The pre-hospital care conference

Abstract

The Pre-hospital Care Conference was the third and final day of the London Trauma Conference. The first speaker, Professor Malcolm Woollard, Director, Pre-hospital, Emergency & Cardiovascular Care Applied Research Unit, Coventry University, spoke on Needle Decompression of the Chest – fact or fiction? Professor Woollard’s comprehensive review of the epidemiology, appropriateness, effectiveness and risks of the procedure illustrated some interesting and important points. He argued that needle decompression of the chest is an infrequently performed procedure with currently taught techniques risking inappropriate use, failure and iatrogenic injury. Critically, multiple studies demonstrate that a standard 14G cannula of 4.5cm length will not penetrate the chest wall in many patients. Moreover, retrospective analysis of interventions undertaken reveals that the insertion site is often incorrect and frequently in the cardiac zone. He concluded that the intervention does have a role in the emergent management of trauma patients but emphasised that appropriate equipment should be used by practitioners with regular re-training in indications, technique and positioning. Surgeon Commander Jason Smith, Royal Navy Consultant in Emergency Medicine, Derriford Hospital recently led a UK consensus group on treatment of crush injury and he spoke on Crush Injury – is it More Than One Syndrome? He answered this question by broadening the definition of the syndrome to ‘the systemic manifestation of muscle cell damage resulting from pressure or crush’ rather than the conventional perception of an injury caused by prolonged entrapment. He encouraged delegates to consider the diagnosis in a broad range of presentations and explained that the severity of the syndrome depends upon the magnitude and duration of the force and the bulk of muscle affected. This focus on damage to the sarcolemma explains how the same condition may develop from an instantaneous massive energy transfer or the prolonged application of a minor force to a large muscle bulk, such as that seen during prolonged immobility on a hard surface. The management of this condition adds an extra dimension to conventional trauma management and hyperkalaemia should be considered as a reversible cause of traumatic cardiac arrest when crush injury is suspected. Prevention of renal failure is paramount in the medical management of crush injury and, again counter to the current management of trauma patients, Surgeon Commander Smith advocated that aggressive crystalloid resuscitation be commenced in the pre-hospital setting. Reports from the management of crush injury in earthquake victims associate delay to fluid resuscitation as a risk factor for the development of renal failure. Mannitol and urine alkalisation should be considered although the evidence is limited, dated and largely anecdotal. Surgeon Commander Smith’s enthusiastic talk was interspersed with reverential pauses to admire spectacular photos of Royal Navy ships and helicopters – his prehospital workplace is rather more impressive than that of most of the conference delegates. The controversial topic of Compression only CPR was addressed by Professor Kjetil Sunde, Oslo University Hospital, Norway in a fascinating and thoughtful analysis of some conflicting literature. There was a conventional central theme to this wide-ranging lecture: survival of cardiac arrest depends upon the chain of survival, consisting of early recognition, early CPR, early defibrillation and post resuscitation care. Professor Sunde’s unapologetic recycling of this familiar message was reinforced by the evidence that there is a 10 fold variation in reported OOHCA outcomes and that much can be done to improve the vital chain of survival. Evidence was presented to confirm that both early initiation and quality of CPR are critical and that the evidence demonstrating the superiority of compression only CPR over conventional 30:2 may reflect this. Non-CPR trained bystanders, particularly when guided by telephone instructions, are more likely to commence resuscitation and achieve adequate cardiac output with compression only CPR than when interrupted with reluctant attempts at ineffective ventilation. Despite Oxford, UK Full list of author information is available at the end of the article Thompson and Crewdson Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20(Suppl 1):I3 http://www.sjtrem.com/content/20/S1/I3