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  • In summary, FAST was better than DPL, but has now been superseded by rapid CT panscan.

 

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