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.

Advertisements

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.

STH Consultant CPD Updates: Pain

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

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

The following areas were covered by Dr Nick Plunkett, Dr Rob Atcheson and Dr Ravi Parekodi (all Consultant Anaesthetists, Sheffield Teaching Hospitals NHS Foundation Trust). Please click the link for a copy of the presentation.

ABRA ASM Nottingham 2013: Key Points

Dr Steve Rowe (@Kangaroosteve) recently attended the Association of Burns & Reconstructive Anaesthetists ASM (November 2013) held in N0ttingham, and has very kindly provided us with his reflections on the talks.

The RCOA Matrix Codes for each talk are shown (in my opinion, the organisers didn’t provide them), along with the details of the speaker.

Association of Burns and Reconstructive Anaesthetists Nottingham 15th November 2013

Long Term Outcomes in Chronic Pain – do perioperative techniques alter outcome? (2E03): Dr Simon Tordoff, Leicester.

  • Chronic pain after surgery is common, but not often consented for
  • Hernia repair @ 1 Year – 19% some pain; 6% moderate or severe pain; 6% Severe pain restricting daily function (Callesen Br J Surg 1999)
  • These outcomes are verified by a very large Swedish study looking at their hernia registry (like our joint registry).
  • Knee replacements – 20% unsatisfied at 1 year due to pain (and pain commonest indication to perform surgery in first place….)
  •  Thoracotomy –   61% pain after 1 year, 3-5% severe pain; Neuropathic pain 21% at 7 years
  •  Amputation – 50-75% Phantom limb pain; 20-50% Stump pain
  • Given the above, the suggestion was that it may be prudent to screen for psychological vulnerability to develop chronic pain.

Significant risk factors are:

  1. Poor post operative pain control
  2. Pre-existing chronic pain
  3. Surgical complication
  4. Multiple surgeries
  5. Obesity and disordered glucose metabolism – sensitizes to post op pain.

Take home message – a conservative estimate of 2-4% severe chronic pain after surgery – probably should be consented for specifically, and a big national audit would be nice.

Opioid rotations and other strategies (2E01): Dr Doug Johnson, Birmingham.

S/E of opioids well known – constipation, N+V, Itch, tolerance

Opioid induced hyperalgesia (OIH) is recognised more, especially in burns patients.

OIH gives increased pain with increased doses of opioids, with a change in the pain charateristics – more diffuse, allodynia, aslong with neuro-excitation phenomena (this is something we are most familiar with – “post-remifentanil” patients in recovery).

Thought to be NMDA/Glutamate mediated.

Recognition is important. First line therapy is to increase the dose of opioid and evaluate for increased efficacy – this would be indicative of tolerance rather than OIH. If pain and other symptoms worsen, OIH likely.

Management

  1. Decrease or eliminate opioid
  2. Switch or rotate opioids
  3. Utilise other agents with NMDA receptor activity – ketamine/gapapentoid
  4. Utilise combination therapies – paracetamol/Nsaids etc etc

Opioid rotation

  • There is incomplete cross tolerance, with different drugs having a range of effects on other receptor systems e.g. Methadone and NMDA receptors
  • The switch is thought to allow the body to get rid of morphine-3-glucuronide, a metabolic product with no significant opioid receptor activity, but implicated in tolerance and other side effects.
  • Switching morphine to fentanyl often fails dues to rapid tolerance developing to fentanyl.
  • Methadone theoretically a good option.
  • Oxycodone also a viable alternative.

Ketamine

Cochrane review in 2010 supports is use in acute post op pain

http://summaries.cochrane.org/CD004603/perioperative-ketamine-for-acute-postoperative-pain

Ketamine in subanaesthetic dose (that is a dose which is below that required to produce anaesthesia) is effective in reducing morphine requirements in the first 24 hours after surgery. Ketamine also reduces postoperative nausea and vomiting. Adverse effects are mild or absent.”

Benefits shown with:

  1. Pre-incision bolus/Bolus at wound closure/continuous peri-operative infusion/post-op infusion with morphine.
  2. No benefit demonstrated with >30mg TOTAL in 24 hours
  3. Doses discussed for bolus treatment peri-operatively were in the range 75-100mcg/kg, though it seems that p to 0.5mg/kg can be used without a rise in side effects.

Gabapentin

  • Indirectly inhibits NMDA receptor overactivity
  • Only convincing evidence is that it decreases “Burns itch” – 300-1200mg tds po

Pregabalin

  • BD dosing, Lower doses, NICE approved
  • More expensive
  • >5% body surface area burns – gives a significant reduction in pain/itch and procedural pain
  • No difference in LOS or opioid consumption
  • No difference in pain at 6 months

Other talks were related to foreign forays providing anaesthesia for reconstructive surgery

The first was for reconstructive surgery after noma (cancrum oris) a disease of poverty in sub-Saharan Africa – the main thrust of the talk was that these patients have difficult airways, often with absolute trismus, but with very careful planning airway disasters were avoided. This involved a 2-consultant airway assessment and documentation of airway plan.

The second was a trainee presentation that won the Russell Davis and Stuart Laird Prize  – the trainee discussed providing regional anaesthesia in a resource poor environment.

The final discussion related to revalidation and appraisal. Whilst useful, it generated no significant take home points.

It is likely that the meeting next year will be held in Manchester, and Sheffield in 2015.