Severe trauma is an increasing global problem mainly affecting fit and healthy younger adults. Improvements in the entire pathway of trauma care have led to improvements in outcome. Development of a regional trauma system based around a trauma centre is associated with a 15-50% reduction in mortality. Trauma teams led by senior doctors provide better care. Although intuitively advantageous, the involvement of doctors in the pre-hospital care of trauma patients currently lacks clear evidence of benefit. Poor airway management is consistently identified as a cause of avoidable morbidity and mortality. Rapid sequence induction/intubation is frequently indicated but the ideal drugs have yet to be identified. The benefits of cricoid pressure are not clear cut. Dogmas in the management of pneumothoraces have been challenged: chest x-ray has a role in the diagnosis of tension pneumothoraces, needle aspiration may be ineffective, and small pneumothoraces can be managed conservatively. Identification of significant haemorrhage can be difficult and specific early resuscitation goals are not easily definable. A hypotensive approach may limit further bleeding but could worsen significant brain injury. The ideal initial resuscitation fluid remains controversial. In appropriately selected patients early aggressive blood product resuscitation is beneficial. Hypothermia can exacerbate bleeding and the benefit in traumatic brain injury is not adequately studied for firm recommendations.

Appropriate imaging is critical in the initial assessment of patients with severe trauma. Plain radiographs remain integral to the primary survey. Focused ultrasonography is useful for identifying intraperitoneal fluid likely to represent haemorrhage in patients who are shocked and also has a role in identifying intrathoracic pathology. Modern scanners permit a greater role for CT, being more rapid and exposing the patient to less ionising radiation. 'Whole body' (head to pelvis) CT scanning has been shown to identify injuries missed by 'traditional' focused assessment and may be associated with an improved outcome. CT identifies more spinal injuries than plain radiographs, is the gold standard for diagnosing blunt aortic injury and facilitates non-operative management of solid organ injury and other bleeding. Coagulopathy occurs early in trauma as a direct result of injury and hypoperfusion. Damage control resuscitation with blood components is associated with an improved outcome in patients with trauma with massive haemorrhage. Packed cells and fresh frozen plasma should be used in a 1:1 to 1:2 ratio. Bedside measures of coagulopathy may prove useful. Adjuvant early treatment with tranexamic acid is of benefit in reducing blood loss and reducing mortality. Limited 'damage control surgery' with early optimisation of physiology augmented by interventional radiology to control haemorrhage is preferable to early definitive care. Limiting haemorrhage by correction of anticoagulation and minimising secondary brain injury through optimal supportive care is critical to improving outcome in neurotrauma.

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The 9 th London Trauma Conference (#LTC2015) and London Cardiac Arrest Symposium (#LCAS2015) built on the previous meetings with an emphasis on innovation, research, and enthusiasm for the medical care of major trauma, cardiac and critically ill patients. From the 8-11th December 2015 delegates from over 20 countries attended The Royal Geographical Society for the four days of the conference. The opening two days of the conference focussed on current issues in major trauma, with air ambulance and pre-hospital critical care on day three, and the London cardiac arrest symposium returning as the fourth and final day. Concurrent breakaway sessions ran alongside the main conference including; trauma haemorrhage research, paediatric trauma, and masterclasses on cardiac ultrasound and resuscitation, thoracotomy, REBOA, and an introduction to ECLS and ECMO. The major trauma programme consisted of two days of lectures, keynote lectures and short 'quickfire' sessions. Professor Tim Coats opened the conference by talking about the role of the highly performing trauma unit in trauma networks -outlining the problems of maintaining high levels of care in systems which increasingly bypass to major trauma centres but bring severely injured irregularly to trauma units. Professor Kjetil Søreide then addressed the topic of iatrogenesis in trauma, giving examples from different points in the patient pathway. The prevention of iatrogenesis is based on acceptance of it's presence and then promoting prevention with a culture of safety, training and focus on the team approach. Dr Matt Thomas finished up by summarising the landscape of research in trauma over the previous year, as well as outlining what can be expected in the year ahead. The following sessions approached key issues in neurotrauma, opened by a seasoned London Trauma Conference speaker Mr Mark Wilson. He spoke on current early neurological imaging, with mobile CT scanning already a reality in mainland Europe and the trialling of near infrared spectroscopy (NIRS) as a potential pre-hospital imaging modality. Professor Geoffrey Raisman followed with a fascinating talk on spinal cord regeneration, outlining how nerve regeneration to replace damaged portions has already been trialled with some success. He related a moving case where olfactory nerve fibres were used to repair spinal cord injury with one of the ultimate medical triumphs -making a paraplegic patient walk again. Professor Andrew Maas then lectured expertly on why he sees head injury as a silent epidemic with potentially life-changing consequences. Dr Markus Skrifvars closed the session with a sobering presentation on the link between alcohol consumption and the vast number of traumatic brain-injured patients that are intoxicated when they present. Lunch was followed by Professor Karim Brohi, who delivered a talk on the early immune response to trauma and novel potential approaches to ameliorate this genomic storm. Other speakers in the afternoon included Professor Marc Turner delivering his vision for the trauma ...

Introduction The societal changes triggered by the COVID-19 pandemic and resultant lockdowns have the potential to alter the incidence and nature of injuries within affected populations. We aimed to investigate these changes within Metropolitan London and the impact lockdown had on London’s Air Ambulance’s (LAA) response to incidents. Methods This retrospective cohort study compared data from all LAA missions in the two-month period following instigation of the 1st UK national lockdown in 2020 to the equivalent period in 2019. Patient demographics, nature and severity of injuries, incident details and LAA mission parameters were assessed. Results LAA saw a significant reduction in the mean (standard deviation) of activations per week under lockdown (32.75 [4.95] versus 54.25 [4.53], p<0.001). The distribution of patients across different trauma aetiologies differed significantly under lockdown, with proportionately more injuries resulting from domestic violence (0.7% versus 3.8%) and deliberate self-harm (DSH [16.5% versus 12.4%]), although the absolute number of DSH fell. Significantly fewer incidents occurred in central areas of London, but injury severity was unaffected by lockdown. After adjustment for confounders, lockdown was associated with shorter drive times, but not overall response times. There was no association between lockdown and aetiology or severity of injuries. Conclusion The COVID-19 pandemic and ensuing UK national lockdown had a substantial impact on major trauma patterns within London and the subsequent LAA response. The feared rise in suicide was not observed, but there was a notable increase in domestic violence frequency.