1. Future developments in
Prehospital Trauma Care
Dr Peter Sherren
Anaesthesia and Intensive Care
The Royal London Hospital

2. Current challenges
• Rapidly evolving PHEM services in the UK
• Charitable funding
• Team consistency and skills variable
• Training for doctors variable
• 24/7 cover
• Appropriate tasking
• New procedures/solutions will not suit all services

3. • Quality services have great attention to
detail
• More important to do the simple things
well than exciting things badly
• First do no harm

4. Time to definitive
intervention is key

5. Can this intervention be
delivered effectively and safely
prehospital?

7. Airway control
• Airway compromise is a significant cause of
preventable deaths
• Hypoxia common on scene in trauma. Stochetti et al. J
Trauma 1997
• Hypoxia and hypercarbia associated with
increased morbidity and mortality in TBI. Sherren
PB et al. Curr Opin Anesthesiol 2012
• Endotracheal intubation is gold standard in
hospital
• Trauma has no respect for geography

8. How? - Intubation without drugs
or sedation only
• Successful ETI of trauma pts without
drugs ~ mortality 99.8%. Lockey D et al. BMJ 2001.
• Low success rates in patients with
reflexes intact (5-30%)
• ETI with sedation
• Still a low success rate
• ↑Secondary brain injury
• ↑Mortality

9. Success rates of pre-hospital RSI
• Physician/paramedic team
• 99.4% London HEMS (348/350) Mackay CA et al. Emerg Med J 2001
• 98.8% London HEMS (397/402) Harris T et al. Resuscitation 2010
• 99.5% GSA-HEMS (185/186) Bloomer R et al. Emerg Med J 2012
• 99.1% SAMU France (685/691) Adnet F et al. Ann Emerg Med 1998
• 100% Germany (342/342) Helm M et al. Br J Anaesth 2006
• Paramedic
• 97% MICA Victoria (152/157) Bernard SA et al. Ann Surg 2010
• 96% Auckland rescue helicopter (~280) Dr Tony Smith
• 86.7% San Diego (209/281) Davis DP et al. J Trauma 2003

10. Pre-hospital RSI has a place,
but who should be doing it?
↓
A TRAINED AND COMPETENT
TEAM

11. Physician-paramedic team
• Good medical
experience
• Anaesthetic
experience
• Doctor ≠ pre-hospital
RSI competent
• Additional pre-
hospital training
• Cost
• Availability

13. PRE-HOSPITAL RSI
↓
KEEP IT SIMPLE
↓
STANDARDISE PRACTICE
(equipment, techniques and drugs)
↓
AVOID HUMAN ERROR
↓
IMPROVE CRM

14. Standard Operating procedures

15. In hospital level of
monitoring and Kit dump

16. Challenge response checklist

17. Quality assurance and clinical
governance

18. Apnoeic Oxygenation +/-
PEEP valve

19. Drugs
Courtesy of Dr Cliff Reid

20. VS

22. Thoracic injuries
Needle thoracocentesis vs open thoracostomy

23. Thoracic injuries
Needle thoracocentesis vs open thoracostomy

25. Haemorrhage
• Focus on massive haemorrhage control early
• MARCH and C-ABCDE

26. Direct pressure
Elevation
Wound packing and splinting
Haemostatic agents
Tourniquet

27. Non-compressible
haemorrhage?
• Foley Catheter or X-stat syringe
• REBOA
• Abdominal tourniquets
• Suspended animation

28. Foley catheter

29. X-stat syringe

30. REBOA

31. REBOA Case
• 70 year old
• M - pedestrian vs lorry
• I – flail chest, Open Pelvic #, bilateral femoral #s,
degloving and multiple #s right leg
• S – RR 35, SpO2 not recording, HR 150, carotid
palpable
• T – RSI, bilateral thoracostomies, pelvic binder,
TXA, 4u PRBC -> CODE red and REBOA activation

32. REBOA Case
• 70 year old
• M - pedestrian vs lorry
• I – flail chest, Open Pelvic #, bilateral femoral #s,
degloving and multiple #s right leg
• S – RR 35, SpO2 not recording, HR 150, carotid
palpable
• T – RSI, bilateral thoracostomies, pelvic binder,
TXA, 4u PRBC -> CODE red and REBOA activation

33. REBOA Case
• 70 year old
• M - pedestrian vs lorry
• I – flail chest, Open Pelvic #, bilateral femoral #s,
degloving and multiple #s right leg
• S – RR 35, SpO2 not recording, HR 150, carotid
palpable
• T – RSI, bilateral thoracostomies, pelvic binder,
TXA, 4u PRBC -> CODE red and REBOA activation
• 6u PRBC/4u FFP in resus -> pH 6.8/lact 16
-> REBOA -> theatres
• Extraperitoneal packing/Ex fix pelvis/Left
AKA/Ex fix right femur and DCR -> ICU

34. PRBCx25, FFPx20, 3g TXA, Cyro/Platx3 pools, CaCL 4g,
1000ml CSL -> HAEMOSTASIS, no vasopressors, normal
BE/ROTEM and REBOA removed

35. Prehospital REBOA
• Training/competence
• High risk delaying scene time in an
exsanguinating patient for a procedure
that may fail
• Its coming….

36. Abdominal tourniquet
• The evaluation of an abdominal aortic tourniquet for
the control of pelvic and lower limb hemorrhage. Mil Med.
2013.
• Abdominal aortic tourniquet, Use in Afghanistan. J Spec Oper
Med. 2013

37. Suspended Animation

38. Damage Control Resuscitation
• 3 essential components:
1. Damage control surgery
2. Haemostatic resuscitation
3. Permissive hypotension
• DCR improves outcomes and mortality.
No level 1 evidence. Cotton BA et al Ann Surg 2011

39. Coagulopathy in trauma
• Medical
• Bleeding diathesis
• Anticoagulants
• Trauma induced
coagulopathy
• Acute traumatic
coagulopathy (↑TM/APC
→ ↓V/VIII, ↑fibrinolysis
and ↓fibrinogen)
• Acidaemia
• Dilutional
• Hypothermia

40. Haemostatic resuscitation
• Volume resuscitation that limits dilution and
ATTEMPTS to mitigate the effects ATC
• Minimise Crystalloid transfusion. NO COLLOID
• PRBC early
• FFP/clotting product
• Platelets
• Early cryoprecipitate
• Use of adjunctive therapies
• Tranexamic acid
• Calcium

41. Feasibility of Prehospital blood
transfusion – GSA HEMS experience
• Three HEMS bases
• Four operational rotary
wings
• ALL bases carry PRBCs
• 3-4 units depending on
base
• Sealed ‘Golden hour’
box
• Stable for 72 hrs
• Replaced and tracked
by local hospital

42. SOP and good clinical governance

43. Demographics of patients receiving a prehospital blood transfusion
Total (n = 147)
Male (%) 102 (69.3)
Age (years), median (IQR) 34.5 (22 to 52)
Mechanisms of injury (%)
Motor vehicle collision 87 (59.1)
Motor bike collision 20 (13.6)
Pedestrian versus car 9 (6.1)
Gunshot wound/stabbing 9 (6.1)
Fall from a height 5 (3.4)
Recreational 6 (4.1)
Other 11 (7.5)
Number of patients trapped on arrival (%) 45 (30.6)
Scene time (minutes), mean (SD) 49.9 (27.8)
Time from tasking to arrival at hospital
(minutes), mean (SD)
126.5 (51.3)
Heart rate, median (IQR) 115 (90 to 130)
Systolic blood pressure (mmHg), median
(IQR)
80 (65 to 105)
RTSo
2, median (IQR) 5.967 (4.083 to 6.904)
Total number of PRBC units transfused 382
Total number of PRBC units wasted 66
Volume of crystalloid (ml), median (IQR) 500 (0 to 1,500)
Pronounced life extinct on scene 22 (15.0)
Sherren PB et al, Critical Care 2013 17(Suppl 2):P295

44. Tranexamic acid

45. FFP vs FDP vs PCC
PCC in non-warfarin patients
Joseph B et al, J Trauma Acute Care Surg 2012 & Schochl H et al, Crit Care 2011

46. Fibrinogen
• CYROSTAT – Early cyroprecipitate associated
with improved mortality signal,14% vs 32%.
Personal correspondence with Prof K Brohi, pilot study, unpublished, ITT only.
• FCC over cryoprecipitate? Schochl H et al, Crit Care 2010
and 2011

47. Permissive hypotension
• Titrated volume resuscitation to maintain organ
viability and not normality until haemorrhage is
controlled
• First clot is often the best = preserve it
• Aggressive early fluid resuscitation in penetrating
trauma with uncontrolled bleeding may be detrimental,
Bickell WH N Engl J Med 1994.
• Poor evidence to inform resuscitation strategies in
blunt trauma with uncontrolled bleeding
• The evidence for maintaining CPP in head injuries is
much stronger

48. Other possible innovations in
DCR
• Novel hybrid resuscitation strategies Doran
CM et al, J Trauma Acute Care Surg 2012
• High flow/low pressure resuscitation –
endothelial resuscitation and
microvascular washout. Richard Dutton

49. Ultrasound

50. Straight to theatres
Code red
• E-FAST +ve
• Exsanguinating limb/junctional trauma
• Penetrating trauma

51. Sherren PB et al. Crit Care 2013

53. TBI
• Good ABC management
• TXA and Crash 3
• Progesterone Ma J et al, Cochrane Database Syst Rev
2012

54. Straight to CT
• Needed?
• Improve trauma patient flow or
bring CT into resus

55. Summary
• Need to ensure 24/7 cover with
appropriately trained critical care teams
• Attention to detail is everything
• High end innovations must not distract
from doing the basics well

56. Questions?