London

Talking Trauma – London Trauma Conference 2024 Day 2

Itā€™s a testament to Professor Lockey and the organizing committeeā€™s efforts that Day 2 of LTC was perhaps even better attended than day one. The grand theatre at the Royal Geographic Society was filled, with standing room only in the balcony area.


TRAUMA SHOCK CALL: ED
For CODE RED trauma patients in cardiogenic shock
Trauma patients that may benefit from discussion include:
Traumatic cardiac/ pulmonary injury ā€¢Direct blunt trauma to thorax
ā€¢ Post resuscitative thoracotomy
.
REBOA Zone 1& 3 patients
Worsening cardiovascular instability with controlled bleeding
ā€¢ Previously low-flow patients with reperfusion injury (refractory hyperkalaemia)
If major haemorrhage controlled +haemodynamic instability
Action: Urgent focussed TTE
If ventricular dysfunction
Action: Initiate Trauma Shock call
NHS
Barts Health
NHS Trust
achycarde
Exclusion Criteria:
ā€¢
.
Uncontrollable major haemorrhage Ongoing CPR
Prolonged CPR (>30 mins)
Significant traumatic brain injury ā€¢ <16 or >60 years
1. Identify patient
2. Call switchboard on 40666
3. Request a 'Trauma Shock Call' to the operator 4. Switch operator will ask for patient MRN - they will activate the alert and call
5. Hang up
6. Dial 0121 285 8116 within 1 min to join the MDT shock call
uma nference!
trauma conference

Professor Karim Brohi is well known to anyone who has even a passing interest in trauma. His efforts through the Center for Trauma Sciences have really pushed forward our understanding of acute trauma resuscitation, in particular around bleeding and coagulation. His talk revolved around the increasing challenge of why severely-injured patients that now get to the hospital through our advances in prehospital resuscitation continue to die, despite appropriate hemorrhage control and blood product resuscitation. The answer may be the heart, and a concomitant degree of cardiogenic shock in some of these patients. He described how his service has developed an approach to supporting people with VA-ECMO, and advocated for advanced invasive cardiac output monitoring (bring back the Swan!) and imaging (such as transesophageal echo). Even though the group has not used ECMO in many patients, a positive byproduct of this endeavor is a better ability to monitor and manage these extremely sick patients. Hear more about this work in this great St. Emlynā€™s podcast with Chris Bishop.

The use of regional anesthesia in the ED is, in my opinion, a fantastic opportunity for emergency physicians to utilize their ultrasound skills to provide rapid pain relief to our patients. Jonny Wilkinson took us through the benefits and risks of various strategies to relieve pain from rib fractures. Although there are numerous options, the serratus anterior plane and possibly the erector spinae plane block might be the most useful for our practice.


London Trauma Conference 2024: Key Insights
Day 2 of the London Trauma Conference delivered impactful discussions on trauma care innovations, including advanced resuscitation strategies, rib fracture management, and prehospital interventions. Highlights featured Professor Karim Brohi's insights on cardiogenic shock, VA-ECMO, and cardiac output monitoring. Talks on blunt cerebrovascular injury, shaken baby syndrome, and interpersonal violence emphasized evolving trauma management approaches. Networking and expert panels underlined the eventā€™s success. Donā€™t miss Osloā€™s Prehospital Trauma Conference in 2025. #FOAMed #TraumaCare #EmergencyMedicine

London Trauma Conference 2024
Evaluation and Management of Torso Gunshot Wounds
Matthew Martin, MD, FACS, FASMBS
Chief, Emergency General Surgery Division of Trauma & ACS
LA County+ USC Medical Center Professor of Surgery, USC
LAC+USC
MEDICAL CENTER
trauma conference

So now that youā€™ve blocked them, what do you do next once theyā€™re admitted? Professor Ben Ollivereā€™s practice and research have revolved around the role of surgical rib fixation. He described the increasing evidence to support this practice in terms of functional and survival benefits. Should we be arranging discussion and referral for these patients to centers of excellence in this procedure? Likely so.

Matt Martin came back on stage to deliver a keynote address on managing torso gunshot wounds, clearly a group of patients who demand rapid evaluation and treatment. A big message here was that time to operative intervention matters ā€“ decision paralysis will kill these patients. There is no need to have a ā€œroadmapā€ CT to determine injuries ā€“ just take them to theater! He described the particular challenges associated with certain injury patterns like transdiaphragmatic gunshot wounds, and touched on the increasing role of minimally-invasive surgical techniques and even robotic surgery to manage some of these patients.

The second session started with a profound discussion about something we hope never to have to see in our practice, shaken baby syndrome. Neurosurgeon Richard Edwards described the pathophysiology and the historical and clinical findings behind this. Poignantly he reviewed that while we must have a low index of suspicion for this, we do sometimes get it wrong. This can have devastating consequences for not only the immediate family, but also the familyā€™s community as well.

I had the opportunity next to speak on a topic that I, admittedly, had not really thought about when I was in training in the UK. Blunt cerebrovascular injury, where either the vertebral or carotid artery develops an intramural tear putting the patient at risk of stroke, has a low incidence (1-2% of all blunt trauma admissions) but can carry significant risk of morbidity and mortality. Although the Denver and Memphis criteria have been developed to try and identify these, they can miss almost 30% of injuries. Hence, we should be moving to universal screening of our blunt trauma patients to avoid the devastating complications of this injury. As I myself experienced, several people approached me afterwards about unfortunate cases they had dealt with that in retrospect they should have been more vigilant about for BCVI.


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for blunt cerebrovascular injury
Ce pyp 262 ebruary 201
6287
neck CTAS
74.7%
sensitivity of eDC
retrospective evaluation of imaging with standard screening
single center
7.6%
had BCVI
14.6%
positive predictive value of eDC

Forensic pathologist Virginia Fitzpatrick-Swallow was up next and provide a fascinating review of how important the pathologistā€™s role is in determining causes of mortality. This, by extension, can provide key information to minimizing potentially preventable deaths. She went on to review how important documentation is for future medicolegal considerations, including leaving specific injury terms to the experts!

A recurring theme in the conference was the emphasis on what happens beyond the prehospital and ED settings with our trauma patients. Some of these patients just really need to get to the operating theater quickly. Trauma surgeon Paul Vulliamy had a great presentation on the importance of time and how, despite multiple advances in trauma care, the mortality for shocked trauma patients hasnā€™t changed in decades. It reminds us that we must actively work not only on our clinical management, but also on our systems-level approach to get these patients through the prehospital and ED journey as quickly as possible. Direct to OR anyone? A question I raised as several US centers have implemented this approach ā€“ Mr Vulliamy agreed this is a good consideration, but the UK MTCs probably arenā€™t there just yet.


Clarke The Journal of Trauma. 2002
40%
ence)
ROYAL GEOGRAPHICAL SOCIETY
(WITH IBG
20+ Years
Harvin
The Journal of Trauma. 2017
46%

Professor Ed Barnard is an expert of blood-product resuscitation. He reviewed the current landscape including key prehospital trials, and highlighted the benefit of moving to the use of whole blood. Admittedly, the civilian evidence is not as robust as that from the military in terms of mortality. Those of us that are using whole blood do seem to see a clear early improvement in patient physiology, though. The current TROOP trial in the US and the SWIFT trial in the UK will hopefully add to the civilian evidence base. The current reality, though is that due to either logistical, legal, or political reasons, different services worldwide remain with different capabilities. The key then is to utilize what is available to you in the most efficient way to most closely replace what is being lost.

Ross Davenport outlined the care of the patient suffering either blunt or penetrating cardiac injuries. Overall, penetrating cardiac injuries are relatively rare (though commonly spoken about at these conferences!) and ideally should be managed in the operating theater via a median sternotomy. There is interesting data that incorporates cardiac rhythm in addition to time to predicting outcomes for these patients (as well as major trauma patients in general).


ALL PERICARDIAL FLUID IN TRAUMA IS BAD
BAD=SURGERY
BAD #CT
tama
ROYAL GEOGRAPHICAL SOCIETY
(WITH IBG)

Mikael Gellerfors, an anesthetist and HEMS doctor in Sweden, surprised us by reporting the significant amount of penetrating trauma (often related to gang violence) experienced in the big cities of that country. Even though it still makes up a small percentage of overall traumatic injuries, nevertheless it prompted the trauma centers in these cities to modify their approach from scene to operating room, emphasizing multidisciplinary care and speed. He reported scene times of less than 60 seconds in many instances, with HEMS clinicians provided all care en-route to the trauma center (an approach we emphasized in our paper), and bypassing the ED for some of the sickest patients. With the increasing amount of penetrating trauma seen around Europe, this talk provided some key lessons to be adopted elsewhere should they have to deal with these injuries.

Mr Martin Griffiths took the stage to wrap up the conference. He has done a tremendous amount of work to tackle the rising burden of interpersonal violence and knife crime in London. He described the approaches that donā€™t work, some that have worked (in particular community engagement and support from people trusted by the victims), and the large amount of work that still needs to be done to tackle this problem.


Ted
@TedCFRGS. Dec 6
Save the Best till Last... Making a Difference and Violence Reduction. Do YOU understand the drivers of violence?
#LTC2024 #Platysma @martinpgriff @LDN_TC @QMUL @Trauma Masters
Violence reduction - what can be
done to address the problem?
London Trauma Conference 2024
Professor Martin P Griffiths
Clinical Director for Violence Reduction New Eng Cand Vaser Surgeon B
27
trauma conferenc
NHS England
1
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Nothing better to do now than to retreat to the local and reflect with friends over some drinks about the high quality of this conference. Everyone I spoke to (immediately and several days after) felt this had been a great use of their time, from the high quality of the talks to the unmeasurable benefit of the networking opportunities. I know I left with some key pearls and a reminder that there is more than one way to think about a problem.

LTC will be continuing as a biennial conference. Next year, the group in Oslo will be holding their prehospital trauma conference, so if youā€™re interested in this topic, mark your calendars now.

Stay safe and well, and have a fantastic New Year.

Best

Zaf

Cite this article as: Zaf Qasim, "Talking Trauma – London Trauma Conference 2024 Day 2," in St.Emlyn's, January 10, 2025, https://www.stemlynsblog.org/london-trauma-conference-2024-day-2/.

Thanks so much for following. Viva la #FOAMed

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