Anaesthesia, 1992, Volume 47, pages 798-800 SPECIAL C O M M U N I C A T I O N
Advanced trauma life support A time for reappraisal
J. R. BENNETT, A. R. BODENHAM
AND
J. C. B E R R I D G E
Summary The experience of Advanced Trauma Life Support training received by three anaesthetists is discussed with parricular reference to the teaching qfuirway management, the grade of staff who should attend the present courses and the relevance to the British hospital sysrem. We conclude that these courses are useful but limited by their inflexibility and failure to recognise rhe difference in skill mix in the British setting. Key words Anaesthesia; trauma. Education.
Over half a million trauma victims are admitted to hospital in the UK each year [I]. Approximately 40 people per day, or 14500 per year, die as a result of trauma. It is the leading cause of death in the under-35-year age group. Deaths from AIDS are rare in comparison, yet only a small percentage of resources are channelled into research and prevention of trauma. The report of the Royal College of Surgeons of England [I] identified suboptimal management as a contributory factor in the high morbidity and mortality of trauma patients in hospital. One initiative has been the adoption of Advanced Trauma Life Support (ATLS) provider courses from America. ATLS started in the UK in 1988 with one course; this year there will be over 40 courses. This has led to the widespread introduction of ATLS teaching in accident and emergency departments. We review our experiences of three different ATLS provider courses which we attended. The origins of ATLS
The concept of ATLS arose from an accident in the deserts of Nebraska, USA, in 1978. A surgeon was piloting a light aircraft which crashed, killing his wife and injuring his three children. No emergency services had been alerted and he had great difficulty in getting his children and himself to the local hospital. On arrival he felt that the basic trauma care was inadequate. Following his experiences, he set up the ATLS courses, aimed at staff found in this type of
isolated (community) hospital. However, ATLS is now being taught widely in the USA and is being introduced throughout the world as an exact, verbatim replica of the American course (apart from the use of animal models for teaching practical skills [2]). The aims of ATLS
The aim is clearly described in the course as, the appropriate management of patients in the early period following trauma-the so-called ‘Golden Hour’. Such management should not only reduce mortality at this time but also reduce the morbidity and mortality which occur in the period 10-21 days after trauma [3]. ATLS achieves this by concentrating o n basic, safe management principles and teaching several practical skills. These skills assist not only in the management of the patient but also provide diagnostic information which should alert the isolated physician to the need for appropriate referral or assistance. To this end, ATLS achieves its aim well. It is a deficiency in our medical training that such basic skills and knowledge are not learnt by our junior doctors at an early stage in postgraduate training or even at medical school. How does it work?
The 3-day course consists of lectures, practical instruction (skill stations) and the moulage (r61e play of a trauma situation). The content is strictly laid down by the
J.R. Bennett, FRCAnaes, Department of Anesthesiology, Oregon Health Sciences University, Portland, Oregon, USA 97201, A.R. Bodenham, FRCAnaes, Consultant, Leeds General Infirmary, Great George Street, Leeds LSI 3EX, J.C. Berridge, MRCP, FRCAnaes, Senior Registrar in Anaesthesia, Yorkshire Regional Rotation, 24 Hyde Terrace, Leeds LS2 9LN. Correspondence should be addressed to D r J.C. Berridge, Academic Unit of Anaesthesia, 24 Hyde Terrace, Leeds LS2 9LN. Accepted 2 December 1991. 0003-2409/92/090798
+ 03 %03.00/0
@ 1992 The Association of Anaesthetists of Gt Britain and Ireland
798
Advanced trauma life support American faculty. Each instructor may be called upon to teach any part of the course irrespective of that instructor's parent discipline. ATLS training uses algorithms for the trainee to follow. The algorithms concentrate on resuscitation and review until the patient is stable. Further algorithms are used to assess other injuries and lead the physician to decide o n referral to a general, orthopaedic, cardiothoracic or neurosurgeon. either within the hospital or elsewhere. There may be situations in which stability cannot be achieved without surgical intervention, in which case the patient is likely to die if no surgeon is available. The algorithms are based on the presence of a three-tier hospital system as exists in America, including the community hospital (level 3), the district hospital (level 2) and the regional hospital (level I Trauma Centre). Trauma services in the U K have been developed on a two-tier system-district general and teaching hospitals, both of which have all basic specialties.
799
Indications for intubation and surgical airway
Unconscious, with blunt trauma
I
Suspect cervical spine injury
I
Airway urgency
I
I Immediate need
No immediate need
I
Oxygenate/venti I ate ApAeic
Breaihing
I
I
I
Obtaincervical spine X ray
I
Problems The three authors. as anaesthetists. identified a number of potential problems in the ATLS teaching, and it is likely that other specialists may have disagreements with the teaching related to their own discipline. None of the algorithms led to a request for the services of an anaesthetist. It is argued that the isolated doctor has no time to send for an anaesthetist. and that a difficult airway problem must be managed to the best of hisiher ATLS skills. This may be appropriate in America, but in the UK there are very few acute admitting hospitals which d o not have an anaesthetist available within minutes, or present in the Emergency Department when the patient arrives. This is preferable to the anaesthetist being sent for after the ATLS-trained casualty officer and surgeon have spent time with the patient. In the smaller British hospitals, the most experienced resident doctor may often be the anaesthetist. Anaesthetists are not mentioned anywhere in the course, and inspection of the course faculty in America reveals no anaesthetic input. Some trauma centres in America. such as Baltimore. advocate the use of anaesthetists specialised in trauma care to lead the trauma team [4],although this is against the ATLS faculty recommendations. Some courses in this country have no senior anaesthetist among the instructors. Anaesthetists should be familiar with the doctrine of ATLS and will benefit from the practical experience of the other techniques taught. In addition, they posses other skills which may decrease morbidity in the less severely ill patient and which may be life-saving in the severely traumatised patient. ATLS training does not allow the use of drugs such as sedatives, analgesics and muscle relaxants to facilitate tracheal intubation. In the semiconscious patient, ATLS training advocates the use of blind nasal intubation, a technique not without hazards, rather than using drugs to aid tracheal intubation (Fig. I ) . Another feature in the management of patients is that central venous cannulation for resuscitation is discouraged on the basis that, in the hands of an inexperienced operator, the complications outweigh the benefits. This dogma fails to address the fact that such skills are often available and in many instances more appropriate than a surgical cut-down. These criticisms do not imply that ATLS training is
',
Servere, maxillafacia I injury, pre:, cluding ability to intubate
Unable
;\\*
Unable
Surgical airway
+
Orotrachea I intubation
"Proceed according to clinical judgment
Fig. 1. Indications for intubalion and surgical airway (reproduced by kind permission of the Trauma Committee of the American College of Surgeons).
wrong. It is one system, but within that system consideration should be given to the specialist experience which is often available in British hospitals, otherwise senior medical staff will find the course less valuable and may not attend. Indeed, these skills may be used more appropriately in conjunction with the training offered by ATLS.
To whom is the course directed? The Royal College of Surgeons of England supports attendance by junior doctors at ATLS courses [I]. However, the ATLS Working Party anticipates that consultants and senior registrars, especially those who may be members of a Trauma Team, will be the main attenders. As there are potential advantages in having one system, the whole Trauma Team should benefit from ATLS. Specialists can learn from other disciplines; for example. many anaesthetists would benefit from the lessons on interpretation of cervical spine X rays, but it is naive to have an orthopaedic registrar teaching trained anaesthetists about the management of the paediatric airway or the reverse in the case of spinal injuries. Recognition of specialised skills needs to be incorporated into the course, otherwise it becomes a pantomime. Some ATLS courses do recognise the benefit of a specialist teaching within his/her specialty, although this is against one of the concepts of the course.
800
J.R. Bennett, A . R . Bodenham and J . C . Berridge
The relevance of ATLS training to British hospitals During the course, much emphasis is placed on working through trauma scenarios on paper, and with people modelling as trauma patients, the so-called ‘moulage’. In both cases, the common thread is that you are isolated in a hospital, usually 100 miles from a Trauma Centre, and with no surgical support immediately available. As noted above, anaesthetic availability is not mentioned, a situation which is unusual in the UK. The Royal College of Surgeons provided funds for a retrospective enquiry into 1000 cases of deaths due to trauma [I]. The results indicate that of 170 preventable deaths, 22 were due to hypoxia and 15 of these secondary to aspiration. This shows the need for skilled staff as early as possible in trauma cases and that aspiration, although not specifically mentioned in the ATLS course, is an important factor. It concludes that major trauma care should be regionalised and that every effort must be made to bring the patient to such a centre during the ‘Golden Hour’, where expert anaesthetic and surgical help must be at hand. It also recommends changes in postgraduate education to allow specialists to rotate through an Accident and Emergency Department. The standard of trauma care could undoubtedly be improved in the UK, but should we propagate a course which was not designed for the British system? The ATLS handbook, containing the course material, is reviewed every 4 years and the next edition is to contain some suggestions from the British ATLS Working Party [2]. There will not be a separate British handbook and the different rhles of anaesthetists across the Atlantic are unlikely to be recognised.
The evidence that ATLS is effective Irving [S] cites missed diagnoses, continuing haemorrhage, hypoxia and lack of timely surgery as the major reasons for poor outcome in trauma, but it has been shown that the establishment of trauma centres has improved outcome in both the UK and America [5,6]. Trauma scoring systems, such as the Revised Trauma Score, have proved useful to indicate when expert help should be requested [7]. One Accident and Emergency Department in Vancouver tried to quantify the improvement in patient outcome
before and after the introduction of ATLS training [8]. The authors documented all trauma patients one year before and one year after the introduction of ATLS training and showed no difference over the 2-year period. The ATLS Working Party in the UK is about to launch a questionnaire survey of those who have attended ATLS courses to establish if their practice has changed. They will also be attempting to assess whether outcome has been improved in departments which incorporate ATLS. Both studies will have implications regarding the future of ATLS in the UK. ATLS is not a ‘magic bullet’ for tackling the enormous number of trauma victims admitted to hospital but improved training and outcome audit are to be welcomed in Accident and Emergency departments. ATLS courses may be an important adjunct to training, as suggested by the Royal College of Surgeons, but there is no evidence to date that this is so. It is perhaps too harsh to describe ATLS as ‘gimmicky’ but it is a ‘package deal’. If there is a place for algorithms in trauma then a recognition of specialist skills should be incorporated, otherwise they may result in inferior care and the ATLS courses will fail to attract senior medical staff.
References [I] Working party report. Management of patients with major injuries. London: Royal College of Surgeons of England. 1988. IR. Animal cadaveric [2] EATONBD, MESSENTDO, HAYWOOD models for advanced trauma life support training. Annals of the Royal College of Surgeons of England 1990; 7 2 135-9. [3] Advanced trauma life support course. Chicago, American College of Surgeons; 1989. CR. Trauma [4] GRANDE CM, STENEJK, BERNHARDWN, BARTON anaesthesia and critical care: the concept and rationale for a new subspecialty. Critical Care Clinics 1990; 6 1-1 I . [5] IRVINGM. The evolution of trauma care in the United Kingdom. Injury: British Journal of Accident Surgery 1989; 2 0 3 17-21, [6] WEST JG, CALES RH, GAZZANIGAAB. Impact of regionalization. The Orange County experience. Archives of Surgery 1983; 118 740-4. [7] FISHERRB, DEARDEN CH. Improving the care of the trauma patient in the Accident and Emergency Department. British Medical Journal 1990; 300: 1560-3. A, WOODV. Impact of advanced (81 VFSTRUPJA, STORMORKEN trauma life support training on early trauma management. American Journal of Surgery 188; 155 704-7.
Advanced trauma life support A time for reappraisal
J. R. BENNETT, A. R. BODENHAM
AND
J. C. B E R R I D G E
Summary The experience of Advanced Trauma Life Support training received by three anaesthetists is discussed with parricular reference to the teaching qfuirway management, the grade of staff who should attend the present courses and the relevance to the British hospital sysrem. We conclude that these courses are useful but limited by their inflexibility and failure to recognise rhe difference in skill mix in the British setting. Key words Anaesthesia; trauma. Education.
Over half a million trauma victims are admitted to hospital in the UK each year [I]. Approximately 40 people per day, or 14500 per year, die as a result of trauma. It is the leading cause of death in the under-35-year age group. Deaths from AIDS are rare in comparison, yet only a small percentage of resources are channelled into research and prevention of trauma. The report of the Royal College of Surgeons of England [I] identified suboptimal management as a contributory factor in the high morbidity and mortality of trauma patients in hospital. One initiative has been the adoption of Advanced Trauma Life Support (ATLS) provider courses from America. ATLS started in the UK in 1988 with one course; this year there will be over 40 courses. This has led to the widespread introduction of ATLS teaching in accident and emergency departments. We review our experiences of three different ATLS provider courses which we attended. The origins of ATLS
The concept of ATLS arose from an accident in the deserts of Nebraska, USA, in 1978. A surgeon was piloting a light aircraft which crashed, killing his wife and injuring his three children. No emergency services had been alerted and he had great difficulty in getting his children and himself to the local hospital. On arrival he felt that the basic trauma care was inadequate. Following his experiences, he set up the ATLS courses, aimed at staff found in this type of
isolated (community) hospital. However, ATLS is now being taught widely in the USA and is being introduced throughout the world as an exact, verbatim replica of the American course (apart from the use of animal models for teaching practical skills [2]). The aims of ATLS
The aim is clearly described in the course as, the appropriate management of patients in the early period following trauma-the so-called ‘Golden Hour’. Such management should not only reduce mortality at this time but also reduce the morbidity and mortality which occur in the period 10-21 days after trauma [3]. ATLS achieves this by concentrating o n basic, safe management principles and teaching several practical skills. These skills assist not only in the management of the patient but also provide diagnostic information which should alert the isolated physician to the need for appropriate referral or assistance. To this end, ATLS achieves its aim well. It is a deficiency in our medical training that such basic skills and knowledge are not learnt by our junior doctors at an early stage in postgraduate training or even at medical school. How does it work?
The 3-day course consists of lectures, practical instruction (skill stations) and the moulage (r61e play of a trauma situation). The content is strictly laid down by the
J.R. Bennett, FRCAnaes, Department of Anesthesiology, Oregon Health Sciences University, Portland, Oregon, USA 97201, A.R. Bodenham, FRCAnaes, Consultant, Leeds General Infirmary, Great George Street, Leeds LSI 3EX, J.C. Berridge, MRCP, FRCAnaes, Senior Registrar in Anaesthesia, Yorkshire Regional Rotation, 24 Hyde Terrace, Leeds LS2 9LN. Correspondence should be addressed to D r J.C. Berridge, Academic Unit of Anaesthesia, 24 Hyde Terrace, Leeds LS2 9LN. Accepted 2 December 1991. 0003-2409/92/090798
+ 03 %03.00/0
@ 1992 The Association of Anaesthetists of Gt Britain and Ireland
798
Advanced trauma life support American faculty. Each instructor may be called upon to teach any part of the course irrespective of that instructor's parent discipline. ATLS training uses algorithms for the trainee to follow. The algorithms concentrate on resuscitation and review until the patient is stable. Further algorithms are used to assess other injuries and lead the physician to decide o n referral to a general, orthopaedic, cardiothoracic or neurosurgeon. either within the hospital or elsewhere. There may be situations in which stability cannot be achieved without surgical intervention, in which case the patient is likely to die if no surgeon is available. The algorithms are based on the presence of a three-tier hospital system as exists in America, including the community hospital (level 3), the district hospital (level 2) and the regional hospital (level I Trauma Centre). Trauma services in the U K have been developed on a two-tier system-district general and teaching hospitals, both of which have all basic specialties.
799
Indications for intubation and surgical airway
Unconscious, with blunt trauma
I
Suspect cervical spine injury
I
Airway urgency
I
I Immediate need
No immediate need
I
Oxygenate/venti I ate ApAeic
Breaihing
I
I
I
Obtaincervical spine X ray
I
Problems The three authors. as anaesthetists. identified a number of potential problems in the ATLS teaching, and it is likely that other specialists may have disagreements with the teaching related to their own discipline. None of the algorithms led to a request for the services of an anaesthetist. It is argued that the isolated doctor has no time to send for an anaesthetist. and that a difficult airway problem must be managed to the best of hisiher ATLS skills. This may be appropriate in America, but in the UK there are very few acute admitting hospitals which d o not have an anaesthetist available within minutes, or present in the Emergency Department when the patient arrives. This is preferable to the anaesthetist being sent for after the ATLS-trained casualty officer and surgeon have spent time with the patient. In the smaller British hospitals, the most experienced resident doctor may often be the anaesthetist. Anaesthetists are not mentioned anywhere in the course, and inspection of the course faculty in America reveals no anaesthetic input. Some trauma centres in America. such as Baltimore. advocate the use of anaesthetists specialised in trauma care to lead the trauma team [4],although this is against the ATLS faculty recommendations. Some courses in this country have no senior anaesthetist among the instructors. Anaesthetists should be familiar with the doctrine of ATLS and will benefit from the practical experience of the other techniques taught. In addition, they posses other skills which may decrease morbidity in the less severely ill patient and which may be life-saving in the severely traumatised patient. ATLS training does not allow the use of drugs such as sedatives, analgesics and muscle relaxants to facilitate tracheal intubation. In the semiconscious patient, ATLS training advocates the use of blind nasal intubation, a technique not without hazards, rather than using drugs to aid tracheal intubation (Fig. I ) . Another feature in the management of patients is that central venous cannulation for resuscitation is discouraged on the basis that, in the hands of an inexperienced operator, the complications outweigh the benefits. This dogma fails to address the fact that such skills are often available and in many instances more appropriate than a surgical cut-down. These criticisms do not imply that ATLS training is
',
Servere, maxillafacia I injury, pre:, cluding ability to intubate
Unable
;\\*
Unable
Surgical airway
+
Orotrachea I intubation
"Proceed according to clinical judgment
Fig. 1. Indications for intubalion and surgical airway (reproduced by kind permission of the Trauma Committee of the American College of Surgeons).
wrong. It is one system, but within that system consideration should be given to the specialist experience which is often available in British hospitals, otherwise senior medical staff will find the course less valuable and may not attend. Indeed, these skills may be used more appropriately in conjunction with the training offered by ATLS.
To whom is the course directed? The Royal College of Surgeons of England supports attendance by junior doctors at ATLS courses [I]. However, the ATLS Working Party anticipates that consultants and senior registrars, especially those who may be members of a Trauma Team, will be the main attenders. As there are potential advantages in having one system, the whole Trauma Team should benefit from ATLS. Specialists can learn from other disciplines; for example. many anaesthetists would benefit from the lessons on interpretation of cervical spine X rays, but it is naive to have an orthopaedic registrar teaching trained anaesthetists about the management of the paediatric airway or the reverse in the case of spinal injuries. Recognition of specialised skills needs to be incorporated into the course, otherwise it becomes a pantomime. Some ATLS courses do recognise the benefit of a specialist teaching within his/her specialty, although this is against one of the concepts of the course.
800
J.R. Bennett, A . R . Bodenham and J . C . Berridge
The relevance of ATLS training to British hospitals During the course, much emphasis is placed on working through trauma scenarios on paper, and with people modelling as trauma patients, the so-called ‘moulage’. In both cases, the common thread is that you are isolated in a hospital, usually 100 miles from a Trauma Centre, and with no surgical support immediately available. As noted above, anaesthetic availability is not mentioned, a situation which is unusual in the UK. The Royal College of Surgeons provided funds for a retrospective enquiry into 1000 cases of deaths due to trauma [I]. The results indicate that of 170 preventable deaths, 22 were due to hypoxia and 15 of these secondary to aspiration. This shows the need for skilled staff as early as possible in trauma cases and that aspiration, although not specifically mentioned in the ATLS course, is an important factor. It concludes that major trauma care should be regionalised and that every effort must be made to bring the patient to such a centre during the ‘Golden Hour’, where expert anaesthetic and surgical help must be at hand. It also recommends changes in postgraduate education to allow specialists to rotate through an Accident and Emergency Department. The standard of trauma care could undoubtedly be improved in the UK, but should we propagate a course which was not designed for the British system? The ATLS handbook, containing the course material, is reviewed every 4 years and the next edition is to contain some suggestions from the British ATLS Working Party [2]. There will not be a separate British handbook and the different rhles of anaesthetists across the Atlantic are unlikely to be recognised.
The evidence that ATLS is effective Irving [S] cites missed diagnoses, continuing haemorrhage, hypoxia and lack of timely surgery as the major reasons for poor outcome in trauma, but it has been shown that the establishment of trauma centres has improved outcome in both the UK and America [5,6]. Trauma scoring systems, such as the Revised Trauma Score, have proved useful to indicate when expert help should be requested [7]. One Accident and Emergency Department in Vancouver tried to quantify the improvement in patient outcome
before and after the introduction of ATLS training [8]. The authors documented all trauma patients one year before and one year after the introduction of ATLS training and showed no difference over the 2-year period. The ATLS Working Party in the UK is about to launch a questionnaire survey of those who have attended ATLS courses to establish if their practice has changed. They will also be attempting to assess whether outcome has been improved in departments which incorporate ATLS. Both studies will have implications regarding the future of ATLS in the UK. ATLS is not a ‘magic bullet’ for tackling the enormous number of trauma victims admitted to hospital but improved training and outcome audit are to be welcomed in Accident and Emergency departments. ATLS courses may be an important adjunct to training, as suggested by the Royal College of Surgeons, but there is no evidence to date that this is so. It is perhaps too harsh to describe ATLS as ‘gimmicky’ but it is a ‘package deal’. If there is a place for algorithms in trauma then a recognition of specialist skills should be incorporated, otherwise they may result in inferior care and the ATLS courses will fail to attract senior medical staff.
References [I] Working party report. Management of patients with major injuries. London: Royal College of Surgeons of England. 1988. IR. Animal cadaveric [2] EATONBD, MESSENTDO, HAYWOOD models for advanced trauma life support training. Annals of the Royal College of Surgeons of England 1990; 7 2 135-9. [3] Advanced trauma life support course. Chicago, American College of Surgeons; 1989. CR. Trauma [4] GRANDE CM, STENEJK, BERNHARDWN, BARTON anaesthesia and critical care: the concept and rationale for a new subspecialty. Critical Care Clinics 1990; 6 1-1 I . [5] IRVINGM. The evolution of trauma care in the United Kingdom. Injury: British Journal of Accident Surgery 1989; 2 0 3 17-21, [6] WEST JG, CALES RH, GAZZANIGAAB. Impact of regionalization. The Orange County experience. Archives of Surgery 1983; 118 740-4. [7] FISHERRB, DEARDEN CH. Improving the care of the trauma patient in the Accident and Emergency Department. British Medical Journal 1990; 300: 1560-3. A, WOODV. Impact of advanced (81 VFSTRUPJA, STORMORKEN trauma life support training on early trauma management. American Journal of Surgery 188; 155 704-7.
