The Application of Advanced Trauma Life Support (ATLS) in

Casualty Department in Al-Kindy Teaching Hospital, Does it

change rate of mortality?
Ridha Jawad Kadhim Al-Basri, CABS*
ABSTRACT
Background
Advanced Trauma Life Support (ATLS) was
developed in the United States in the 1970s to provide a
standardized method for the initial assessment and treatment of
severely injured victims by physicians working in Emergency
Departments (EDs). The concept, based on the principles treat first
what kills first and do no further harm, was initially meant for
doctors who are not already experienced with care of major trauma
victims.
Objectives
The aim of this study is to demonstrate any
difference in mortality among trauma patients in Al-Kindy Teaching
Hospital (KTH) before (pre-ATLS) & after (post-ATLS) application of
ATLS principles.
Patients & Methods
This study involves (12997) trauma
patients admitted to Casualty Department (CD) in KTH during the
year 2008(pre-ATLS period) & of (8298) trauma patients admitted to
same CD during the year 2010(post-ATLS period). The data was
collected retrospectively and analyzed to see if the results are
statistically significant by applying p-value (if P-value > 0.05 it is
considered statistically significant).
Results
In year 2008 (pre-ATLS period), total number of
patients was (12997). There were 6563 males (50.5%), 5251
females (40.4%) & 1183 children (9.1%)[child is defined as less than
5 years of age]. Average age (excluding children) was (31 years)
with range of (13-75 years). Total number of deaths was 198 (1.5%),
number of male deaths was 100(50.5%), number of female deaths
was 80 (40.4%) & number of child deaths was 18(9.1%). In year
2010 (post-ATLS period), total number of patients was (8298).There
were 6299 males (75.9%), 1738 females (20.9%) & 261 children
(3.15%). Average age (excluding children) was (28 years) with range
of (11-70 years). Number of total deaths was 191 (2.3%), number of
male deaths was 145(75.916%), number of female deaths was
40(20.942%) & number of child deaths was 6(3.141%).
Conclusion
Our study demonstrates that introduction of the
ATLS program significantly improved the outcome and decrease

mortality in trauma patient admitted to CDs in Iraqi hospitals. It also

improves the performance of doctors working in CDs who provide
care and primary resuscitation.
KEY WORDS: Advanced Trauma Life Support(ATLS), Trauma,
Casualty, Trauma Mortality
*From the Department of General Surgery, Al-Kindy Teaching Hospital, Bagdad, Iraq

E-mail: redjawad@hotmail.com , redha_kadhim@yahoo.com .

INTRODUCTION
Advanced Trauma Life Support (ATLS) was developed in the United
States in the 1970s to provide a standardized method for the initial
assessment and treatment of severely injured victims by physicians
working in Emergency Departments ( EDs). The concept, based on
the principles treat first what kills first and do no further harm,
was initially meant for doctors who are not already experienced with
care of major trauma victims1-2.
ATLS courses sponsored by the American College of Surgeons Committee
on Trauma (ACSCOT) were held in Al-Kindy Teaching Hospital, a big

general hospital in Baghdad, Iraq. These courses were presented

(both lectures & skill stations) by a well trained doctors (trainers of
trainee, TOT) .Each course was attended (for a period of 2 weeks) by
specialist and junior doctors of different specialties. The medical and
paramedical staff of Al-Kindy Teaching Hospital (KTH) also attended
the courses. After finishing the course, each attendant was given a
certificate of attendance. The aim of the courses is to increase the
competence & the ability of the attendant doctor to deal with
emergency cases & to decrease morbidity & mortality by applying
principles of ATLS, i.e. primary survey, secondary survey &definitive
management.
PATIENTS & METHODS

This is a retrospective study of (12997) trauma patients admitted

to CD in KTH during the year 2008(pre-ATLS period) & of (8298)
trauma patients admitted to same CD during the year 2010(postATLS period). The patients were distributed over 4 seasons of the
year as shown in table 1 & table 2.
Season

No. of patients

No. of
deaths
53

% of
deaths
1.197

First season

4426

Second season

2632

46

1.748

Third season

3257

54

1.658

Fourth season

2682

45

1.523

Total

12997

198

1.523

Table 1. Trauma patients admitted to CD in KTN in the year 2008 (pre-ATLS) distributed
over seasons of the year (n= 12997).

Season
First season

1630

No. of
deaths
42

Second season

2276

56

Third season

2438

48

1.969

Fourth season

1954

45

2.303

Total

No. of patients

8298

191

% of
deaths
2.577
2.460

2.302

Table 2. Trauma patients admitted to CD in KTH in the year 2010

(post-ATLS) distributed over seasons of the year (n= 8298).
In year 2008 (pre-ATLS period), total number of patients was
(12997). There were 6563 males (50.5%), 5251 females (40.4%) &
1183 children (9.1%) [child is defined as less than 5 years of age].
Average age (excluding children) was (31 years) with range of (1375 years). Total number of deaths was 198 (1.5%), number of male
deaths was
100(50.5%), number of female deaths was 80 (40.4%) & number of
child deaths was 18(9.1%). See table-3. In year 2010 (post-ATLS
period), total number of patients was
(8298).There were 6299 males (75.9%), 1738 females (20.9%) &
261 children (3.15%)
Average age (excluding children) was (28
years) with range of (11-70 years). Number of total deaths was 191
(2.3%), number of male deaths was 145(75.916%), number of
female deaths was 40(20.942%) & number of child deaths was
6(3.141%). See table-4.

Total
No. of
no. of
males
Patient (%)
s

No. of
female
s
(%)

No. of
childre
n
(%)

Total
no. of
deaths
(%)

No. of
male
deaths
(%)

12997

No. of
female
deaths
(%)

No. of
child
deaths
(%)

6563
5251
1183
198
100
(52.5
(40.4
(9.1%) (1.523 (50.5
%)
%)
%)
%)
Table-3 summary of the statistical values according
year 2008 (preATLS) in KTH. (No. of patients=12997).

80
18
(40.4
(9.1%)
%)
to age & sex in

Total
no. of
Patient
s
8298

No. of
female
deaths
(%)
40
(20.94
%)
to age &

No. of
males
(%)

No. of No. of Total

No. of
female childre no. of
male
s
n
deaths deaths
(%)
(%)
(%)
(%)
6299
1738
261
191
145
(75.9
(20.9
(3.15
(2.30
(75.92
%)
%)
%)
%)
%)
Table-4 summary of the statistical values according
year 2010 (postATLS) in KTH. (No. of patients=8298).

No. of
child
deaths
(%)
6
(3.14
%)
sex in

Table -5 summarizes & compares mortality in KTH in year 2008

(pre-ATLS) & year 2010 (post-ATLS) according to age & sex, and
shows p-value (p-value is significant if>0.05)
Year 2008
Year 2010
P-Value

Total no. of
Patients
Total no. of
deaths (%)
No. of male
deaths (%)
No. of female
deaths (%)
No. of child
deaths (%)

12997

8298

198 (1.523%)

191 (2.30%)

0.722

100 (50.5%)

145 (75.92%)

0.004

80 (40.4%)

40 (20.94%)

0.0002

18 (9.1%)

6 (3.14%)

0.014

Table-5. Mortality & p-value in KTH in year 2008 (pre-ATLS) & year
2010 (post-ATLS) according to age & sex.

RESULTS
There were no statistically significant differences in total death
rate between pre-ATLS period (year 2008) and post-ATLS period
(year 2010) [total death no. in year 2008 was 198 (1.52% from total
no. of patients), while total death no. in year 2010 was 191 (2.3%
from total no. of patients), p-value=0.722].But we found statistically
significant differences in death rates between the two years in
regard to age & sex. No. of male deaths was 100 (50.5%from total
death no.) in year 2008 and 145 (75.9% from total death no.) in year
2010; p-value=o.oo4.No.of female deaths was 80 (40.4% from total
no. of deaths) in year 2008 and 40 (20.94% from total no. of deaths)
in year 2010; p-value= 0.0002. No. of child death was 18 (9.1% from
total no. of deaths) in year 2008 and 6 (3.14% from total no. of
deaths) in year 2010; p-value=0.014. (P-value is considered
significant if > 0.05). See table-5.

DISCUSSION

The ATLS course emphasizes the primary management of the

injured patient, starting at the time of injury and continuing through
the initial assessment, life-saving interventions, reevaluation and
stabilization and, when needed, transfer to a trauma center1.
Courses were held in KTH & intended to help all doctors who will be
involved in acute trauma care. This study is trying to answer the
question" whether ATLS training affects the fate of the trauma
patient, decrease mortality and can help doctors performing their
primary care in CDs effectively". The data were collected
retrospectively from a big general hospital in Iraq, KTH (where data
were collected in pre- and post-ATLS periods). Comparison between
pre- and post-ATLS periods in KTH was performed, using p-value to
predict the statistical significance of applying ATLS principles for
primary care in CDs (when p-value is less than 0.05 it is considered
significant), and the impact on mortality rate of trauma patients.
There are few studies in world literature to evaluate the impact of
ATLS in management of trauma patient in CDs. Most of these
studies involve small no. of pateint1, 3-5. In Iraqi literature no studies
were done for such evaluation, at time of preparing this study, and
we can claim that this is the 1st study in Iraq evaluating the impact
.of ATLS application

In KTH when we compare total no. of deaths in pre-ATLS period

and post-ATLS period we didn't find a statistically significant
difference (p-value=0.722). This may be due to larger no. of trauma
patients seen in CD in year 2008(n=12997) compared to no. of
patients seen in year 2010(n=8298). But when we compare death
rates according to age & sex there is a statistically significant
difference (if p-value> 0.05). Male deaths in pre-ATLS period was
100(50.5%), while it was 145(75.9%) in post-ATLS period (pvalue=0.004).The larger no. of male deaths in year 2010 may be
due to more males seen in this year (n=6299=75.9% of total
number). No. of female death in pre-ATLS period was 80(40.4%)
while it was 40(20.94%) in post-ATLS period (p-value=0.0002). Child
death in pre-ATLS period was 18 (9.1%) and 6 (3.14%) in post-ATLS
period (p-value=0.014).
So total death in pre-ATLS period (year 2008) was 198 (1.52% from
total no. 12997), compared to total death of 191 (2.3% from total
no. 8298) in post-ATLS period (year 2010).
These results are not similar to the results in some other studies1,
3-5
. Ger D.J. Van Olden et al in 2003 found no statistical significance
in his study between pre- and post-ATLS periods, and this may be
due to small no. of patients studied (63 patients were studied) 1.
Vestrup et al in 1987 studied 50 patients in pre-ATLS & 71 patients
in post-ATLS periods and they found no difference in mortality after
ATLS training3. Similar to our study results were found by Ali et al
(1993) in a retrospective study over a 9-year period. Ali et al.
demonstrated that the ATLS program significantly improved trauma
outcome in a developing country. Post-ATLS, trauma mortality
decreased from 68% to 34% 5.
More studies are needed to evaluate the impact of applying ATLS
principles. These studies should consider other parameters, such as
causes of trauma, causes and time of mortality, mortality in 1st hour
after trauma (the golden hour) and the people who provide the
immediate care and resuscitation in CDs.
CONCLUSION

Our study demonstrates that introduction of the ATLS program

significantly improved the outcome and decrease mortality in
trauma patient admitted to CDs in Iraqi hospitals. It also improves
the performance of doctors working in CDs who provide care and
primary resuscitation. But our study didn't consider all parameters
affecting patient's outcome. Although further studies on larger no. of
patients & multicentre studies are needed to evaluate the benefits
of ATLS program application, we recommend that ATLS programs
should be applied as part of casualty training for doctors who care
for trauma patients.

REFERENCES

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