RCoA/RCEM Trauma Study Day: Session 3

Summary of the first session at the RCEM/RCoA Trauma Study Day. The full programme of the meeting can be found here.This is a summary (with references) of the talks I was able to attend.

Pelvic fracture management. Dr Gareth Davis, London. [2A02, 2A05, 2A12]

<5% of ED # with majority from RTCs & 50% have associated long bone #.

Mortality 15-50%; risk greatest if hypotensive.

Classification system of most practical use is Young & Burgess [http://www.orthobullets.com/trauma/1030/pelvic-ring-fractures]

Screen Shot 2015-11-24 at 14.50.44

Lateral compression # (LC): usually visceral rupture rather than pelvic bleeding.

Vertical shear # (VC): venous plexus injuries common.

AP compression (APC): “open book”, common in motorcyclists. Ligament rupture and venous bleeding +++

Blood goes into retroperitoneal or intraperitoneal spaces. Majority is venous from venous plexus (90%); only 10% from internal iliac artery. VS > APC > LC in terms of blood loss.

USS suffers with intra-observer variability. CT + angiography is diagnostic and therapeutic.

Treatment – movement of patient (log rolls, packaging for transfer) associated with hypotension secondary to clot disruption and loss of tamponade. Scoops can reduce this movement significantly, especially if used in the prehospital setting. Don’t rock & roll!

Pelvic binders work a bit but not a lot! REBOA can be used in zone 3 (base of bifurcation) in the prehospital setting but not as easy to insert as you think.

Manage coagulopathy as per any major trauma. Try to maintain normothermia.

RCoA/RCEM Trauma Study Day: Session 2

Summary of the second session at the RCEM/RCoA Trauma Study Day. The full programme of the meeting can be found here. This is a summary (with references) of the talks I was able to attend.

Management of traumatic bleeding. Prof Karim Brohi, London [2A02, 2A05, 2C04]

  • Major trauma haemorrhage associated with 50% mortality at 1 year. Early deaths – you didn’t stop the bleeding, late deaths you didn’t resuscitate them well enough.
  • People are still dying from early exsanguination.
  • Early goal is to stop bleeding and maintain haemostatic competence. Maintain basal cerebral & coronary perfusion only. Not targeting base deficit, lactate or a target SBP.

Four pillars of management

  1. Early haemorrhage control: rapid transit to DCS/IR/tourniquets/REBOA
  2. Permissive hypotension
  3. Limit fluid infusions: all fluids inc. PRC dilute coagulation factors. Avoid all crystalloids/colloids whilst bleeding.
  4. Target coagulopathy: fibrinogen, fibrinogen, fibrinogen….
  • Two types of coagulopathy: traumatic & iatrogenic.
  • 25% of patients have a traumatic coagulopathy (ATC) with associated 25% mortality. By the time the PT is elevated you are already miles behind the disease process.
  • ATC is not a deficiency in coagulation factors but rather fibrinogen loss due to fibrinolysis. Trauma patients present with fibrinogen levels at 50%.
  • After 8 units PRC, you will have no fibrinogen! Keep fibrinogen > 2.0. TXA to minimise fibrinolysis.
  • Give 1:1:1 to avoid the administration of crystalloid. Crystalloid undoes all the beneficial effects of major trauma packs.
  • iTACTIC study on the use of TEG/ROTEM awaited [http://www.tacticgroup.dk/%5D]

Trauma Team Leadership. Dr Caroline Leech, Coventry [1I02, 1I03, 2C01]

  • What can trauma teams (which are unique) learn form other teams.
  • One key element is practice; in situ simulation may be the answer to practice and develop marginal gains. A 1% improvement becomes significant over time. Also develop shared mental models and implicit knowledge.
  • From the prehospital environment we have learnt that task completion increases with the use of names. Why not add names to the trauma tabbards?
  • Avoid individual briefings prior to trauma calls and do not get complacent – you will lose the mental model and shared goal.
  • Checklists are really helpful!
  • Tiered responses help avoid fatigue for recurrent trauma call attendance when not needed.
  • Make attendees to the trauma call welcoming. Introduce, check names etc.
  • Ensure that we have a shared mental model – update with briefings.
  • What makes a good trauma team leader? Common themes include excellent communication, directive with orders and good briefings.
  • Closed communication: Call out, check back, closed loop. Precise instructions with clear directions.
  • Need to reflect on your leadership style as a trauma team leader.
  • Video debriefing useful to review leadership style.
  • Peer review also of value for both technical and non-technical skills.

RCoA/RCEM Trauma Study Day: Session 1

Summary of the first session at the RCEM/RCoA Trauma Study Day. The full programme of the meeting can be found here.This is a summary (with references) of the talks I was able to attend.

The trauma airway and the trauma anaesthetic. Dr Steve Rowe, Sheffield. [1B02, 2A01, 2A08, 2F01]

IMG_3138

  • How to write checklists? Read the Civil Aviation Authority Guidance [http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=158]
  • PPPPPP: local simulation is of great value; the more realistic the better.

ATLS: Archaic or advanced trauma life support

This is a copy of the slides I used during a talk I gave at the RCEM/RCoA Major Trauma Study Day. 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. I also made some suggestions as to how trauma training could be improved in the UK.

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

ATLS RCEM/RCoA Trauma 2015

I published an editorial on the same topic earlier this year in Anaesthesia. The article is open access and can be found at the link below:

ATLS: Archaic Trauma Life Support?