STH Consultant CPD Updates: Renal Medicine

This is the summary of the PowerPoint presentations from this December’s consultant CPD teaching programme.

This month’s session provided an update on endocrine anaesthesia  in line with the Royal College of Anaesthetists Matrix.

The following topic was covered by Dr Cavin Gray (Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust) and Dr Roz Simms (Senior Clinical Lecturere in Renal Medicine, Sheffield Teaching Hospitals NHS Foundation Trust). The aim was to give an overview of anaesthesia for patients with renal disease and for renal surgery. Please click the link for a copy of the presentation.

Renal Update for Anaesthetists [2A12]

Anaesthesia and Renal Disease [1A01, 2A05]

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LTC 2014 Session 4

Summary of the final afternoon session at the 2014 London Trauma Conference. The full programme of the meeting can be found here.

Meaningful monitoring of the head injured brain – Dr. Mauro Oddo, CHUV Hospital, Switzerland.

What is the role for non-blood products in pre-hospital and emergency department trauma management? – Mr. Ross Davenport, Barts & London.

Should isolated head injuries be cooled in the early phase of care? – Mr Mark Wilson (@markhwilson)

  • Cochrane 209 showed no evidence of benefit of cooling in TBI in ICU.
  • Unclear about prehospital care….
  • Head cooling (e.g. ThermaHelm) in isolation of no benefit.
  • Need further trials!

Should calcium be given to all shocked patients? – Dr. Julian Thompson, Bristol.

  • No, but maybe if the patient is shocked.
  • Calcium vital for coagulation & platelet function.
  • Ca(i) < 1 mmol/l associated with increased mortality and greater transfusion requirements (predicts better than fibrinogen levels).
  • Highest levels of citrate in FFP/platelets; takes 5 mins to metabolise the citrate in one unit of red cells. Try to avoid citrate toxicity.
  • Replacement of calcium doesn’t alter outcomes however. Short half-life. 5-10 mg/kg CaCl ideally via CVC (need 3x as much calcium gluconate).
  • Suggest give 10mls 10% CaCl every 4u PRCs (keep > 0.9 mmol/l)

IO access is overrated – Dr. Dan Ellis, Director MedSTAR.

  • IO better, faster, quicker than iv cannula.
  • Cheaper than CVCs
  • Useful in cardiac arrest
  • Use if time critical and/or need for emergent drugs or fluids.
  • IO fine for RSI.
  • IO flows 70-160 mls/min (cf 250 for 14G cannula).
  • Much more difficult to infuse blood through IO and may all be haemolysing due to pressure required.
  • Complications <1% but due to increased use, these may increase!

FAST scanning has had its day – Professor Tim Harris, Barts & London.

  • Increased access and use of [fast] CT scans may render USS unnecessary.
  • In stable patients FAST adds nothing, and 1/3 fast negatives.
  • Poor sensitivity for PTX outside expert hands (but we don’t know what levels of scans define expert).
  • Difficult to differentiate between pleural, pericardial and peritonel free fluid.
  • In summary, FAST was better than DPL, but has now been superseded by rapid CT panscan.

 

LTC 2014 Session 3

Summary of the first afternoon session at the 2014 London Trauma Conference. The full programme of the meeting can be found here.

This is a summary (with references) of Jerry Nolan’s excellent talk on c-spine control in trauma.

Airway management and the cervical spine Dr. Jerry Nolan – Royal United Hospital, Bath

“DISPLACEMENT OF CERVICAL SPINE IS MAXIMAL AT TIME OF TRAUMA”

LTC 2014 Session 2

Summary of second morning session at the 2014 London Trauma Conference. The full programme of the meeting can be found here.

Telemedicine in trauma care – Dr. Conor Deasy, Cork University Hospital

“TELEMEDICINE BRINGS THE DOCTOR & EXPERTISE TO THE ISOLATED ENVIRONMENT”

  • 3G major advance; 90% of Uganda/Nigeria has access to 3G, but data encryption not possible.
  • 8% of calls to Cork telemedicine line are about termination of resuscitation.
  • Can support prehospital decision-making re. bypassing smaller units to get to definitive care.
  • LifeBot5 = awesome toy; bidirectional video plus USS transmission.
  • Fall detection by acclerometers in mobile phones. Just need the elderly to get iPhones…
  • Telemedicine can reduce costs associated with unnecessary transfer flights.
  • Virtual consults are very cost-effective ($6 million in one US study).
  • Tele-ICU promising as a result of Lilly RCT [http://jama.jamanetwork.com/article.aspx?articleid=900247]
  • In Arizona, blanket consent for filming and photography.
  • Telemedicine may also have a future role for rehabilitation.
  • Concerns remain regarding malpractice liability, but may actual decrease claims http://journals.lww.com/ccmjournal/Abstract/2014/11000/Critical_Care_Telemedicine___Evolution_and_State.14.aspx

 

Can trauma care be an elite sport? – Dr. Tom Evens, British Rowing Coach

“HIGH PERFORMANCE IS ABOUT DOING EVERYTHING IN THE BEST WAY”

  • Parallels between high-performing trauma teams and high-performing athletes.
  • Turn weaknesses into strengths.
  • Need a common mental model to achieve aims.
  • Only make mistakes once; debrief, learn and move on.

 

Primary Trauma Care: Trauma training in a low resource environment – Dr. Doug Wilkinson, Oxford.

  • Trauma courses in developing world limited by cost, personnel and ownership.
  • Courses need to depend less on equipment, use local teachers with no or minimal charge.
  • Must be appropriate, affordable, adaptable and sustainable.
  • To address this, the Primary Trauma Care (PTC) foundation was established [http://www.primarytraumacare.org/]
  • 62 countries to date.
  • Free course, information available on line. Manual can be downloaded at http://www.primarytraumacare.org/wp-content/uploads/2011/09/PTC-Manual_For-PTC-China_-June-2010-Edition.pdf
  • The first part of the course is training the trainers, allowing the cascade of information and training throughout the country.
  • Huge success: >1500 trained in 2014, 65% in rural locations.
  • Difficult to prove benefit; RCTs not possible.

ATLS has had its day…

This is a copy of the slides I used during a talk I gave at the 2014 London Trauma Conference. The full programme of the meeting can be found here.

The talk was designed to look at the history leading to the development of the ATLS course and how it fits in with the management of trauma in the 21st century. As you may be able to guess from the title, I think that it’s time to consign ATLS courses to history.

The pdf of my presentation can be downloaded by clicking the link below:

ATLS LTC 2014

 

LTC 2014 Session 1

Summary of morning session at the 2014 London Trauma Conference. The full programme of the meeting can be found here.

Paediatric Trauma – Mr. Ross Fisher, Sheffield Children’s Hospital

“CHILDREN ARE NOT SMALL ADULTS”

  • A rare event. 37 paediatric polytraumas per annum per unit; most present to trauma units not MTCs.
  • 37% mortality.
  • Over triage a problem. PECARN prediction tool for abdominal trauma may be useful [http://www.ncbi.nlm.nih.gov/pubmed/23375510]
  • Whole-body CT equivalent 1000 CXRs in child. Utilise ALARA (as low as reasonably achievable) principle.
  • FAST scan in paediatric trauma 50% sensitivity (use coin toss instead!)
  • Primary prevention still most important way to reduce paediatric trauma deaths.
  • As with adults, rehabilitation is vital to outcomes; again must be paediatric specific.

 

Trauma in pregnancy – Professor Tim Draycott, University of Bristol.

“WHAT IS BEST FOR MOTHER IS BEST FOR THE BABY”

  • <1% trauma admissions are pregnant.
  • If patient needs trauma surgery, stay in MTC; if patient needs obstetric surgery go to Obs.
  • If 2nd/3rd trimester and >50% burns, deliver baby for maternal benefit.
  • If needs ICD put in 1-2 spaces higher to avoid fetus.
  • After 4 minutes of unsuccessful CPR, perimortem LSCS (for maternal benefit) [4 in UK in most recent CEMACH report].
  • In USA obstetric trauma (RTC 55%, Domestic violence 22%, Falls 22%).
  • CEMACE report 2014 – 11x more obstetric deaths with influenza than RTCs.
  • Head injury remains the most common injury in pregnant patients.
  • Gun-shot wounds: if below fundus almost never visceral injury; fetal death rate 67%.
  • Stabbing: 93% morbidity, 50% mortality. If involves uterus then need exploratory laparotomy.
  • Most eclampic fits only last 90s. DO NOT GIVE DIAZEPAM.
  • TXA safe in pregnancy.
  • Cord prolapse; don’t touch the cord, keep the cord warm, fill the bladder with 500 ml fluid (stops fetal head compressing cord), transfer.
  • Breech delivery; don’t interfere. Let the mother push.
  • If pre-term birth, put the baby in a plastic freezer bag to keep it warm.
  • Cardiac arrest –manual displacement of uterus [aortocaval compression decrease efficacy of CPR] but otherwise standard ALS.