Trauma Care Conference Abstracts 2023

The 2023 year saw a change in conference strategy for Trauma Care. Instead of the traditional 5-day conference in Yarnfield, there were three hugely successful regional conferences in Birmingham (March), Manchester (June) and Bristol (October). As we hoped and expected, these conferences were attended by representatives of just about every profession and group involved in the care of the trauma victim.

Reproduced here are the abstracts of the winning posters presented at the three conferences which we hope you will both enjoy and find useful. The opportunity to present a poster at a major conference is a significant milestone, especially for trainees, and we are always delighted that so many people choose to engage in our competitions.

When we return to Yarnfield in March 2024, I am pleased to announce that there will also be an opportunity to present new research in the form of short oral presentations and I very much hope that you will consider presenting your work in this way. Our annual prizes for the best work will, I hope, continue to be seen as small but significant incentives to get involved in activities designed to improve the care of those who are at the heart of everything we do.

Birmingham – March 2023: 10@10 – Trauma skills teaching in the emergency department

Hannah Philpott

Frimley Health NHS Foundation Trust, Camberley, Surrey

Background: Pressures in the emergency department (ED) make it difficult for staff to find time to attend long training sessions. We developed a weekly trauma skills teaching programme available to all Frimley Park ED clinical staff which could be delivered in 10 minute 1-to-1 slots.

Methods: Each week clinical staff were invited to sign up for a 10-minute slot between 10 and 11am, during which a trauma skill was demonstrated and explained by the teacher before they practised themselves. They were then given the opportunity to teach the skill to the next person. A different basic skill (chosen from NICE guidelines¹ or ATLS²) was taught each week and data was collected over four sessions – Kendrick splints, airway adjuncts, Belmont and trauma documentation. Attendees completed anonymous Qualtrics surveys documenting their confidence in the skill (from 1 ‘I know nothing about this topic” to 5 “I am 100% confident in this skill’) before and after the teaching. The survey after the teaching also asked whether their confidence in the skill had improved due to the teaching and how useful the teaching was (from 1 “not at all useful” to 5 “extremely useful”).

Results: Twenty-six staff attended over the four sessions including medical students, physicians associate students, SHOs, registrars, consultants and nurses. Of these, 22 completed the before survey (84.6%) and 19 completed the after survey (73%). Average confidence went from 1.8/5 before teaching to 4.1/5 after. And 100% of respondents said their confidence had improved due to the teaching and on average the usefulness of the teaching was rated as 4.8/5.

Conclusions: The low confidence rating before teaching confirms the need for trauma skills teaching for ED staff. There was a large improvement in confidence in the skills taught attributed to the teaching. The high usefulness rating suggests relevant topics were taught.

References

1. Major trauma: Assessment and initial management [Internet]. NICE. National Clinical Guideline Centre; 2016 [cited 2022Oct25]. Available from: https://www.nice.org.uk/guidance/ng39/evidence/fullguideline-2308122833

2. Advanced trauma life support: Student course manual. Chicago, IL: American College of Surgeons, 2018.

Masque ecchymotique: Tell-tale of impact of trauma?

S Pokale, V Garnelorey, M Mathiarasan

Department of Critical Care, St Marys Hospital, Imperial College Healthcare NHS Trust, London. [e-mail]

Introduction: Masque ecchymotique is a characteristic facial appearance of craniocervical cyanosis, subconjunctival hemorrhage and severe petechiae associated with traumatic asphyxia. It is caused by thoracoabdominal compression after deep inspiration against a closed glottis, which results in venous hypertension in the valveless cervicofacial venous system. It can be accompanied by life-threatening systemic features such as cerebral edema, crush injury of thorax and heart, spinal cord ischaemia and visual loss. We present a rare case of traumatic asphyxia with masque ecchymotique with unusual mechanism of injury associated with complicated intensive care unit (ICU) course.

Case Report: A 23-year-old male was found unresponsive in standing position in a 3 m deep pit with a ladder over his chest and he was buried in gravel up to upper chest. A digger was used to remove the gravel and he was given bystander cardiopulmonary resuscitation (CPR) of 6 minutes after rescue and intubated at scene by HEMS. He had bluish discolouration of face and anterior chest wall up to the level of patterned abrasion of the ladder. Computed tomography (CT) showed right-sided rib fractures with pelvic fractures including right sacroiliac joint disruption and pelvic hematoma. The patient was found to have raised creatinine kinase, troponin and alanine aminotransferase which gradually improved on resuscitation. His course in the ICU was complicated by non-reactive pupils and episodes of desaturation though CT brain and bronchoscopy showed no significant findings. He later developed rising oxygen requirements with ground glass opacities and was referred for Extra Corporeal Membrane Oxygenation (ECMO). However, treatment was challenging due to multi-systemic involvement, infection, limitations in positioning and anticoagulation. His condition gradually stabilised without ECMO and was subsequently extubated on day 15 following improvement in Glasgow coma score though he continued to remain delirious.

Conclusions: The unusual signs of traumatic asphyxia can be useful in determining the impact of trauma. Multi-system involvement and life-threatening injuries like cardiorespiratory failure, crush injuries and central nervous system involvement should be anticipated in patients showing masque ecchymotique irrespective of the mechanism. Early on-site intervention and specialised intensive care management can improve chances of good outcomes.

Manchester – June 2023: The effect of calcium administration following pre-hospital blood transfusion in major trauma patients between 2019 and 2023

G Clarke¹, S Carley², M Pode¹, S Beattie², P Haywood², R. Evans²

¹University of Manchester Medical School

²North West Air Ambulance [e-mail]

Background: Pre-hospital blood transfusion has become a more widely practiced intervention in major trauma patients in the United Kingdom. Whilst it makes pathophysiological sense to replace lost blood, there are risks. Hypocalcaemia is one such concern as it is associated with increased mortality in trauma patients and is a component of the trauma diamond of death due to its effects of impaired clotting capability and cardiac contractility. There is currently no consensus across UK pre-hospital services as to the amount of supplemental calcium to be given alongside blood products to prevent this. At North West Air Ambulance, 10ml of calcium chloride is given with every two units of blood product. This study aims to look at the first blood gas from a series of patients who were treated by the NWAA Service and delivered to a major trauma centre following blood transfusion. The objective is to establish the relationship between blood products, calcium levels and the current calcium replacement protocol.

Methods: We identified major trauma patients who had received blood products from NWAA between January 2019 and April 2023 using HEMSBASE records. The number of units of blood product and calcium given was identified. We linked this data to outcomes from TARN to understand patient outcomes. The first blood gas upon admission to hospital was used to determine whether calcium levels were abnormal following transfusion.

Results: One hundred and seventeen patients received blood products from the NWAA Service during the study period; 53.0% (n = 62) had a blood gas identified. Overall, 45 patients received calcium pre-hospital: 44.4% (n = 20) were hypercalcaemic on the first blood gas, 13.3% (n = 6) were hypocalcaemic and 42.2% (n = 19) had normal calcium levels. For the 17 patients who did not receive calcium pre-hospital, 5.9% (n = 1) were hypercalcaemic, 70.6% (n = 12) were hypocalcaemic and 23.5% (n = 4) had normal calcium levels.

Conclusions: Patients who received calcium were significantly less likely to be hypocalcaemic (13.3%) than those who did not receive calcium (70.6%). The NWAA regime of 10ml CaCl with every two units of blood product led to a significant number of patients with hypercalcaemia on first hospital gas.

Wild Trials 2023: A case for pre-hospital teaching in UK medical schools

H Breed, E Davies, M Woodward

University of Manchester Medical School [e-mail]

 

Background: Manchester Wilderness Medicine Society is a student-run organisation providing medical students an opportunity to further their knowledge of pre-hospital medicine. In April 2023 the society hosted a competition, Wild Trials, inviting medical students from across the country to compete in simulated scenarios. The event tested their knowledge and team working skills whilst providing an opportunity for furthering their knowledge of trauma and pre-hospital care. This study aims to evaluate the event and gather data on student exposure to pre-hospital medicine in the United Kingdom.

Methods: Eighty students competed in teams of four. Teams were asked to respond to 10 simulated pre-hospital scenarios. Following the weekend a questionnaire was sent to participants, they were asked about their experiences and exposure to pre-hospital care during medical school and the contributions made by their Wilderness Medicine Societies (WMS).

Results: Forty students responded to the questionnaire, 65% (25/40) stated they were considering a career in pre-hospital medicine, but 82.1%(32/39) of respondents stated they had had no exposure to pre-hospital medicine (excluding student-led events) during their degree. Furthermore, 71.4% (25/35) stated they had 0 hours of experience or teaching related to pre-hospital medicine during their degree (excluding student-led events). Considering the contributions made by WMS, 100% (40/40) of respondents stated their WMS had provided learning opportunities for pre-hospital medicine and 100% (40/40) of respondents agreed that Wild Trials improved their knowledge of pre-hospital medicine. Finally, when asked if there is enough opportunity to experience pre-hospital medicine in medical school, 87.5% (35/40) of students stated there were not enough opportunities to explore this specialty.

Discussion: The survey results demonstrate that pre-hospital care is currently poorly or entirely overlooked in medical education curricula and that exposure is currently being provided to some extent by student- led WMS. Wild Trials was a successful student-led event that allowed medical students to experience simulated pre-hospital scenarios with input from field experts. Whilst WMS will continue to enhance knowledge of pre-hospital care, there is a need for the medical school curriculum to improve exposure to the specialty.

Bristol – October 2023: Is pre-hospital thoracotomy ever necessary? A literature review

Emma Baker

The University of Bristol Medical School [e-mail]

 

Introduction: Pre-hospital resuscitative thoracotomy is performed in traumatic cardiac arrest due to cardiac tamponade and exsanguination, with the aim of maintaining cerebral and cardiac perfusion. Performing this procedure in the pre-hospital environment allows definitive treatment of time sensitive trauma injuries. In recent years the procedure has been incorporated into trauma algorithms, such as the Advanced Trauma Life Support guidelines.

Aims: To assess the necessity of the pre-hospital thoracotomy in the context of the attempt at survival it allows major trauma patients, balanced with the traumatic nature of the procedure itself.

Methods: A literature search was carried out on the Medline data base. Phrases searched for were: “prehospital” OR “pre-hospital” AND “thoracotomy”.

Results: Mechanism of injury, time to arrival of emergency medical services, signs of life on arrival of HEMS and age of patient are discussed as factors which may impact outcomes after resuscitative thoracotomy, therefore impacting it's necessity. Data on the impact of mechanism of injury on outcomes has varied conclusions. Some have found that blunt mechanisms of injury are associated with a reduced rate of survival to discharge compared to penetrating trauma. Others have found that the blunt cohort have superior outcomes. The nature of cardiac tamponade and exsanguination make them time sensitive. Longer time to arrival of HEMS on scene may be associated with increased mortality. Signs of life on arrival of HEMS are found to be a positive predictor of survival to discharge, with patients who have a witnessed arrest of a known cause having the best outcomes. Increasing patient age is shown to negatively impact outcomes, with patients over 60 being extremely unlikely to survive.

Conclusions: Age < 60, rapid access by HEMS and having signs of life on medical team arrival are positive predictors for resuscitative thoracotomy outcome. In these situations resuscitative thoracotomy is necessary. More data needs to be collected on if mechanism of injury impacts this, ensuring we are maximising the lifesaving impact of the procedure, whilst maintaining patient dignity.

Predicting blood transfusion following traumatic injury using machine learning models: A systematic review and narrative synthesis

W Oakley, S Tandle, M Marsden

University of London [e-mail]

 

Introduction: Haemorrhage is the leading cause of early preventable death after injury. Predicting the need for blood transfusion can be challenging. Blood transfusion prediction tools are not in widespread clinical use. Machine learning (ML) techniques have the potential to improve prediction.

Aims: This systematic review aimed to identify and critically evaluate all ML models that predict blood transfusion in trauma patients.

Methods: The systematic review was registered on PROSPERO (CRD42022371109). A search of MEDLINE, Embase and CENTRAL databases was completed to identify publications that describe ML models for blood transfusion prediction. Results were screened by two reviewers. Data were extracted from eligible publications using a published prediction modelling checklist. Risk of bias and model applicability was assessed using the Prediction model Risk Of Bias Assessment Tool. Data were synthesised using a narrative approach due to significant heterogeneity.

Results: The search identified 4602 results. Twenty two publications were included, in which 25 ML models were identified. The models varied in ML algorithm used, model predictors and predictive performance. The most frequently reported performance metric was area under the receiver operating characteristic curve (AUROC). Predictive performance was variable (AUROC 0.69–0.99) but 17 models predicted blood transfusion-related outcomes with excellent discrimination (AUROC > 0.80) in internal validation. Two models reported calibration metrics. Only four models have been externally validated in prospective cohorts: the Bleeding Risk Index, Compensatory Reserve Index, the Marsden model and the Mina model. These models predict blood transfusion-related outcomes with acceptable to excellent discrimination. All modelling studies were considered at high risk of bias due predominantly to retrospective datasets, small dataset size and lack of external validation.

Conclusions: High-performing and appropriately validated blood transfusion prediction models using ML have been reported and could lead to personalised, precision blood transfusion in injured patients. Further research is required to externally validate all ML models and integrate models into clinical systems.