Meaningful monitoring of the head injured brain – Dr. Mauro Oddo, CHUV Hospital, Switzerland.
- ICP monitoring associated with decreased mortality in meta-analysis of TBI (http://thejns.org/doi/abs/10.3171/2009.8.JNS09738)
- BEST-TRIP showed that adding ICP monitoring to Latin-American TBI care didn’t effect mortality (which was 40% cf 20% in developed world) but did guide therapy for management of intracranial hypertension.
- ICP is associated with mortality and long-term functional outcome (http://link.springer.com/article/10.1007/s00134-012-2655-4)
- Multiple potential causes for elevated ICP in TBI; need to know what you’re dealing with so you can treat it effectively! (http://www.nejm.org/doi/full/10.1056/NEJMra1208708)
- We still don’t know at what level of elevation in ICP we should intervene.
- Remember TBI is a heterogonous disease.
- Suggests TCD might have a role, but didn’t mention the huge problems with inter- and intraindividual variability.
- Brain tissue oxygen sensors plus ICP may be optima (keep PbtO2 >15 mmHg) http://link.springer.com/article/10.1007/s12028-014-0024-6
- May correlate with global CBF (http://europepmc.org/abstract/med/25393700)
- Monitoring does not equal effective therapy. Need a clinician to put the information together.
- Consensus statement for brain monitoring http://link.springer.com/article/10.1007/s00134-014-3369-6#page-1
What is the role for non-blood products in pre-hospital and emergency department trauma management? – Mr. Ross Davenport, Barts & London.
- ATC associated not with decreases clotting factors, but clot strength. Need fibrinogen!
- Hybrid resuscitation (only allow decreased BP for 60 mins) then drive BP.
- Best resuscitation fluid remains diesel!
- Protect the clot with TXA; may also be anti-inflammatory as well (http://journals.lww.com/annalsofsurgery/Abstract/publishahead/Tranexamic_Acid_Use_in_Severely_Injured_Civilian.97853.aspx)
- Fibrinogen concentrates may be of value but no clear evidence…
- Future may be REBOA and artisunate (an antimalarial which may be anti-inflammatory).
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.