These may be old news to some of you, but they were news to me. I got sent the blog of today's State of the Art meeting, a three day update run each year by the Intensive Care Society.
There were a few interesting bits, I thought - one was the concept of one hour of hypotensive resuscitation followed by normotensive resuscitation, balancing clot formation with acidosis, the different views on the ratio of packed cells to FFP acutely, traumatic cardiac arrest, and the other being the CRASH-2 trial result. It looks a solid paper, and while not suited to the roadside, they were getting the good results (significant reduction in all-cause mortality) in tranexamic acid was given within eight hours of massive haemorrhage. Something to think of when we can't get rid of a casualty immediately. I'll not be cracking chests, but it's good to know what the options are further down the line. Enjoy!
"
It’s an early start on the second morning with the choice between organ support or trauma. I’ve opted for the latter as it promises to be deliver insight from the military, with Lt Col Jeremy Henning from the defence medical services. Over the last few years the wars in Afganistan and Iraq have sadly provided plenty of trauma experience and the lessons learnt can be translated into the civilian world. The Lt Col starts with a brief history of military ICM – more soldiers have historically died from disease rather than battle injury (although clearly this is no longer the case). Major advances came through helicopter evacuation in Korea and dialysis in field hospitals. The British Army really started ICM at war in the Balkans, and by the time we were back in the Gulf for the second time the record shows that ICM was as good in field hospitals as it was back home. The Lt Col goes on to present some quite astonishing figures from the most recent period he was in Afghanistan. In three months the field hospital conducted 1400 CTs and operated on 350 emergency patients. Of note he stated that MEWS doesn’t work in this population group (76% inappropriate triggers mostly due to physiological bradycardia). From there it’s on to hypotensive resuscitation, a concept we are all now familiar with. The evidence suggests that this method inevitably results in development of acidosis and the military is now moving towards novel resuscitation – one hour of hypotensive resuscitation to allow the clot to form, after which they revert to normotensive resuscitation (by this point the clot will be as firm as it will get). From fluids to the resultant coagulopathy, the military adopt a hit them hard and fast rule, with 1:1 RBC:FFP and early platelets. In Bastion they routinely see massive hypocalcaemia and routinely use 40 – 50 mls of calcium in the first hour of a trauma. If all else fails they go to the “Bastion plug†– 5 units platelets, 5 units FFP, 10mg VII, 5 units cryo. There is no time for lab testing in the field hospitals; the military are using point of care testing to guide coagulation treatment. The amazing facts keep coming – traumatic cardiac arrests are no longer seen as hopeless; if a patient arrives in cardiac arrest from trauma they bypass the ED and go straight to theatre with early echo and aortic cross clamping – there have been 27 survivors from this approach in the last 3 years. Whilst we will (hopefully) never see the volume of trauma in the NHS that the Lt Col has experienced some of the lessons can help us improve the care we are delivering. He finishes on a note of caution: the majority of traumatic presentations to the NHS are car crashes, not gunshots and blast injuries.
From the military we move to the global picture of trauma in the civilian world. Mike Parr is back on the stage and highlights again that most trauma in the world is due to motor vehicle collisions. The largest cause of death from trauma is head injury (42%), which we can really only improve with primary prevention. 39% however result from haemorrhage, something we can potentially treat and it appears that coagulopathy is a major contributory factor. The CONTROL study randomized 573 patients (powered for 1500) to look at factor VII in trauma but was stopped early due to futility (the mortality was too low). During this time there was a significant reduction in blood product use, but the reduction was only 1-2 units. Prof Parr (an author on the study) ran through the study protocol, highlighting the high standard of care that the patients received as a result of inclusion (perhaps the reason why the mortality was low). One of the protocol stipulations was that only damage control surgery was allowed during the first 24 hours. The Prof presented a retrospective analysis of the data set that showed a statistically significant difference in mortality related to use of damage control surgery. Whilst this is interesting it has to be remembered that this was not what the study was designed to test; perhaps an area for future research. In contrast to the previous speaker the Prof does not appear to believe in 1:1 resuscitation, citing the 2007 evidence which was actually 2:3; a note of caution there. CRASH 2 is presented next, with the finding that tranexamic acid can be safely used to reduce death in trauma patients; again if you haven’t read the study go to [url]http://www.crash2.lshtm.ac.uk/[/URL] , it may change your practice. Prof Parr ends with another advert for the Liverpool Hospital in Australia, and an open invitation to all registrars to apply for a job there!
If you weren’t at the meeting there will be a podcast of Prof Parr’s talk on the ICS website in the near future ([url]www.ics.ac.uk[/URL])"
There were a few interesting bits, I thought - one was the concept of one hour of hypotensive resuscitation followed by normotensive resuscitation, balancing clot formation with acidosis, the different views on the ratio of packed cells to FFP acutely, traumatic cardiac arrest, and the other being the CRASH-2 trial result. It looks a solid paper, and while not suited to the roadside, they were getting the good results (significant reduction in all-cause mortality) in tranexamic acid was given within eight hours of massive haemorrhage. Something to think of when we can't get rid of a casualty immediately. I'll not be cracking chests, but it's good to know what the options are further down the line. Enjoy!
"
State of the Art Meeting 2010 Day 2
From the military we move to the global picture of trauma in the civilian world. Mike Parr is back on the stage and highlights again that most trauma in the world is due to motor vehicle collisions. The largest cause of death from trauma is head injury (42%), which we can really only improve with primary prevention. 39% however result from haemorrhage, something we can potentially treat and it appears that coagulopathy is a major contributory factor. The CONTROL study randomized 573 patients (powered for 1500) to look at factor VII in trauma but was stopped early due to futility (the mortality was too low). During this time there was a significant reduction in blood product use, but the reduction was only 1-2 units. Prof Parr (an author on the study) ran through the study protocol, highlighting the high standard of care that the patients received as a result of inclusion (perhaps the reason why the mortality was low). One of the protocol stipulations was that only damage control surgery was allowed during the first 24 hours. The Prof presented a retrospective analysis of the data set that showed a statistically significant difference in mortality related to use of damage control surgery. Whilst this is interesting it has to be remembered that this was not what the study was designed to test; perhaps an area for future research. In contrast to the previous speaker the Prof does not appear to believe in 1:1 resuscitation, citing the 2007 evidence which was actually 2:3; a note of caution there. CRASH 2 is presented next, with the finding that tranexamic acid can be safely used to reduce death in trauma patients; again if you haven’t read the study go to [url]http://www.crash2.lshtm.ac.uk/[/URL] , it may change your practice. Prof Parr ends with another advert for the Liverpool Hospital in Australia, and an open invitation to all registrars to apply for a job there!
If you weren’t at the meeting there will be a podcast of Prof Parr’s talk on the ICS website in the near future ([url]www.ics.ac.uk[/URL])"