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Surgery and Surgical Procedure

The Advanced Trauma life Support approach

Following the death of his wife and serious injury to his three children in an air crash in the l970s, an American orthopaedic surgeon, Dr James Styner, introduced a structured trauma management training programme which was soon adopted by the American College of Surgeons and developed into the ATLS educational package now in widespread use in the UK and in 23 other countries. To date, over 200 000 doctors have been trained and the approach is now regarded as the gold standard in early trauma initial assessment and resuscitation.

The philosophy

ATLS management is based on a ‘treat lethal injury first, then reassess and treat again’ strategy. The steps in management are given below.

ATLS component steps

• Primary survey — identify what is killing the patient

• Resuscitation — treat what is killing the patient

•Secondary survey — proceed to identify all other injuries

• Definitive care — develop a definitive management plan

NB. Primary survey and resuscitation must be concurrent.

The philosophy is based on the urgency and crisis sur­rounding early management of a multiply injured patient whose life is in danger. Underpinning this approach is the quite recent realisation that death following injury is a function of time and occurs in a predictable and measurable way.

The ATLS approach focuses on the second or early death group where death is preventable. Within this so-called preventable group, death will follow if treatment is withheld or delayed and will do so in a predictable way. Early and effective treatment during the period when the second group of deaths occurs also reduces the number of deaths during the third phase of the trimodal distribution.

An obstructed airway in a victim with head injury will kill in 3—4 minutes, well before death might occur from the effects of injury to the brain. Equally, a life-threatening injury

within the thorax will kill before a life-threatening bleed within the abdomen. Finally, major haemorrhage in the limbs, chest or abdomen will kill before a life-threatening space-occupying lesion. While these are generalisations and exceptions do occur, they support the ‘primary survey and resuscitation’ management doctrine. The elements of this ABCDE approach are listed below and will be explained in more detail later.

Elements of the primary survey

• Airway with cervical spine control

• Breathing and ventilation

• Circulation with control of haemorrhage

• Dysfunction of the central nervous system

• Exposure in a controlled environment


April 2, 2009 - Posted by | Accident and emergency | ,

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