International Trauma Anesthesia and Critical Care Society (ITACCS). NA Stavanger, Norway. May 23–25, 2002.
The 15th Annual Trauma Anesthesia and Critical Care Symposium was attended by 1,100 delegates from 43 countries. The theme, “Trauma Chain of Survival,” provided continuity to the lectures and workshops.
A preconference session focused on the role of trauma registries in improving patient care and survival. Speaking from the public health perspective, Howard R. Champion, F.R.C.S., F.A.C.S. (Professor of Surgery and Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA), suggested that injury caused by violence (interpersonal, self-inflicted, and war) is the most significant public health challenge of the 21st century. Petter Andreas Steen, M.D., Ph.D. (Division of Surgery, Ulleval University Hospital, Oslo, Norway), reviewed “Recommendations for uniform reporting of data following major trauma—the Utstein style,” developed by the International Trauma Anesthesia and Critical Care Society in 1999. 1Thomas A. Genarelli, M.D., F.A.C.S. (Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA), discussed difficulties with current injury severity scoring systems and presented suggestions toward an update of the Abbreviated Injury Scale. 2
In the opening plenary, Peter A. Oakley, M.A., F.R.C.A., M.R.C.G.P. (Consultant in Anaesthesia and Trauma, North Staffordshire Hospital, Stoke-on-Trent, UK), noted that the trauma chain of survival has shifted over the past 30 yr from survival to rehabilitation. C. William Schwab, M.D. (Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA), described the clinical challenges presented by the exsanguinating patient. Kerstin Sluys, R.N. (Clinic of Surgery, Karolinska Hospital, Stockholm, Sweden), introduced the Swedish Association of Trauma Nurses. Defining “extreme conditions” as lack of access to medical care, Mads Gilbert, M.D. (Anestesiavdelingen, Regionsykehuset i Tromsø, University Hospital of North Norway, Tromsø, Norway), related his experiences in impoverished areas, where medics have been trained in trauma care protocols developed in the northern hemisphere but with adaptations allowing realistic applications in remote communities.
In the session on patient safety, Paul R. Barach, M.D., M.P.H. (Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA), cited medical safety as an ethical imperative. With recent studies revealing thousands of preventable errors in US hospitals, studies of human errors will move health care from error counting to harm prevention. Peter A. Oakley, M.A., F.R.C.A., M.R.C.G.P. (Consultant in Anaesthesia and Trauma, North Staffordshire Hospital, Stoke-on-Trent, UK), emphasized the importance of communication in effective trauma team leadership, warning that arrogant leaders “fly into mountain sides.” Daniel Scheidegger, M.D. (Department of Anaesthesia, University of Basel, Kantonsspital, Basel, Switzerland), presented an insightful critique of the teaching of trauma care, emphasizing the need for standardized briefing when patients are transferred from one phase of care to another. Noting variations in the use of animal models and cadavers in medical training, Jerry P. Nolan, M.B., Ch.B., F.F.A.R.C.S. (Department of Anaesthesia, Royal United Hospital, Bath, UK), observed that ethical issues are leading to the use of manikins and simulation in many medical schools. Guttorm Brattebø, M.D. (Haukeland University Hospital, Bergen, Norway), described a medical simulation project in which trauma teams critique videotapes of their performance and work together to identify and implement changes.
Introducing the pain management session, Per E. Haavik, M.D. (Department of Anesthesia and Intensive Care, Rogaland Central Hospital, Stavanger, Norway), noted that articles abound on alleviation of postoperative pain, but little has been published about the management of pain after trauma. Studies are underway in the prehospital and in-hospital phases of care. Peter A. Driscoll, B.S.C., M.B., Ch.B., F.R.C.S., F.A.A.E.M. (Emergency Department, Hope Hospital, Salford, UK), stressed that analgesia must be maintained until the source of pain is identified and removed. Asgeir Kvam (Seksjonsoverlege, AMK, Ullevål Sykehus, Kirkeveien, Oslo, Norway) advocated a prehospital approach employing few protocols and one analgesic (morphine). A pain management technique used successfully by prehospital care providers in Vienna is acupressure, as described by Alexander Kober, M.D. (Research Institute of the Vienna Red Cross, Vienna, Austria). Johan Ræder, M.D. (Department of Anesthesiology, Ullevaal Hospital, Oslo, Norway), rated various anesthetics according to their effects on parameters such as ease of emergence, suppression of respiratory function, and avoidance of nausea and vomiting. Anthony H. Dickenson, M.D. (Department of Pharmacology, University College, London, UK), reviewed new agents developed for pain treatment (e.g. , opioids, cyclooxygenase-2 inhibitors, and antiepileptic drugs). The role of epidural analgesia was explored by Narinder Rawal, M.D., Ph.D. (Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden), and the importance of aggressive pain control after burns was discussed by Sam R. Sharar, M.D. (Department of Anesthesiology, University of Washington School of Medicine and Harborview Medical Center, Seattle, Washington, USA). Strategies for preventing posttraumatic chronic pain were reviewed by Audun Stubhaug, M.D. (Department of Anaesthesiology, Rikshospitalet, University Hospital, Oslo, Norway).
Advantages of the Advanced Trauma Life Support and Prehospital Trauma Life Support protocols were debated in a session titled “American Imperialism or the Road to Improved Outcome?” Carl L. Gwinnutt, M.B., F.R.C.A. (Department of Anaesthesia, Hope Hospital, Salford, UK), described the American College of Surgeons’ domination of the Advanced Trauma Life Support system by “encouraging dependence” (allowing its use, after purchase, only with an American College of Surgeons–approved course). Claus Falck Larsen, M.D., Ph.D. (Copenhagen University Hospital, Trauma Center, Copenhagen, Denmark), stated that Advanced Trauma Life Support provides consistency and has changed the way trauma care is managed. The consensus among participants was that Advanced Trauma Life Support provides a framework on which hospitals in different nations can build and tailor their own approaches.
During the intensive care in trauma session, Lars Heslet, M.D. (Intensive Care Unit, Rigshopitalet, University of Copenhagen, Copenhagen, Denmark), reviewed the pathophysiology of sepsis and suggested methods to decrease infection in trauma patients. The use of prophylactic oral antibiotic paste has decreased the incidence of pneumonia and subsequent mortality in intubated patients. Early short-term (< 48 h) antibiotic therapy targeted to the organ of injury has decreased the incidence of infection. Both sepsis and the adult respiratory distress syndrome (ARDS) have been linked to the number of units of blood products transfused. Pedro Navarrete-Navarro, M.D. (Critical Care and Emergency Department, Virgen de las Nieves University Hospital, Granada, Spain), reviewed risk factors for ARDS in trauma patients. His research uncovered a 10% decrease in mortality from ARDS over the past decade secondary to advanced interventions and treatment modalities (improved mechanical ventilation strategies, pulmonary toilet, prone-positioning therapy, and extracorporeal support). In a discussion of ventilatory strategies for patients with lung injury or ARDS, Walter Mauritz, M.D., Ph.D. (Department of Anesthesia and Critical Care Medicine, Trauma Hospital “Lorenz Boehler,” Vienna, Austria), noted that only a few interventions have improved outcome in this patient population: small tidal volume ventilation, intermittent prone positioning in the most critically ill, steroids late in the course of ARDS, and extracorporeal support for those with severe ARDS. Surfactant, partial-liquid ventilation, and high-frequency ventilation have not improved outcome. Maureen McCunn, M.D. (Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA), discussed interhospital transport of trauma patients, demonstrating a reduction in mortality in a subgroup with severe ARDS (average arterial oxygen tension–fraction of inspired oxygen ratio, 60). Advanced interventions, including intermittent prone positioning, airway pressure release ventilation, continuous renal replacement therapies, and extracorporeal support, were instituted when indicated following transport to a trauma center.
A new Annual Trauma Anesthesia and Critical Care Symposium session focused on conduct of research and publication of results. David J. Dries, M.D. (Editor, Air Medical Journal ; Regions Hospital, St. Paul, Minnesota, USA), described development of research questions and review criteria. 3,4In a discussion of statistical analysis, Petter Andreas Steen, M.D., Ph.D. (Division of Surgery, Ulleval University Hospital, Oslo, Norway), advocated reliance on common sense and a critical eye when interpreting the significance of study results. Sven Erik Gisvold, M.D. (Editor-in-Chief, Acta Anaesthesiologica Scandinavica ; Department of Anaesthesia, St. Olav Hospital, University Hospital, Trondheim, Norway), recommended caution in the use of journal impact factors. Commonly used measures are weighted in favor of major, established journals and therefore against smaller, lesser-known publications. Peter Baskett, M.D. (Editor-in-Chief, Resuscitation , Bristol, UK), and Jerry P. Nolan, M.B., Ch.B., F.F.A.R.C.S. (Department of Anaesthesia, Royal United Hospital, Bath, UK), discussed the Consolidated Standards of Reporting Trials statement. 5
C. William Schwab, M.D. (Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA), opened the session on hypothermia, acidosis, coagulopathy, and damage control surgery by explaining the concept of damage control derived from the US Navy. Following penetration of a ship by explosives, emergent procedures are used to stabilize the vessel and prevent sinking. Definitive repair is done later. This analogy can be extrapolated to the patient in hemorrhagic shock following injury. This patient is usually hypotensive, bradycardic, coagulopathic, and hypothermic. A triphasic management approach involves (1) immediate operation to control hemorrhage by packing, (2) rewarming and correction of the coagulopathy in the intensive care unit, and (3) return to the operating room 24–36 h following admission for definitive repair of injuries. Indications for this management approach include pH < 7.3, temperature < 35°C, > 10 units of packed erythrocytes transfused, and > 60 min from the time of injury to these parameters. The adverse effects of intraoperative hypothermia were reviewed by Charles E. Smith, M.D., F.R.C.P.C. (Department of Anesthesia, MetroHealth Medical Center, Cleveland, Ohio, USA). Patient rewarming to normothermia is associated with a decrease in the incidence of infection, improved coagulation, and a decrease in mortality following trauma. Mauricio Lynn, M.D. (Division of Trauma and Surgical Critical Care, Ryder Trauma Center, University of Miami School of Medicine, Miami, Florida, USA), discussed his work with recombinant Factor VIIa (NovoNordisk, Gentofte, Denmark) to stop uncontrolled hemorrhage. Recombinant Factor VIIa, used to treat bleeding from hemophilia, enhances production of thrombin, which then speeds formation of the fibrin clot. Administration of Factor VIIa has yielded significant decreases in both surgical and nonsurgical (coagulopathic) bleeding in patients unresponsive to conventional therapies. This is followed by a decrease in transfusion requirements and renormalization of prothrombin time and partial prothrombin time. A multicenter trial is now underway in Europe.
The 16th Annual Trauma Anesthesia and Critical Care Symposium will be held May 15–17, 2003, in Dallas, Texas. Information is available at http://www.itaccs.com.