Main trauma conference – the first day

The event organisers, Professor David Lockey and Dr Gareth Davies, both Pre-hospital Care Specialists at London’s Air Ambulance, as well as consultants in Anaesthesia and Intensive Care, and Emergency Medicine respectively, welcomed the delegates before proceedings got underway. The hosts had devised a diverse programme with a faculty of renowned subject experts from across the world. Each invited speaker had been challenged to answer 3 specific questions on their expert area with the aims of challenging dogma, airing contentious issues and encouraging excellence in pre-hospital care. Major haemorrhage is a leading cause of death in trauma patients, and the first session of the day focussed on this important issue. Current data suggest 40% of trauma deaths may be attributed to uncontrolled haemorrhage, and 55% of trauma patients arriving at hospital are coagulopathic; 3% require massive transfusion. Dr Anne Weaver, a consultant at the London Air Ambulance, spoke on the topic of Massive Transfusion and the implementation of a ‘Code Red’ policy for management of massive haemorrhage, developed in the Major Trauma Centre (MTC) at which the London Air Ambulance is based. The trauma team leader declares Code Red if the systolic blood pressure is less than 90mmHg, a poor response to initial fluid resuscitation and suspected active haemorrhage. Prehospital Code Red activation provides an early pre-hospital alert to the receiving hospital ensuring packed red cells are available at the helipad on arrival of the aeromedical team; in addition the Level 1 cell salvage system is primed with blood, and fresh frozen plasma is requested from the laboratory. Furthermore Dr Weaver discussed the roles of prothrombin complex concentrate and tranexamic acid in the reduction of mortality from major haemorrhage. Dr Paul Wallman, a Manchester emergency medicine consultant, focussed on early reversal of warfarin in trauma patients found to be receiving oral anticoagulation. Whilst several guidelines in current clinical practice highlight the need for recognition of anticoagulated patients who sustain trauma, this does not always occur in a timely fashion. Early identification of this patient group, and subsequent treatment with vitamin K, prothrombin complex concentrate and fresh frozen plasma can improve outcome, and Dr Wallman was able to demonstrate this with personal data. The session was concluded by Professor Karim Brohi speaking on the topic of Damage Control Surgery, an eminent trauma surgeon, Professor Brohi was able to speak from firsthand experience. His talk centred around the pros and cons of damage control surgery and the triad of hypothermia, acidosis, and coagulopathy commonly associated with trauma. The second session was entitled ‘Novel Thoughts’ which provided two excellent talks giving alternative views to current clinical doctrine. Professor Jonathan Benger discussed the routine use of cervical spine immobilisation in the management of trauma patients, highlighting the fact that there is no high quality research indicating spinal immobilisation benefits patients. Professor Benger argued that as significant injury is rare, most immobilisation is unnecessary. He questioned the rationale of immobilising patients ‘just in case’, or immobilising those patients walking on scene, or those who walk into the Emergency Department. Cervical spine immobilisation is not without complications, most significantly, it can make the airway more difficult to manage, and slow pre-hospital extrication and therefore delay the onset of definitive care. In conclusion, Professor Benger suggested that alert and cooperative patients should be clinically assessed and then managed appropriately; nonalert patients are at risk of cervical spine injury and should be immobilised. The final talk in this session was from Dr Emrys Kirkman a research scientist working with the UK military. He presented evidence on the potential time limitations of hypotensive resuscitation and discussed the concept of novel hybrid resuscitation where after a period of hypotensive resuscitation normotension is targeted to maintain organ perfusion. Bristol, UK Crewdson Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20(Suppl 1):I2 http://www.sjtrem.com/content/20/S1/I2