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.
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