Despite the socializing and “Stand-Up Science” events that ran pretty late into the night, there was no holding back the full cohort of attendees for Day 2 of LTC. Let’s see what this day offered:
Neurosurgeon Aminul Ahmed began the day with an interesting review of the role of stem cells in head injury. Traumatic brain injury (TBI) remains a continuing challenge to trauma clinicians from point-of-injury to rehabilitation. Mr. Ahmed described how TBI can stimulate some cells to act as brain cells. There is a strong signal from animal studies that these can help repair the damage. Watch this space for future research in this area.
Dr. Robbie Lendrum, a cardiothoracic anaesthestist and intensivist as well as London HEMS doctor, reviewed the anatomical and physiological mechanisms behind hemorrhagic shock. I’ve worked with Robbie over the last several years on prehospital REBOA, and as part of that we have emphasized the benefit of early femoral arterial line placement. The results of early invasive blood pressure readings in critically injured patients is fascinating. He discussed the arterial system as a pressure-reservoir. Disruption from injury leads to loss of this reservoir and a widened pulse pressure – essentially creating vasodilatory hemorrhagic shock. Since cardiac perfusion is dependent on diastolic pressure, the loss of the driving force creates in essence a significant additional element of cardiogenic shock. Ultimately, brain perfusion suffers. Successful resuscitation cannot then focus only on volume administration – the result will be a failed heart and brain.
Up next was Mark Forrest of ATACC course fame. He had the rather daunting task of reviewing an oft-forgotten and under-resourced element within the under-resourced whole that is trauma care. It is important to remember that for every fatality, there are 3-4 survivors left with some sort of disability. The WHO estimates an annual disability rate worldwide of 45 million from injury, but even more (about 2.4 billion) could benefit from some form of rehabilitation. So, it certainly needs more investment and care. But rehabilitation cannot be a “one-size-fits-all” approach – it must be individualized to the person. Citing the example of Dr Grace Spence Green, not every disabled person wants to be a Paralympian. For example, the decision to provide a prosthetic limb may be life-empowering or seemingly life-ending for different people. He ended with the thought, “just because we can, does not always mean we should.”
Alex Psirides provided a thoughtful debate on the ethics of acute care (along with some fantastic slides!). I found myself recalling the crisis standards of care we may have needed to adopt at the beginning of the pandemic. There are no easy answers: the three schools of ethics (deontology, utilitarianism, and virtue) can provide guidance, but need to be adapted to your own situation and system. Another great quote (from Edward Wilson) to end, “The real problem with humanity is this: we have paleolithic emotions, medieval institutions, and god-like technology.”
No matter how much we talk about resuscitative thoracotomy, we always seem to find another area of study that can refine our practice. Trauma surgeon and London HEMS doctor Zane Perkins presented their data on 601 prehospital thoracotomies. The majority had either tamponade or exsanguination as indications. Unsurprisingly, better outcomes were achieved the sooner it was done, with 90% of the tamponade survivors having it done in the first 10 minutes, with this group having an impressive 40% survival-to-discharge rate. However, there were no survivors in the exsanguination group when thoracotomy was done beyond 5 minutes. What was interesting was the temporal transition of rhythm on cardiac monitor to predict good outcomes. The first 7 minutes showed a transition from sinus rhythm to narrow complex bradycardia, to wide complex agonal rhythm. At all these points the heart is still beating and survival is possible. Over 10 minutes, the rhythm is typically asystole, and efforts are futile. This provides two lessons: the cardiac monitor can be used to predict time from insult and likelihood of outcome; and these interventions really need to occur close to point of injury to be meaningful.
I have to hand it to Dr. Amit Pawa, an anaesthetist focusing on regional anesthesia, for giving a fantastic talk combining fancy anatomical graphics, ultrasound images, and simple rules for four blocks that would be useful in trauma care: the fascia iliaca block, the pericapsular nerve group (PENG) block, the serratus anterior plane block, and the erector spinae plane block. Regional anesthesia I feel has a key role in the ED management of pain that can spare excessive opiate use. Setting up a program in coordination with your anesthesia and trauma/orthopedic colleagues can go a long way to helping your patients while they await more definitive care. Check out his YouTube channel for more great tips.
Kenji Inaba took to the stage again to provide a review of esophageal trauma. Injury can occur within the neck or thorax, and requires a high index of suspicion and careful investigation (either through contrast imaging or endoscopy) to identify. Most if not all require operative intervention and we were shown several videos of injuries and repair – one which occurred through a misadventure with a chest tube!
Karim Brohi returned to the stage with an excellent call to arms on managing critical limb ischemia from trauma. Of the 600 limb amputations annually, many can be prevented. Early identification is key – put away the Dopplers and don’t worry about capillary refill – if there is no palpable pulse, consider the limb to be ischemic and expedite imaging (and reporting). The next step is timely transfer to a vascular center for operative or endovascular intervention. Given the logistics, pushing this to the 6-hour mark is about as good as if you had just amputated the limb yourself. This requires a concerted effort from trauma networks to ensure imaging and intervention can be expedited.
Dr. Inaba came back on stage to deliver the second keynote address, his thoughts on trauma care in 2030. He reviewed the challenges of the evolving training system in the US, with graduating surgeons having had fewer major operations (and even less trauma operations) than in prior classes. Although part of this is due to the shorter duty hours, we are sometimes the victims of our own success as we have moved more to non-operative or minimally-invasive management of surgical disease. What is the solution? No clear answer. Perhaps lengthening training, perhaps increased use of perfused cadaver labs, and definitely educational opportunities such as those at LTC.
The afternoon continued with quickfire sessions. Ross Davenport discussed the methodology surrounding the RePHILL trial. Ultimately despite the results, people may end up choosing what they feel is better for the patient but the reality is we still don’t have a clear answer on which product to utilize when. Perhaps devolving the role to the ground paramedic may shorten the time to intervention and produce different results. Tim Nutbeam shed more light on the gross disparities of care received by women compared to men, specifically in relation to TXA administration but more broadly to pretty much every other aspect of medicine. Women typically are half as likely to receive TXA for the same injury pattern than men. We must do better. I then followed with a review of vasopressors in trauma. Similar to Robbie Lendrum’s talk earlier that day, I described how ongoing hemorrhagic shock turns into a vasodilatory state not only due to anatomy but due to a neuroendocrine process described nicely here. A deficiency of vasopressin and calcium may feed into the vasodilatory state, and could warrant replacement as pressors in some patients. The great Anne Weaver wrapped up the quickfire session with her review of the Code Black implementation at the Royal London Hospital. While the specific protocol may not be transferrable to other hospitals, the principle of changing the culture clearly helps. By having key decision makers from the ED, radiology, and neurosurgery attend the patient on declaration, they managed to shorten the time from incident to craniotomy from 370 minutes to 184 minutes – 50%! Do things differently, get different results!
Finally, no trauma conference these days is complete without a talk on REBOA. Robbie Lendrum faced off with Paul Parker in a debate on whether this intervention is here to stay. With the building physiologic evidence of the need for early, point-of-injury intervention in hemorrhaging patients, Robbie made a valiant attempt to support this technique, whereas Paul very humorously (and perhaps rightly) demonstrated the challenge of obtaining solid evidence to support this intervention across the board, calling on us to also look at other existing and developing mechanisms to manage torso bleeding. The audience took about an equal vote for either argument. My stance is that this is not a panacea but a tool to be used in the right patient within the right system.
That wraps up another London Trauma Conference. Overall, speaking to the attendees and other speakers, we felt this was a very strong program, with everyone diligently taking notes on all the excellent presentations. I am sure everyone had at least one (but likely many) pearl to take away with them. Rightly so, because that is the essence of a conference like this – to educate, to challenge, and to improve the management of the patients we are privileged to take care of.
Stay safe, stay well, and happy holidays.