Advanced Trauma Life Support
Encyclopedia
Advanced Trauma Life Support (ATLS) is a training program for medical doctors in the management of acute trauma
cases, developed by the American College of Surgeons
. Similar programs exist for nurses (ATCN) and paramedics (PTLS). The program has been adopted worldwide in over 40 countries, 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 center
s. 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 mixed evidence to show that ATLS improves patient outcomes.
, 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
, penetrating injuries and bruising can be recognized by inspection.
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.
in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.
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.
s and numerous emergency services, the course runs numerous times per year for candidates drawn from all areas of medicine and trauma care. 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).http://www.nbcn.nhs.uk/emsb.htmhttp://www.itim.nsw.gov.au/go/education-and-training/courses/external-provider-courses/emsb
, an orthopedic surgeon
piloting a light aircraft, crashed his plane into a field in Nebraska
. His wife was killed instantly and three of his four children sustained critical injuries. 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.
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.
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 nurse
s. 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.
Trauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
cases, developed by the American College of Surgeons
American College of Surgeons
The American College of Surgeons is an educational association of surgeons created in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.-Membership:...
. Similar programs exist for nurses (ATCN) and paramedics (PTLS). The program has been adopted worldwide in over 40 countries, 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 center
Trauma center
A trauma center is a hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries. Trauma centers grew into existence out of the realization that traumatic injury is a disease process unto itself requiring specialized and experienced...
s. 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 mixed evidence to show that ATLS improves patient outcomes.
Primary Survey
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.A — Airway Maintenance with Cervical Spine Protection
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 sucking instruments. In case of obstruction, pass an endotrachial tube.B — Breathing and Ventilation
The chest must be examined by inspection, palpationPalpation
Palpation is used as part of a physical examination in which an object is felt to determine its size, shape, firmness, or location...
, percussion
Percussion (medicine)
Percussion is a method of tapping on a surface to determine the underlying structure, and is used in clinical examinations to assess the condition of the thorax or abdomen. It is one of the four methods of clinical examination, together with inspection, palpation and auscultation...
and auscultation
Auscultation
Auscultation is the term for listening to the internal sounds of the body, usually using a stethoscope...
. Subcutaneous emphysema
Subcutaneous emphysema
Subcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air, occurs when gas or air is present in the subcutaneous layer of the skin. Subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to trapped air...
and tracheal deviation must be identified if present. The aim is to identify and manage six life threatening thoracic conditions as Airway Obstruction
Airway obstruction
Airway obstruction is a respiratory problem caused by increased resistance in the bronchioles that reduces the amount of air inhaled in each breath and the oxygen that reaches the pulmonary arteries...
, Tension Pneumothorax
Pneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
, Massive Haemothorax, Open Pneumothorax, Flail chest
Flail chest
A flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall...
segment with Pulmonary Contusion
Pulmonary contusion
A pulmonary contusion is a contusion of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels...
and Cardiac Tamponade
Cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium ....
. Flail chest
Flail chest
A flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall...
, penetrating injuries and bruising can be recognized by inspection.
C — Circulation with Hemorrhage Control
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 given. If the patient 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.D — Disability (Neurologic Evaluation)
During the primary survey a basic neurological assessment is made, known by the mnenomic 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 injurySpinal cord injury
A spinal cord injury refers to any injury to the spinal cord that is caused by trauma instead of disease. Depending on where the spinal cord and nerve roots are damaged, the symptoms can vary widely, from pain to paralysis to incontinence...
level.
The Glasgow Coma Scale
Glasgow Coma Scale
Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment...
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
Hypoglycemia
Hypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...
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
Traumatic brain injury
Traumatic brain injury , also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism , or other features...
until proven otherwise.
E — Exposure / Environmental control
The patient should be completely undressed, usually by cutting off the garments. It is imperative to cover the patient with warm blankets to prevent hypothermiaHypothermia
Hypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as . Body temperature is usually maintained near a constant level of through biologic homeostasis or thermoregulation...
in the emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient privacy should be maintained.
Secondary Survey
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 historyMedical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
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.
Alternatives
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 CollegeRoyal College
A Royal College in some Commonwealth countries is technically a college which has received permission to use the prefix Royal. Permission is usually granted through a Royal Charter. The charter normally confers a constitution with perpetual succession and the right to sue or be sued independently...
s and numerous emergency services, the course runs numerous times per year for candidates drawn from all areas of medicine and trauma care. Specific injuries, such as major burn
Burn
A burn is an injury to flesh caused by heat, electricity, chemicals, light, radiation, or friction.Burn may also refer to:*Combustion*Burn , type of watercourses so named in Scotland and north-eastern England...
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).http://www.nbcn.nhs.uk/emsb.htmhttp://www.itim.nsw.gov.au/go/education-and-training/courses/external-provider-courses/emsb
History
ATLS has its origins in the United States in 1976, when James K. StynerJames K. Styner
James K Styner, MD, FACS is an orthopaedic surgeon, practicing in Lawndale, California. He was instrumental in the development of the Advanced Trauma Life Support program.- Tragedy :...
, an orthopedic surgeon
Orthopedic surgery
Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system...
piloting a light aircraft, crashed his plane into a field in Nebraska
Nebraska
Nebraska is a state on the Great Plains of the Midwestern United States. The state's capital is Lincoln and its largest city is Omaha, on the Missouri River....
. His wife was killed instantly and three of his four children sustained critical injuries. He carried out the initial triage
Triage
Triage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...
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.
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
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
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.
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 nurse
Registered nurse
A registered nurse is a nurse who has graduated from a nursing program at a university or college and has passed a national licensing exam. A registered nurse helps individuals, families, and groups to achieve health and prevent disease...
s. 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
National Association of Emergency Medical Technicians
The National Association of Emergency Medical Technicians ' is a national Emergency medical services professional association representing all EMTs and Paramedics....
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.
See also
- Trauma teamTrauma teamA Trauma team is a group of healthcare workers who tend to seriously ill or injured patients who arrive at a hospital emergency department. The team is composed of a number of specific roles, with a typical team consisting of:...
- Basic Life SupportBasic life supportBasic life support is the level of medical care which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by...
- Advanced Life SupportAdvanced Life SupportAdvanced Life Support is a set of life-saving protocols and skills that extend Basic Life Support to further support the circulation and provide an open airway and adequate ventilation .-Components of ALS:These include:...
- Advanced Cardiac Life SupportAdvanced cardiac life supportAdvanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
- Pediatric Advanced Life SupportPediatric Advanced Life SupportPediatric Advanced Life Support is a 2 day American Heart Association training program. The goal of the course is to aid the pediatric healthcare provider in developing the knowledge and skills necessary to efficiently and effectively manage critically ill infants and children, resulting in...
- Definitive Surgical Trauma SkillsDefinitive Surgical Trauma SkillsThe Definitive Surgical Trauma Skills course is a joint development between The Royal College of Surgeons of England, The Royal Centre for Defence Medicine and The Uniformed Services University of the Health Sciences in Washington DC, USA....
- ABC (medicine)
- List of emergency medicine courses