RCEM ASC conference 2024. Day 2.

I’m back at the Sage in Gateshead for day 2 of the conference.

David Williams and William Rutherford lectures.

These are two prestigious named lectures at ASC. Dr John Ryan spoke on his journey through emergency medicine training from the very early days of EM in Ireland, through the UK, to Australia and then back to the UK, and finally landing back at St Vincent’s in Dublin. This was a really fantastic talk that outlined the development of UK and Irish EM, it also helped us understand why we are where we are at the moment in terms of politics, relationships and sustainability. John also talked about his passion for Rugby Union and the Leinster team whom he has worked with for many years. It’s another example of the advantages of a portfolio career to maintain a sustainable career. You can read more about David WIlliams here.

Chris Hook spoke on his experience working with MSF across a range of deployments, and most recently in Gaza. He spoke eloquently and passionately about the horrors of war and the incredibly difficult circumstances that health care workers find themselves in within the Gaza strip. We heard three recorded messages from clinicians in Gaza explaining what it was like to work in such difficult circumstances. Hearing their messages was really powerful and made many in the audience ask what they could do to support. Chris recommended learning more from the MSF website (https://academy.msf.org/) and to keep the awareness of what is happening in Gaza and other conflict zones in the public eye.

Infectious diseases session

I really enjoyed this session that explored the identification, diagnosis and treatment of emerging infectious diseases. There were so many useful tips and tricks in this talk which I forgot to write down, but the main points I recall were

There are really good advice sites that we should routinely use. Bookmark these sites.
- Latest info on outbreaks https://promedmail.org/
- UK Gov site https://www.gov.uk/health-and-social-care/health-protection-infectious-diseases
Take a good history and do a good examination. See Janos’s work on the blog here.
- A good history and examination will really, really help
If they are from a malaria area
- Check if it is malaria, if not…
- Check again if it might be malaria….., and if not
- Check one last time that it isn’t malaria
The Climate Emergency is driving infectious disease in many ways. We may see past ‘tropical diseases’ in places that were not previously considered at risk.
- Outbreaks of Dengue in Italy
- Congo-Crimean Haemorrhagic Fever in Turkey and Spain
PPE is essential to keep you, your colleagues and other patients safe. We heard. agreat reminder of the circumstances around the first SARS outbreak in Toronto where multiple health care workers died. We need to remember these lessons and ensure our own safety, which is a huge challenge in our overcrowded departments.

Rod Little Prize Papers

This session highlighted the best research papers submitted to the conference.

Chris Gough took over the reporting at this point and his notes are below, The quality of presentations at the recent gathering was notably impressive, reinforcing the importance of collaborative learning in our speciality.

The FEED Study: Prevalence of Frailty Across Europe

The FEED study is designed to determine the prevalence of frailty across Europe, based on a comprehensive survey of departments. Key findings include:

A majority (78%) of respondents reported having reasonable walking aids and pressure-relieving mattresses, but the availability of poor overnight meals and frailty input remains a concern.
In July 2023, a 24-hour monitoring initiative using the Clinical Frailty Scale (CFS) included 3,479 patients aged 65 and older, along with an additional 2,000 younger patients. Notably, 60% of the older patients scored CFS 5 or higher, indicating significant frailty. A headline figure is that 1 in 7 adult emergency department patients are living with frailty.
While 69% of sites suggested that CFS should be completed, only 38% mandated it, resulting in just 55% compliance. CFS completion rates varied by race and other potential confounders, highlighting the need for caution in interpreting the data.

Anatomical injury severity, physiological shock, and the biological response to trauma

The analysis of anatomical injury severity, physiological shock, and the biological response to trauma is evolving. The study categorized tissue injury using the Injury Severity Score (ISS) and assessed shock through the base deficit metric. This study was. a subset of the ACIT-II Study

A subset of the ACIT-II study removed patients with head/neck AIS 5 injuries, penetrating trauma, and those who received prehospital transfusions.

The analysis involved 400 patients with a median ISS of 11 and a base deficit of -0.6. Interestingly, some correlated ISS-related signaling pathways correlated with injury, while cellular processes were linked exclusively to base deficit metrics.
This research could pave the way for identifying potential biomarkers at arrival that predict traumna outcomes and tailored therapies?

Exploring effects of trauma pattern and injury severity on outcome

An exploration into the effects of trauma patterns and injury severity on outcomes is critical for improving triage, clinical management, and research. The findings from a focused subset of the ACIT-II at the Royal London Hospital. The study included:

Analysis of 2,300 patients who had trauma team activation within 2 hours of injury, divided into groups based on ISS and anatomical clusters.
The results revealed that a cut-off ISS >25 consistently indicated higher mortality rates at 28 days, particularly in patients with head injuries.

This analysis suggests that understanding anatomical injury patterns may refine our ability to compare and group patients for research purposes, even if current clinical approaches may remain unchanged. Will injury pattern/anatomical clusters give us a better tool to compare/group patients for research (not all ISS 25 patients are the same)? Probably won’t alter clinical approaches currently

The Impact of Self-Rostering on Emergency Medicine Trainee Wellbeing

Given the high burnout rates in emergency medicine, self-rostering has emerged as a modifiable factor influencing trainee wellbeing. A survey of emergency medicine trainees revealed that those who self-rostered reported:

Increased satisfaction and ease in swapping shifts, alongside lower recovery scores. Notably, there were more long-term flexible trainees (LTFT) and higher specialty trainees (HST) among those utilizing self-rostering.

While response rates were low and multiple confounders existed, these insights warrant further exploration.

Nebulised Ketamine: A Potential Role in Pain Management

The use of nebulised ketamine in emergency settings is garnering attention. Recent studies indicate:

Bioavailability ranges from 20-40%, with effects lasting between 20-40 minutes.
Dosing at 0.75, 1, and 1.5 mg/kg demonstrated similar pain score profiles, though comparisons with other analgesics remain challenging.
While currently unlicensed in the UK, the need for a specialised nebuliser to minimize atmospheric “spillage” underscores the importance of ongoing research to define its role in UK emergency medicine.

Clot-astrophy averted – VTE assessment post-injury

A Cochrane review highlighted a 40% increased risk of venous thromboembolism (VTE) following lower limb injuries, with a 3% DVT risk linked to temporary casting. Key insights include:

Immobilization due to lower limb injuries correlated with a 5-39% increase in VTE risk, which baseline data shows is between 0.12-0.18%.
Thromboprophylaxis was associated with a 50% reduction in VTE, although awareness remains a challenge. At baseline, only 30% of practitioners were aware of the risks, improving to 64% within three months after an intervention.

Future local efforts will focus on understanding VTE events and improving medication prescribing, emphasizing the need for bridging knowledge gaps within routine practice.

Whole Body CT in the Elderly: A Radiologist’s Perspective

With an increase in whole-body CT (WBCT) scans among elderly patients, particularly those with ground-level falls, a review of the REACT-2 findings indicated:

No mortality benefit from WBCT compared to targeted approaches, although it may reduce hospital length of stay (LOS) in some cases.
A closer examination of injury patterns revealed a lack of significant change in overall mortality, with some patients exhibiting high mortality despite having no injuries on CT.

These findings may prompt a reevaluation of conservative management strategies and highlight the need for a focused approach to imaging in trauma care. (Editorial note – However, there were a lot of people who heard this talk who questioned whether the presenter really understood the realities of practice from an EM perspective).

TARN Insights and Future Directions

Tim Coats and Fiona Lecky provided valuable insights into the impact of the Trauma Audit Research Network (TARN) over the past 33 years. The introduction of the New Major Trauma Registry (NMTR) aims to enhance data utility:

Positives: Improved interactivity and real-time data linkage with other datasets, including national patient-reported outcome measures (PROMS).
Negatives: Challenges include distinguishing registry data from audit/QI, potential biases in oversight, and impacts on research.

The potential for real-time oversight, rehabilitation data, and natural language processing (NLP) analysis in radiology heralds exciting developments in trauma care.

Updated 2024 RCR Paediatric MT Imaging Guidelines

As we advance in our understanding of paediatric trauma management, the 2024 RCR Paediatric Major Trauma Imaging Guidelines present a balanced approach between radiation exposure and effective diagnosis. These guidelines highlight the importance of safe transfer and timely access to diagnostics, ultimately influencing CT scanning rates. The tone throughout the guidelines emphasizes civility, teamwork, and a shared decision-making process, ensuring that focus remains on outcomes rather than strict thresholds for scanning.

BLUNT Trauma Management

A focused and holistic approach is essential when addressing blunt trauma. Key recommendations include:

Head Injuries: Follow NICE guidelines; utilize 3D reconstructions to assess fractures.
Neck Assessment: Adhere to NICE recommendations for neck injuries.
Thoracic Evaluation: Conduct a normal examination and chest X-ray (CXR), unless rapid deceleration is evident (i.e., falls over 6 meters or speeds exceeding 40 mph).
Abdominal Imaging: Perform a CT scan when clinically indicated.
Thoracolumbar Spine: Conduct a clinical examination; MRI should be the first-line imaging modality if feasible.
Limbs: Use plain films unless complex vascular issues are suspected, in which case a CT scan is warranted.

It’s essential to lower the threshold for imaging in cases where patient history or clinical examinations are compromised, ensuring no injuries are overlooked. Additionally, dedicated guidelines for suspected physical abuse are included, following RCR guidance.

PENETRATING/BLAST Trauma Management

In the context of penetrating or blast injuries, the guidelines stress the need for ubiquitous scanning. The phrase “The gloves are off” encapsulates the urgency of these cases, where the limiting factor often becomes the capacity for CT scanning during mass casualty situations.

Decision-Making Tools

Appendix 1 of the guidelines features a concise, one-page decision tool that serves as a tick-box exclusion tool, facilitating quick and effective decision-making in trauma scenarios.

So that’s the end of another great day at the conference and special thanks to Chris Gough for his notes today that have really improved the blog