Spotlight on ATLS

Monday, August 2, 2010
Connie J. Mattera, MS, RN, EMT-P

In February 1976, Jim Styner, MD, FACS, an orthopedic surgeon, crashed his small airplane in rural Nebraska. One of his children had only minor trauma, but three were critically injured. Styner’s wife was killed instantly, and he was severely injured. They all received inadequate care at the receiving hospital, stemming from the lack of proper education of the receiving emergency department (ED) staff regarding early trauma management.1

It may be hard to believe, but when Styner and several family members were finally rescued and taken to the closest hospital, the ED door was locked and the “night nurse” had to call in doctors who were on call from home.1

When they arrived, one general practitioner picked up Styner’s son by his shoulders and knees and carried him to the X-ray room for X-rays of his injured head. It was clear to Styner that the doctors and staff at the small rural hospital had little or no preparation for the multiply injured patients they had thrust upon them.1

Styner was later quoted as saying, “When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed.”1

And indeed, the system was changed. In 1978, he and several colleagues held the prototype Advanced Trauma Life Support (ATLS) course in Auburn, Neb.1

The American College of Surgeons (ACS) Committee on Trauma launched it nationally in 1980. The ATLS course evolved naturally from the mission of the ACS, which was founded in 1913 to raise the standards of surgical practice and improve the care of surgical patients.

Very shortly after the successful introduction of ATLS for physicians, Norman McSwain, MD, first chair of the ACS ad hoc committee for ATLS, started advocating for a similar course for EMS personnel. Working with the National Association of Emergency Medical Technicians (NAEMT), he created a curriculum that became the Prehospital Trauma Life Support (PHTLS) course.

Pilot programs were conducted in 1983 at four locations, followed by the first national faculty course in 1984. In that pre-Internet era, early national and regional faculty members traveled the country recruiting faculty and advertising PHTLS. Initial courses focused on advanced life support (ALS) care. In 1986, a basic life support (BLS) course was introduced.

PHTLS students learn to:

• identify the mechanism of injury;
• recognize life-threatening injuries;
• relate pathophysiology to injuries;
• assess and manage trauma patients; and
• perform appropriate interventions.3

Like ATLS, PHTLS has grown to a thriving international enterprise as a division of NAEMT partnered with the ACS Committee on Trauma to provide medical direction. Thousands of participants take the course each year. The seventh-edition PHTLS texts and programs will be rolled out next month. In addition to the civilian and military texts, there will be, for the first time, a “PHTLS Trauma First Response” text geared toward EMS providers and other emergency responders.

How ATLS Works
As with other life support courses, ATLS offers hospital-staff-validated, standardized, concise ways to assess and resuscitate multiply injured trauma patients while acknowledging the potential existence of other acceptable approaches based on the patient’s and practitioner’s needs.

Part of the course’s success lies in its simplicity of methodology, at the heart of which is an easily remembered algorithm that’s become the touchstone of trauma management by other programs. ATLS also provides a scaffold for evaluation, treatment, education and quality assurance—in short, a system of trauma care that’s measurable, reproducible and comprehensive.4

ATLS training participants are presented with information that enables them to:
1.  Assess the patient’s condition rapidly and accurately.
2.  Resuscitate and stabilize the patient according to priority.
3.  Determine if the patient’s needs exceed a facility’s capacity.
4.  Arrange appropriately for the patient’s interhospital transfer (who, what, when and  how).
5.  Ensure that optimum care is provided and that the level of care doesn’t deteriorate at any point during the evaluation, resuscitation or transfer process.4

The course remains contemporary and current by issuing updates every four years. Breaking with a traditional approach, which involves heavy reliance on expert opinion coupled with literature reviews, for the 2008 revision, the authors adopted an evidence rating system that ranked published studies submitted as suggestions for change on a scale of 1 to 5. A ranking of 1 was the highest rating, indicating that a study met rigorous research standards. A rating of 5 indicated expert opinion only.

This framework, published by Wright, et al, in 2003, had been adopted by prominent journals, was easily interpreted and appeared to have a high degree of reliability.2 The process was highly successful in gaining buy-in from the international trauma community.

Cases
The following cases illustrate how ATLS training and information helped guide care and influence treatment and transportation decisions in the field and in the hospital:

• A 62-year-old male is found unresponsive (GCS ≤ 10) in a hallway during an apartment fire with deep partial thickness burns to his chest and back, inhalation burns to his larynx, trachea and lungs, plus a large abdominal abrasion. The EMS crew inserts a King airway. On arrival at the ED, the patient is intubated and placed on a ventilator. He remains on a ventilator for three days and is discharged alive and well on day four after excellent trauma care that averted pulmonary complications.
• EMS is activated for chest pain. On arrival, the crew finds a 79-year-old male who fell (and, according to family members, had fallen a few times over the past few weeks). On this day, he lost consciousness and presented to EMS with a GCS of 13. He also had a history of valve replacement and was on Coumadin, ASA and Plavix (which were discontinued on ED admission). On CT scan, the patient was found to have a small intraventricular hemorrhage and a biparietal subarachnoid hemorrhage. Of note, labs revealed a prothombin time 67.6 (11–12.5 seconds), INR 6.7 (< 1.5) and partial thromboplastin time 62 (25–50 seconds), which indicated that the patient was in a severely anticoagulated state. The patient received four units of fresh frozen plasma (FFP) and 10 mg vitamin K subcutaneously for the elevated INR to reverse anticoagulation caused by warfarin (Coumadin) and was placed on an insulin drip to control hyperglycemia, which is harmful to patients with traumatic brain injury. The bleeding was controlled, and the patient was discharged, first to rehab and then to a skilled nursing facility six weeks after injury. What could have been the outcome if physicians were unfamiliar with optimal treatment of patients with head trauma on anticoagulants?
• A 22-year-old female is involved in a motor vehicle collision (MVC) and sustains a grossly angulated grade III open fracture to her right tibia, a significant crush injury to her left hand that needs immediate operative repair and rehab to prevent permanent disability. She’s initially transported to a basic trauma care facility, but she’s soon transferred to a trauma center where specialists manage her injuries and prevent her from having permanent disability because of her crush injuries.
• A 2-year-old is struck on the head by her brother with a fireplace poker and sustains a 7 mm diameter, moderately comminuted, depressed skull fracture and open fracture to the parietal calvarium. When contacted by the prehospital crew, the closest hospital recommends the patient be transported to a trauma center by air. In flight, cerebral perfusion pressure is maintained and, at the hospital, brain tissue oxygenation is monitored using a LICOX catheter. The young patient survives after an extended stay involving complicated neurosurgery and rehab.
• A 15-year-old victim of an assault with a baseball bat suffers a spleen laceration and fractured ribs. The patient is combative and a flight risk. He is transported by ground ambulance to a Level I trauma center, where he’s treated with open abdomen management using a vacuum bag and is able to salvage his spleen and prevent abdominal compartment syndrome.
• A 49-year-old suffers a gunshot wound to the abdomen that requires bowel resection, bladder/splenic repair and colonoscopy. The early vital signs revealed a BP of 90/74. The BLS crew meets an ALS crew as they proceed to a trauma center, and the patient receives care with limited normal saline fluid infusion to just maintain the systolic blood pressure at 90 (controlled resuscitation and permissive hypotension) that prevented his clotting factors from being diluted from over-infusion of crystalloid solution and an inappropriate elevation of his BP prior to operative management that could have caused augmented bleeding.
• A 63-year-old is pinned against a loading dock wall by a forklift and sustains a Malgaigne “open-book” pelvic fracture with significant peritoneal and retroperitoneal bleeding and shock. The patient is snugly wrapped with a sheet in the field and remains marginally stable. His status rapidly deteriorates in the ED as internal bleeding from the fracture increases. The ATLS-trained trauma surgeon applies a T-pod to the patient in the ED to stabilize the pelvis and prevent further fracture extension and movement. The ED team implements its massive transfusion protocol and the patient receives surgery for open reduction with pelvic fixation. The physicians and interventional radiologists discuss whether the patient is a candidate for embolization, but his condition stabilizes after the T-pod application and they elect a surgical approach.
   

One Million Strong & Growing
Throughout the 1980s, Canada, Trinidad and Tobago, Chile, Mexico, the U.K., Australia, Brazil and Argentina adopted the common language and approach of ATLS. Today, there are 16 regions covering every state in the union; the U.S. and Canadian military through the ACS Military Committee on Trauma; and 52 foreign countries on every continent under the International ATLS subcommittee, which is led by John Kortbeek, MD, FACS, FRCSC. Currently, more than 60% of ATLS students are outside of the U.S. and Canada.

To date, more than one million participants have completed the ATLS course. Although designed for physicians, the ATLS subcommittee, chaired by Karen Brasel, MD, FACS, approved a rule revision at their March 2010 meeting allowing advanced practice nurses and Special Forces medics to participate as physician extenders.1 Nurse practitioners and physician’s assistants had previously been approved as physician extenders. Auditors are allowed on a space-available basis and are given a nonphysician’s certificate of attendance, but are not granted the credential and are not included in instructor/student ratios.

Despite universal acclaim, ATLS continues to improve its courses and materials. The evidence for change for the eighth edition of the course was published in the Journal of Trauma in June 2008, and a ninth edition is in the works.2 In addition to medical updates, new information was added with respect to principles of disaster management.

• Key changes or additions that had EMS implications include:
• Use of capnography encouraged to confirm endotracheal tube placement.
• Definition of the use of a laryngeal mask airway and laryngeal tube airway (LTA).
• Introduction of the gum elastic bougie.
• Use of the mnemonic LEMON encouraged to help assess for a difficult airway prior to attempting intubation.
• Framed considerations for electrolyte solution resuscitation and commented on the use of hypertonic saline.
• Expanded recommendations regarding fluid volumes to be infused in the context of balanced or controlled resuscitation and permissive hypotension.
• Recommendation that patients in cardiac arrest with penetrating thoracic trauma who require CPR by EMS personnel be evaluated for any signs of life. If none and no cardiac activity is present, no further resuscitative efforts should be made.
• Discouraged use of ED thoracotomy for patients with blunt trauma and cardiac arrest.
• Additional information on injuries caused by explosive devices.
• Added recommendations on stabilizing or closing a hemodynamically unstable pelvic fracture using a commercial compression device or sheet.
• Affirmation that there was insufficient evidence to support the routine use of steroids in spinal cord injury.
• Affirmation that the use of tourniquets may be life- and/or limb-saving in the presence of ongoing hemorrhage uncontrolled by direct pressure.
• Expanded section on compartment syndrome, emphasizing that an absent distal pulse is uncommon and shouldn’t be used to diagnose the condition.
• Comments on the use of vehicle restraints and deployment of airbags in pregnant women involved in MVCs.
• Added commentary that the incidence of abdominal injury is significantly higher if abdominal wall bruising is present during the primary or secondary survey.

Summary
We know each team member must perform with precision to best practice models to reap optimal outcomes for seriously injured trauma patients. Key players may include professional and support staff in the ED, trauma and specialty physicians and staff throughout the hospital and rehab facilities. Every health-care professional who touches one of these patients directly or indirectly is an essential link in their recovery.

Therefore, if critical clues are missed that suggest significant injury and the need for timely and appropriate trauma interventions, optimal decisions and care may not result. The ATLS course helps ensure that physicians and physician extenders are trained to make the proper decisions relative to our patients.

This update was intended to give you an appreciation for the benefits provided to patients managed by practitioners in multiple disciplines that have been educated in ATLS. This training helps fill educational gaps with respect to trauma management, provides evidence-based recommendations for contemporary practice, and ultimately improves the treatment and transfer decisions for our injured and wounded. JEMS

References

1. Styner JK. The birth of advanced trauma life support. J Trauma Nursing. 2006;13:41–44.
2. Kortbeek JB, AL Turki SA, Ali J, et al. Advanced Trauma Life Support, 8th edition, the evidence for change. J Trauma. 2008;64:1638–1650.
3. www.naemt.org
4. ATLS Web site. www.facs.org/trauma/atls/index.html

This article originally appeared in August 2010 JEMS as “The Trauma “A” Team: Advanced trauma life support training enhances ED & hospital trauma care.”