Society Of Trauma Anesthesia And Critical Care (STACC), India Newsletter

TRAUMA NEWSLETTER
ISSUE 1
January 2023
LEADING THE WAY TO TRAUMA CARE IN INDIA

Advanced Trauma Centre at PGIMER Chandigarh was started in the year 2011 to provide care for trauma patients from most of the Northern India.
It has grown exponential since its inception and receives approximately 37-40 patients every day.

Trauma anaesthesia and Acute Care, a subspeciality of Department of Anaesthesia and Intensive Care, PGIMER, started providing care to trauma patients under the dynamic leadership of Professor YK Batra. After supernation of Prof Batra, Prof Kajal Jain took over the role and continued to work for providing smooth acute care and Anaesthesia services at Advanced Trauma Centre. Other members of the team included Dr Jeetinder Kaur Makkar, Dr Nidhi Bhatia, Dr Tanvir Samra, Dr Amarjyoti Hazarika, Dr Shyam Charan Meena and Junior residents. As the number of patients continued to increase, a doctorate degree in Trauma and Acute Care was started in 2018.
OUR SERVICES
Trauma anaesthesiologist work with other departments to provide patient care from admission to discharge.
Trauma Triage:
Triage area at PGIMER is divided into four sections using a color-coded system. Red area: Patients are received in this area on arrival. Primary survey is conducted and prompt intervention is carried out. Patients requiring necessary interventions, such as radiology are transferred to CT scan area located adjacent to triage. After initial stabilisation, patients are transferred to the yellow (needs additional assessment or intervention) or green area (requiring observation). Triaging to a specialty wards, ICU or OT is done based on the needs of the patient . Initial triage is handled by General surgeons. Orthopaedician, neurosurgeons, plastic surgeons, anaesthetists, CTVS surgeons, ENT surgeons, and ophthalmologists then provide specialist opinion as needed. Our Trauma Anaesthesia Response Team (TART) ensures immediate and smooth control of airways (both red area and yellow area) when called for. TART is equipped with a video laryngoscope, an intubation kit, and ready to use sedative and emergency medications. Team has a response time of less than three minutes. 267 patients were intubated by TART in year 2022. Our team members are also actively involved in resuscitation of polytrauma patients as well as management of acute pain on arrival in Trauma Bay. We assist in placement of challenging intraosseous or invasive lines. Nearly 200 central lines were inserted this year. Our response team is sensitized to the fact that disasters can happen anytime and are adequately prepared for same

Trauma OT: Our team effectively identifies complex medical needs of patients at particular risk from the lethal effects of trauma thus effectively discharging their duties as perioperative physicians. . Trauma patients are provided prompt surgical treatment when needed in our five state of art Trauma OT,s which are operational 24hrs a day. Patients with polytrauma, skeletal trauma, and neurotrauma are mostly operated in these OT’s. Four to five consultants work with , two senior residents and five junior residents for smooth functioning of these five operating rooms. The OT teams handle all anaesthesia-related services, including general anaesthesia, regional anaesthesia, neuraxial anaesthesia, pain management, routine and advanced hemodynamic monitoring, and perioperative resuscitation. High flow nasal oxygen therapy (HFNO), USG machine (GE) with an option for intraoperative transoesophageal echocardiography, video-laryngoscope, and percutaneous submental intubation approach have been added to our arsenal of state-of-the-art equipment. In the modular trauma centre, more recent anaesthetic workstations are in operation. Epidural and peripheral catheters are used to deliver acute pain services when indicated.

Preoperative stabilisation, resuscitation, and peripheral nerve blocks are also performed in the preoperative area, which has six monitored beds. The postoperative recovery room, with six monitored beds, is used to monitor, and manage high-risk cases overnight, such as reimplantation, major degloving, major flap surgery, patients on inotropic support, and patients requiring significant blood transfusions after surgery. Three ventilators in the recovery area can be used for short-term mechanical ventilation (less than 24 hours).

Trauma ICU: The 14-bed Trauma Intensive Care Unit manages difficult and critically injured patients. Under the direction of an on-call consultant, one senior resident and three junior residents are managing it during a 12-hour shift. Patients get routine treatment such as neuromonitoring, advanced hemodynamic monitoring, respiratory and ventilator management, sepsis management, organ donor management, and standard ICU care bundles. ICP monitoring has been added to our armamentarium recently
In the year 2022, Trauma ICU treated nearly 500 patients, including 41 deceased organ donors. Our Trauma team members have executed 200 intrahospital patient transfers.
Teaching
There are several organized teaching activities that provide ample contact time for teaching and Resident interaction

DM Trauma: Doctoral programme in "Trauma Anaesthesia and Acute Care" was started in 2018. Two candidates are enrolled each year into the three-year programme. Out of a total of 36 months, trainees rotate between 18 months in trauma Operation Theatre, 9 months in trauma intensive care, 3 months in the triage area, and the remaining time is split up among different other assignments. For DM trainees, regular classes are offered on Monday and Wednesday. Internal examination is conducted every 6 months for on roll candidates . Till date, two candidates (Dr Haneesh Thakur and Dr Mandeep Kumar) have completed the programme successfully. Two candidates are currently Dr Bismanjeet Khurana and Dr Revathi Nair.
Dr Haneesh Thakur, received two awards ISSCM best paper awards, 2022 and ISSCM Best image award, 2022 at CRITICARE 2022.

MD Teaching:
“Fabulous Friday" Senior residents conduct once-weekly online classes named on Zoom for junior residents. In addition to assisting junior residents in learning, this also gives senior residents a platform to enhance their teaching skills.

"Orientation classes" are taken at the beginning of each month for Junior residents to acquaint them with protocol followed in trauma centre.

Trauma Teaching Rounds (daily): Specific trauma cases are reviewed with discussions. Residents may be asked to make a presentation at this forum

Book on Acute Care of Trauma Patients in Indian scenario:
The first edition of "Acute Trauma Care in Developing Countries: A Practical Guide" was written by faculty members of PGIMER actively involved in management of Trauma victims. Book provides an integrated, comprehensive approach necessary to enable the resident doctors to evaluate, resuscitate, and work-up the trauma patient. Dr Kajal Jain and Dr Nidhi Bhatia, core team faculty members of the "Trauma Anaesthesia and Acute Care" programme, are the editors of this book.
Training
Building foundational awareness of trauma-informed approaches should begin early in a provider’s education and be reinforced through continuing education. With this motto, one continuing medical education programme, two workshops, and one bootcamp was conducted in year 2021-22 Trauma Anaesthesia and Resuscitation Conference: Organised on October 9 and 10, 2021, with the aim of advancing immediate trauma life care from "Golden Hour to Platinum Ten" , a total of 350 delegates attended this conference and it was broadcast on several YouTube channels. On October 9, a workshop on regional trauma blocks was held. Nearly 80 students got a chance to perform a hands on of live scanning on volunteers. Our training wasn't just for doctors; we also held separate sessions on BLS and trauma care for police officers and another state-of-the-art, one-day continuing medical education programme for nurses, emphasising the value of a team approach and their function in the care of trauma victims.

Workshop on Plan A Blocks
To improve the teaching of regional anaesthesia, we held a workshops on "Plan A block" on March 20. Around 60 delegates attended this workshop. Our course received rave reviews from participants, and was a huge success in terms of raising interest in future advanced workshops in this area.

Bootcamp on resuscitation "Make the heart- Beat”
On May 15, a bootcamp called "Make the heart- Beat" was held to teach participants the basics of emergency room resuscitation. Around 100 delegates from diverse backgrounds, including anaesthesiologists, doctors, surgeons, orthopedicians attended this.

Half day CME’s
On October 16, 2022, we collaborated with ISCCM (Chandigarh Chapter) to host a conference on disaster management. A disaster management drill for medical personnel was held on November 17, 2022. Three distinct training sessions for police officers on fundamental life-saving techniques, how to treat and transport trauma patients. Till now, 250 police officers have received our training.
Building Awareness and Competency Trauma is a public health issue and calls for public education campaigns akin to those used in anti-smoking efforts, vaccination promotion, and seat belt use. Three distinct training sessions for police officers on fundamental life-saving techniques and safe transport of trauma victims were held in the month of August and September . Till now 250 police officers have received our training. A half day workshop on advanced Trauma life support was conducted at Nursing institute of national education on 11-11-21. Our faculty has been actively involved in delivering lectures at numerous national and international conferences. Even our DM residents participated in outreach programmes and gave lectures on "Emergency care" to Punjab police (17th November Workshop on Traffic Management), "Sudden Cardiac Arrest" to teachers (16th October 2022 Vidyarthi Vigyan Manthan), "Advanced life support" to doctors (17th December 2022 Workshop on medical update), and "POCUS in trauma" to anaesthesiologists (YUVACON, 14th October 2022).

Building Awareness and Competency
Celebration
We participate enthusiastically in birthday festivities, passout parties, Independence Day celebrations, Diwali celeb rations, Anaesthesia Day celebrations, and welcome parties in addition to our academic activities

QUALITY IMPROVEMENT INITIATIVES BY THE TRAUMA ANAESTHESIA TEAM

The team of trauma anaesthesia and acute care, since its inception, has continuously striven to provide optimal patient care and protocolize treatment strategies in accordance with recent medical advances. An important pre-requisite to this constant effort to upgrade our practices has been the use of quality improvement initiatives in various forms. The most recent, yet by far the most effective method strategized in this direction, has been the setting up of morning discussion sessions.

Every morning, prior to case handovers, a debriefing session is conducted wherein the operated cases of the last 24 hours are discussed. Junior residents on duty do structure format case presentation. The discussion is open to all with free two-way communication between residents and faculty. Residents discuss the difficulties faced during case management, novel approaches used to tackle any such difficulty and the feasibility thereof. This also improves the presentation skills of the residents

From sonoanatomy images captured while performing a peripheral nerve blocks to video laryngoscopy images in difficult airways, each resident is encountered by to display an image of interest. Any challenging case is discussed in an attempt to (improve quality of care and patient outcomes) better the management in future, should such a scenario arise. As a result, trainees completing their month tenure in the Advanced Trauma Centre complex develop the confidence to manage crises better (improve their advanced care skills) than they would have before. Residents have now begun volunteering to present data of interest, seeking to learn from the open-ended discussions that follow. The discussions have worked as an effective way to notify the administration of shortcomings that need to be fixed, and critical appraisal of the trainees’ management skills. As a result of these, our inventory has expanded to include newer drugs (dexmedetomidine, ropivacaine, balanced salt solutions). The debriefing sessions also help with daily auditing of inventory usages and functionality status.

Other quality improvement strategies in place include monthly audits, fortnightly hands-on skill stations (Front of Neck Access, Airway ultrasound, Cervical spine stabilization, Intraosseous access etc.) With all these, the goal has always been exchanging of knowledge, and promotion of research, whilst optimising medical practices.

Deceased Organ Donation

Organ donation is one of the biggest medical breakthroughs and miracles of medical science. It is the only beckon of hope for majority of patients battling end organ failure. It gives them a second chance at life. There are lakhs of patients in India who are waiting for an organ transplant. Unfortunately, many may never get a call saying that a suitable donor has been found for them.

The first and foremost premise of a successful organ transplant is availability of “a willing donor”. Contrary to the common belief, organ donation can be done by an alive as well as a deceased donor. Organs which can be donated by an alive donor are restricted to only a single kidney, or some part of his liver and lungs. On the other hand, a deceased donor can save up to 8 lives by donating a greater number of organs and improve over 100 lives through tissue donations. Heart, liver, lungs, kidneys, pancreas, corneas (eyes) are among some of the organs and tissues that PGIMER has successfully transplanted in last two decades. The golden hours after donation and retrieval an organ, before which organ transplantation should be done to maintain viability of the organs, varies for different organs. While kidneys and skin can be transplanted up to 24 hours of retrieval, heart and liver are required to be transplanted within first 4 and 8 hours respectively.

Till a few decades back the whole concept of organ donation used to create fear and anxiety in the minds of general public as well as doctors and other stakeholders in organ donation process. To allay these fears and create an atmosphere of awareness and trust, the Government of India initiated several strong steps. A legal act “THOA” was implemented in 1994 (amendment 2011) to regulate the process of organ & tissue donation and protect the rights of those donating them. Mechanisms were introduced to improve transparency in the whole process and ensure spread of correct information among general masses, especially the population in need of organ transplantation.

True meaning of courage and compassion can be learnt from the families who say “yes” to saving many lives of total strangers, moments after losing someone who meant everything to them. These organ donor families on one of the worst day of their lives take a decision to do good for others. There are many myths regarding age, health, gender, religion etc. of the donors. However, none of these factors are a bar for to donating one’s organs.

“It Takes a simple Yes to save lives” अंगदान महादान

Paradigm shift in management of trauma patients at our centre : The increase role of US guided nerve blocks.

The management of trauma patients has been streamlined with the primary survey followed by the secondary survey being the management protocol at all trauma centres. This has played a role in decreasing the immediate/ short term mortality in the triage areas. However, the management of injury, pain, infection, co-morbid conditions have to be initiated immediately after the primary and secondary survey to further improve patient outcomes. Definite clinical care pathways for the same have been developed in the western world, however the same are lacking in developing countries. RTA death rate in low-income countries is expected to almost double than that in high income group (2/10,000 people in developing countries by 2024 < 1/10,000 in high-income countries) in the near future. Delays in presentation to the hospital, delay in definitive management, inadequate pain relief and infections are imitations of the developing world which need to be managed on urgent basis.

Increase in use of US guided nerve blocks is one such initiative undertaken by the anaesthesiologist at Advanced Trauma centre (ATC) of PGIMER. Two major areas have been identified for the same:
1. Triage: On arrival blocks/ blocks in acute trauma setting have been encouraged
2. Blocks in operating rooms (ORs) have been encouraged over general anaesthesia/ central neuraxial block

Uses of US guided nerve blocks in Triage
US guided nerve blocks can be administered to a patient who has sustained a major injury before a definitive time slot for surgery has been decided. The advantages with this are enumerated below:
1. Immediate pain relief: Pain is untreated during the initial part of resuscitation but should not be ignored after resuscitation and initial stabilisation is done. Untreated pain aggravates stress response to injury and increases oxygen demand which can precipitate myocardial ischemia. Chronic pain is a consequence of undertreated acute pain. Posttraumatic stress disorder leads to long-term complications and thus we should take appropriate measures to make the trauma patient pain free.
2. Avoids administration of opioids: Heath care providers in triage of developing countries are overworked and need to do multi-tasking as resources are limited and the population is large. Side effects of opioid administration like respiratory depression, nausea and hypotension cannot be monitored on an hourly basis (especially if used in high doses)
3. Permits a pain-free detailed clinical evaluation of the injury, radiology, patient transfer, mobilisation, and physiotherapy.
4. Improves patient satisfaction.
5. Assists in reduction of dislocated joints, fracture reduction, wound care, etc so that patents can be discharged home as soon as possible.

Uses of US guided nerve blocks in ORs General anaesthesia, central neuraxial block and regional nerve blocks can be administered for either damage control surgery after trauma or definitive repair. Traditionally in our centre either general anaesthesia or central neuraxial blocks (subarachnoid and epidural) were administered in the ORs but in recent years a paradigm shift has been seen and regional nerve blocks have now becoming the first choice. General anaesthesia or central neuraxial blocks are administered only if there is a contra-indication like allergy to amide local anaesthetic drugs, patients with thrombocytopenia/coagulopathy, on anti-coagulant and thrombolytic therapy, neurological diseases, infections in the intervention site, or patients with psychiatric illness or the procedure cannot be done a regional block. The preference for PNBs s based on the following:
1. The chemical sympathectomy produced by peripheral nerve blocks (PNBs) is advantageous after microvascular surgery, reimplantation, and free flap procedures.
2. The neurohormonal, metabolic, and immunological stress responses to injury release chemical mediators like bradykinin, substance P, leukotrienes, and interleukin. These chemical mediators in turn produce changes in the end organs and systemic inflammatory response syndrome (SIRS) in worst case scenarios. PNBs limit all the above and mitigate stress responses.
3. ERAS is achievable with PNBs which decreases the cost of healthcare which is advantageous in a developing country. PNBs hasten recovery, decrease intensive care unit and hospital length of stay, improve cardiac and pulmonary function, decrease infection rates, decrease sympathetic activation, and promote earlier return of bowel function.
Concerns of Regional Anaesthesia Techniques in Trauma Patients
Concerns in relation to availability of equipment are non -existent as an US machine is always available in the triage for FAST and ORs are also well equipped. Expertise of the anaesthesiologists is also not a hindrance as some of the blocks have a steep learning curve. We are regularly training our junior resident and trained DM resident are mostly available even in non-office hours. Recently many postgraduate theses have given in use of PNB e.g Parascaral block with two different technique in lower limb surgery, Costoclavicular vs Supraclavicular block for upper limb Surgery, comparing two technique of fascia illicia block etc. As a result, junior residents are more eager and enthusiastic to learn and perform PNBs.
PNBs are invasive procedures but if asepsis is maintained then PNBs do not pose any risk of infection, nerve injury, vascular injury, pneumothorax, and/or local anaesthetic toxicity. General anaesthesia is to be chosen over PNBs in patients with multiple fractures at diverse locations to minimise multiple blocks and need for catheters due to prolonged surgical duration. Patients with suspicion of compartment syndrome and coagulation abnormalities are not ideal candidates. Compartment syndrome left undiagnosed due to PNB could result in amputation of extremity or in multiple organ failure with lethal outcome. PNBs lead to complete analgesia and could mask pain and paraesthesia which are early symptoms of compartment syndrome, or nerve injury. Patients with fracture of forearm bones, lower limb both bones, crush injuries and prolonged immobilization are at risk whereas patients with hip and femoral fractures are less prone to development of compartment syndrome.

REFERENCES
Büttner B, Mansur A, Kalmbach M, Hinz J, Volk T, Szalai K, Roessler M, Bergmann I. Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial. PLoS One. 2018 Jul 2;13(7):e0199776.

Ketelaars, R., Stollman, J.T., van Eeten, E. et al. Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures provide safe and effective pain relief: a prospective observational study in The Netherlands. Int J Emerg Med 11, 12 (2018).