London Trauma Conference 2013

Photo credit: Lee Parker

The seventh London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 10 December and 13 December 2013. Consisting of a main programme of presentations supplemented by breakaway sessions held parallel to the main conference, the speakers addressed a number of key questions in trauma and emergency medicine. The Journal of Paramedic Practice attended the London Cardiac Arrest Symposium held on 10 December, which returned for the second time following its success in 2012, and the Air Ambulance and Pre-hospital Care Day held on 12 December, which focused on some of the wider trauma issues faced in the pre-hospital setting.

London Cardiac Arrest Symposium

Dr Richard Lyon discussing the TOPCAT study. Photo Credit: Lee Parker

The conference kicked off with a discussion from Dr Richard Lyon on the TOPCAT study. Looking at the rationale behind the trial and some of the problems that arose, the interim results presented by Dr Lyon suggested a number of indicators for potential improvements in the management of pre-hospital cardiac arrest.

Prof Simon Redwood spoke on post-cardiac arrest syndrome, outlining its cause, how it should be treated and how it can be prevented. Prof Redwood emphasised the need to develop and adopt a systems approach to all events of pathophysiological processes.

Prof Tim Harris then gave a talk on the use of ultrasound (USS) in cardiac arrest. Considering whether USS can aid resuscitation, Prof Harris illustrated training requirements for its use and its potential application in the pre-hospital setting.

After the first coffee break, Prof Charles Deakin delivered a presentation on cardiogenic shock after return of spontaneous circulation (ROSC). The key elements of his talk looked at how cardiogenic shock should be treated pharmacologically, how it should be treated mechanically, and what treatments are on the horizon—suggestions he alluded to included synchronised pacing, therapeutic hypothermia, extrathoracic ventilation and gene therapy.

Prof Bryan McNally spoke on the Cardiac Arrest Registry to Enhance Survival (CARES), considering evidence for whether cardiac arrest registries improve survival and whether they should be implemented regionally, nationally or locally. He outlined how registries allow for communities to determine OHCA outcomes and identify risk groups and neighbourhoods, as well as enabling clinical benchmarking to identify opportunities and track the diffusion of new therapy.

Dr David Zideman delivers the Douglas Chamberlain Lecture on the challenges of providing field of play (FOP) medical care at the London Olympics. Photo Credit: Lee Parker

The Douglas Chamberlain Lecture was given by Dr David Zideman on the challenges of providing field of play (FOP) medical care at the London Olympics. Dr Zideman was the lead clinician for the emergency medical services at the London Organising Committee of the Olympic and Paralympic games. He outlined how FOP care is different depending on the sport and so knowledge, preparation and training was essential in providing the best care at London 2012.

Following lunch, Prof Karim Brohi discussed open chest cardiac massage. After alluding to the fact that external chest compressions have been around since the 1960s, Prof Brohi went on to question whether they are the best way to generate a cardiac output. In canine models, coronary perfusion pressure has been seen to be five times better with internal cardiac massage, although there are few studies showing the outcome in humans. Prof Brohi therefore questioned whether it is time to do a trial of open cardiac massage.

Dr David Menzies then spoke on community first responder schemes, considering challenges they face and their potential solutions. One of the predominant issues concerns the maintenance of skills and interest, especially as training is not always standardised. Given the high level of cardiac arrests that occur at home, the continued need for CFR schemes is evident.

After the afternoon coffee break, Dr Matt Thomas spoke on neuroprotective strategies for post-cardiac arrest syndrome. Dr Thomas highlighted the importance of controlled re-oxygenation as well as considering therapeutic hypothermia, a treatment that has received much debate recently. The main take home message from the talk was to not prognosticate too early, as improvements patients following OHCA can be seen as late as 72 hours.

Dr Eldar Soreide spoke on recent advances in improving OHCA in the Stavanger region of Norway. Dr Soreide mentioned how we are obsessed with medical breakthroughs rather than follow-throughs, and how focusing on bystanders can improve outcomes of OHCA.

Prof Daniel Davis gave the final talk of the day on what makes up a high-performing hospital team. Highlighting the work of the UC San Diego Center for Resuscitation Science, he emphasised the importance of advanced resuscitation training, inpatient/technology-specific algorithms and the need for an organised approach to data analysis.

Air Ambulance and Pre-hospital Care Day

The Air Ambulance and Pre-hospital Care Day, which was co-hosted by the Norwegian Air Ambulance Foundation, began with a talk from Prof Bryan McNally on US emergency medical services and bad weather. Prof McNally stressed the importance for health communities to be prepared for cases of extreme weather. By having a plan in advance, good decision-making can be enabled.

Dr Rasmus Hesselfeldt then spoke on introducing HEMS to a well-organised urban trauma system in Denmark and whether it has improved outcomes for patients. Hesselfeldt conducted an observational study looking at data five months before the trial and 12 months after. While the time to primary hospital didn’t see a notable improvement, time to trauma centre was significantly improved.

Prof Hans Morten Lossius speaking on physician-staffed pre-hospital critical care. Photo Credit: Lee Parker

Prof Hans Morten Lossius then gave a talk on physician-staffed pre-hospital critical care. Providing a defence of the need for pre-hospital physicians, he argued that it is a matter of competence not profession. This competence comes through adequate training and qualifications. However, he did stress that paramedics are the backbone of the pre-hospital team and that without them the system would fail.

Prof Daniel Davis gave a talk on the US experience of pre-hospital intubation by paramedics, which acted as a counter to Prof Lossius’ previous talk. Prof Davis argued that the question of pre-hospital intubation is one of training, and that confidence and competency comes through adequate practice, whether through simulation or carrying out the procedure on patients.

Dr Geir Arne Sunde then gave a talk on the results of the prospective observational HEMS study, AIRPORT. Conducted in six countries and involving 21 HEMS services, the findings indicated that intubation success rates are high (98%), with a complication rate of 10–12%.

Dr Matt Thomas spoke on the pre-hospital feasibility study REVIVE, which looked at airway management in OHCA, comparing the I-gel, LMA Supreme and standard care. The study assessed the feasibility of a prospective cluster randomised clinical trial, indicating that research in this area is possible.

Prof Wolfgang Voelckel gave the final talk before lunch on the role of video laryngoscopy in pre-hospital care. Comparing the different models of video laryngoscopes available, he concluded that video laryngoscopy is the future, but that training and skills are needed.

Following lunch, Dr Matt Thomas gave a talk on pre-hospital advanced cardiac care. Considering echocardiography, automated mechanical CPR devices, cooling and vasoactive drugs, Dr Thomas emphasised that the key to improving pre-hospital cardiac care lies in the aggregation of marginal gains.

Dr Erik Dietrichs then spoke on inotropic support during rewarming in the treatment of hypothermia. Dr Dietrichs highlighted that Milrinone and Levosimendan both have good effects on preventing rewarming shock.

After the afternoon coffee break, a number of rapid fire sessions were given, looking at a wide range of topics. Mr Jan Jansen spoke on pre-hospital amputation, providing indications and an outline of the procedure. He concluded that pre-hospital amputation is necessary. Dr Ross Davenport discussed the desirable kit to have on-board a helicopter to treat haemorrhage. Dr Nils Petter Oveland spoke on the feasibility of pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA). Showing the manikin he developed for REBOA training, his team were able to achieve an average skin to balloon time of 3.3 minutes. Mr Mark Wilson spoke on the need for a culture shift concerning fixed dilated pupils and how there is a low threshold for surgery in bilaterally fixed extradural haematoma. Chief pilot for the Norwegian Air Ambulance, Erik Normann, gave an inspirational talk on the steps taken to reduce the number of deaths of HEMS workers. Between 1988 and 1996, 13 people died, leading to concerns on whether the HEMS system could be continued, and if so, how it could be done safely. Improved training and the addition of night vision goggles and advanced maps has helped to make this possible. Dr Malcolm Russell spoke on the provision of medical care in the tactical environment, considering its viability. While there is no risk-free option,

Dr Russell emphasised the importance of knowing your plan and following it, and highlighted the benefit of having training as realistic as possible.

Prof Hans Morten Lossius gave the final rapid fire session on on-board CT scanners, illustrating how they are more cost-effective than stroke units.

The final talk of the day was given by Dr Gareth Grier and Mrs Marte Ramborg on balancing charity-PR against patient privacy in the hot zone. They emphasised the need for public exposure for funding but highlighted a number of the concerns involved, including whether care is compromised in patients who are filmed, the fact that many patients are not able to give consent to be filmed, and whether they should shoot first and ask later.

Although the Journal of Paramedic Practice was only able to attend a small portion of the London Trauma Conference, its breadth of speakers and level of detail make it an integral part of the calendar for any pre-hospital practitioner.

Taken from Journal of Paramedic Practice, published 10 January 2014.