Hi. I feel like I’ve just bumped into someone I haven’t seen for a while and then realised that it’s been a whole year since we last met. My last post in this blog was a whole year ago, reporting on the wonderful Trauma Care conference 2017. I only attended one day this year, but there was plenty to get stuck into.
John Prowle – Renal rehab – looking after the kidney in major trauma
John Prowle is a Senior Clinical Lecturer in Intensive Care Medicine within Prof. Rupert Pearse’s Critical Care and Perioperative Medicine Research Group and is an Honorary Consultant Physician in Intensive Care Medicine and Renal Medicine at the Royal London Hospital John’s academic interests include the Pathogenesis, Diagnosis and Treatment and Outcomes of Acute Kidney Injury, Continuous Renal Replacement Therapies in the ICU, Fluid Therapy and Medical Complications of Major Surgery. – https://www.researchgate.net/profile/John_Prowle
This presentation explained that it was particularly difficult to predict which patients would get an Acute Kidney Injury (AKI) following a major trauma, but his team had put together a scoring system which had some success. He explained that a renal insult from trauma is resultant from the whole body insult, part of the stress response and other changes in the internal milieu.
Dr Prowle went on to discuss the usefulness and limitations of the KDIGO AKI Classification:
Changes in baseline creatinine are important – orders of magnitude, 1.5x, 2x, 3x. Patient who develop AKI 2-3 have a mortality of up to 50%, even when confounders are adjusted for.
It is important to remember that Creatinine is related to muscle mass as well as renal function, and significant muscle wasting in these patients in intensive care leads to a gradual reduction in creatinine. If accounting for wasting, there could be a further 135% increase in CKD diagnoses! Cystatin-C is much more accurate, and shows this effect. It’s not just muscle wasting, beware the amputees who have less muscle mass too!
Markers predicting need for Renal Replacement Therapy are Age, Volume of blood transfused 3units or more, high initial lactate and initial phosphate below 0.8. The tool has a good negative predicted value. It was shown to be a good way of predicting mortality, PPV 50%. As Clare Bosanko reported from the talk, things get worse as the presenting state is worse.
Interesting to not that Creatine Kinase (CK) is not predictive for the need for RRT in the initial bloods, but high levels later could be. It takes time for CK to rise.
Modern intravenous contrast agents are very low-risk for AKI. Dr Prowle personally has no concerns for contrast use in major trauma patients. There is no need to be concerned about post-contrast nephropathy any longer.
AKI can lead to Chronic Kidney Disease (CKD) in the mid to longer term, so it’s important to care for AKI promptly to prevent long term morbidity. It was seen that proteinuria is a good predictor of CKD, eGFR less so.
Dr Rachel Jenner, Manchester ED Paeds Learning
Dr Jenner is a Consultant in Emergency Medicine and Paediatric Emergency Medicine at Royal Manchester Children’s hospital. She shared her personal and her department’s learning of the major incident last year; the bombing at the Manchester Arena.
Open lines of communication, pre-existing are crucial to rapid personnel recruitment. It was felt that WhatsApp was very handy, but not everyone had their phones with them, and many were on silent leading to feelings of guilt afterwards. They have since set up a specific WhatsApp group for major incidents to filter important messages.
It is important to maintain business continuity during a major incident (MaI), it’s not just the MaI that’s happening. There was at least one other sick child who presented to the ED who was treated by a paediatric medical team who were drafted in from the wards.
Dr Jenner called the CAMHS team in, which was not in the MI plan, but it was felt to be really helpful to have a psych team in the middle of things providing support, both in the immediate and medium term phases. They were able to provide support to patients, families, responders, and medical care teams.
Flexibility with clinical areas being redesignated was important. Having been able to send all non-urgent patients from the waiting room home, there was more space to assess the urgent cases. The initially designated area for MaI command point proved useless as it was tucked away from the goings on, and they couldn’t see anything from there. They used a large corridor next to the ambulance doors which was much better.
In order to improve flow, when in CT, all patients got a decision on disposition; the patient was sent to theatre, ITU, or the ward, no one returned to ED, maintaining space to assess the newly presenting patients.
Scott Beattie – Adult ED – Manchester
I only had the chance to see Scott’s answer to a question having missed his talk, but he said how useful this was:
Nicola Curry – @nicola_curry – Everything you need to know about blood transfusion in Major Trauma
FFP may be improving the health of the glycocalyx rather than providing clotting factors. I personally wonder if a move to Cryoprecipitate (should it happen) remove this effect? There is much more work to be done in understanding the pathophysiology of the acute coagulopathy in trauma.
Interestingly there is no strong evidence for early platelets in most trials, PROPPR showed a trend towards improvement but they were studying two interventions as a bundle and the effect could be due to the higher FFP ratio.
It was said at last year’s Trauma Care conference that cold stored platelets may be physiologically more active, have a higher shelf life and could reduce waste. Dr Curry reiterated this, it’s in the pipeline; it’s a shame there hasn’t been more movement on this in the past 12 months.
Dr Curry pointed out that platelets are crucial to clot formation due, importantly because of their phospholipid surface. Clots just will not form in the absence of this. However, there are some artificial platelet therapies in trial, but these are also a long way off.
The MATTERS II study showed an improved outcome when combined Tranexamic Acid and Cryoprecipitate were combined. The Cryostat 2 trial is now recruiting, Dr Curry is involved. The hope is to see if early Cryoprecipitate improves outcomes.
It was asked why should cryoprecipitate be given itstead of fibrinogen concentrate? Dr Curry explained that cryo also has factor 13 and another anti-fibrinolytic, which should improve clot integrity over fibrinogen alone. Work is ongoing to try to prove that cryo is better than fibrinogen concentrate.
It was also asked if the age of the red cells provided by the blood bank makes a difference as has previously been believed. Dr Curry told us that a systematic review of 6000 patients hasn’t shown if age of PRBCs since donation is important. There is a comprehensive article on this topic available freely online.
Silver Trauma – Dr David Raven – @hectorcares
Elderly patients don’t get seen quickly in the ED.
The reasons why they don’t get the same reponse are multifactorial. They don’t display the usual signs of deterioration, get undertriaged, get left in corridor for hours, get cold, their pressure area care is poor, and are much less likely to be seen by a consultant quickly in ED and much less likely to have a trauma call than younger trauma patients.
The team @hectorcares, which involves partners from all three Major Trauma Centres in the West Midlands, has developed the Silver Trauma Safety Net – an alternative (or perhaps supplementary) triage tool. Like the Major Trauma Triage Tool, it contains elements of Physiology, Anatomy, and Mechanism. There is a lower threshold for transfer to MTC if the patient is taking anticoagulants.
- Physiology – Older patients have a higher GCS for same injury. ‘Normal BP’ as arbitrary values are unreliable in elderly blunt trauma, as the patient could normally be hypertensive. Venous lactate is a better predictor of injury than vital signs. Don’t forget B-blockers, which will artificially lower the heart rate and reducing the tolerance to hypovolaemia
- Anatomy – In addition to triage tool –> more standby calls for compound fractures, etc. Injury to 2 or more body regions. Only requires one closed femoral fracture, rather than two
- Mechanism – Injury scores in the elderly are higher for a given mechanism, top to bottom of stairs introduced. Any RTC. Pedestrian or cyclist vs car
This triage tool is much more about getting standby alert calls through to the receiving hospital rather than hospital bypass to an MTC. The tool is currently held by the regional trauma desk to aid with team decision making rather than passing it out to all road crews.
My question is: How can we identify significantly head injured patients for CT if GCS is not useful in this population. Does it matter to patient outcomes if a delay is introduced, given most elderly patients have more space intracranially and take longer to deteriorate? Dr Raven agreed the answer to this is not clear.
Peter Isherwood – @UHBHumanFactors – Human factors and ergonomics in acute care
A fascinating talk about how systems can be changed to minimise delays, effort and mistakes, streamline care and processes. A beginners’ guide to ergonomics. There are three main elements to consider here:
- Cognitive ergonomics – regards individuals, and includes stress, resilience, and decision making
- Organisational ergonomics – team working, hierarchies
- Physical ergonomics – equipment, building layouts, etc.
When thinking about systems it is important to understand that all staff members are highly trained and trying to do the best they can. (This mirrors the sentiments of @orangedis, Dr Chris Turner, and his #civilitysaves compassionate governance campaign). There is scope to be a lot more introspective and change yourself and your team in order to help others change their behaviour. Look for systemic solutions for problems perceived to be problems with individuals.
There was an interesting case study which involved changing the route patients with chest pain travel through the ED, the existing process was mapped out and there was significant wasted travel distance and time. A new process, which sent patients through a different door, with a red card which staff would notice and treat urgently is used to minimise delays.
It was pointed out that there is an average of 209 policies per Trust, (8000 pages, 2 million words). Guidelines are not designed for end users. Suggestion from speaker – each guideline should be summarisable onto one sheet as a flowchart or it’s too complex.
A great point from this talk, Trusts probably have ergonomists on the payroll doing chair assessments, etc. Engage with them for process solutions.
Lt Cdr Elspeth Hulse – Organophosphate (OP) poisoning
A particularly topical discussion about Organophosphate poisonings. It’s not just terrorist attacks but also pesticide poisonings, although hopefully you’ll get fewer casualties with the latter.
OPs are Acetylcholinesterase inhibitors. They elicit a combination of muscarinic and nicotinic features, combined with unconsciousness.
You can remember the features using the DUMBBELS mnemonic.
- Miosis/muscle weakness
You will possibly see fasciculations and foaming at the mouth. More than one patient is a good clue!
It’s difficult to identify which OP toxin is used, and it does make a difference to some of the treatment options – although thankfully not the basics.
Decontamination. Lose clothes, shower/irrigate. Water, soap (and hypochlorite solution if you have it). You should have Hazmat suits, including double gloves and boots. Do it outside the hospital!!!
Seizures are treated with Diazepam – 5mg PRN
Atropine – treats the antimuscarinic effects. 1-2mg iv then double every 5 mins until desired effect. (Dry chest, HR>80, Dry axillae, SBP>80mmHg, pupils no longer pinpoint). You will need potentially huge doses. During a pesticide poisoning, the mean dose to achieve atropinisation was 23mg! No need to give oxygen before atropine as has previously been described.
OXIMES – You should ideally know the agent, but generally 2g Pralidoxime then 1g 4-6hrly.
If the above doesn’t sort respiratory distress, intubate.
OPs block esterases, so suxamethonium can prolong paralysis up to 12 hours, and takes 2 mins to work. Try to get a disposable ventilator or dedicated machine for OP poisonings as contamination is a difficult problem. You will also see a prolonged effect of prilocaine, mivacurium, esmolol, remifentanil.
BIS monitoring for surgery in poisoned patients was discussed. Depth of Anaesthesia can be difficult to predict and you may need much lower anaesthetic doses.
Later, during an intensive care wean – if not breathing enough, check cholinesterase levels.
Simon Carley – Top 10 Trauma Papers of 2017-18
Don’t just read my interpretations on these papers, check out Prof Carley’s original blog article.
It was great to see that simple bedside tests can still be relied upon to rule out significant injury to the arterial supply to the leg in penetrating injury. Normal ABPIs can rule an injury out. Absent flow on ultrasound suggests a need for theatre.
This paper highlights that we are scanning more people looking for immediately life threatening injuries, but these scans are also picking up diagnoses which if missed could have just a significant impact. Prof Carley suggests we all make sure that we have hospital followup solutions in place so early diagnoses can be acted upon.
This was better than I thought. Surprised but pleased to be part of a system which is trying to rectify the biases found and highlighted by the @HectorCares team mentioned above.
It’s difficult to understand the ins and outs of this paper. Either EMS crews are spending too much time on scene and those brought to the front door of the hospital by witnesses are able to access definitive care much quicker, or there are a significant number of patients who are stabbed outside the hospital’s front door. This used to be a thing, but I don’t know how prevalent it is now. We should all be mindful of the usefulness of our therapies and point-of-care tests and balance it against the potential for harm. This fits with the model recommended by the Faculty of Prehospital Care’s advice on spinal immobilisation in penetrating trauma, if delaying to put a collar on causes harm, a FAST scan could potentially do the same.
The PECARN data shows that we should be mindful of the radiation we expose children to. The concept of ALARA – as little as reasonably appropriate – is a good one. For every 500 pan-scans, there is one malignancy. Serial US and observation is appropriate in the stable paediatric trauma patient.
There’s still no consensus as to what to do with blood pressure in TBI. Higher is better. However! Does forcing it to be higher also make patient outcomes better, or are those with naturally higher BPs more likely to survive? Still no definitive answer on what to do with those patients who are exsanguinating at the same time. Prof Carley is now tempted to allow those patients’ BPs to come up a bit more than before.
My take – makes sense, more oxygen is better, where’s the harm? If it’s part of everyday practice, it may make a difference in difficult airway cases without you having to think too hard. NB – these things usually go out of fashion sooner or later.
Nice that there were two different speakers saying the same thing about this today.
It has become almost routine practice to place an intercostal chest drain for any visible (on CT) pneumothorax if that patient is subsequently going to get intubated and ventilated either in theatre or on the intensive care unit. This is not my practice, and I’m backed up by this paper. Could be a difficult dogmatic culture to shift though.
I’m sure there will be even more HF in the coming months and years, our performance as clinicians makes more difference than the fanciest machine and most expensive drugs. Let’s all get on board with this and give our patients’ the best shot.
A great day out!
Thanks for reading all the way to here, I hope you found it useful. Kudos to all the speakers, and thanks for all their hard work in making the day another great day of learning!