Resuscitative thoracotomy is an uncommon event that can yield good survival rates (27% blunt trauma and 42% penetrating trauma) when clear clinical triggers and appropriate training have been introduced.
This presentation will review the decision processes required, the outcomes expected, and the training required – using The Alfred and the Pamela Youde Nethersole Eastern Hospitals program as an example.
 

Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) is indicated to be used in exsanguinating pelvic fractures not responsive to fluid resuscitation. In primary survey, there has been no less invasive and effective means to stop internal non-compressible bleeding in exsanguinating pelvic fractures. Before the introduction of REBOA, the patients can only be managed by the following ways with their respective limitations:
- Fluid resuscitation and blood transfusion: these are not targeted on hemorrhage control but circulation replenishment which is recently proven to be harmful
- Application of pelvic binder: this is with limited efficacy
- Cross-clamping of descending aorta through thoracotomy wound for bleeding control: this is seldom practiced locally
Those non-responders or partial responders to fluid resuscitation cannot be saved or suffered from a stormy postoperative course in ICU with significant mortality because of massive blood loss and blood products transfusion. REBOA can have temporary control of bleeding for initial assessment and resuscitation and buy time for effective surgical planning and definitive treatment. The procedure of REBOA is to be performed on the resuscitative table in AED resuscitation room for initial bleeding control, followed by definitive treatment including 3-in-1 procedures in the operation theatre. Current evidence from the literature supports the use of REBOA. Training courses for designated operators have been organized before patient use, in order to ensure safety and minimize potential complications of the procedure.
 

In Hong Kong, blunt trauma prevails. Carotid artery is vulnerable to be injured in different common mechanisms like hyperextension in neck whiplash, stretching of the carotid by mandibular or LeFort’s fractures occurred in fall or motorcycle accidents. Blunt carotid artery injuries account for 3 to 10% of all carotid injuries and 1% of blunt trauma cases. It is not common but not rare. It has high neurovascular sequela if left untreated and unnoticed. The natural progression and presentation is bizarre, from asymptomatic initially, vague neurological and vascular soft signs, to stroke within 30 days. Carotid blunt trauma does respond to medical and surgical treatment if it is diagnosed early. In the late 90’s, different trauma centres have been looking into and tried to predict the occurrence of blunt carotid trauma from various signs, symptoms and risk factors of concomitant injuries. If the patients fit the screening criteria, they should have an imaging within 12 hours. Screening modalities are CTA (60%), MRA (22.8%), conventional arteriography (15%) or duplex USG (1.7%). Denver group further grades the disease with the injury morphology, stroke rate, mortality rate, progress and suitable treatment modalities. The goals are to minimise disease progress, decrease ischemic event and improve neurological deficits. In the endovascular era, the inaccessible part of the carotid can be accessed and treated by stenting together with medications like Aspirin or anticoagulant. In KCC, a conjoint screening programme was embarked in 2018 based on the signs, symptoms and the associated neighbouring fractures to look into this under-diagnosed but disabling disease.
 

Point of Care Testing (POCT) is becoming increasing popular in different specialties of medicine. It has gained its popularity and recognition gradually over recent years. It allows for real-time and rapid assessment of patient status. It is especially important for those situations in which the patient status is changing rapidly, for example, dire medical emergencies, dire surgical emergencies, haemorrhage situations (including trauma, post-partum haemorrhage, major surgical reconstruction cases), transplants, etc. It allows for rapid titration of our management to the rapidly changing patient’s needs. This facilitates the success of management of modern medicine and surgery.
In major trauma cases, severe bleeding is commonly encountered. How to control the bleed and to minimize the bleed is the key to successful management. Apart from good surgical skills to control the bleeding source, optimising the patient’s haemostatic environment is also very important. In major trauma cases, very often, torrential bleeding is frequently encountered. In these cases, various processes involved in haemostasis (clot formation, clot stabilisation, fibrinolysis) are all changing from minute to minute. How to monitor these changing parameters on real-time basis can be the key to success. This supports the Anaesthesiologist to tackle the lethal triad (coagulopathy, acidosis and hypothermia).
Point of Care Test (POCT) is increasingly used in different major Trauma Centres in different parts of the world (Europe, Australia, Asia and US). Sonoclot, TEG, ROTEM are different viscoelastic technologies providing POCT test on haemostatic profile. Studies have shown that this allows for reduction in consumption of blood products in major bleeding cases.