Category Archives: LIVES Forum 2016 – PORTO

Day 3: Outcomes



The immunologic response to severe trauma (Jean-Daniel Chiche)

Inflammation is part of the immune response to trauma and its mechanisms are very similar to that for other causes of inflammation

The systemic immune response to trauma: an overview of pathophysiology and treatment –

The danger model: a renewed sense of self –

Trauma alarmins as activators of damage-induced inflammation –

A genomic storm in critically injured humans –

The difference in individual immunogenomics may explain some of the difference in pt outcomes to same injury.

Uncontrolled systemic inflammation causes MOF


When is the right time to go back to the OR for secondary surgeries? (Luke Leenen)

A second hit from secondary surgeries is evident but the clinical implications of timing of secondary operations however is undetermined.

When should we go back to the OR?

  • As soon as possible
  • Hemodynamically stable
  • Respiration not deteriorating
  • Temperature controlled
  • Coagulation corrected

Doing too much, too early will cause problems for the pt

Therapy will be adapted to the individual immune response of the patient.

New techniques being developed based on neutrophil capabilities to evaluate immunological competence.

Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group.

Antibiotic prophylaxis and infectious complications (José Artur Paiva)

Antibiotics are important but is only one element in the management of infection in the trauma pt

Judicious use of antibiotics with stewardship programme is needed

Trauma leads to

  • bacterial burden
  • broken physical barriers (as does ICU)
  • immunosuppression

The collateral damage of antimicrobial resistance is very seldom considered both clinically and in research

Antibiotic prophylaxis would ideally be at the time of innoculation i.e. at time of trauma but what is the second best thing to do?

Most important action is to reduce bacterial burden by wound debridement and disinfection

antibiotic choice is balance between efficacy and limiting collateral damage

Speakers review of literature

  • Basilar skull fractures do not require antimicrobial prophylaxis (even if there is CSF leak)
  • No role of abx for facial fractures except mandibular fracture
  • Short courses of antibiotics (24hrs) for penetrating abdominal trauma
  • Single dose antibiotic for closed fracture repair
  • For open fracture, there are conflicting recommendations – short course (24hrs) of 1st generation cephalosporins combined with prompt wound management as long course (5 days). Bacterial pathogens have changed over time from gram positive to mostly gram negative.

Localised therapy may be the answer compared to systemic administration.

Emergence of Imipenem-Resistant Gram-Negative Bacilli in Intestinal Flora of Intensive Care Patients

Prophylactic antibiotics for penetrating abdominal trauma

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

Systematic review and meta-analysis of the additional benefit of local prophylactic antibiotic therapy for infection rates in open tibia fractures treated with intramedullary nailing

Post traumatic thromboembolism: Risk factors and prevention (Dietmar Fries)

80% of lethal PE have no previous clinical signs (Epidemiology and risk factors for venous thrombosis)

Frequency of DVT in trauma pts with no prophylaxis is between 40-80%

Monitoring using traditional coagulation test e.g. PT, APTT are useless to help decide timing of DVT prophylaxis (do not present the balance between pro and anti-coagulatory system)

TEG detected hypercoagulable state which was not proved by plasma PT or APTT

Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time

Study – Comparison of low dose heparin and LMWH heparin in trauma pts

Study – Dalteparin vs enoxaparin for VTE prophylaxis in acute spinal cord injury and major orthopaedic trauma: DETECT trial

Heparin resistance is an underestimated problem

No IVC filter!

Start mechanical devices ASAP


The elderly trauma patient (Rui Paulo Moreno)

70% of falls in elderly pts occur whilst they are attempting to perform activities of daily living

Following a single fall, 65% will fall again with significant injury

Increased risk of dementia in pts with TBI


  • Preventive measures
  • Screen for history of brain injury
  • Strategies to support e.g. memory and orientation checklist
  • Resource and referral as rehabilitation works


Caring for the burn patient during the first 24 hours (Matthieu Legrand)

Caution with concomitant alcohol intoxication, poisoning (e.g. cyanide) and inhalation injury

Management of cyanide poisoning (review)

Burns to the face is not an indication for tracheal intubation in itself but may become difficult if it is required later

Legrand uses balance solution e.g. Ringers Lactate. Amount – Parklands formula (rough estimate)

Burn injury is a changing haemodynamic profile: early low output, high resistance state to high flow, low resistance state. Hence, haemodynamic monitoring recommended.

Systemic and pulmonary hemodynamic changes accompanying thermal injury.

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study

Prevent hypothermia.

Risk factors for hypothermia in EMS-treated burn patients.

Consider escharotomies (chest and limbs) actively. If limb pressures > 30mmHG = escharotomy

Ten tips for managing critically ill burn patients: follow the RASTAFARI!



Prognostication in traumatic brain and spinal cord injury (Geert Meyfroidt)


Clinical predictors of recovery after blunt spinal cord trauma: systematic review.

MRI most important prognostic tool in traumatic SCI (

3 possible patterns for SCI

  • haemorrhage of cord
  • oedema of the cord
  • combination

Early prognosis in traumatic brain injury: from prophecies to predictions.


CRASH Head Injury Prognost

Determination of neurologic prognosis and clinical decision making in adult patients with severe traumatic brain injury: a survey of Canadian intensivists, neurosurgeons, and neurologists

Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too?

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication,

Novel methods to predict increased intracranial pressure during intensive care and long-term neurologic outcome after traumatic brain injury: development and validation in a multicenter dataset

Psychosocial, and Ethical Management : A Position Statement for Healthcare Professionals from the Neurocritical Care Society


Long-term outcome of traumatic brain injury and severe trauma (Rui Paulo Moreno)

Mortality after hospital discharge following trauma mirrors that of the general public.


  • Mortality causes
    • Week 1: 90% due to direct infarct
    • Week 2-4: PE
    • Week 8-12: Infection
  • Importance of secondary prevention


  • Increased risk of seizures
  • Association with Alzheimers dementia and Parkinsons (especially moderate-severe TBI)
  • Other associations – dementia purgulistica, MS

Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage.

  • 2/3 survivors regain functional independence but half have cognitive impairment
  • 1/3 will resume the same work as before

Ethical considerations in neurotrauma patients (Paulo Maia)

Prospective important – balance of expectations and reality

Attitudes of European physicians, nurses, patients, and families regarding end-of-life decisions: the ETHICATT study

Dying with dignity on the ICU –

UK Code of practice and diagnosis of death


Early rehabilitation: What can we do in the ICU? (Matthieu Legrand)

Functional disability after ICU is common

  • physical weakness
  • cognitive impairment

Barriers – CVS instability and deep sedation

Systematic review of early exercise in intensive care: A qualitative approach

Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany

The power of the mind: the cortex as a critical determinant of muscle strength/weakness

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit.

Comfort and patient-centred care without excessive sedation: the eCASH concept


Post Traumatic Stress Disorder syndrome prevention: ICU strategies for prevention (Diederik van Dijk)

How to measure PTSD?

  • Goal standard – psychiatric interview
  • Questionnaires

Prevalence varies depending on tool but approximately 20% (5-63%)

PTSD in critical illness survivors

Medications to prevent post-traumatic stress disorder (PTSD): a review of the evidence

Risk factors

  • female gender
  • younger age
  • pre-existing psych illness

Prevention of PTSD

Treatment of PTSD

  • ICU diary
  • ICU follow-up clinic DID NOT help with PTSD
  • Self-help rehabilitation manual
  • Eye Movement Desensitisation and Reprocessing (EMDR)

There is some evidence that steroids may prevent occurrence and aid in treatment of PTSD- Medications to prevent post-traumatic stress disorder (PTSD): a review of the evidence

This was not shown in this study- The Effect of Dexamethasone on Symptoms of Posttraumatic Stress Disorder and Depression After Cardiac Surgery and Intensive Care Admission: Longitudinal Follow-Up of a Randomized Controlled Trial.

That is all we have. Hope you have enjoyed and found the signposts useful. @avkwong and @drjimday

Day 2: Haemorrhage/ICU



Haemorrhage control: When to go to the operation room? (Luke Leenen)

Trauma is dynamic and constant evaluation with decision-making are the norms. You need to check, check and check the patient again.

Physiology is key. Imaging only aids this.

The role of damage control surgery is NOT to restore anatomy.

Phase 1 – damage control (abbreviated surgery), life saving only. Control haemorrhage/contamination, pack, temporary closure. Physiology leads the decision making in theatre.

Phase 2 – restoration of physiology on ICU; temperature, acidosis, coagulopathy

Phase 3 – definitive surgery. When not to go when hypothermic and uncorrected coagulopathy.

Phase 4 – reconstructive surgery (can be months later)


The Impact of an Intensivist-Model ICU on Trauma-Related Mortality

“It’s Parallel Universes”: An Analysis of Communication Between Surgeons and Intensivists.


Haemorrhage control: When to go to the angiography suite? (Sophie Hamada)

The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations).

Damage control radiology –

Embolization for multicompartmental bleeding in patients in hemodynamically unstable condition: prognostic factors and outcome.

Management of penetrating trauma (Pierre Carli)

MARCHE – Massive bleeding control, airway, respiration, circulation, head, evacuation

Triad of death – coagulopathy, acidosis and hypothermia

Damage control resuscitation –…

Practical translation of hemorrhage control techniques to the civilian trauma scene.

Transfusion strategies in severe trauma (Anne Weaver)

Bart’s and the London NHS Trust (Home of London Air Ambulance) Trauma Transfusion Protocols:

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These are the a selection of papers of trials/studies that have guided current practice and some more underway to guide future therapies.

The pathophysiology of trauma-induced coagulopathy.

Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma: The PROPPR Randomized Clinical Trial

Karim Brohi on TXA –

Early fibrinogen trial –

RePHILL (Resuscitation with Pre-Hospital Blood Products)

CRYOSTAT: A feasibility study for a multicentre, randomised controlled trial evaluating the effects of early administration of cryoprecipitate in major traumatic haemorrhage

iTACTIC – RCT looking at viscoelastic haemostats assays versus empiric transfusion protocols

Stopping trauma-induced coagulopathy (Dietmar Fries)

Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes.

FINTIC trial- Fibrinogen Concentrate (FGTW) in Trauma Patients, Presumed to Bleed (FI in TIC)


Haemorrhage associated with direct/novel oral anticoagulants (Giuseppe Citero)

There is very little published data and working clinical knowledge of NOACs in trauma

Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Reversal of anticoagulants: an overview of current developments

Management of direct oral anticoagulants-associated bleeding in the trauma patient.



Radiology quiz (Sophie Hamada)

Transcranial Doppler after traumatic brain injury: is there a role?

Transcranial Doppler pulsatility index: what it is and what it isn’t –

U/S of ONSD for detection of raised intracranial pressure: a systematic review and meta-analysis –

The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis –


Severe traumatic brain injury (Giuseppe Citerio)

The GCS is still being used to classify TBI BUT it is a very heterogenous group of conditions. Reducing GCS at scene correlates very well with mortality

TBI severity ratio of hospitalised pts is changing – 90% are mild

Causes of TBI have also changed – rising car crashes in Asia and India. UK/US/Australia has reducing numbers of car crashes causing TBI and falls increasing numbers.

Older pts being admitted – changing TBI population median age has increased by a decade in last 10-15 years.


Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM –

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care –

Spinal cord injury (Geert Meyfroidt)

Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*

Early versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) –

Cochrane review – Steroids for acute spinal cord injury


  • Early surgery and decompression
  • Steroids not recommended original trials flawed (NASCIS 2 and 3 trials)
  • Supportive therapy according to level



Severe chest trauma (John Laffey)

ANZCOR Guideline 11.10.1 Management of Cardiac Arrest due to Trauma

Surgical intervention rarely needed in chest trauma (besides chest tube)

Role of surgical fixation for flail segments – poor evidence

Pulmonary contusion – common

Indication to fix ribs is uncertain unless thoracotomy for other reasons.

RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, RF, & trachy –

NIV may have a role but only used in 5% of patients- Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review

ECMO in trauma patients (Dirk Donker)

First survivor of VA ECMO was in 1972 and was a trauma patient.

Traumatic lung injury treated by extracorporeal membrane oxygenation (ECMO) –

Prevalence of Venous Thrombosis Following Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Respiratory Failure –

Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury –

Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study –


  • Feasible
  • Limited heparinisation is relatively safe (not a big problem in the first week)
  • Evidence is scarce
  • Respiratory failure in trauma is different from non-trauma
  • ECMO in trauma is challenging and complex, patients are complex



Managing combined injuries (Luciano Gattinoni)

Acute brain and lung injuries – contrasting needs. Trying to balance O2, CO2, TV, fluids etc

If lungs are very compliant, ventilation is not going to be a problem.

Alternatives strategies

  • Intracheal gas insufflation
  • High frequency oscillation
  • VV extracorporeal CO2 removal

High Pleural pressure and PCO2 strategies

  • Protective lung ventilation
  • Prone (care with position of the head)
  • Abdominal pressure considerations

Intra-abdominal pressure may be decreased non-invasively by continuous negative extra-abdominal pressure (NEXAP).

Effects of continuous negative extra-abdominal pressure on cardiorespiratory function during abdominal hypertension: an experimental study

Conservative management of abdominal trauma (Luke Leenen)

Non-operative management of abdominal trauma is increasingly utilised. Non operative management of liver trauma was routinely used from the 1980s

Puritanism/Free air/Abdominal gunshot still reasons to go to OR.

Abdominal trauma can result in bleeding but also CONTAMINATION

Increase in non operative management goes hand in hand with improvements in imaging

Sonography as the primary screening method in evaluating blunt abdominal trauma –

Multiplicity of Solid Organ Injury: Influence on Management and Outcomes after Blunt Abdominal Trauma

Delayed splenic rupture – no evidence for bedrest. Success of non operative management is not predicted by grade of injury or size of haematoma.

Nonoperative management of blunt splenic injury: what is new?

Prospective trial of angiography and embolization for all grade III to V blunt splenic injuries: nonoperative management success rate is significantly improved.

Observation Versus Embolization in Patients with Blunt Splenic Injury After Trauma: A Propensity Score Analysis.

Adjuncts to non-operative management

  • embolisations
  • ERCP
  • Laparoscopy
  • CT guided drainage

Pitfalls are small bowel, pancreas and diaphragmatic injuries not readily seen on CT.

Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center


Compartment syndromes (Jacques Duranteau)

Abdominal and compartment syndrome of the extremitis requires timely diagnosis

Primary abdo compartment syndrome develops in patients with abdominal injuries.

Secondary abdo compartment syndrome develops in pts needing large volumes of transfusion/fluids for other injuries

Abdominal Compartment Syndrome: pathophysiology and definitions –

Postinjury abdominal compartment syndrome: from recognition to prevention

Secondary abdominal compartment syndrome after severe extremity injury: are early, aggressive fluid resuscitation strategies to blame? –


Diagnosis and treatment of acute extremity compartment syndrome –…


Prehospital/ED – Porto Conference



Reminder of all the terrorist attacks this year and last – Paris, Brussels

Improvement of trauma care has never been more important



The epidemiology of trauma (Sebastian Kuhn)

Accidents happen anywhere, anytime and can affect everyone
WHO Global Health Estimates 2014 –

Trauma = cancer + heart disease + HIV

Prevention e.g. education and Design e.g. airbags have reduced deaths on the road

Trauma registry – information about status quo and help to improve efficiency and quality of care

Trauma registry e.g. EuroTARN (

  • Function
    • system for performance improvement
    • quality control queries
    • monitor trauma system trends
    • supply benchmarking data
  • Reports:
    • Comprehensive quality report once a year
    • up-to-date quality report online
  • Content:
    • Descriptive data
    • Comparative report on hospital mortality/outcome data

How to improve

  • Structural guideline
  • Treatment guideline
  • Trauma network
  • Trauma registry


The essence of pre-hospital trauma care (Luis Meira)

Trimodal to bimodal distribution of death in trauma (Golden hour to platinum ten)

Not everything can be done pre-hospital

What is essence of trauma?

  • Management of the scene?
  • Management of airway and ventilation?
  • Management of circulation?

“It is the art of managing priorities”

Traumatic cardiac arrest: Unsurvivable? (Anne Weaver)

Clearly it is survivable.

Common cause of traumatic cardiac arrest (pic)

  • unsalvageable haemorrhage
  • hypoxia
  • hypovolaemia
  • cardiac tamponade
  • tension pneumothorax
  • medical

BUT outcomes poor: 0-3% survival (depending on criteria)

Who survives?


Resuscitative thorocotomy –

Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) –


Securing the airway and anaesthetising the unstable trauma patient (Martin Dünser)

The indications for securing the airway in trauma pt are numerous but haemodynamic instability (potential) underlies all of them.

RSI in theatre vs trauma (v different priorities)



Process of key (pic)


Shock values –


3 tips peri-intubation

  • Arterial line
  • Pre-emptive use of vasopressor
  • Start with moderate minute volume



The role of sonography (Daniel De Backer)

Sonography and CT complement each other

Leading causes of haemorrhage chock – spleen/liver, retroperitoneal, haemothorax, multiple fractures, wounds

Role of ultrasound in trauma

  • detection of free abdo fluid
  • detection of haemothorax/pneumothorax
  • detection of cardiac tamponade

US faster than CT and detects significant alterations BUT solid organ lesions and retroperitoneal bleeding may be missed.

FAST scan in trauma –



CT-scan: When and for whom? (Marc Leone)

Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims.

Vittel criteria for severe trauma triage: Characteristics of over-triage

Incidental findings on whole-body trauma computed tomography: Experience at a major trauma centre

Whole-Body CT in Haemodynamically Unstable Severely Injured Patients – A Retrospective, Multicentre Study



Who needs damage control resuscitation? (Jacques Duranteau)

Only interventions to control haemorrhage and focus on re-establishing survival physiological status


The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition…

Norepinephrine Decreases Fluid Requirements and Blood Loss While Preserving Intestinal Villi Microcirculation during Fluid Resuscitation of Uncontrolled Hemorrhagic Shock in Mice

Give transexamic acid (1gm) within 3 hours of injury

Screen Shot 2016-04-28 at 20.07.24

Early shock resuscitation: Fluids and/or vasopressors (Dirk Donker)

Trauma pts have the potential to have all 4 forms of shock – hypovolaemic, distributive, cardiogenic and obstructive.

Utility of the shock index in predicting mortality in traumatically injured patients

A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial

A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters