an ATLS Provider. Self evidently some people attend an ATLS course with a wealth of expertise in specific aspects of trauma. These skills are recognized on the course and such students may be used to help in the group teachings. However, the aim is that everyone on the course, irrespective of their primary speciality reaches the required standard in all aspects of trauma care. ATLS undergoes constant reappraisal by the American College of Surgeons Committee on Trauma and includes advice from representatives of countries where ATLS is established. The course manual is revised every 4 years to keep up-to-date with latest developments in trauma care and allow problems identified with the course to be corrected. A good example of this was the clarification of the use of nasal and oral intubation between 1988 and 1992 [3]. Consequently all candidates, students and instructors alike, must reverify their competence with ATLS every 4 years, using the new manual. Instructors There are well-defined criteria for offering Providers the opportunity to become Instructors and teach on ATLS Courses. They must complete an ATLS Course to a high standard as well as demonstrating an appropriate attitude to the ATLS philosophy. They should in addition have the basic interpersonal skills which when developed, will enable them to instruct clinicians of various grades and specialities. Finally, in the UK, they must also be in a career training post. Should the candidates fulfill these criteria and be unanimously supported by the course faculty, then they are invited to attend a three day Instructor Course, the primary emphasis of which is educational techniques. It incorporates training in lecturing, the teaching of practical skills, small group teaching and assessment of candidates. On successful completion of the Instructors Course, the provider becomes an 'Instructor Candidate' and undergoes further assessment whilst teaching on an ATLS course. Provided this is satisfactory, the clinician becomes a full instructor. To retain this status they must teach on two ATLS courses per year and recertify every 4 years. In 1995, a 2 day Instructors Course has been piloted in the UK similar to the 'abbreviated' Instructor Courses more popular in North America. However in the UK, the Instructors Course is frequently the first exposure that most clinicians have to educational techniques and we wait to see whether the advantages of a shorter course outweigh the reduced teaching practice. In both North America and the UK, Instructors tend to be actively involved in trauma care as part of their normal clinical practice. Not infrequently, they are also trauma enthusiasts who are dedicated to teaching. This is an important factor because there is no remuneration for teaching on an ATLS course. International dissemination of ATLS By the end of 1978, ATLS had become a statewide program in Nebraska. Subsequently it spread throughout the USA and Canada and within 2 years became the gold standard for the initial management of trauma victims. In 1988 the first combined Provider and Instructor ATLS Course was held at the Royal College of Surgeons of England. Courses are now to be found world-wide (Table 2), but have only very recently gained a foothold in civilian medical practice in mainland Europe. A pilot course was run in Belgium in 1993, and courses were subsequently established in Greece and Italy. The latest recruit is The Netherlands as a result of cooperation between the American College of Surgeons and the Dutch Trauma Society. To date nearly 200 000 doctors have been trained world-wide (I. Hughes, personal communication).Table 2: Dissemination of ATLS Dissemination in the UK Since its introduction into the UK, there has been a steady rise in the numbers of ATLS Provider Courses each year. By the end of 1994, 51 centres were registered with the Royal College of Surgeons of England and 5027 clinicians had been trained (O. Collins, personal communication). Almost every acute speciality is represented with Anaesthesia, Emergency Medicine, Orthopaedics and General Surgery leading the field in terms of absolute numbers (Table 3). The percentage of doctors within each speciality who have successfully completed the course would be more informative but this data is not currently available.Table 3: Specialities of UK doctors trained in ATLS to the end of 1994 The responsibility for the ATLS Courses in the UK rests with the ATLS Committee of the Royal College of Surgeons. This consists of six elected ATLS Instructors, representing the specialities of Anaesthesia, Emergency Medicine, Orthopaedics, General Surgery, the Armed Services, and one representative for the other specialities involved in trauma resuscitation, (currently a Neurosurgeon). There is also an elected Chairperson. The Committee's remit is to ensure the maintenance of standards and oversee the development of ATLS in the UK. To facilitate this, each centre must submit its course program, faculty and subsequent performance of candidates to the College. A significant development instituted by the Committee was the decision that the faculty on any UK ATLS Provider Course must contain a senior anaesthetist in recognition of the important role played by this group in resuscitation. Validity The ATLS program was based upon a major assumption: that with a proper educational format, training physicians in the knowledge and skills to apply the underlying concepts would result in an improvement in the outcome of trauma patients (1). Nevertheless there are few studies which have assessed specifically the effectiveness of ATLS on patients' outcome. In 1992 Driscoll and Vincent showed that organizing a trauma team along ATLS lines resulted in a reduction in resuscitation times and an improved outcome for patients who presented to the Emergency Department in a compromised respiratory, cardiovascular or neurological state [4]. Furthermore a population-based study in the USA showed that ATLS was one of several factors associated with low per-capita trauma death rates [5]. An attempt at a more comprehensive study into the effectiveness of ATLS was carried out over 8 years in Trinidad and Tobago (July 1981-December 1985 pre-ATLS and January 1986-June 1990 post-ATLS). This demonstrated that the mortality rate fell and the functional recovery among survivors rose following the introduction of ATLS which was also associated with an increase in ATLS procedures in the Emergency Department [6]. However these results should be interpreted with some caution; there were differences in the patients treated in the control and study groups, with the latter having a higher incidence of penetrating trauma and on average, a lower injury severity score. Furthermore, other factors may have occurred incidently during the post-introductory period thereby influencing the results. Finally, before extrapolating the relevance of the findings to European practice, the considerable differences in the socioeconomic structure of Trinidad and Tobago must also be taken into account. Assessment of candidates who have participated in an ATLS Provider Course indicates improvements in their knowledge, skills, confidence and ability to communicate with other specialists when dealing with trauma patients [7-11]. Furthermore, physicians change their clinical practice following the course [12] and appear to have a more positive attitude which helps with the introduction of ATLS principles into their respective departments [13]. Unfortunately, not all reports have been so favourably disposed towards ATLS. Specific aspects, its overall relevance and effect on patient assessment and outcome have all been questioned [14-17]. Criticism of a doctor assisted by a single nurse as being unrealistic is not supported by the findings of the Major Trauma Outcome Study (MTOS). This showed that in the UK, 68% of trauma victims are managed initially by a Senior House Officer alone and in only 24% is a 'trauma team' present (F. Campbell, personal communication). Of particular concern is the claim made by Vestrup and colleagues that following the introduction of ATLS there were more missed injuries and no significant alteration in mortality rate [17]. However such conclusions must be judged in the light that the study contained relatively small numbers of patients (50 and 71 in the pre- and post ATLS groups respectively) and the time to endpoints such as urinalysis, cystography and rectal examination were used to assess the impact of ATLS, rather than the time to completing the primary survey which is more valid and clinically important [4]. In addition, a retrospective review for evidence of delay in diagnosis of intra abdominal injury was used as a performance indicator. The validity of such a marker must be questioned particularly when one of the ATLS concepts has always been that "the primary factor in assessing abdominal trauma is not the accurate diagnosis of a specific type of injury, but rather the determination that an abdominal injury exists" [2]. Interestingly they did note that following ATLS training no airway errors occurred. A major problem in trying to determine the effectiveness of ATLS is that it only represents one link in the chain of care from the scene of the incident through to rehabilitation [18]. Self evidently the impact of ATLS in the early stages will be limited if there is poor pre-hospital care and no subsequent access to appropriate surgical, anaesthetic and intensive care facilities. A further confounding factor is that the application of ATLS skills will not benefit all trauma patients; some are either so badly, or so minimally injured that ATLS will not effect their ultimate outcome. The absolute number of patients in any location who would potentially benefit from ATLS is not known, but it is not unreasonable to assume that it will vary with the aetiology of trauma, local geography, medical facilities and other elements in the trauma care system. Each country will therefore need to determine for itself the effectiveness of ATLS rather than extrapolating results from non-comparable areas. If ATLS is shown to be beneficial, it will be essential to ensure that the improvement in knowledge and skills that occurs in the short term are maintained [13,19]. Retention of cardiac resuscitation skills have been shown to deteriorate significantly with time [20,21], with retention of skills being better in those who are actively involved in teaching or actively participating in resuscitation [22]. It is likely that physicians trained in ATLS will behave similarly, if they rarely have the opportunity to practise the skills acquired on the course. Indeed, it has been shown that more than half of the Washington State surgeons holding an ATLS qualification had not performed the majority of the skills taught on the course in the previous year [23]. Surprisingly, despite the lack of evidence to support the original hypothesis, ATLS in the USA is now looked upon as a legal standard of care for the initial management of trauma victims. Many States legislate that all physicians dealing with trauma patients must have successfully completed an ATLS course [1]. In the UK as yet, the requirements are not so stringent. The Royal College of Anaesthetists encourages trainees to attend an ATLS course, while the Faculty of Emergency Medicine guidelines strongly recommend that trainees should have successfully completed an ATLS Provider Course prior to finishing their Higher Professional Training. The Royal College of Surgeons similarly recommends that surgical trainees undertake an ATLS course prior to the Member of the Royal College of Surgeons of England (MRCS) Diploma examination. Only the limited number of courses currently available prevents this recommendation being made a mandatory requirement. The future Unlike North America, the UK failed to recognize the need for a surge in the number of Instructor Courses in the early stages [1,24]. Despite the gradual increase in the number of Provider Courses (from 7 in 1989 to 112 in 1994), the number of Instructor Courses has remained far more static, with only five run in 1994 and 10 proposed for 1995. This has resulted in a number of significant problems. First there is a shortage of Instructors, limiting the number of Provider Courses that can be run, despite an ever increasing demand. Second, the currently active Instructors are pressurized into teaching on increasing numbers of courses each year. This has not found universal favour amongst the Trusts in the new style National Health Service when senior clinicians are frequently spending 2-3 days away from their clinical duties. As a result, the majority of teaching in the UK is done during the clinicians' free time or during their vacations. If this situation is allowed to continue, it may result in a significant atrophy in the number of Instructors or, more likely, a restriction in the number of ATLS courses which can be run each year. Finally, the limited number of Instructor Courses has led to delays in candidates' obtaining a place on an Instructor Course, which they must do within 2 years of completing a Provider Course. It is unlikely that there is any single solution to this problem. Certainly this impasse cannot be solved by simple financial renumerations to Instructors or their employing authorities as this would make the course prohibitively expensive. Nevertheless an answer needs to be found or else the ATLS initiative in the UK will be stifled. Possible solutions lie in the following: A 2-3 year emphasis in training Instructors. This will mean even more than the 10 Instructor Courses planned for 1995. Abandoning the current restriction on sites allowed to run Instructor Courses. Currently only the Royal College of Surgeons of England, the Royal College of Physicians and Surgeons of Glasgow and the Royal Army Medical College are approved. This restriction appears odd because no such limitation exists in the USA. If half the total number of ATLS centres each ran one Instructor Course per year, 416 candidates would be trained (assuming a conservative estimate of 16 candidates per course). The number of Instructor Courses could be then regulated by the College so that a steady state is achieved. Recognition by all the Royal Colleges, in the form of awarding continuing medical education points for teaching on both Provider and Instructor Courses. Recognition by the Department of Health and Hospital Trusts that ATLS teaching is a justifiable use of a clinician's time. Those countries in Europe about to establish ATLS training programs would be well advised to learn from the mistakes made in the UK and avoid repeating them. Since its introduction into the UK, the grade of doctor attending ATLS courses has gradually fallen; nevertheless places are still preferentially offered to middle and higher level trainees (registrars and above). However it remains common for trauma victims to be managed intially by relatively inexperienced junior staff [25]. As spaces on ATLS courses are so limited, it has been suggested that local courses should be set up specifically for the most junior staff dealing with trauma so that the core elements are covered [26]. Furthermore it has been shown that either the whole, or part of the ATLS course can be effectively taught to undergraduates, and in view of the enthusiasm with which it has been received, it has been suggested that ATLS should be come part of their curriculum [7,19,27]. This may ultimately help provide another alternative solution to the situation of demand far exceeding supply in the postgraduate years. The problem of scientific validation of the effectiveness of ATLS remains a source of concern and ultimately has to be faced. The data from Trinidad and Tobago is encouraging and a project has been established in The Netherlands to assess the impact of ATLS in specific hospitals. Preliminary results are expected early in 1996. Summary From a family tragedy 20 years ago, ATLS has truly become an international trauma care program. Its success is demonstrated not only in the large number of physicians that have been trained, but also in the appearance of a number of affiliated courses with a similar structure, aimed at training medical, nursing, civilian and military personnel in how to deal with trauma in a variety of settings. A great deal of time and money has been spent on reaching this point and ATLS has undoubtedly had a profound effect on members of the medical profession worldwide. Few would doubt that ATLS has contributed to the overall improvement in the care of the victims of trauma and saved lives; yet we still lack the evidence to support what many of us feel so strongly about. We are now faced with the next major stage in the development of ATLS, namely to provide the evidence for the efficacy of this in an acceptable scientific manner. It is a challenge we should accept with the same enthusiasm that originally embraced ATLS, and where better to meet this challenge than within the countries of Europe? Acknowledgments The authors would like to express their grateful thanks to: Oonagh Collins and Tracey Headd at the Department of Education London, Professor Jim Ryan, Chairman of the ATLS Committee at The Royal College of Surgeons of England and Irvene Hughes, Manager, ATLS Division, The American College of Surgeons.