So here we are in Chicago with the biggest FOAM if not EM-Critical Care conference on the planet this year!! Here’s a whistle stop tour of some of the sessions from the first day at the conference, which followed the dramatic opening ceremony and I’ll just cover the major take home messages from each session………
Cliff Reid’s opening lecture, ‘Advice to a young resuscitations’ not only gave advice on the placement of a whoopee cushion on ward rounds under your consultants behind but the journey through confidence, competence and the following key bits of advice;
- The importance of following patients up and reviewing your care and outcomes’.
- When something goes wrong you need to learn from it and change something.
- ‘No one cares how much you know until they know how much you care.’ quote from Greg Henry
- Choose your colleagues and workplace wisely
- Maintain a perspective, don’t just make a difference when you’re there but change systems and influence practice in ways that will last when you’re not there (e.g. governance and audit)
- Behave as you want to be remembered and remember the ripples you create in the pond
John Hinds was next up with ‘Crack the chest, get crucified.’ First of all, before performing such an invasive treatment such as thoracotomy think ‘Are my intentions honourable and am I doing this for the right reasons?’ Look out for different opinions and understand skewed views, beware of the hype surrounding thoracotomy and inappropriate sensationalisation and that most difficult part of a thoracotomy is not performing it but dealing with opinions and strong opinions afterwards. The importance of having grab trays for emergency procedures both in theatre and ED. Share your mental model in times of stress and in cases such as thoracotomy. In summing up for thoracotomy;
- Prepare for this
- Make your intentions honourable
- Do it when it’s indicated (don’t commit errors of omission)
- Seek out the skeptics
- Never allow a w*nker to bring you down!
Then Scott Weingart on ‘The Resuscitationist Mindset; bread baking and ooda loops‘
What was most appropriate for a resusciationist, system 1 or system 2 thinking? Experts look for the right things in a system 1 approach because they know to look for it, ATLS uses a relatively slow system 2 model and formulaic approach. Scott spoke on the importance of mental readiness. Think about patterns of presentations and response to treatment e.g penetrating chest trauma, blunt ado trauma, pelvic injury…. prepare mentally for these and be ready for a rapid response in the trauma room.
When you don’t know what’s going on flip from reactive system 1 thinking to methodological system 2 thinking. Resuscitation is a game that should be played by experts and experts should be system 1 thinkers.
Not least Scott demonstrated how to command a stage whilst your powerpoint slides go off in a seizure of auto timing and still delivered a superb talk.
Liz Crowe ‘Why Critical Care Doctors Should not Challenge Religion‘. She talked about the irony of our open minds to performing ridiculous procedures such as thoracotomy but we seem so anti thinking about god or spirituality except in a crisis and spoke about our ‘Crisis Orientated Faith’ and only embracing faith when things are going catastrophically wrong.
If we ignore patients belief we are potentially ignoring an intervention that could help that patient during their care. Maybe it’s time to change by using the AMEN theory
Scott Weingart came back for his second talk with ‘Critical Care in the Trauma Bay‘. He presented a case and stressed the importance of not being falsely reassured by a lack of a tachycardia in sick trauma patients. He also talked about ignoring intial BPs when normal and keeping a very close eye on the subsequent readings over the next few minutes. You may then be wondering what you can trust and Scott’s answer to this was the importance of ETCO2 in reflecting not only your respiratory function but also significance of a low ETCO2 as a reflection of hypo perfusion.
He ran through a his system for assessment of the sick trauma patient following strong FOAM themes of haemostatic resuscitation, 1:1:1 ratio of blood products following the recent PROPPR trial and the importance of arterial lines to get accurate blood pressure measurements. Scott did emphasise that a MAP may reflect many intravascular states. Finally he emphasised that we should not have to choose between IR and the OR, they need to be collocated.
Karim Brohi talked about ‘Tranexamic Acid in Trauma‘. TXA has an NNT of 125 to save a life and this will cost about £3000, current studies looking at populations with a higher baseline mortality rate are showing much smaller NNTs as low as 5! It was a tongue and cheek talk which challenged dogma and arguments against the evidence for TXA including the relative underuse of TXA in the states asking if that is because Americans are different?? Karim hammered home the message, lets make sure we’re giving TXA when indicated in trauma.
Anders Perner spoke about ‘When to Pull the Transfusion Trigger (in patients not actively bleeding)?’ and covered the TRISS trial, showing no difference in ICU mortality when using a transfusion trigger in sepsis between 7g/dl and 9g/dl. He also spoke about the possibility of 7g/dl becoming the new normal for a transfusion threshold including those with IHD.
‘How to Stop Bleeding Without a Hospital‘ by Howie Mell concluded the mornings sessions. Howie dispelled myths such as-using a tourniquet will definitely result in amputation of that limb.
After lunch Karim Brohi was up again talking about ‘Genomic Storms and Butterfly Wings‘. He started off reminding us that half of all deaths following trauma occur after the first 24 hours. Karim spoke about the common perception that multi organ failure following trauma is attributed to too greater inflammatory response but that trials have never shown benefit from anti inflammatories such as steroids. Karim spoke about the genomic storm that trauma patients experience that are not truly understood but in which 80% of the entire genome are activated. The analogy of the butterfly wings come from the analogy of a small beating of butterfly wings (a tiny event) very early in the timeline of trauma sets a cascade of genomic activation. In future we should be able to target these butterfly wing episodes to benefit patient outcomes?
Deborah Stein on ‘REBOA: Who, What and Why?’ Haemorrhage is the leading cause of death in trauma which can actually be reversed. Non compressible bleeding accounts for 85% of preventable deaths which includes bleeding into the abdomen and torso but these are extremely difficult to get to theatre in for resuscitative treatment in time.
Why not perform an ED thoracotomy? Well that’s giving the patient a massive 2nd major trauma!
The algorithm for REBOA at Baltimore Shock Trauma was presented as an option for treatment; A practical tip of placing a right femoral arterial line in trauma that can then be converted easily to REBOA if needed was highlighted and then a fantastic case that arrested, had conversion and then survived to hospital discharge, superb stuff!
Case reports of the usage of REBOA on non trauma patients were also highlighted. John Hinds came back with more ‘Cases From the Races‘ and gave some great examples of cases he’s been involved in and highlighted the importance of mechanism in the likelihood of significant injury. He gave some fantastic examples of great PHEM and some amazing outcomes, look out for this podcast release, it’ll be a great SMACC episode!
Michael Mc Gonigals ‘Paediatric Pitfalls in Trauma‘.
- Don’t waste radiation, set up radiological guidelines that are evidenced based
- Transfer your patients promptly
- Choose the right trauma centre
- Ensure radiology line between departments are setup and streamlined
- Treat them like adults, sometimes…….
- Do a complete exam
- Know where your paediatric resuscitation kit is
- Don’t scare the child
- Watch the fluids
- Watch the meds
- Add a paediatric intensivist to the trauma team
- Don’t forget the parents
- Always consider child abuse
The day finished with an expert panel on ‘Sepsis‘. The array of experts led to some really controversial statements on the the concern over protocolised care stating ‘algorithms make stupid people stupider and smart people stupid’! The importance of treating the patient infront of you and reacting to them and their needs should be the main goal.
It’s fair to say the panel challenged commonly held belief and each other and one thing about the future of sepsis was clear – it’s set to evolve not only diagnostically but prognostically and its therapy.
Can’t wait to see what day 2 will hold…..