Advanced Trauma Life Support

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Advanced Trauma Life Support ( ATLS ) is a training concept that standardized diagnostic and therapeutic courses of action in the early in-hospital first aid to seriously injured ( multiple trauma ) patients in the emergency room defined. It was developed by the American College of Surgeons (ACS) in the 1970s and is now trained and used in a wide variety of countries. Advanced Trauma Life Support / ATLS are protected terms.

development

The impetus for the development of the ATLS concept came from an accident of the American trauma surgeon James Styner, who had an accident with his family in a private plane in 1976. The emergency medical first aid was so inadequate that Styner noted serious deficiencies in the medical training for the care of seriously injured people. Various regional working groups were set up on his initiative to develop concepts for first aid for the injured. ATLS was developed by the American College of Surgeons on the basis of this work in the late 1970s . The didactic concepts that the American Heart Association had recently introduced with Advanced Cardiac Life Support were used. ATLS has since become the standard in the care of trauma patients in the United States. It is now being trained in over 50 countries; in Great Britain, Switzerland, the Netherlands and other countries it is a compulsory part of medical training. ATLS has since derived various concepts for preclinical trauma care by the emergency services ( International Trauma Life Support , Pre Hospital Trauma Life Support ).

concept

The basic idea of ​​the ATLS is to quickly record and treat the most threatening injuries and disorders of the patient's vital functions (“treat first what kills first”).

In the event of cardiovascular arrest , resuscitation according to the ERC guidelines is started immediately .

In all other cases, a diagnostic and therapeutic block (“primary survey”) begins, which helps to identify and treat potentially fatal consequences of the multiple trauma, sorted by priority . After this initial care, all relevant injuries and illnesses are diagnosed in a second, more detailed phase ("secondary survey"), whereby imaging methods ( X-ray , CT ) are also used.

For the care of the seriously injured, a so-called AF scheme (ABCDEF scheme) has been developed, which includes the following treatment steps:

  • A Securing the airway
  • B ventilation
  • C Circulation (securing a minimal circulation)
  • D (urgent) diagnostics
  • E Emergency operation
  • F "Fingers" (all further clinical and laboratory tests).

In recent years, critical blood loss has become more and more the focus, so that the <C> ABCDE scheme is now used more and more often. The <C> stands for "Catastrophic Bleeding" or "Catastrophic Haemorrhage Control". Massive sources of bleeding are stopped before the airway is secured using compression, pressure bandages or tourniquets. All further measures such as the installation of a large-lumen peripheral venous catheter then take place as before with "Circulation".

ABCDE scheme in the rescue service

The ABCDE scheme in its current form is now also used in the rescue service. In the form of an instruction ( SOP = standard operating procedure ) it is a fast, reliable and priority-oriented strategy for assessing the patient's condition and the targeted initiation of measures for medical and non-medical staff. On the one hand, the scheme serves to quickly categorize the patient as critical or non-critical. In this sense, it forms a fixed algorithm and follows the principle: "Treat first what kills first". Only when a higher-priority problem (A> B> C> D> E) has been resolved or dealt with does the next point in the scheme proceed. On the other hand, the scheme also provides a comprehensive overview of non-life-threatening injured or sick patients. Basic vital parameters as well as initial traumatological and neurological findings are provided by the ABCDE scheme.

Primary Survey - initial examination: "ABCDE scheme"

In the primary survey, the most important consequences of a multiple trauma are diagnosed and treated in order of priority. As long as the number of treating persons is severely limited (e.g. ambulance service at the accident site), strict adherence to the sequence is necessary (for example, it makes no sense to improve the ventilation of the lungs as long as the patient does not have a safe airway ).

If enough staff is available (e.g. emergency room ), the order can be deviated from as long as the point of highest priority is treated unhindered (e.g. surgeon takes care of heavy bleeding while the anesthesiologist secures the airway).

The following ABCDE scheme is used both in the emergency room and in the rescue service. In the latter case, it is also used as a basic algorithm for non-life-threatening injured and sick people.

A - Airway

The upper respiratory tract is assessed here. Basically the questions are:

  • are the airways clear and safe?
  • is there a cervical spine trauma ?
  • is there a risk of displacement or swelling?
  • are the airways blocked?

to answer. If the upper airways are considered to be open and safe, then there is no (no longer) a problem and you can continue with B. On the contrary, the algorithm cannot go to B as long as the airways are obstructed or swollen.

→ View into the mouth / throat
→ overstretch head
Guedel tube , Wendl tube
Endotracheal intubation
→ Apply a cervical support

B - Breathing (ventilation)

  • normal breathing (frequency, depth of breath / tidal volume, breathing pattern)?
  • Breathing sounds, auscultation ?
  • Oxygenation? Signs of cyanosis ? Oxygen saturation ?
  • Breathing work (chest movements on the same side? Use of auxiliary respiratory muscles?)
  • Skin emphysema , congested neck veins?

→ Breathing support position
→ Oxygen delivery
→ Intubation, controlled ventilation
Monaldi drainage

C - Circulation

→ Large-lumen peripheral venous catheter
→ Volume application
Pressure bandage , ligature
Pelvic clamp , external compression of the pelvis
Emergency laparotomy

D - Disability (neurological deficit)

E - exposure (exposure, environment)

  • Complete undressing, full body examination
  • Brief history

→ heat retention
→ wound care
→ splint fractures

Secondary Survey

After completion of the most important diagnostics and the stabilization of all vital parameters, a more detailed assessment follows, which should reveal any injuries. It consists of a physical examination, radiological examination, and (foreign) anamnesis.

education

The ATLS training takes place in a two-day course; in Germany, the German Society for Trauma Surgery is certified to perform. For this purpose, theoretical preparation takes place using a course manual; the course itself included theoretical units and above all practical exercises. After a written and oral exam, the ATLS Provider certificate , which is valid for five years, is awarded.

reviews

The benefits, structural quality and the adoption of the ATLS concept to Europe are controversial. Since the need for priority-oriented, standardized treatment is generally accepted, proponents of the concept see the ATLS as a suitable means of treating patients effectively. Thanks to its simple and clear structure, it can be used internationally without any problems and improves the care of severely traumatized patients. Critics counter this that a benefit for the patient and an improvement in the prognosis has not yet been proven.

Weaknesses are also seen in the methodology of the concept. According to the criteria of the German Instrument for Methodical Guideline Assessment (DELBI) , ATLS contains deficiencies in various areas: Interdisciplinary cooperation ( surgery , anesthesia , radiology, etc.), as is common in the emergency room , is not provided for in the surgically oriented ATLS; Only national accident surgery specialist societies are allowed to act as ATLS licensees. Updating the course content is also slow, and the ACS does not allow adaptation to regional conditions. The ATLS manual is still not available in free trade, so the content is not openly accessible. Criticism is also made of the commercial aspects, since the ACS receives large sums of license fees every year, so that editorial independence is not given.

Various technical aspects of the concept are also criticized that do not correspond to the current state of knowledge and are to be regarded as out of date, such as inadequate airway management , the assessment of the circulatory situation using obsolete parameters (see shock index ) and the uncritical use of immobilization techniques from the various side effects can result.

The takeover of the American ATLS is valued differently in Europe. While it is part of medical education and training in various countries, others are more opposed to the concept. After the demands of British doctors for local adaptations were not met by the ACLS, the development of an own concept was discussed in the United Kingdom . Due to the discussed weaknesses of ATLS, on the initiative of the European Resuscitation Council, the European Trauma Working Group , which is composed of representatives from various specialist societies, has developed a European interdisciplinary alternative concept, the European Trauma Course .

See also

Web links

Individual evidence

  1. ^ JK Styner: The birth of Advanced Trauma Life Support (ATLS). In: Surgeon. 4 (3), Jun 2006, pp. 163-165. PMID 16764202
  2. a b c d e K. C. Thies, P. Nagele: Advanced Trauma Life Support - A standard of care for Germany? In: Anaesthesiologist. 56 (11), Nov 2007, pp. 1147-1154. Review. PMID 17882389
  3. Holger Harbs: Procedure on the patient: The ABCDE scheme. (PDF) Kiel University Hospital; Retrieved April 14, 2014.
  4. a b c M. Helm, M. Kulla, L. Lampl: Advanced Trauma Life Support - A training concept also for Europe. In: Anaesthesiologist. 56 (11), Nov 2007, pp. 1142-1146. Review. PMID 17726585
  5. Walied Abdulla: Interdisciplinary Intensive Care Medicine. Urban & Fischer, Munich a. a. 1999, ISBN 3-437-41410-0 , p. 469.
  6. Emergency paramedic / rescue service textbook . Cornelsen Verlag, Berlin 2014, ISBN 978-3-06-451000-5 , pp. 319, 320 .
  7. B. Bouillon, KG Kanz, CK Lackner u. a .: The importance of the ATLS in the emergency room. In: trauma surgeon. 107, 2004, pp. 844-850. PMID 15452655
  8. H. Shakiba, S. Dinesh, MK Anne: Advanced trauma life support Training for hospital staff. In: Cochrane Database Syst Rev. (3), 2004, p. CD004173. PMID 15266521
  9. cf. German instrument for methodological guideline evaluation ( www.delbi.de )
  10. Karl-Christian Thies: Advanced Trauma Life Support: With blue light in the dead end? In: Dtsch Arztebl. 101 (26), 2004, pp. A-1874 / B-1564 / C-1500.
  11. M. Davis: Should there be a UK based advanced trauma course? In: Emerg Med J. 22, 2005, pp. 5-6.
  12. ^ D. McKeown: Should the UK develop and run its own advanced trauma course? In: Emerg Med J. 22, 2005, pp. 6-7.
  13. ^ J. Nolan: Training in trauma care moves on - the European Trauma Course. In: Resuscitation. 74 (1), Jul 2007, pp. 11-12. PMID 17466433
  14. K. Thies, C. Gwinnutt, P. Driscoll, A. Carneiro, E. Gomes, R. Araújo, MR Cassar, M. Davis: The European Trauma Course - from concept to course. In: Resuscitation. 74 (1), Jul 2007, pp. 135-141. PMID 17467871