www.c4ts.qmul.ac.uk
C4TS Newsletter Winter 2018 Issue 15
C4TS RESEARCH NEWS WINTER 2018 In this edition of our newsletter, we discuss our involvement in the U.K REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) trial. The trial aims to shed light on whether this innovative method for stemming internal haemorrhage post-injury is more effective than standard clinical practice. C4TS researchers have also been examining how patients with traumatic brain injuries are triaged in London hospitals to determine any variations in outcomes and we outline our findings. We also share some education highlights from our MScs in trauma sciences and media coverage of our research.
UK-REBOA Trial
by Major Max Marsden, Clinical Research Fellow
A new technique for controlling internal bleeding after major injury is the subject of a new clinical trial. Uncontrolled bleeding is a leading cause of preventable death following major injury. Military experience has shown that the use of tourniquets improves survival, by stopping bleeding before surgery. However, tourniquets are only effective at stopping bleeding from the extremities, they are no use when the bleeding is inside the torso. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a new technique designed to stop internal haemorrhage. REBOA involves passing a small inflatable balloon into the aorta (the main artery in the body) to stop the bleeding until a patient can be taken to an operating theatre. While REBOA has shown early promise, we do not yet know whether it is better than standard care given to trauma patients. The UK REBOA trial aims to
Dr Samy Sadek, Consultant in Emergency Medicine and Prehospital Care at Barts Health, demonstrates REBOA techniques to paramedics at the Royal London Hospital. compare standard major trauma care that includes REBOA to standard major trauma care alone. The study has been designed by Chief Investigator Jan Jansen and researchers from Aberdeen University. It has some unique challenges, such as conducting a Randomised Controlled Trial in critically injured patients with an extreme time pressure to intervention, and only including those patients thought to have exsanguinating (life-threatening) haemorrhage. Because patients such as these are a relatively rare in the UK, Dr Jansen has designed the trial using a Bayesian design that is very different to the majority of clinical trial designs. A Bayesian design allows relatively small numbers of patients to be enrolled in the study while still producing meaningful evidence of the effect of REBOA. The trial expects to involve approximately 120 patients, across 10 Major Trauma Centres, over four years. (con’td p2)
SAVE THE DATE The second London Major Trauma System symposium will be held at the Royal Geographical Society, South Kensington, London on 12th June 2018. More information available on www.londontraumasystem.org
C4TS Newsletter Winter 2018
Page | 2 UK-REBOA Trial cont’d The Royal London Hospital and the Centre for Trauma Sciences (C4TS), were the first of these sites to “Go Live”. We completed the trial training in early summer 2017 and officially opened as a recruiting site in November 2017. The Royal London Hospital also had a head start on the other centres recruiting into this trial as we are the only hospital in the country regularly treating patients that have had a REBOA inserted either by doctors on London’s Air Ambulance or in the Emergency Department of the Hospital. The trial will record whether the patient survived and measure a range of other outcomes. In addition to patient outcomes, the trial will also look at the financial costs of those who received REBOA with those who did not. A large multi-disciplinary team of clinicians and researchers are involved in caring for these patients and running the trial. The team involves surgeons, emergency medicine doctors, anaesthetists, intensive care doctors, nurses and clinical research fellows. Dr Samy Sadek is the Principle Investigator For more information on the REBOA trial: https://w3.abdn. ac.uk/hsru/REBOA/Public/Public/
The triage of isolated head injury patients within the London Trauma System by Dr Henry Obinna Nnajiuba
Traumatic brain injury (TBI) is a significant cause of death and disability in the United Kingdom. Each year approximately 1.4 million people attend emergency departments with a head injury. The ongoing economic cost of long-term care and lost productivity is estimated to be in the region of £15 billion per annum. In London, as with most other parts of the UK, trauma patients are managed within an organised trauma system, meaning that the most severely injured patients are taken directly to Major Trauma Centres (MTCs) which have the required clinical expertise and resources. In many cases this means ambulances bypass nearby Dr Henry Obinna Nnajiuba studied hospitals on their way to the MTC with triage outcomes for the aim being to get the patient to the London’s TBI patients right place first time. It is recommended that patients with severe TBI are triaged directly to MTCs as MTCs have the required on-site neurosurgical capabilities. In some instances, the severity of a head injury may be underestimated by the prehospital assessment guidelines used by ambulance staff to triage patients (triage tool). As a result, these patients are taken to Trauma Units (TUs) which are not set up to manage patients with severe injury. This is known as ‘undertriage’ and it is potentially detrimental to patients’ outcomes as it delays the provision of definitive care. These patients often require onward transfer to MTCs. Conversely, injury severity may be over-estimated and patients conveyed unnecessarily to MTCs. This ‘overtriage’ has the potential to overburden MTCs, reducing the quality of care for all patients. In the context of isolated TBI it is still unclear to what degree over and undertriage impact on patient outcomes and whether a larger proportion of TBI patients could potentially be safely managed at TUs in order to reduce the burden on MTCs.
The Study
In this retrospective study, we used data from the UK’s national trauma registry (Trauma Audit and Research Network- TARN). We analysed all patients aged 16 and over who were admitted to hospitals in the London Trauma System with a severe isolated TBI from January 2014 to December 2016. Isolated TBI refers to patients with severe head injuries who did not have severe injuries to other body regions. The patients were broadly divided into two separate groups: • •
REBOA involves inserting a small inflatable balloon into the aorta
Patients who had neurosurgery or received neurocritical care. We compared patients from this group who were directly admitted to MTCs vs patients transferred from TUs Patients who were treated conservatively. We compared patients from this group who were admitted directly to MTCs vs patients admitted to TUs (non-transferred)
Within these groups, patients were further sub-divided into age cohorts of ‘adult’ (16-69 years) and ‘elderly’ (≥70 years). Outcomes considered were 30-day mortality, discharge destination and hospital length of stay.
Page | 3 Findings Figures 1 and 2 below show the results for mortality and home discharge respectively in the neurocritical group. In both age groups, the patients admitted directly to a MTC had a longer hospital stay. When other confounding variables such as injury severity and level of consciousness are controlled for, our data show that direct admission to a MTC is not a significant independent predictor of mortality in the younger adult population. Moreover, in the elderly neurocritical care population, it appears to be associated with an increased mortality risk. Primary triage to MTC is not a significant independent factor in determining the likelihood of home discharge.
Figures 3 and 4 show the results for mortality and home discharge respectively in the conservative group. Once again, MTC lengths of stay were longer in both age groups. When confounding variables were adjusted for, we saw no significant independent effect of primary triage to MTC on mortality rates. In both age groups, MTC triage was shown to be a significant independent factor in increasing the odds of home discharge.
Figure 1:
Figure 3:
Figure 2:
Figure 4:
Implications
Our results suggest that primary triage to an MTC may not be a key factor in determining the outcomes of all TBI patients. In many patients who were managed conservatively or who went on to require neurocritical care, it would appear that admission to a TU was not automatically associated with worse outcomes (provided patients requiring neurosurgery could be quickly transferred to MTCs). Further research is underway to determine which parts of the prehospital triage tool are most sensitive for predicting trauma patient outcomes. Using this information, we may be able to improve the triage tool to ensure we select the most severely injured patients who will benefit most from direct MTC admission, whilst safely keeping more patients at TUs and maintaining the efficient running of the trauma system as a whole . More information about research across the London Major Trauma System: http://www.c4ts.qmul.ac.uk/research-1-research/research
Page | 4
EDUCATION HIGHLIGHTS In November 2017, C4TS held the second annual trauma summit for former students of our MSc Trauma Sciences programmes.
TRAUMA MSC & PGDIP 2017 GRADUATES How many? 44 students Where from? 24 UK, 12 Europe, 2 Aust/NZ, 3 US/Canada, 2 Asia, 1 Africa
Science media personality Dr Kevin Fong gave a ‘breathtaking’ address to the C4TS MSc alumni event in November 2017
MSc Trauma Sciences Alumni Event by Dr Barry Schyma, Education Research Fellow
In November 2017, a capacity crowd of our MSc trauma sciences’ alumni enjoyed enthusiastic speakers within the grandeur of London’s Bishopsgate Institute. The evening kicked off with a hotly contested poster presentation. After much deliberation the winner of the event was Fiqry Fadhlillah for his poster exploring the analgesic efficacy and safety profile of fascia iliaca compartment blocks (pain relief) in patients with hip fractures. The poster presentation reinforced the high quality of work that is being produced by our MSc students. As the C4TS trauma anaesthesia and education fellow, it was my pleasure to give a high octane discussion about what happens
when you mix physiology, trauma system design, tropical climates and racing drivers. I talked about my experiences in motorsport medicine and Formula One and highlighted the challenges of working in an extreme sporting environment.
Professional background? 32 doctors, 6 nurses, 4 paramedics Speciality? Emergency medicine, trauma, orthopaedics, anaesthesia & surgery
The keynote speaker was Dr Kevin Fong. Dr Fong is a consultant anaesthetist at University College London and has an enviable and diverse CV that includes work with the BBC, NASA and as the Wellcome Trust’s engagement fellow. His concluding presentation was motivating, inspiring and breathtaking. He brought together his experience of anaesthesia, the media, aviation (and statistics) to illustrate the challenges being faced in the NHS, risk assessment and the role of human factors in incident prevention. For more info about our MScs and education events: http://www.c4ts. qmul.ac.uk/education-outreach/msctrauma-sciences
Dr Barry Schyma, C4TS education fellow & racing fan
Page | 5
AWARDS AND MEDIA C4TS Research Fellow Major Max Marsden wins award at Imperial College’s Centre for Blast Injury Studies’ Research Symposium. Max presented recent work from the prediction group within C4TS, led by Colonel Nigel Tai, to the Symposium in November 2017. The need for enhanced decision-making stems from the nature of trauma care. Trauma clinicians often have to make decisions about patient treatments with incomplete information. Decision making under these uncertain conditions risks accurate clinical judgement. Max presented a coagulopathy prediction tool to improve decision making around the activation of a Major Haemorrhage Protocol. The work compared using a machine learning tool to predict coagulopathy with the decisions clinicians made without the tool. Encouragingly, the machine learning approach appeared to perform just as well as clinicians in a head to head comparison. Finally, Max demonstrated the potential improvement in accuracy of decision making that might be gained when clinicians are given the tool to use. The hope is that improved decision making will lead to benefits for the patient and the trauma system as a whole. Our prediction group is working to develop a suite of bespoke decision support tools which will give clinicians additional information when treating patients.
Major Max Marsden accepting his award.
C4TS in the news On 1st February 2018, ITV’s This Morning show broadcast a 5 minute segment about trauma and bleeding, which featured an interview with Mr Ross Davenport. Mr Davenport was filmed at the Blizard Institute discussing the Cryostat-2 clinical trial his interview starts at 2:29. https://www.itv.com/ thismorning/health/dr-zoe-life-in-a-trauma-ward On 8th February 2018, The Guardian newspaper published an article examining social inequalities in outcomes for USA trauma patients. C4TS lead Professor Brohi was quoted discussing the factors that can affect survival outcomes from traumatic injury. https://www.theguardian.com/inequality/2018/ feb/08/trauma-trap-whats-causing-inequalities-inemergency-care
Mr Ross Davenport being interviewed by Dr Zoe Williams on ITV’s This Morning show.
Barts Charity’s Transform Trauma appeal, which seeks to raise money for trauma research and treatments, is off to a good start this year, as trauma clinicians Rosel Tallach (anaesthetist, Royal London Hospital) and Tam Jones (paediatric neurorehabilitation occupational therapist, Kings College Hospital) set off on a fundraising ultramarathon across Costa Rica. You can support them and other fundraisers in 2018 by visiting the appeal page: https://www.justgiving.com/campaigns/charity/blc/transformtrauma