Traumatic Brain Injury Management in the ED

This is a handout designed to supplement a talk I gave at the NACCSGBI ASM in London, 2017. The full programme of the meeting can be found here.

This talk was designed to provide an update for anaesthetists in the management of traumatic brain injury with a particular focus on management within the emergency department.

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

NACCS TBI Summary

This summary of an earlier talk may also be of value and it discusses the value of spinal immobilisation in trauma.

NACCS SCI Update 2016

NACCSGBI Level 3 CPD Neuroanaesthetic Update

This is a summary document of all the talks I attended during the Neuroanaesthetic Level 3 CPD Update day organised by NACCSGBI. The full programme of the meeting can be found here.

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

NACCSGBI Summary 2015

 

RCoA Trauma Anniversary Meeting 2014: Key Points

I recently attended the Royal College of Anaesthetists Trauma Anniversary Meeting, March 2014.

In order to allow those who were unable to attend the meeting to gain a flavour of the topics covered by the speakers I have created a summary of the key points of each talk from the Twitter feeds of myself (@STHJournalClub) and (with a far greater input of points!) Dr Steve Rowe (@kangaroosteve). The complete document of summary points can also be downloaded here: RCoA Trauma Meeting 2014 Summary.

The RCOA Matrix Codes for each talk are shown, along with the details of the speaker.

Trauma systems Prof Chris Moran, Nottingham, National Clinical Director for Trauma. (3A10)

  • Early trauma CT in trauma – early diagnosis directs ongoing care.
  • The sicker the patient, the greater the benefit of a trauma CT. NNT for trauma CT = 17. Be brave & go to CT if SBP >70 mmHg (Lancet 373: 1455-1461, 2009).
  • MTCs in England have increased survival. OR 1.41 in 2013-14. 40% survival improval in 18 months! Changing the system has saved lives.
  • Prehospital care and rehabilitation care all have to move forward with the development of MTC. It’s the full patient journey.

 

Trauma scores and databases Prof Fiona Lecky, Clinical Professor of Emergency Medicine, University of Sheffield. (2A02)

  • ATLS shock classification does not exist in patients in TARN database.
  • GCS, SBP, RR and SaO2 in combination are more useful, but not highly sensitive.
  • Severely injured kids are hypertensive. If a child with trauma has a normal BP (for age), they’re probably hypovolaemic.
  • No triage tool based on physiological parameters predicts severity of injury in the prehospital setting.
  • New NICE head injury guidelines. CT 95% sensitive for TBI, but only 40% specific. 100K CT brains p.a. in UK.
  • Early TARN data showed that TBI as part of trauma increases RIP by x 10! Improved by 50% with transfer to Neurosurgical centre.

 

Bastion to Birmingham: How civilian patients can benefit Prof Sir Keith Porter, Clinical Service Lead for Trauma Services, Queen Elizabeth Hospital Birmingham (2A02, 3A10, 3A14)

  • 41 unexpected survivors with ISS 60-75 in military cohort. Many in traumatic arrest due to haemorrhage.
  • 24/7 cons delivered care with focus on CmABCDE & avoidance of trauma coagulopathy. 1:1:1 Tx ratios decreased mortality by 46%.
  • Damage control resuscitation occurs in conjunction with damage control surgery. Admit straight to OR with on-going resuscitation.

 

Prehospital anaesthesia-the same but different Prof David Lockey, Clinical Director for the Severn Major Trauma Network (3A10)

  • Trauma interventions are more effective the earlier they are delivered.
  • In London 2012-13 63% of trauma patients had evidence of airway compromise on arrival of Air Ambulance.
  • Serious airway compromise is time critical -NCEPOD 12.6% had significant airway obstruction on arrival at ED.
  • London 2021-13 only 64% successful intubation by paramedics. The majority of these were in patients who had arrested.
  • Many challenges to Prehospital anaesthesia – Environment, remoteness, weather, positioning – all add into the risk vs benefit decision.
  • Need a SOP defining: consistency, team approach, auditing outcome, limit choices – keep it simple!
  • Oxygenate prior to induction – hi flow nasal specs, sedation prior to induction, ventilation prior to intubation.
  • Plan B for prehospital RSI is surgical airway, thus roc not sux. Cricoid pressure is largely optional.
  • London Air Ambulance have done 7500 Prehospital RSIs – 100% success with surgical airway (knife + tube) of which 50% were done as the primary airway technique.
  • Paramedic RSI 3-15x more likely to have failed intubation but much better with drugs/paralysis than without.

 

Transport of the trauma patient Dr Gareth Davies, Medical Director London HEMS (2A11, 3A11)

  • Better outcomes if transported to hospital by private vehicle compared with an ambulance”. Is this because of stay-and-play effects?
  • 85 accidents, 77 fatalities over 6 years in US Medivac system. Helicopter medic more risky job than North Atlantic fishing.
  • Land transfers in UK. 4-9 fatalities per annum – risky business. Wear seat belts; ask yourself if you need to go blue light?
  • In Australia 59% of transfers associated with adverse event. So transfers risky for patients & medics alike – do not treat lightly!
  • Patient movement is bad! Vital clots dislodged. Minimise movement and don’t spring the pelvis!
  • If a patient is transported from a trauma unit to an MTC they should be met by a full trauma team.

 

Haemodynamic Changes in Trauma Dr Emrys Kirkman, Defence Science and Technology Laboratory (2A02, 3A10)

  • Blast injuries major challenge in military (>70% of injuries) with haemorrhage leading cause of death.
  • Trauma bleeding doesn’t follow the textbook physiological response (described by Barcroft et al in 1944).
  • The physiology of simple haemorrhage is a biphasic response-inc HR , then dec HR. However, this is not what happens in major trauma. In major trauma there is sympathetic over activity first, and then as system empties, a vagal response predominates.
  • Lower O2 extraction ratios in traumatic animal models of trauma. Diversion of blood flow from renal/splanchic to skeletal muscle.
  • Three  parts to blast injury: Pressure wave, then penetrating injuries from particles, then blunt injury from being thrown by gas wave.
  • New concept of hybrid resuscitation. Short period of permissive hypotension (<60 min) to allow stable clot, then drive BP to normal.
  • Haemostatics resuscitation with blood products confers a survival advantage, using hybrid novel resuscitation as a model. Helps the clot form.


Triage – Rank Lecture Prof Peter Cameron, Head of Prehospital, Emergency and Trauma, Monash University, Melbourne Australia (2A02, 2A03, 3A10)

  • “Triage should allow the right patient to get to the right place in the right time”. This may mean bypassing hospitals
  • Paramedics gut feeling 98% sensitive at detecting major trauma, but poor at determining exact injury.
  • Prehospital triage scoring systems specific but not sensitive. Under/over triage very common. Victoria state use a complex hybrid system based on physiology, anatomical injury and risk factors.
  • Victoria triage system 98% sensitive, 83% specific. 2% under triage, 17% over triage. Avoids overload of MTC.
  • Interhospial transfers in Victoria take a median of 7 hours. Much better to transfer direct to MTC in first place.
  • Two tier trauma system, but if physiological derangement full team response needed.

 

Coagulation in trauma Lt. Col Rhys Thomas, Army Consultant Anaesthetist with 16 Air Assault Medical Regiment (2A12, 3I00)

  • ACoTS – coagulopathy of trauma shock. Caused by trauma independent of dilution/consumption of clotting factors. Brohi Ann Surgery 2007; 245.
  • Address ACoTS with shock packs. PRC, FFP, Plts, Cryo 1:1:1:1. Lowers Hct to 0.29 but this gives optimal flow.
  • Age of PRCs doesn’t matter if transfusing < 5 units. Above this, greater rates of VTE with older PRCs.
  • Vasopressors worsen outcome in trauma- 2x mortality increase. Sperry et al J of T 2008:64:9-14. (Not in isolated HI though)
  • Base deficit best guide to resuscitation. Can still be hypovolaemic with normal BP. Aim BD 0 to -2.
  • Aim Ca2+ > 1.0 Hypocalaemia worsens clotting, myocardial contractility and increases mortality.
  • 10 in 10 rule in military trauma: every 10 mins surgeon must talk to anaesthetist for 10 seconds.

 

Orthopaedic damage control resuscitation and surgery Prof Chris Moran, National Clinical Director for Trauma (3A10, 3A08)

  • “It’s decisions rather than incisions that makes the difference in major trauma care – it is all about the team.”
  • Blood and plasma are safe! Use for volume resuscitation. Don’t forget TXA.
  • Three golden rules for the pelvis. Do not spring the pelvis, do not log roll the patient & apply pelvic binder. Protect the clot.
  • Pelvic binder: around trochanters not iliac crest.
  • Repeat X-ray when binder removed if you’re suspecting pelvic trauma despite normal radiology with binder on.
  • Early total care (ETC) is definitive fixation of LONG BONE fractures within first 24hrs. ETC does not = immediate total care. If temp <35C, INR>1.5, plts<120, BE>-5, pH<7.25 – damage control surgery (DCS) only. 90% of patients are for ETC.
  • Monitor lactate during DCS. If lactate > 2.5 stop and splint and return to ICU. DCS should take < 60 min.

 

Abdominal damage control resuscitation and surgery Mr Adam Brooks, Clinical Lead Trauma, Nottingham University Hospitals (2A02, 3A10)

  • Open abdomen occurs less due to reduced crystalloid resus. Good, there is as high complication rate from open abdomens on ICUs.

 

Damage control radiology – when to go, where to go Dr Sam Chakraverty, Dundee Radiology Coordinator (2A12, 2F03, 3I00)

  • CT has a major role in managing the severely injured patient.
  • 76% of pneumothoraces visible on ct are not visible on plain chest x-ray.
  • +ve FAST scan indicates haemoperitoneum. -ve FAST scan does not exclude haemoperitoneum.
  • “Haemodynamic instability is a reason to try and perform CT, not avoid it”
  • Stent graft is better than open repair for traumatic aortic disruption.

 

The Trauma Team Prof Luke Leenen, The Netherlands, President of the European Society for Trauma and Emergency Surgery (1I02, 3A10)

  • Trauma teams require instantaneous, simultaneous multidisciplinary working.
  • A team approach optimises resuscitation times. This in turn decreases the time to definitive treatment.
  • Leadership and non technical skills are key. Can be improved through video review and simulation.

 

Lessons from Motorsport Dr Tim Moll, Regional Teaching Coordinator, Sheffield (3A10, 3I00)

  • Anaesthesia is the most common medical specialty working in Motorsport.
  • The damage to helmets doesn’t necessarily correlate with the severity of injury.

 

ATLS in the 21st Century: fit for purpose? Dr Matt Wiles, Consultant Neuroanaesthesia, Sheffield (2A02, 3A10)

  • Slides available here: http://wp.me/p3m5ax-5Y
  • RSI, MILS, nasopharyngeal airways in trauma. All challenged successfully in the literature.
  • Next challenge – GCS of 8-> intubation. We know that this is wrong. 1/3 of patients with GCS 13-14 had intracranial pathology.
  • ATLS is not designed for trauma care in the UK. It’s probably ok if you are a single handed rural doctor in the USA.
  • Etomidate is still mentioned in ATLS, whole body CT is not….
  • Cochrane review 2009 – no evidence that ATLS has had any effect on mortality if from trauma in developed countries.
  • Stop routine recertification in ATLS. Move to local solutions with simulation training.

 

Managing the anticoagulated head injured patient Dr Suzanne Mason, Professor of Emergency Medicine, University of Sheffield (2A12, 3F00)

  • 1% of the population now on anticoagulants (this does not include antiplatelet agents.
  • AHEAD study looking at risk factors for adverse outcomes in patients in warfarin with head injury. n=3534 but poor follow up….
  • AHEAD most patients GCS 13-15 & > 65. 10% abnormal CT. Only 0.5% had neurosurgery & only 5% had warfarin reversed.
  • AHEAD risk factors for adverse outcome GCS <13, vomiting, LOC. OR for GCS <13 was 14.6! Seems like CT a must if GCS<13 & on warfarin.

 

Role of Hypothermia in Trauma Care Prof Peter Andrews, Centre for Clinical Brain Sciences, University of Edinburgh (3A10, 3F00)

 

Critical Care for trauma-is it different? Dr Robert Winter, Nottingham, Medical Lead for the Mid-Trent Critical Care Network (2C01, 3A10, 3F00)

  • Abdominal compartment syndrome is a common problem, especially after large volume crystalloid resuscitation.
  • 40% of polytrauma pts have a TBI – permissive hypotension to a target of 70-80 SBP is not the right target – aim higher.
  • rib # fixation – emerging evidence for reducing ICU stay, reducing ventilator days, reduced pneumonia.
  • Elderly patients with rib fractures contribute significantly to the trauma workload. Managing these well = good use of resource.

 

Trauma outcomes and rehabilitation Col. John Etherington, Director of Defence Rehabilitation (3A10, 3I00)

  • Trauma rehab needs to be embedded into acute care. We need more than a safe/rapid discharge.
  • Long term outcome may not be predicted by initial ISS.
  • It’s clear the military have rehab sorted. The NHS have not. This needs to change to make the initial resus phase worthwhile.
  • Average time from injury to entering rehab in UK defence casualties is only 4 weeks!
  • Prostheses are very expensive (£16-40000) but allow early run to work. Ave time to work from wounding – 7 months in military!
  • 77% military TBI pts are employed or employable at 4 months post injury!

 

Oxygen in trauma: Friend or foe Dr Jerry Nolan, Bath, RCoA Council, Board Member of the European Resuscitation Council (3A10)

  • Hyperoxia reduces ICP, and causes cerebral vasocontriction shunting blood to ischemic regions (in one study)
  • Normobaric hyperoxia-increases tissue pO2, reduces brain lactate values, reduces ICP. Effects sustained beyond treatment period.
  • American observational study – 60% mortality hyperoxia group – worse outcome than normoxia AND hypoxia groups (47, 53%)
  • Post cardiac arrest, hyperoxia worse than normoxia or hypoxia.
  • In summary – avoid hypoxia, aim for normoxia.

 

Knives and guns Prof Andreas Grabinsky, Seattle USA, Program Director and Section Head, Emergency & Trauma Anesthesia, University of Washington (2A02, 3I00)

  • Penetrating injury accounts for 10% of trauma patients in Seattle.
  • 50% USA military fatalities potentially salvageable. 80% bleed to death- most in first 60 mins.
  • With entrance and exit wounds, can reasonably determine bullet track. With just an entrance would bullet could be anywhere.

 

Burns Prof John Kinsella, Professor and Head of Section of Anaesthesia, Pain & Critical Care Medicine, Glasgow University (2A02)

  • Burn injury rates are dropping in the UK. Much bigger problem in the third world.
  • 10% of patients in a terrorist incident have a burn injury.
  • Psychological burden of burn injury is significant – MDT approach vital to detect and treat these sequelae.
  • Big diff between smoke inhalation & upper airway burns – thermal injury to upper airway needs urgent Rx.
  • Factors that predict the need for intubation in smoke inhalation pts: http://www.ncbi.nlm.nih.gov/pubmed/16696366 
  • Baux score > 160 = futility. (Age +% burn); Baux score 110 = 50% mortality.
  • CarboxyHb of 50% = 50% chance of dying
  • Volume resuscitation is really tricky in burn patients. Under and over resuscitation is bad. Parkland formula still recommended.
  • BLEVE: A boiling liquid evaporating vapour explosion. Rule of thumb: if you put your thumb up and you can still see the fire – RUN!
  • Burns anaesthesia – keep them warm at all costs, hypothermia increases mortality
  • Burns patient in a non burns centre? Remember you can call the burns anaesthetic consultant at your burns centre to ask advice.

Debunking Trauma Myths and Pseudoaxioms

This is a copy of the slides I used during the Regional Anaesthetic SpR Teaching on 14/03/2014.

It essentially an extended version of the talk I delivered at the recent Trauma Anniversary Meeting run by the Royal College of Anaesthetists. 

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

STH Regional Trauma Day Summary

STH Consultant CPD Updates: Trauma

This is the summary of the PowerPoint presentations from the STH Consultant CPD teaching programme.

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

The following areas were covered by our trauma lead, Dr Ben Edwards @madders76 (Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust). Please click on the links for a copy of the presentation.

BSOA ASM London 2013: Key Points

I recently attended the British Society of Orthopaedic Anaesthetists Annual Scientific Meeting, November 2013.

In order to allow those who were unable to attend the meeting to gain a flavour of the topics covered by the speakers I have created a summary of the key points of each talk (in my opinion).

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.

An orthogeriatric perspective on the peri-operative care of patients with fractured neck of femur (2A07): Dr Celia Gregson, Bristol

  • Avoid drugs with anticholinergic effects due to risk of delirium in NOF. Remember constipation as a cause of confusion. Use Lactulose!
  • Orthogeriatrics view on NOF. Usual Hb drop 2.5g (4g in IM nail). Do Hemocue in PACU. Transfuse early so can mobilise next day.

Perioperative orthopaedics: The perfect translational research model (1A02): Dr Gareth Ackland, UCL

  • VISION study (JAMA 2012); 40K pats, age>45, non-cardiac SxGA. 12% had T-I inc (>50% asymptomatic w/o ECG changes). Assoc with inc LOS.
  • Research update: postop complications double mortality up to 10 yr postop! This includes “small” complications like wound infections.

What matters in cervical spine injury (2A01): Dr Rob McCahon, Nottingham

  • Direct laryngoscopy induces forces primarily at C0-C2 BUT lots of room here for the cord to flex & extend (only takes up 25% of available room). The space is decreased if your rotate the neck – avoid rotational forces at all costs.
  • Risk factors for c-spine injury: pelvic #, ISS > 15, age < 40. [Clayton Injury 2012]. Max-fax injuries not a factor (despite ATLS teaching).
  • < 50% of the normal population aged over fifty have evidence of canal stenosis/impingement on MRI. Don’t just take care in trauma cases!

Paediatric regional anaesthesia (2D05, 2G03): Prof Peter Marhofer, University of Vienna

  • aPPT frequently abnormal < 45 weeks post conceptual age. Not a CI to central neuraxial blockade.
  • ADARPEF study (2010) Complication rate for RA in children 0.12% (Central:Peripheral 6:1). No serious morbidity.
  • Paed RA: Supraclavicular best for upper limb as axillary nerves as superficial and difficult to visualise with USS

Lower limb arthroplasty, regional anaesthesia and outcome (2G01): Dr Barrie Fischer, Redditch

  • No clear benefit between analgesic technique & functional outcome or LOS. The total package of care is more important.
  • PROSPECT Guidelines: THR: SAB plus IT opiate or GA plus LPB. Little evidence for LIA. TKR: SAB plus IT opiate or GA plus FNB (not SNB)
  • THR/TKR: Meta-analyses show RA less blood loss, pain, PONV, and possibly VTE. In US >75% GA only 11% SAB. SAB decreases postop comps & RIP.
  • TKR: femoral nerve catheters are not associated with better analgesia compared to single-shot FNB and just impair mobilisation.
  • Enhanced Recovery & FNB. Adductor canal blockade may be no better in terms of ability to mobilise (RAPM 2013;38).
  • Local anaesthetic infiltration: not beneficial in THR; may be of value for 6-12 h in TKR (if used as part of multimodal analgesia regimen)
  • Do not ignore pain in favour of non-EBM local anaesthetic infiltration techniques. 36% of TKR pats end up with chronic pain, or which having severe early postoperative pain is a predictor.

Ultrasound for regional anaesthesia: Teaching, learning and competence (1H02): Dr John Barcroft, Royal National Orthopaedic Hospital

  • Training in USS & RA: 1. Go on good course 2. Learn sonoanatomy 3. Practice on phantoms & cadavers 4. Try on patients with an expert.
  • Dreyfus Skill Levels: 1. Novice 2. Competent 3. Proficient 4. Expert 5. Master. We should aim for expertise not competence in USS RA.
  • Newly acquired motor skills (e.g. USS RA skills) will almost degrade to baseline if not used for 18 days! No place for occasional USS RA!
  • Create your own USS phantom: 4 x packets of supermarket jelly with 25% of the recommended water, filled with some olives. Cost < £4!!
  • “Only those who have the patience to do simple things perfectly ever acquire the skills to do difficult things easily”. Practice USS!!

Pathophysiology and management of acute coagulopathy of trauma (ATC) (1A01, 2A05): Mr Ross Davenport, The Royal London

  • Acute trauma coagulopathy (ATC): 24% on arrival to ED. ATC directly related to ISS & base deficit and increases RIP by 400%.
  • ATC thought to be caused by “thrombin switch”. Thrombin production decreased and aPC activated (decreasing factors V & VIII).
  • ATC predominately aPC mediated thrombinolysis, not DIC (other clotting factors often still > 75%). Platelet dysfunction is also a factor.
  • Only 50% of those with ATC will have PT that is abnormal and the test will take > 60 mins. Use ROTEM/TEG for a diagnosis in < 5 mins.
  • ROTEM can miss occult fibrinolysis. Most of your trauma patients with ISS > 16 will be fibrinolytic and will need tranexamic acid.
  • Ratio of PRC:FFP:Plts still unknown. Probably not 1:1:1 but optimal ratios unclear. RCT in progress (PROPPR) – results awaited.

Damage control resuscitation and anaesthesia for major trauma (2A02): Major Claire Park, King’s College Hospital.

  • Trauma Team Dynamics. Good review J R Army Corps 2001; 157: S299-304. Concepts such as tunnel vision, situational awareness, task fixation.
  • Damage control anaesthesia: suggestion for RSI Fentanyl:Ketamine:Rocuronium 3:2:1 (reducing to 1:1:1 if unstable).