Focused Trauma Conference 2017: Deel Drie

In the third part of the day we focused on balloons, namely REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - the Life in the Fast Lane post can be found here.  The talk was by @emeddoc.  This procedure is intended for cases of non-compressible traumatic haemorrhage.  Before REBOA the best possible method to achieve haemostasis was through compressing the descending aorta via resuscitative thoracotomy (RT).  Data from the American Association for the Surgery of Trauma (AAST) in 2014 shows that REBOA is at least non-inferior to RT.  In trauma patients in LOST (ie not TCA yet) who required REBOA 92.6% survived their stay in ED and 22.2% survived to discharge.  Increasingly work has shown REBOA to be feasible in the pre-hospital setting and has the best survival rates if performed pre-hospital.  

However, a study from Japan showed that REBOA is associated with an increase of 16.5% in mortality.  However, the median door to surgery time was 97 minutes and further research has shown in animal studies that lactate clearance is intact 45-60 minutes post REBOA but after that the ischaemia distal to the balloon may be irreparable hence the poor date from Japan. This raises the possible of future research into partial inflation to not completely cut off distal flow and have some permissive hypotension.  

REBOA is not just for the pre-hospital medics to be concerned about; it requires clear handover to the hospital and theatre teams after it is used as it will alter physiology.  It it there to buy time for the definitive surgery and it was emphasised several times that any unit wanting to implement REBOA will require widespread organisation and culture change.  

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It was a brilliant and interesting day; thank you to all the organisers.  Antwerp is a lovely city and the Belgian people were very welcoming; if you can visit do!

Focused Trauma Conference 2017: Deel Twee

In the second part of the Focused Trauma Conference we were treated to a focus on the role of ultrasound and clam shell thoracostomy.

Dr Jim Connolly (@jiconnoly) kicked off the second part by imagining a post-stethoscope world (Stethxit) and instead where we all have hand held ultrasound devices - a reality that's closer than we think - he believes once they crack a cost of <£1000 (i.e. the cost of the new iPhone) a unit we will all have one! POCUS will help identify the majority of causes in cardiac arrest (pretty much all of 4Hs and 4Ts apart from hypothermia or toxins).  POCUS reduces the time to operation, the number of CT scans and even the length of stay in hospital.  It is time critical, helps with Bayesian reasoning and with answering Yes/No answers.  It is more sensitive than auscultation and x-ray in detecting pneumothorax and takes a quarter of the time that CXR does.  However it is important to remember its limits:

• A FAST scan needs about 500ml blood in the abdomen to pick up - "you need blood to bleed" and so there may be false negatives
• It changes nothing in penetrating TCA

However in blunt TCA it is useful to pick up cardiac standstill (a very poor prognosis) and also to distinguish pseudo from real PEA.

It was then onto thoracostomy with Professor Lockey and then Dr Connolly again.  The procedure was first performed in 1988 and provides better visualisation than the left lateral approach.  Professor Lockey talked about the approach in 'street thoracostomy' often performed in cases of stabbings and even terrorism:

1. Open the pericardium
2. Seal the hole (ideally a single hole in the right ventricle) - occlude with a finger, stitch or staple it or use foley catheter
3. Restart the heart - flick it, volume load, 2 handed massage, ventricular adrenaline, given bicarbonate (usually young people getting stabbed so should be fine) and calcium
4. Clip the internal mammary arteries and clamp aorta and hilar
5. If the patient wakes during anaesthetise with Midazolam 1mg and Ketamine 30mg
6. Forensic awareness is also important in cases of stabbings 

The whole procedure should take less than 2 minutes.  It is not to be performed in cases of shootings/high energy transfer, if the heart is empty or if the TCA has been prolonged.

Dr Connolly reinforced many of these messages as well as emphasising that the biggest barrier to before the clamshell is the fear of being criticised.  It is a procedure not an operation designed to achieve damage control and restore physiology NOT anatomy.  It is to be performed in witnessed TCA or if there were very recent signs of life or if the systolic BP is <70mmHg despite fluid resuscitation.  The wound most likely to survive is a wound to the right ventricle with a tamponade.  When suturing a horizontal mattress suture is least likely to occlude the coronaries.  He also emphasised the importance of training - at times of stress we revert to our lowest level of training.  There are other considerations to have - once output is restored the patient needs to go straight to theatre and can have only vertical sliding not horizontal.  

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Focused Trauma Conference 2017: Deel Een

It was great to attend the inaugural Focused Trauma Conference hosted at the University of Antwerp.  Although run with a Belgian slant on things there were a number of British speakers and the whole event was in English which was useful for my dotard ears as one of the few uni-linguists in the audience.  The venue was amazing.  

Thanks to the breaks the day roughly broke up into three sections with different topics explored.  So, like the aorta in REBOA, (more of that later) we will tackle the day in three parts.  

In the first part Professor Nijs began by exploring major trauma in Belgium.  Belgium has twice the mortality rate due to trauma of the UK and has no system of Quality Assurance.  I was really proud to be part of the NHS as he highlighted the improvements seen in the UK since the MTC network was set up.  Whilst he pointed out that all systems need a 5 year maturation period in the UK we had seen immediate improvements in outcomes which increased year on year.  Major Trauma is an area of constantly changing paradigms: we no longer consider traumatic cardiac arrest a futile endeavour and there are ever improving methods of haemorrhage control such as REBOA.  He feels Belgium should aspire to the UK model but they will need:

    1.    The resources

    2.    People who understand

    3.    People who have the skills

Dr Ed Barnard (@edbarn) then spoke about traumatic cardiac arrest (TCA).  There is no universal definition of traumatic cardiac arrest which makes research difficult but this is predominately a disease of young people. Whilst initial papers gave low survival rates recent Trauma Audit and Research Network (TARN) data from 2009-2015 shows a 7.5% survival to hospital discharge rate as well a 2/3 moderate to good neurological outcome post TCA.  He discussed methods of public engagement as well as distinguishing between low output states in trauma (LOST) and no output states in trauma (NOST).  Whilst the standard methods of controlling bleeding and IV filling may work in LOST the future of resuscitation in NOST may involve methods of controlling and providing flow such as selective aortic arch perfusion.

In the final talk of part one discussed the European Resus Council (ERC) algorithm for TCA,

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Universal cardiac arrest algorithms are not suitable for TCA as they can result in delays of nearly 10 minutes whilst looking for a reversible cause such as tension pneumothorax.  The ERC algorithm places chest compressions at a lower priority in TCA than treating hypoxia, tension pneumothorax, tamponade and hypovolaemia.  Dr Truhlar (@TruhlarA) openly admitted that the role of CPR is unknown.

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The only nation to reject the ERC guidelines was the UK (insert Brexit reference) with the UK Resus Council producing its own guidelines as above which keeps thoracostomy and needle decompression as considerations not standard practice for all TCA.  

Dr Monsieurs (@kmonsieurs) continued this debate of the role of chest compressions in TCA.  He felt that maybe chest compressions provide little benefit in TCA and get in the way of other things which provide much more benefit.  There was discussion about how hard it can be for a professional to stop CPR for other procedures once bystanders have been doing compressions after calling for help.  Dr. Barnard made the interesting point that chest compressions whilst improving systolic BP cause diastolic BP to drop and so reduce coronary perfusion.  

I think the role of chest compressions in TCA and the ERC and UK TCA algorithms will provide much more fuel for research in the years to come!  

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