Itās a testament to Professor Lockey and the organizing committeeās 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.
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. Emlynās 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.
So now that youāve blocked them, what do you do next once theyāre admitted? Professor Ben Ollivereās 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 āroadmapā 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 familyās 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.
Forensic pathologist Virginia Fitzpatrick-Swallow was up next and provide a fascinating review of how important the pathologistās 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 hasnāt 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 arenāt there just yet.
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).
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 donāt 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.
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 youāre interested in this topic, mark your calendars now.
Stay safe and well, and have a fantastic New Year.
Best
Zaf
