NIHR-RCS Trauma Workshop Topics
This document contains the topics developed at the NIHR-RCS Trauma Workshop held on the 23rd May 2017 at the Royal College of Surgeons of England, Lincoln’s Inn Fields, London.
Table of Contents
1)Pre-Hospital Care
a)Pain management strategies (23 votes)
b)Identification and despatch of appropriate resource to trauma patients (13 votes)
c)Use of plasma for pre-hospital resuscitation (13 votes)
d)Hypertonic saline for head injury (12 votes)
e)Pre-hospital ultrasound (8 votes)
2)Emergency Medicine
a)Resuscitation for traumatic haemorrhage (20 votes)
b)Coordinated care on a multidiscipline trauma ward (20 votes)
c)Patient-led pain relief (13 votes)
d)Flow targets following traumatic haemorrhage (4 votes)
e)Early assessment of the elderly by a multidisciplinary trauma team (3 votes)
f)Chest drains vs conservative management (3 votes)
3)Critical Care & Anaesthesia
a)Models of acute/high level care for elderly/high risk trauma (17 votes)
b)Optimising nutritional and metabolic support in trauma patients (15 votes)
c)Separating sepsis and inflammation (8 votes)
d)Early goal directed therapy post trauma (flow targeted vs standard resuscitation) (8 votes)
e)(Regional) Analgesia/Anaesthesia in trauma (4 votes)
4)General Surgery & Trauma Services
a)Stratification and resource use in elderly trauma (21 votes)
b)Early diagnostics for stratification and personalised care (19 votes)
c)Can novel therapeutics and blood products reduce haemorrhage and improve outcomes in bleeding trauma patients? (14 votes)
d)Which early interventions can stop haemorrhage and improve outcomes? (14 votes)
e)Use of digital health for cross-network and pre-hospital communications (8 votes)
f)Which outcomes are important and acceptable to trauma patients? (8 votes)
g)What therapeutic or device intervention can protect organs & tissues after trauma? (8 votes)
h)How do we optimise the functionality of trauma networks? (6 votes)
i)How can we identify and manage patients at high risk of venous and arterial thrombosis after trauma? (2 votes)
5)Plastics and Reconstruction
a)Frailty and minor trauma (11 votes)
b)Digital nerve repair vs no repair (11 votes)
c)Chronic pain following tibial fracture (8 votes)
d)Biomarkers in burns, sepsis and trauma (6 votes)
e)Treatment of minor burns in emergency department versus in burns service (2 votes)
f)Outcome benefit of orthoplastics in MTCs (1 votes)
6)Trauma & Orthopaedics
a)Core outcome set for recovery after pelvic fracture (37 votes)
b)Cervical spine immobilisation in the elderly - a hazardous distraction? (29 votes)
c)RCT of operative vs non-operative management of ankle fractures (19 votes)
d)Humeral shaft fracture - operative vs non-operative (10 votes)
e)Surgical augmentation vs conservative care in elderly fragility vertebral fracture (9 votes)
7)Neurotrauma
a)Seizure prophylaxis after traumatic brain injury (24 votes)
b)Does acute assessment of traumatic brain injury better personalise care? (21 votes)
c)Does use of neuro stimulants improve cognitive dysfunction following traumatic brain injury (10 votes)
d)Behavioural disturbance during post trauma amnesia (9 votes)
e)If and when do you restart anticoagulant post traumatic brain injury in patients who have/have had(?) Atrial Fibrillation (7 votes)
8)Rehabilitation
a)What is the cost effectiveness of multi-disciplinary team rehabilitation for people following musculoskeletal trauma? (28 votes)
b)What is usual care for rehabilitation in the UK MTC? (13 votes)
c)Improving care coordination in follow-up (9 votes)
d)What is the capacity and demand for rehabilitation across the care pathway following trauma? (7 votes)
e)Composition of the multi-disciplinary rehabilitation team (2 votes)
f)What are the barriers and facilitators in terms of service delivery, access and human factors impacting on physical and emotional recovery of trauma patients? (0 votes)
9)Paediatrics
a)Rehabilitation following major trauma in paediatrics (17 votes)
b)Resuscitation in major trauma in paediatrics (15 votes)
c)Paediatric wrist fractures - operate or not? (14 votes)
d)Can we direct neuromonitoring by looking into people’s eyes (in paediatrics)? (14 votes)
e)Establishing unified outcomes in the injured trial (in paediatrics) (11 votes)
f)Resuscitation in paediatric burns (9 votes)
10)Mental Health
a)SSRI prophylaxis for mental health problems after major trauma (all). (not voted on at the workshop)
b)Irritability months following a traumatic brain injury (not voted on at the workshop)
c)Alcohol abuse and major trauma (not voted on at the workshop)
d)Psychiatric assessment and treatment following mild traumatic brain injury (not voted on at the workshop)
1)Pre-Hospital Care
a)Pain management strategies (23 votes)
P. Patients of any age, trauma / burns, moderate to severe pain
I. Novel analgesia via novel routes, administered by paramedics
C. Standard care
O. Reduction in pain, patient experience, transfer of pain management through to hospital care
Why is this question important: Don’t know whether we have optimum packages for analgesia and routes to administer it. Lots of evidence from Australia but not the UK.
Potential impact of the research: evidence suggests early effective pain management improves patient outcomes and experience. Patients in pain unnecessarily. Drugs not available due to skill set/legislation. Need evidence to make full range available.
b)Identification and despatch of appropriate resource to trauma patients (13 votes)
P. All 999 calls regarding trauma
I. Strategies to identify major trauma early and facilitate despatch
C.
O. Improved triage tools – patients get to right place quicker with better outcome
Why is this question important: Not identifying early enough a significant number of trauma patients. Telephone triage not sensitive enough. Therefore, patients not getting appropriate pre-hospital care
Potential impact of the research: patients get appropriate resource in a timely manner and get sent to the right place. Will improve patient outcomes. Identify ‘key words’ during initial call
c)Use of plasma for pre-hospital resuscitation (13 votes)
P. Hypovolaemic major trauma patients
I. Plasma +/- red cells
C. Standard care (post REPHILL)
O.
Suggested Methods/Design: Evidence synthesis?
Why is this question important:Management of hypervolemia in the pre-hospital environment has yet to define the optimum fluid. Correct fluid could have significant benefit to patient outcomes. Plasma more available and practical due to a) freeze-dried and b) new guidance from NHS blood and transplant.
Potential impact of the research: define optimum fluid for resuscitation in trauma with defined patient outcome benefits (eg less sepsis, transfusion requirements, mortality, deranged clotting)
d)Hypertonic saline for head injury (12 votes)
P. Patients with isolated head injury
I. Hypertonic saline
C. Standard care
O. Mortality, morbidity, disability
Why is this question important:Traumatic brain injury is a major cause of mortality, morbidity and disability. Use of NHS resources. Conflicting evidence and practice over use of hypertonic saline in early stabilisation of isolated head injuries.
Potential impact of the research: better functional outcomes. Medical vs surgical management
e)Pre-hospital ultrasound (8 votes)
P. Major trauma patients
I. Use of pre-hospital ultrasound to aid clinical decision making
C. No ultrasound
O. Time to transfer and destination, Identification of life-threatening injury, Decision about where to send patient following treatment, Speed and accuracy of access to major trauma centre.
Suggested Methods/Design: Compare pre-hospital outcome to trauma scan? Diagnostic accuracy
Why is this question important: Large amount of time and cost for training. Cost of devise (£2- £3k) and maintenance. No other ambulance intervention with this resource burden. Becoming popular with no evidence of benefit to patients. Potential harm through delays and false reassurance. Practise driven by marketing
Potential impact of the research: Determine benefits and harms. Disinvest if no benefit/clinical and cost-effectiveness
2)Emergency Medicine
a)Resuscitation for traumatic haemorrhage (20 votes)
P. Resus for traumatic haemorrhage +/- head injuries, + children
I. Fluid resuscitation strategies - (saline/whole blood/blood component/polymer O2 carrying)
C. Saline pre-hospital and blood in hospital
O. Survival, Economics, QALYs
Why is this question important: Common problem. Variation in practice - Blood products coming into practice - pathway from point of injury. No evidence which is best. Volumes? Patient harm potentially. Costs. Limited resources - ICU length of stay, blood. Timing of intervention
Potential impact of the research: appropriate/effective resuscitation. Life saving and reduced morbidity. Cost saving. Could impact worldwide practice (crystalloid in Europe). UK intellectual property
b)Coordinated care on a multidiscipline trauma ward (20 votes)
P. Moderate to severe/major trauma (to be defined) e.g ISS 9+
I. Coordinated care on a multidiscipline trauma ward (to be defined) / 3rd arm – cohorted care
C. General ward care
O. Early discharge, PROMs, length of stay, patient experience, mortality, identified complications, patient/staff satisfaction, function
Why is this question important: Variation in practice – no evidence. Effective resource utilisation. Patient centred care Eg like Stroke care cohorting. Coordinating care, rehabilitation
Potential impact of the research: organisation – improve hospital flow. Patient/staff experience. Minimal waste. Medical records with multiple handover reduce errors. Reduce falls. Trauma Network – rehab and repatriation earlier. Improve patient experience. Patient safety, infection
c)Patient-led pain relief (13 votes)
P. Patients with moderate / severe pain in trauma
I. Patient administered analgesia: transmucosal, IV, inhaled, transcutaneous
C. Routine bolus analgesia
O. Patient experience, length of stay, early mobilisation, use of analgesia, pneumonia complications
Why is this question important: 70% of patients want better management of pain. More than 50% of emergency department patients are in pain. Huge problem. Analgesic gap – poor patient experience. Physiological parameters. Re-attendance, chronic pain. Increase length of stay – complications eg pneumonia, PTSD
Potential impact of the research: reduce utilisation. Patient experience and empowering and patient centred care. Drug rounds. Reduce complications. Early mobilisation. Patient satisfaction and staff resource use. Safety
d)Flow targets following traumatic haemorrhage (4 votes)
P. Traumatic haemorrhage +/- head injury
I. Flow targets eg point of care microcirculation, cardiac output monitoring, NIRS and permissive hypotension
C. Blood pressure driven targets
O. Survival, length of stay. Sub group analysis by age
Why is this question important: No evidence for current practice. Variation (pre-hospital - resus room - ICU). Elderly trauma population increasing. Optimising endpoint to reduce resource use. Paediatric subgroup
Potential impact of the research: saving lives, effective resource utilisation, reduce critical care stay, reduced organ dysfunction. Standardise current practice
e)Early assessment of the elderly by a multidisciplinary trauma team (3 votes)
P. Elderly trauma patients
I. Early assessment by multidisciplinary trauma team
C. ED assessment in non-major trauma centre
O. Length of stay, return to premorbid living environment, quality of life, morbidities, earlier identification of injury, costs/economics
Why is this question important: Elderly increasing population. Multidisciplinary trauma team resource intensive. More elderly patients in Trauma Unit vs ICU Trauma team. Reduce economic burden. Increase quality of life and duration. Public health issue
Potential impact of the research: appropriate staff use. Deal with increasing burden of disease Efficient use of trauma resources. Identification of rehabilitation. Organisation of Trauma Network – informed. Patients and relatives experience improved. Earlier identification of injuries – earlier independence
f)Chest drains vs conservative management (3 votes)
P. Traumatic pneumothorax
I. Conservative management (watchful waiting)
C. Chest drain (subgroup by size of chest drain)
O. Length of stay, complications, patient experience, risk of harm
Why is this question important: If don’t need chest drain – reduce resources, morbidity, complications. Harm free care. Monitoring – variation in practice: survey to current practice; reduced ionising radiation. Personal experience based care – evidence based. Informed consent / shared decision-making risk stratification
Potential impact of the research: minimised complications, decreased length of stay, avoid admission, confidence what to do, reduce treatment cost, infection
3)Critical Care & Anaesthesia
a)Models of acute/high level care for elderly/high risk trauma (17 votes)
P. Fragility hip fracture (but other groups); possibly lower limb trauma; polytrauma in elderly; polytrauma in frailty
I. Critical care input as bundle - pre-op, intra-op, post-op
C. Current standard care (best practice tariff, BOAST, NICE CG124)
O. ICU admission, Mortality, Return to baseline function at 4 months, health economic impact (NHS/Social Care)
Design: stratified (e.g. by Nottingham Hip Fracture Score)?
Why is this question important: increased numbers of elderly trauma, critical care - limited and expensive resource, mortality/morbidity/functional outcomes are poor, large variation in outcomes, unclear benefit of higher level care, failure to rehabilitate causing capacity/flow issues, role of critical care is a NICE CG124 research question
Potential impact of the research: positives - reductions in direct NHS costs, LOS, decrease In social care costs, functional recovery; morbidity - physical/cognitive, Mortality benefit
Negatives- Potential service delivery/resource implications
b)Optimising nutritional and metabolic support in trauma patients (15 votes)
P. Critically ill trauma patients with duration of mechanical ventilation greater than 48 hours excluding major TBI (ISS >=4 brain) and spinal cord injuries.
I. Targeted nutritional intervention comprising strict attainment of energy protein goals +/- vitamin and trace elements
C. Standard dietetic practice
O. ICU free days, ventilator free days, functional status at 6 months, SF-36 mental and physical, objective test of muscle mass and function
Why is this question important: Major trauma patients receive a large upfront investment in acute/critical and surgical care but there is comparatively less research and quality improvement focus on the aspects of ongoing care in the ICU aimed at avoiding secondary harm.
Critical illness & polytrauma in particular is associated with significant acquired muscle wasting/weakness which is associated with delayed recovery, prolonged need for ICU/hospital intervention and worsened physical and mental health status.
There is a poor evidence base for existing nutritional targets and other metabolic interventions on the ICU and major trauma.
Trauma patients present a high risk/high potential benefit group for intervention.
Potential impact of the research: better patient health status, return to home/work; reduced use of hospital, primary care and social care resources; prevention of long term chronic disease (long term effects of acute organ dysfunction).
c)Separating sepsis and inflammation (8 votes)
P. Polytrauma patients admitted to hospital with or without current infection
I. "Surveillance" (serum marker) testing to identify infection e.g. PCT, CRP, WCC (other discriminators with diagnostic study)
C. Standard therapy / physician decision/ existing protocol
O. Stewardship / safety, reduced antibiotic usage (more appropriate), antibiotic free days.
Design: Non-inferiority basis (care 'no worse' than standard care)
Why is this question important: Nosocomial infection is common. Cost implications/resource. Antibiotics widely administered to all trauma patients. Often prolonged, many of whom do not actually have infection (limiting aspect is inability to differentiate with our current model). Disordered inflammatory response. Mimics and masks. Antibiotic stewardship principles to limit administration - Creation of multidrug resistance, gut protection, cost of drugs NOT recognising infection. Also implications on morbidity and mortality.
Potential impact of the research: reduction in unnecessary antibiotic usage. Correct administration to infections in timely manner, avoidance of drug resistance, improving sepsis outcomes in trauma patients. Cost saving for treatment (limiting duration of treatment). Morbidity benefit avoiding gut flora adverse effects
d)Early goal directed therapy post trauma (flow targeted vs standard resuscitation) (8 votes)
P. Traumatic injury and blood loss. Requirement for blood products. Perfusion deficit on presentation to ED/?lactate greater than 3, probably exclude severe TBI
I. Adoption of flow directed resuscitation (eg oesophageal doppler/Lidco/Picco Echo) versus standard pressure based resuscitation
C. Standard care including protocolised approach to all aspects of management
O. Organ failure scores at day 7 (Sofa/Dener), mortality, peri-resus lactate clearance, return to pre-morbid functional state at 6 months
Why is this question important: Post trauma multiple organ failure affects around 20% of patients with haemorrhagic shock. Patients with multi organ failure have a higher mortality and prolonged recovery period. Animal and observational clinical studies have demonstrated that maintenance of tissue perfusion during and post resuscitation is related to development of multi organ failure. Targeting tissue perfusion using flow monitoring may ameliorate this problem
Potential impact of the research: reduction in mortality/morbidity and critical care dependency, Reduction in tertiary level critical care, Earlier rehabilitation and return to pre-morbid functional status at an earlier stage, Possible mechanistic spin offs to investigate the causes of multiple organ failure (e.g. genomics). Does the intervention affect these?
e)(Regional) Analgesia/Anaesthesia in trauma (4 votes)
P. Specific patient subgroups; multiple rib fractures / Other groups - hip fracture, traumatic amputation
I. Specified regional anaesthetic technique (eg non-epidural regional)
C. Specified standard care (care needed here as varying definitions of standard care/best practice e.g. may be appropriate to have epidural vs non-epidural regional or non-epidural regional vs opioid-based [or stratified combination of the above])
O. Admission to ICU, Pain score/satisfaction with pain management, Respiratory complications (defined and validated), ventilator free days, ICU days, Length of stay, Breakthrough analgesia
Why is this question important: Burden - number of trauma patients. Analgesia poor/difficult in rib fracture, hip fracture, traumatic amputation etc. Ineffective analgesia may result in poor short term outcomes - humanitarian, delirium, prolonged length of stay, ICU admission. Poor long term outcomes - decrease in function (prolonged length of stay), long term pain, long term respiratory morbidity. Increased cost - length of stay, ICU admission. Use of ineffective treatments (e.g. epidural services have a cost/resource implications), potential harm.
Potential impact of the research: improved quality of early care. Avoidance of ICU admission, long term pain, decreased length of stay
4)General Surgery & Trauma Services
a)Stratification and resource use in elderly trauma (21 votes)