Newsletter
Issue 2 Summer 2005

In the developing world infectious disease grabs all the headlines, in the developed world cancer and heart disease are always in the news. However, there is now a growing interest from politicians and health planners in trauma as a global health problem. The strong leadership from the WHO Department for Injuries and Violence Prevention http://www.who.int/violence_injury_prevention/en/ has made a major contribution to this mind shift.

Appropriately, injury prevention is a major focus of the work of the WHO department but the strong WHO support for the CRASH-2 trial signals very clearly that trauma care is also high up on the agenda. Importantly, the recent publication by WHO ‘Guidelines for Essential Trauma Care’ offers a blueprint for an effective trauma system that is applicable across the world, whatever a country’s state of economic development. The global approach to the epidemic of injury fits very well with the global approach of the CRASH-2 trial – leading on from the original CRASH trial we are very much at the forefront of moulding the way that clinicians, and perhaps also politicians, think about injury.

In the past coagulation following injury has been seen as problem that occurs several hours after injury. A coagulation screen was not included in the ATLS list of blood tests until the latest edition. It is now known that many patients have disturbed coagulation on arrival in the Emergency Room, and that this is an independent risk factor for death. Modulation of clot breakdown by an antifibrinolytic has the potential to improve patient outcomes by preventing bleeding (the cause of half of in-hospital deaths following injury). The publicity around recombinant factor VIIa has added to the enthusiasm for non-surgical methods of bleeding control following trauma.

The combination of a growing political awareness of the importance of trauma to the World Burden of Disease and the growing clinical awareness of the importance of non-surgical approaches to bleeding control following injury means that everyone involved in the CRASH-2 trial is right at the cutting edge of current thinking about trauma management.

Tim Coats

recruitment has started!!!
CONGRATULATIONS!
CRASH-2 is growing at a tremendous rate, with surgeons and physicians from about 60 countries applying to become collaborators. The interest in this trial has been exceptional and current collaborators will be pleased to know that we have had about 300 new expressions of interest.

Hospitals in 5 countries have started recruiting patients:

• FIRST PATIENT RANDOMISED 19 May 2005 by Guy Mazairac
  Centre Hospitalier Regional de Namur, Belgium

* * * CONGRATULATIONS * * *

• Albania 1st patient Fatos Olldashi, National Trauma Centre Hospital
• Ecuador 1st patient Mario Izurieta Ulloa, Hospital Luis Vernaza
• Nigeria 1st patient Edward Komolafe, Obafemi Awolowo University Teaching Hospital
• UK 1st patient Dr Ayling, Royal Sussex County Hospital (PI Rowley Cottingham)
• Also 1st patient Emma Brown, Darent Valley Hospital (PI John Thurston)

ETHICS APPROVALS PER MONTH

43 hospitals already have
ethics approval and several
national approvals are pending.

Many congratulations
to the following new centres:

most frequently asked questions

'RISK OF SIGNIFICANT HAEMORRHAGE'
Patients with major trauma who are likely to need an early blood transfusion in the view of the attending doctor, after taking into account mechanism of injury, findings from secondary survey, physiology and response to fluid infusion.

TRAUMA SCORING SYSTEM?
Many anatomical severity scores, such as the Injury Severity Score, are applied in retrospect. These are therefore not useful in the CRASH-2 trial, where the treatment may be given before all the injuries are defined. The type of injury itself does not necessarily tell us how much bleeding has occurred – a fractured pelvis may or may not be associated with significant haemorrhage depending on the amount of damage to pelvic blood vessels.

Physiological severity scores, such as the Revised Trauma Score, give a heavy weight to level of consciousness, so they do not define the group that has significant bleeding. All forms of scoring require training and add a level of complexity to the patient entry process. For these reasons a severity score has not been used in the CRASH-2 trial.