TRAUMA 2006 - TRAUMA: WHAT'S NEW?

Anaesthesia Trauma and Critical Care Second International Trauma Conference

20-22nd November 2006 Liverpool Town Hall, Liverpool, UK

Session 1 – Pre-Hospital Care Models

Following the opening session in which the ATACC Medical Director (Dr. Mark Forrest – Consultant Anaesthetist and Intensive/Critical Care Consultant) welcomed all delegates to the conference, an update on the clinical and educational activities of the ATACC organisation was presented by Mrs Kate Warbrick (ATACC Director and Trustee). This was followed by Dr. Jane Beattie’s presentation (Consultant Anaesthetist and Chairman of the Ambulance Service’s Clinical Advisory Group) on the Mersey Regional Ambulance Service’s pre-hospital care model and its activities. Dr. Marc Scot, Consultant Anaesthetist in the Netherlands gave his insight into the Dutch pre-hospital care model and the differences between the UK and the Dutch pre-hospital care system. It was interesting to note the differences in the systems between the two countries which proved useful in that it highlighted the improvements that could be made by utilising the positive aspects of each system.

Session 2 – Terror On Our Doorsteps

The clinical implications of trauma patients due to particular terrorist attacks in the U.K. were presented:

• The Warrington Bombings - A Blast From The Past

Mr Barry Taylor (Consultant General Surgeon), Warrington Hospital – presented his involvement in the care of the patients who were injured and killed by the IRA Terrorist Warrington Bombings in 1992 and the aftermath of the event. Many forgot that the UK has been subjected to a prolonged terror campaign and that the medical profession learnt a lot of the lessons in managing trauma many years ago.

• The London Bombings – London Ambulance Service Gold Control

Mr Ian Todd (Assistant Director of Operations and Assistant Chief Ambulance Officer), London Ambulance Service – presented his involvement as part of Gold Command during the events of the London bombings on the 7 July 2005 and how the event was managed by the various emergency services involved. The insight given was extremely interesting in understanding the many logistical and communication problems encountered during the incident and how the emergency services and command coped with the high demands placed on them.

• The London Bombings – The Hospital Response

Mr Michael Walsh (Consultant Trauma and Vascular Surgeon & Clinical Director of Trauma Surgery), Royal London Hospital – presented the various London hospital’s responses to the bombings and the surgical management of the trauma patients after the bombings including the various operations carried out and the timings for each (including the role of Damage Control Surgery.) Many of the delegates appreciated the urgency of operating on the injured patients and the short operating times required. An analysis was made of the patients who required multiple damage control surgical procedures and the lengths between taking each patient back to the operating theatre and the intensive care unit and a breakdown of the various procedures performed.

• The London Bombings – The Regional Burden To Intensive Care Units

Dr. Kevin Fong (Specialist Registrar in Anaesthesia and Intensive/Critical Care), University College Hospital London – presented the substantial burden placed upon the intensive care units in the London region on the 7th July 2005 and thereafter; and how each intensive care unit coped with the surge capacity demand it experienced. Considering the normal daily demands placed upon intensive care units, the presentation informatively demonstrated the efficiency with which each hospital and intensive care unit managed the substantial increase in number of patients requiring intensive care on the day in question and for a prolonged period afterwards.

Session 3 – Prevention Is Better Than Cure – Reducing Road Risk : What’s New?

• Collision Prevention & Road Safety Design

Chief Inspector Douglas Hogg (Road Policing Commander, Northern Ireland) – gave an interesting insight into road safety units and how they employ the road safety campaigns effectively in reducing death and injury from road traffic collisions.

• Collision Investigation

Mr Damian Coll (Forensic Officer, Science Agency, Northern Ireland) – outlined the role of road traffic collision investigations and how scientific evidence is retrieved and used as part of the investigations.

• The Power Of Advertising

Miss Julie Anne Bailie (Lylebailie International Limited) – demonstrated the effectiveness of road safety advertising and media campaigns in developing strategies to reduce road accidents and improve road safety.

Session 4 – Breakout Session 1 – Research Education & Technology : What’s New?

Tools Toys & Trauma

i) Inside Demonstrations – hands-on workstations were on display for demonstration and inspection of the latest medical and equipment used in trauma

ii) Outside Demonstrations – an extrication demonstration was displayed for the benefit of all delegates to experience at first hand the extrication by medical and rescue teams of entrapped trauma casualties in real vehicles. Full demonstration of the latest Halmatro extrication cutting equipment was used and the role of the ATACC Medical Rescue Team and the Rescue 1 Project was shown to highlight the prompt response required in extricating trapped casualties who are time critical due to traumatic injuries received.

Session 5 – Breakout Session 2 – Research Education & Technology : What’s New?

Pre-Hospital

i) Out Of The Water, But Not Out Of The Woods: Drowning & Near Drowning (Dr. Peter Larcombe, Consultant Neuro-Anaesthetist & Royal National Lifeboat Institute Coxon, Brighton) – gave a fascinating presentation regarding drowned & near-drowned victims as a result of his work with the Royal National Lifeboat Institute and the management. It highlighted the many dangers that can be found out at sea and the various methods in order to prevent them. Medical management of the various emergencies which are regularly encountered by the lifeboat teams were discussed and provided useful guidance for the clinicians not normally involved in delivering medical care in such environments.

ii) Incident Management: Who Should Be Doing What? (Mr Nicholas Holmes, Sub-Officer of Cheshire Fire and Rescue Service) – highlighted the many risks involved to medical teams in road traffic collisions. The various hazards resulting from the large number of airbags and modern vehicle designs and technology were discussed; outlining the risks to both the casualty, rescue teams and medical teams in providing medical care to the trapped injured patient before and during extrication. The roles of the various emergency services were discussed and the health and safety issues were also considered, aiming to educate those who might find themselves in such unfamiliar and potentially hazardous circumstances; thereby eliminating or reducing them as much as possible.

iii) The RTACC Concept (Miss Sharon Blanckley, Specialist Registrar in Orthopaedic Surgery, Queens Medical Centre, University Hospital Nottingham & ATACC Medical Rescue Team Member) – gave an informative presentation on the role and expertise of the RTACC concept. The first of its kind worldwide, the RTACC trauma training courses (i.e. trauma training for non-medics) demonstrate the role and requirement for such training and the various indication, methods and techniques for the RTACC Trauma Training Courses were discussed and the progressive training syllabus was detailed. Many emergency services, organisations and commercial companies were present in order to obtain further information on the RTACC trauma training system, many of which progressed to implement and develop formal RTACC training programmes for their personnel, who either do, or have the potential to, encounter trauma victims on a daily basis as part of their normal working environment.

In-Hospital

i) Modernising Medical Careers: The Impact On Trauma Careers (Mr Daniel Brown, Consultant Orthopaedic Surgeon, Royal Liverpool University Hospital) – updated delegates on the impact that the Department of Health and Postgraduate Medical Education Training Board project “Modernising Medical Careers” will have on postgraduate surgical training and the subsequent careers for future trauma surgeons in the U.K. The changes that this is envisage to involve were discussed. The main consensus of the discussion was that no formal surgical training programme has yet been confirmed in the U.K. as a result of Modernising Medical Careers and that changes are taking place on an almost daily basis. Further information is to be awaited from the Department of Health on the project.

ii) Hi-tech Clinical Skills Trainer (Mr Mark Pimblett, Hi-tech Clinical Skills Trainer, Lancashire Teaching Hospitals) – demonstrated the new technology and clinical skills simulators that are being employed throughout the U.K. in developing and teaching trainees’ clinical skills and techniques. It is clear that practical training techniques are significantly more efficient and advantageous over theoretical teaching models, when it comes to the practical application of trainees’ clinical skills developments and improvements.

iii) Simulation & Evacuation: When The Lights Really Go Out (Dr. Claire Hammell, Senior House Officer in Anaesthetics, Warrington Hospital) – offered a remarkable account of the major incident which took place at Warrington Hospital when a large fire destroyed part of the hospital near to the intensive care unit leaving it without electricity and requiring total evacuation of the entire patients on the intensive care unit during a complete power failure of all electrics and lighting. This posed a number of issues including the high number of ventilated patients, many of whom required multiple infusions of sedation and inotropic support and the whole evacuation had to be co-ordinated promptly and safely with repatriation of the patients to intensive care units in neighbouring hospitals within the region.

Session 6 – Caves, Cold & Chaos : What’s New?

These fascinating sessions demonstrate medicine and the clinical care of trauma patients pre-hospital in the most extreme environmental conditions in the world:

• Cave Rescue – The Truth

Dr. Robert Mark & Mr Paul Lethebee (Yorkshire Cave & Mountain Rescue) – discussed some of their most challenging cave rescues in the extreme conditions of the Yorkshire Dales. Accounts of mountain rescue following walkers’ falls off cliffs during heavy snowfall and pot-holing entrapment disasters in cave tunnels requiring intricate and prolonged cave rescue. It was clear from the case scenarios demonstrated that much of the initial medicine was in the rescue and that the medicine came afterwards; due to the fact that such cramped and dangerous conditions prevent medical equipment being taken to the trauma patients, but instead must wait until after the patient has been rescued.

• The Trauma Casualty & Your Equipment In Extreme Cold Environments – Stuck On Everest!

Lieutenant Colonel Dr. Malcolm Russell (Senior Medical Officer, RAMC & Senior Lecturer in Pre-Hospital Emergency Care at the Royal Centre for Defence Medicine, Birmingham) – this enthralling presentation outlined the many dangers of providing medical, trauma and casualty care in extremely hazardous and remote environments. Many of the particular implications and special considerations that must be considered for group expeditions were discussed and appreciated; specifically the physiological effects of high altitude and the profound sub-zero temperatures on the human body with only the simplest of interventions that are available in such environments to treat and prevent such injuries. A fascinating presentation for anyone considering undertaking such an expedition in extreme climates.

• Deploying Healthcare In Extreme Environments – The Hostile Military Experience Of Trauma

Mr David Connell (Military Medic & Director, Ex-Med+ UK Group) – presented the substantial risks involved in providing trauma care to patients in extreme and hostile environments in areas of conflict around the world. This lecture recognised the requirements and setup of field hospitals in such conditions, and the latest techniques and medical equipment necessary to facilitate the provision of trauma care in such scenarios. Another aspect of the presentation was the method of stabilising trauma patients and how to repatriate them to the U.K. and other countries around the world. An interesting aspect of trauma care under military conditions for those that are used to providing care under civil conditions.

Session 7 – Non-Surgical Management Of The Trauma Patient

One of the great highlights of the conference, this session explored the latest techniques in the management of the trauma patient from use of the Novalung, the role of interventional radiology and CT scanning in the bleeding and unstable trauma patient and great debate relating to the pros and cons of permissive hypotension:

• The Novalong – A New Pumpless Extracorporeal Arterio-Venous Lung Assist Device In Severe ARDS 

Professor Thomas Bein (Professor of Anaesthesia, University Hospital of Regensburg, Germany) – educated everyone on the role of the Novalung (a newly developed extracorporeal AV lung assist device) in trauma patients. This exciting development provides the capability for oxygenating patients which prove extremely difficult to ventilate due to non-compliant stiff lungs. This technology improves oxygenation considerably and will no doubt evolve to become a mainstay of such patients in the future.

• Interventional Radiology & “The Doughnut Of Death” In The Unstable Bleeding Trauma Patient

Dr. Tony Nicholson (Consultant Radiologist, St James University Hospital, Leeds) – exploring the previously unexplorable, this presentation identified the role for interventional radiology and CT scanning in the management and care of the unstable bleeding trauma patient. Previously forbidden, it was apparent that there is clearly a role for interventional radiology utilising the use of CT angiography combined with embolisation in order to arrest uncontrolled haemorrhage in the bleeding unstable patient. Various other avenues were explored relating to embolisation of the splenic vessels rather than performing a splenectomy; However subsequent discussion demonstrated that a consensus has not yet been reached on this subject and many are advocates that the place for a bleeding spleen is in a bucket of formalin!

• DEBATE – How Low Can You Go? : The Role Of Permissive Hypotension

Many of the well-known arguments resurfaced (with new ones as well!) for this favourite contentious old topic!

Dr. Mark Forrest (Consultant Anaesthetist and Intensive/Critical Care Consultant, ATACC Medical Director) – “I Believe In Permissive Hypotension Resuscitation”

Dr. Forrest presented many of the arguments for permissive hypotension from a clinical and scientific point of view. Evidential argument behind the basis was explained including the deleterious effects of over-resuscitation in the initial stages of “popping the clot”, coagulopathy, metabolic acidosis, hypothermia, ARDS, oedema etc. until such time as surgical/interventional radiological control of the bleeding had been stopped. Although a very strong advocate of permissive hypotension, Dr. Forrest highlighted the criteria for implementing volume resuscitation (albeit low volume) through the judicious use of IV fluids such as hypertonic saline for those patients who require higher mean arterial pressures (such as patients with head injuries etc.) but reduce the risk of potential catastrophic complications from over-resuscitation with other IV fluid preparations. It was reiterated that, once haemostasis had been achieved, patients may require volume replacement and that this was necessary, but nevertheless should be administered in a controlled and appropriate manner.

Professor Mervyn Singer (Professor of Intensive/Critical Care Consultant, University College Hospital, London) – “I Do Not Believe In Permissive Hypotension Resuscitation”

Professor Singer also presented in a similar vain to Dr. Forrest but detailed many of the counter-arguments against permissive hypotension from a clinical and scientific point of view. Professor Singer based his arguments on the physiological effects of the body’s response to trauma and its tissue perfusion and oxygenation requirements at a cellular level. It is based upon this reasoning that trauma patients with ongoing haemorrhage require cyclic volume resuscitation and therefore should not be subjected to permission hypotension. This is believed to be due to the fact that the patient’s increased blood pressure will result in increased organ tissue perfusion (through increased circulating volume following IV fluid administration.) It was however acknowledged that increased saline fluid administration would result in an increased metabolic acidosis, coagulopathy and hypothermia; but it was maintained that this was less than the acidosis caused by tissue hypoperfusion and ischaemia.
Following all of the arguments given by both speakers, and subsequent conference discussion with the delegates, a vote was taken by all present (moderated by Mr Karim Brohi – Consultant Trauma and Vascular Surgeon, Royal London Hospital & Founder of Trauma.org) which found unanimously in favour of the arguments for permission hypotensive resuscitation.

Session 8 – Surgical Management Of The Trauma Patient

One of the most educating and insightful sessions of the conference, this session explored the techniques that are not, as yet, universally employed in the surgical management of the trauma patients. Fascinating management techniques and tips were demonstrated of complicated trauma patients and how to management them in difficult scenarios.

• The Management Of Vascular Injuries

Mr Michael Walsh (Consultant Trauma and Vascular Surgeon & Clinical Director of Trauma Surgery, Royal London Hospital) – gave an update on the latest surgical management of vascular injuries; demonstrating the methods used to gain vascular access, how to control ongoing catastrophic haemorrhage, the use of damage control surgery and the temporising use of intra-arterial vascular shunts until definitive surgery can be performed on the patient (once stabilised and the patient’s condition has been optimised on the intensive care unit.) Delegates then appreciated how patients’ vascular injuries can be managed using surgical techniques never previously considered or thought possible.

• Cervical Spine Clearance

Professor Keith Willett (Professor of Orthopaedic Trauma Surgery, University of Oxford and John Radcliffe Hospital, Oxford) – outlined the dynamic fluoroscopy protocols used in his hospital regarding the diagnosis and management of patients with cervical spine injuries, Further discussion was raised regarding how to manage these patients (particularly in the unconscious ventilated patients on the ITU) and who should be performing these techniques. As many of these patients were unstable on admission and required urgent surgical/anaesthetic interventions, it has often not been possible to arrange for formal scanning of such patients nor it is possible to rule out such injuries clinically due to the patients’ conscious level. It was highlight that this technique, when used in experienced hands, could successfully and clearly demonstrate/diagnose such injuries.

• Damage Control Surgery

Mr Karim Brohi (Consultant Trauma and Vascular Surgeon, Royal London Hospital & Founder of Trauma.org) – gave an informative presentation on Damage Control Surgery, its role and its application in severe critically injured trauma patients. Comparisons were made with traditional definitive surgical procedures (which took place over many hours) in which patients frequently had their anatomy restored but later succumbed on the intensive care unit due to severe physiological insults placed upon them by the injury and exacerbated by long, complicated surgery. The well-recognised causes and complications of such surgery were detailed and the aims of Damage Control Surgery in preventing these were clearly identified and discussed; including situations when such techniques should be employed and what interventions are considered to be Damage Control Surgery techniques. The ideal time period for further surgery (i.e. definitive corrective surgery) was discussed and how this should be planned and prepared for by the surgical and intensive care teams. Following the presentation, many of the delegates appreciated the role of Damage Control Surgery and thereafter became aware of when and how to apply such techniques and therefore adapt their future clinical practice accordingly.

Session 9 – Complex Humanitarian Disasters

Given international disasters and national terrorist incidents over recent years, this session was dedicated to the management of major disasters and how individuals involved should manage such disasters effectively (including the medical and humanitarian implications that such disasters create.) It was clear that clear command, control and communications are vital parts of managing such large scale disasters.

• Co-ordinating International Disaster Relief

Mr Ted Pearn (Humanitarian Affairs Officer, OCHA, United Nations, Geneva, Switzerland) – provided an insight into the role of the United Nations Office for the Co-ordination of Humanitarian Affairs and how it co-ordinates international disaster relief on such an extraordinarily large scale. The outcome of which is that, in such large international disasters, groups wishing to provide relief, disaster support and medical aid should offer their services to UNOCHA who can properly co-ordinate the humanitarian response and ensure that relief teams do not themselves become a burden on disaster areas; thereby consuming the aid provided; due to an improper response which can all too frequently occur.

• Crush Syndrome : Learning From Disasters

Dr. Jason van der Velde (Disaster Response Team Co-ordinator, ATACC) – highlighted the substantial and detrimental impact that crush syndrome has in major disasters and demonstrated that the syndrome is all too often missed and not diagnosed (either at all or too late) when the condition causes irreversible morbidity and mortality. The pathophysiology of the syndrome was discussed and how the condition should be diagnosed (including a high index of suspicion given the patients’ mechanism of injury etc.) and how the patients should be properly and rapidly treated. The role of prophylactic compartment syndromes for trash foot and compartments syndromes were detailed, in addition to the deleterious effects on cardiac, respiratory and renal functions (resulting in multi organ failure.) An essential informative guide on the pathology and management of crush syndrome for all clinicians.

• Managing An International Disaster Response

Major Rene Wagemans (Belgian Defence Staff, Belgian First Aid & Support Team [B-FAST]) – gave a thought provoking presentation into many of the considerations to be employed when deploying to and managing an international disaster response. A European perspective of such disaster management was detailed included the sheer logistical requirements in order to provide such medical and disaster relief aid, including the co-ordinated response of many different teams working together as a single functional disaster response unit. It was clearly demonstrated that the co-ordinated response of many different teams working together was advantageous and provided an ideal and effective response with more favourable outcomes in respect of aid and disaster relief management than single un-coordinated units can provide working alone.

The conference was formally brought to a close by Dr. Mark Forrest (ATACC Medical Director) in which he thanked those responsible for their hard work and support in making the conference such a successful event and especially all delegates for their attendance (without which the conference would not prove to be anywhere near as successful as it has been.) The support of the conference sponsors was highlighted as being invaluable in sponsoring the event and ensuring its viability and success. Details were given of further ATACC events (courses, seminars and conferences) further details of which are available on the ATACC website (www.atacc.co.uk)

Conference Dinner

The formal conference black tie dinner was held at the superb historic Liverpool Town Hall Ballroom on the Monday evening. A memorable and enjoyable evening was had by all and provided the opportunity for people to mingle and network with like-minded colleagues from around the globe.