Matt WilesConsultant Neuroanaesthesia/NICUSheffield Teaching Hospital NHS Trust

@STHJournalClubhttp://sthjournalclub.wordpress.commatthew.wiles@sth.nhs.uk

"When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed.“

James K. Styner

[ Muenzberg et al. Eur J Trauma Emerg Surg 2013; 39: 517-522]

[ Muenzberg et al. Eur J Trauma Emerg Surg 2013; 39: 517-522]

[ Mohammed et al. World J Surg 2014; 38: 322-29]

[Jayaraman et al. Cochrane Database Sys Rev 2014]

Advanced Trauma Life Support program increases emergency room application of trauma resuscitative procedures in a developing country.Ali et al. Trauma 1994; 36: 391-394

Trauma outcome improves following the Advanced Trauma Life Support Program in a developing country.Ali et al. Trauma 1993; 34: 890-899

Clinical Impact of Advanced Trauma Life Support.Van Olden et al. Am J Emerg Med 2004; 22: 522-525

[Demetriades et al. J Am Coll Surgeons 2005; 201: 343-348]

[De Knegt et al. Injury 2008; 39: 993-1000]

[Guly et al. Resuscitation 2011; 82: 556-559]

[Mutschler et al. Resuscitation 2013; 84: 309-313]

[Mutschler et al. EMJ 2015; 32: 134-7: ]

Intervention ATLS (9th Edition, 2012) UK MTC Practice

Tranexamic acid Not mentioned 1g load, 1g over 8h

DCR 1-2 L crystalloid & reassess.Blood only if class III/IV shock

Permissive hypotension.PRC:FFP:Plts ≈ 1:1:1

Coagulation According to APTT/PT/Platelet POC tests or empirical

PaCO2 in TBI 4.67 to 6 kPa 4.5 to 5.0 kPa

Pelvic stability Can spring pelvis x 1 Await CT

Imaging FAST or DPL rather than CT CT Panscan

[Huber-Wagner et al. Lancet 2009; 373: 1455-62] [Wada et al. Critical Care 2013; 17:R178]

ATLS is a dogmatic approach to trauma resuscitation in the civilian hospital setting. It would be naïve to apply the same model to each echelon of care within the conventional military evacuation chain.

BATLS 2008 is a stepwise approach to trauma resuscitation that acknowledges the tactical constraints at point of wounding, together with the incremental enhancement of interventional skills, diagnostic equipment, experience-based judgement and trauma team sophistication at successive echelons of care.

Robust training platforms exist for prehospital trauma care,

though not all course training syllabi keep apace of current

best practices…..

…… It is generally expected that medical providers remain

current with the most currently available evidence-based

practice standards and use them in guiding their decision-making and care of patients.

“Individuals play the game, but teams beat the odds”

US Navy SEALS

time in the resuscitation room time to key investigations time to definitive care rate of missed injury

[Georgiou & Lockey. Scand J Trauma Resusc Emerg Med 2010; 18: 66]

[Trauma Team Performance. Barach & Weimger; http://www.academia.edu/5270549/ITTACS_Team_Performance]

[Capella et al. J Surg 2010; 67: 439-443]

[Capella et al. J Surg 2010; 67: 439-443]

[Steinemann et al. J Surg Educ 2011; 68: 472-77]

1. Treat ATLS as BTLS2. Stop routine recertification3. Remove ATLS as a requirement for CCT and

consultant posts involving trauma4. Focus future training on non-technical,

leadership and communication skills5. Institution specific training

Protocols & simulation

Team working & Leadership

Debriefs

1. Treat ATLS as BTLS2. Stop routine recertification3. Remove ATLS as a requirement for CCT and

consultant posts involving trauma4. Focus future training on non-technical,

leadership and communication skills5. Institution specific training

Protocols & simulation

Team working & Leadership

Debriefs

All trauma team training should take place as a multidisciplinary team and should be undertaken within the usual working environment of that team

Train as a team in order to perform and deliver as a team