DFTB MSc goes to Nottingham – the NEPTUNE Conference 2025

NEPTUNE stands for the National Emergency Paediatric Trauma Update and Networking conference, and is the only dedicated paediatric trauma conference in the UK.

2025 marked the second year of NEPTUNE, hosted again by Nottingham University Hospitals trust (NUH) – one of the largest major trauma centres in the UK. 2023 had seen an excellent host of contributors, and this year’s conference promised to live up to the exceptional standard set by the previous event. 

If you weren’t able to come along, we’ll fill you in on the highlights from this year’s leading minds in the world of PEM trauma. 

You can see the full programme and workshop information here.

The stereotypical East Midlands drizzly, overcast skies did not put a dampener on the arrival of the day 1 delegates, who were rewarded with fresh coffee and pastries and a welcome from a well-choreographed events team. After a welcome from our host, Dr Vikram Baicher, we kicked off with our first speaker. 

Don’t Be so Clever, You Forget to be Kind – Reflections from a Major Incident – Dr Bimal Mehta.

First, Bimal and his team walked us through a stabbing incident in Merseyside. I was a junior doctor working locally at the time – the psychological imprint is still fresh—five trauma rooms. Three children died. Up to 40 staff coordinated the response under unwavering leadership from the ED consultants.

We saw the Clever in motion – trauma simulations, rapid infuser training, standardised kit boxes, guidelines, checklists, and briefings. It worked. But it wasn’t enough in that situation.

Because then came the Kind. Families weren’t the only ones grieving. Staff – clinical, non-clinical, and volunteers – were stuck either ‘on’ or ‘off’. Hot debriefs within 48 hours, cold debriefs at four weeks, and visible leadership made a difference. The Staff Advice and Liaison Service helped shoulder the emotional load.

Trauma-informed care isn’t just for patients. It’s for us too. Be clever, yes – but never forget to be kind, with three simple actions.

Traumatic Cardiac Arrest in Children and Young People by Dr Jake Turner

Dr Jake Turner gave us a whistle-stop tour of the world of traumatic cardiac arrest in children. 

Traumatic cardiac arrest in children is rare, and the pooled survival outcomes are generally low – 1.2%, compared with 3.8% in adults, according to Alqudah et al (2020). We’re very algorithm-driven in emergency medicine, but we may need to shift the focus to a more diagnostic approach in our resuscitation, thinking more about what is actually causing the arrest and focusing on reversing it. 

A is for Airway

Airways that are smaller soil and obstruct more easily. Using gravity, i.e. through postural drainage, is crucial if a child’s airway is rapidly soiling, and you can still maintain spinal immobilisation in the left lateral position.

Rapid soiling can occur with large maxillofacial arterial shears due to sports injuries, such as speed biking, which children increasingly participate in. In these circumstances, the RSI does need to be rapid, but it can’t be rushed and has to be safe.

In the pre-hospital environment, pre-filled colour-coded syringes and checklists can help facilitate this.  

B is for Breathing

We were presented with the findings from the paper by Leigh-Smith and Harris (2005), which challenged our views on how a tension pneumothorax can present and how this can be very different in the ventilated patient vs the spontaneously breathing patient. In the latter, the cardiorespiratory compromise can present much more insidiously, contrary to traditional teaching. We must therefore always be vigilant of this in chest trauma patients. 

We covered the concept of pain contributing to ventilatory failure, and that aggressively analgesing patients with something rapidly-titratable, e.g. Fentanyl, to eliminate this, can avoid proceeding to invasive procedures that they may not have needed. If patients continue to be hypoxic following this, they may well have ventilatory pathology such as a lung contusion, so following on to RSI and PPV is justified. 

C is for Circulation

Little et al (1995) – It can be challenging to establish a patient’s circulatory status from any non-invasive monitoring, so placing an arterial line during the primary survey is recommended. 

Giving balanced, warmed products to a child via a Belmont or Ranger should be familiar to the resus team, and incorporating this into your local trauma simulations can promote retention and application. Cold products do not make for a happy gas! 

We covered LOST or “Low Output State due to Trauma”, which is a conceptual reframe proposed by Watts et al to describe what actually happens in TCA vs medical cardiac arrest.  The patient is not in “true” cardiac arrest in the sense that the heart has failed due to an electrical or myocardial issue – the heart may still be capable of generating output, but cannot do so because of hypovolaemia, tension pneumothorax or cardiac tamponade. This is important as it shifts the emphasis from CPR and defibrillation to HOTT principles.

D is for Disability

In a hyperacute head injury, cardiovascular compromise can occur even in the absence of direct trauma to the chest, due to dysfunction of the neuro-respiratory and neuro-cardiac axis and the subsequent catecholamine surge. A primary survey is therefore still essential, even in seemingly isolated head injuries. The ETCO₂ can provide a clue as to whether the cardiovascular findings are due to haemorrhage or head injury – in bleeding patients, this will be low (but their PaCO₂ will be normal). But in head-injured patients, the ETCO₂ is normal. 

If a scalp wound is exsanguinating, consider placing a few stay sutures to control haemorrhage temporarily. 

E is for Early Correction?

We touched on the importance of metabolic resuscitation, which means TCA isn’t just about hypovolaemia or tamponade. It’s also a state of severe acidosis, hypocalcaemia, hypomagnesaemia, mitochondrial failure and oxidative damage. Early correction of this is a vital component of the resuscitation process. 

And of course, we couldn’t talk about TCA without mentioning resuscitative thoracotomy! Hot off the press were the findings from Perkins et al’s 2025 retrospective cohort study looking into survival outcomes for TCA for those having had resuscitative thoracotomies. The key findings are on the slide below. Essentially, there is only a brief window for intervention, and survival outcomes are best when the underlying pathology is tamponade.

To sum up, Jake’s take-home messages were:

Insights from the Violence Reduction Academy (VRA) – Michael Carver

We heard from Michael Carver, Clinical Lead at the VRA, about the NHS London Violence Reduction Programme, which was set up in 2019 to help clinical teams address youth violence in ways that work for communities.

The estimated cost of violence to the NHS is enormous.

Violence is not a criminal justice issue alone. There is a need for multi-agency collaboration for violence-reduction strategies to be impactful. Health agencies are also expected to be part of efforts to prevent and reduce serious violence.

Each level of the pyramid above represents opportunities for targeted intervention. Most of our resources are spent at the tip of the pyramid (for instance, after someone is injured or arrested). Still, the most significant impact on patients comes from investment at the base – early education and prevention, just as in disease prevention. We must act early, understand risk factors, and build resilient communities to reduce long-term harm.

One of these targeted interventions is the provision of hospital-based navigators, who can make contact with young people in the ED affected by violence at that critical or “reachable” moment. It consists of tailored support by an experienced advocate, who can then liaise with multiple professionals on behalf of the young person and family. The young person’s relationship with their key worker becomes a trusted one.

Research outcomes include reduced re-injury and re-attendance at hospital, improved wellbeing, improved relationships, and improved engagement with employment and education. In a 5-year evaluation of the programme at Royal London Hospital, the re-attendance rate was reduced from 18% to 8%.

Trauma in Hazardous Areas: Insight from a Specialist Paramedic – Thomas Hammond

We received a privileged and rare insight into the world of the Hazardous Area Response Teams (HART).

HART are specially recruited and trained personnel who provide ambulance response to major incidents involving hazardous materials (or hazardous environments) that have occurred as a result of an accident or been deliberately caused. Each region in the UK has a HART team. They train for all eventualities and train regularly (each 6-week rota includes 1 week of training) so that the kit and drills are familiar.

In a major incident, the Hot Zone is the area with the highest risk and potential for exposure to hazards, requiring responders to wear specialised protective equipment. It is for life-saving interventions only, but time on scene should generally be minimised as well.

Lessons shared by Tom from his experience were that:

– Risks are dynamic, and things change fast, so you don’t have to stick to a plan. Leave your ego at the door, be a good leader, and recognise and admit when you need to change tack. Listen to your team and be prepared to adjust plans as situations change.

– It’s never going to be perfect – make it happen!

Suppose you’re thinking of becoming a HART paramedic. In that case, you volunteer for the role and embark on a gruelling recruitment and selection process over a few days, consisting of a physical assessment. The words “being in water, being at height and being in small spaces” were mentioned (and this was before the interview itself!), and it was at this point that I knew it wouldn’t be for me (!). The training course lasts around 2-3 months.

Paediatric Abdominal and Thoracic Trauma – Mr Shallinder Singh

In this lecture, Mr Singh shared some of the many insights he gained throughout a paediatric surgical career spanning India, Australia, the Middle East, the USA and the UK.

He began his talk with a discussion of the differences between adult and paediatric physiology and how these relate to trauma scenarios; children often maintain their systolic blood pressure until 40% of circulating volume is lost (compared to 10% in adults), and therefore, a normal BP should never reassure the clinician. Diastolic blood pressure can often be a helpful indicator; however, when a child loses 10% of their circulating blood volume, diastolic BP rises, narrowing pulse pressure.

Trauma is classified as injury to a solid organ, a visceral organ and other injuries.  An important point to cover while history taking for Mr Singh is how much initial blood loss there was, and how much blood loss there was on the way. This is particularly important in penetrating trauma as it’s not contained so it cannot be estimated in theatre.

CT is very valuable in aiding diagnosis and the grade of traumatic injury. However, one must note that free air secondary to a hollow viscous injury may not be visible on initial scan. 

Liver and splenic traumatic injuries are increasingly managed non-operatively. Angiographic embolisation is another option if a blush is seen on CT. Operative management includes splenectomy (done in more resource-poor settings where PICU/intensive monitoring is not available) or splenorrhaphy or partial splenectomy (preferred to save splenic function, but requires staff experience and a haemodynamically-stable patient).

Non-operative management prevents overwhelming post-splenectomy sepsis (OPSS), and so we see lower morbidity rates compared with laparotomies. In conservative trauma management, the splenic salvage rate is 90%, but when surgically intervening, this drops to 40% – mainly because you’re more likely to proceed then to do something with the spleen!

With traumatic liver injuries, 95% of cases are managed non-operatively. Indications of surgical intervention include peritonitis, ongoing haemorrhage, or haemodynamic instability.

The 3P’s of liver trauma surgery are  “pressure, packing and Pringle’s manoeuvre” (Pringle’s = clamping of the hepato-duodenal ligament). Caution must be taken when packing, as overpacking can impair venous return or lead to portal venous thrombosis. Packing is most useful in the right lobe and with venous bleeds. It is less helpful with the left lobe (as it is not as easily compressed against the diaphragm or chest wall) or arterial bleeds.

If the patient continues to bleed despite these interventions, damage control surgery or definitive intervention may be required.

Mr Singh also discussed thoracic trauma, highlighting how, unlike abdominal trauma, CT is rarely required in these cases, with chest x-rays typically being sufficient. Indications for emergency thoracotomies were highlighted.

Imaging in Paediatric Trauma: RCR updates and more – Dr Katherine Halliday

As President of the Royal College of Radiology, there was nobody better placed to deliver this update than Dr Halliday. For the recent update from the College itself, see

Major paediatric trauma radiology guidance | The Royal College of Radiologists, as well as this smashing post from our very own friends here at DFTB…

Imaging in paediatric trauma- what’s new? – Don’t Forget the Bubbles

Neurodiversity in Trauma: Diverse or Divided? – Dr Kirsty Challen

The scene was set for this session with the case of a 16-year-old boy with autism, crushed by a car while working at a garage. A trauma call and primary survey are done in the Emergency Department; no life-saving interventions are needed. CT shows a small traumatic subarachnoid haemorrhage, rib fractures, and pulmonary contusions. In the ideal scenario, after good management and a stay on the trauma ward, he goes home – everyone is happy.

But his actual story went differently.

Management included a scoop, immobilisation, and IV lines. He became scared, overwhelmed and dysregulated. It was assumed he could not communicate. He was held down for interventions, became more dysregulated, and could not be safely managed.

He was intubated and went to Intensive Care. He is stepped down overnight – to an adult ward. Lights on, alarms going off, and resistance to his parent staying. In the end, they self-discharged against advice.

You can see the difference from the ideal scenario here.

The speaker linked this case to the Swiss Cheese Model we talked about in Human Factors. What lines of defence could have improved his care?

My main take-home messages from this session were:

– Healthcare settings can be challenging for everybody, especially people with neurodiversity. Not only in terms of environment and accessibility, but all–cause mortality rates are higher in people with autism than in those without. We should be aware of this and think about how we can do better.

– Take a look at Autistic SPACE. This is a framework that considers five core autistic needs, as well as physical, processing, and emotional space. Being aware of these, even making small adjustments for our neurodiverse patients, could improve their experiences and outcomes.

– Your colleagues, or even you, may be affected by neurodiversity. Autistic Doctors International was sign-posted to by Kirsty here, and we were encouraged to be more aware of our neurodiverse colleagues.

– Tune in to reasonable adjustments. Look after each other.

Paediatric Ophthalmic Emergencies – Ms Siobhan Wren

For a patient, the possibility of losing their sight can be deeply distressing. Siobhan briefly covered some sight-threatening presentations and some pearls of wisdom from her experience as a consultant ophthalmologist.

Chemical injuries

Patient comfort is paramount to allow for thorough irrigation (proxymetacaine for topical anaesthesia and ketamine for sedation). We covered the ingenious idea of using nasal cannulae for bilateral eye irrigation, allowing saline to trickle from above. 

Hyphaema

Elevate the head of the bed to prevent a secondary bleed.

Trauma Sim Workshop

To end Day 1, Demetri and Sandi consolidated our learning and put it into practice by attending the trauma simulation workshop with Dr David Smith, where we had the opportunity to participate in a high-fidelity simulation alongside our colleagues.

Our young person was the victim of a stabbing and required a resuscitative thoracotomy for his TCA. We covered the TCA algorithm, the human factors involved in a TCA resuscitation, and some procedural skills.

One of the discussion points was the need to be mindful of communicating to the broader team that a TCA is managed differently from a medical cardiac arrest, which is why standard CPR is omitted.

For team members unfamiliar with TCA, the concept can be very alien and difficult to comprehend, given that all we are taught from the moment we learn BLS is that “time of the chest is detrimental to patient outcome”.

Minor Injury Workshops

Tasnim, Sandi, and Wei opened their second day with the minor injury session, a set of skills-based workshops covering both common and less common procedural skills.

We had a go at applying steristrips and triangular bandages with Amie Clelland, ACP from QMC.

We covered skin traction for femoral shaft fractures with Angel Timmons, a Band 5 nurse from Paeds ED in QMC and ENP Ryan Clarke.

We met Matt Batten and Chris Hickey from Teleflex, who demonstrated their impressive wound packing simulators, and practised packing a wound and applying adequate pressure against the clock!

We finished with a whistlestop tour into the world of plastering with Sister Liz Allen and ENP Saya Thompson. We concluded that applying a pretty but functional backslab is far easier than it looks!

Spinal Trauma in Paediatric Patients – Mr Shakil Patel

In this talk, Mr Patel shared insights and lessons from his career as a spinal surgeon, focusing on managing traumatic spinal injuries. He highlighted that spinal trauma is uncommon, but comes with many challenges – including potentially devastating and often lifelong consequences; managing patient expectations; anaesthetic considerations; compliance issues with therapies; and the innate difficulty of fixing tiny bones!

Clinical assessment of a child’s spine, therefore, involves a high index of suspicion, checking for neurological dysfunction (they have a SCI or TBI until proven otherwise), and serial neurological exams.

It is important to note that immediate neurological dysfunction may not exist – it can take up to 5 days to develop. There can also be delayed recognition in non-verbal, younger children. If a significant concern exists, safe immobilisation followed by CT of the cervical spine is recommended.

Canadian C-Spine, NEXUS or PECARN clinical decision aids are recommended to guide imaging decisions. The latter has helped reduce CT imaging from 17 to 6% of cervical spinal injuries in children in centres using the PECARN C-Spine tool.

The Role of Clinical Psychologists in Supporting Teams – Dr Beth Thompson and Dr Rachael Staniec

We were introduced to this novel service at Queens Medical Centre in Nottingham, whereby a dedicated clinical psychology team is located within the ED.

There is definitely a need for this, with 49% of ED staff complaining of unwanted images and memories, 40% at high risk of mental health problems, 71% reporting burnout and 65% citing work stressors as negatively impacting their mental health (Ford 2021, Jachman et al 2025, Howard 2018, McAleese et al 2016, Mind 2015-2023).

A few years ago, Mind launched the Blue Light Programme, looking at the impact of workplace environment on pre-hospital and ED staff (read more, here https://www.mind.org.uk/news-campaigns/campaigns/blue-light-programme/)

In QMC, initial support was identified for staff through self-referral, 1:1 consultation, reflective practice, check-ins following debriefs, and teaching and training.

We were introduced to the concept of “big T” and “little t” traumas.

Little t-traumas often get brushed under the carpet, but these can accumulate and create big T-like symptoms over time. And whilst the big T-traumas can’t be avoided in emergency medicine (exposure to major trauma, death and dying, violence, etc), if the little t-traumas can be supported (system failure, high-pressure decision making, shift work, sleep deprivation) then this can weather the storm when the big T-traumas happen.

The many ways that trauma can affect individuals and teams are outlined below:

Psychology supports this by using a tiered model, such as the one below:

But the service or department might need one thing and individuals something else, so it can be a complex balancing act between trying to serve both equitably.

The team at QMC is already unsurprisingly seeing growing demand from staff and is looking to expand to meet this demand. So far, the reasons for accessing the service have primarily been due to burnout, a traumatic event at work or a personal trauma.

They have created a wellbeing flow chart, enabling quick signposting of staff to available services and, as they expand, they hope to create a hot debriefing pathway, wellbeing initiatives and training initiatives regarding wellbeing within the ED.

If you are interested in becoming a Clinical Psychologist, the pathway involves a 3-year undergraduate degree +/- a 1-year master’s degree. This is then followed by an average of 5-8 years’ work in the NHS or private settings, a 3-year doctorate (DClinPsy) and subsequent HCPC registration. You then start at Band 7 or Band 8a.

The many roles of a clinical psychologist are to do indirect and direct assessments to help them to understand how problems have developed and what’s keep them going (this is referred to as “formulation”), the interventions themselves, evaluation of service, research, supervision and consultation, teaching and training and service development (i.e. how they can help managers and departments to support a service and staff).

Explore more about the career here, https://www.healthcareers.nhs.uk/explore-roles/psychological-therapies/roles/clinical-psychologist.

And, a thought to leave you with,

“Resilience is not about being able to tolerate everything. It’s about understanding the impact of stress and trauma and creating the right conditions for healing” – Gabor Maté.

The speakers have invited anyone with questions or reflective comments to contact them.

Dr Beth Thompson – Bethany.thompson19@nhs.net

Dr Rachael Staniec – r.staniec@nhs.net

Nuhnt.edpsychology@nhs.net

NAI Police Perspective – DI Gail Routledge and Tessa Buxton, Nottinghamshire Child Abuse Investigation Team

We had an insightful and moving talk from the Child Abuse Investigation Unit but given the sensitive nature of the cases discussed and current legal proceedings, we are unable to share detailed information about the session.

We learnt that the purpose of CAIU is to safeguard and protect children, investigate offences against children and prosecute offenders. And Gail and Tessa shared with us a few things to bear in mind as emergency department staff:

Keep clothing as evidence – even in a bag at the end of the bed. This can be vital for prosecutions.

Be aware that the police might want a blood sample from a child – this will be for toxicology.

Major Trauma Updates and Insights from a Major Trauma Lead – Dr Rachel Tricks

We were thrilled to hear from Rachel, Major Trauma Lead at Sheffield Children’s Hospital, a dedicated paediatric major trauma centre. Drawing on experience from both mixed and specialist centres, Rachel shared insights into national and local challenges – from staffing pressures and block funding to the closure of Trauma Audit and Research Network (TARN) and complex network coordination.

Notably, April saw a spike in severe injuries, with a bimodal arrival pattern (17:00 and 20:00), and road traffic collisions accounted for 40% of all injuries. These mainly involved isolated head injuries. Data on length of stay and mechanisms of injury are similar to those in the national registry.

Despite reducing staffing and expertise, the team takes pride in their dedicated rehabilitation service and continues to push forward with new trauma pathways and simulation-based training. Rachel’s reflections?

Civility Saves Lives: Excellence Through Inclusivity – Dr Heena Yousaf

This was a talk I was really looking forward to as I am a huge advocate and enthusiastic supporter of the Civility Saves Lives campaign, and Heena did not disappoint. This was a thought-provoking and, at times, a humbling talk.

Heena’s definition of “Civility”? “ Respectful, inclusive and professional behaviour in every interaction”, where the term “respectful” means valuing one another, irrespective of the person or their background, “professional” means upholding our core values, and “inclusivity” is the culture of valuing the lived experiences of everyone, regardless of background.

To be included in any conversation, it is essential to feel psychologically safe, where we can speak freely and feel listened to. When present, it has been shown to improve team cohesion and, in turn, patient outcomes.

We were presented with the famous studies by Katz et al., Riskin and Erez, and Rosenstein et al., all showing that when rudeness is present, it increases errors.

The clinical implication? Even subtle rudeness can significantly compromise patient safety by degrading team function in critical moments. We were asked to imagine, “how do you feel if you are being criticised whilst doing a task?”

We were introduced to the concept of “social capital”, which refers to the networks, relationships and shared values that exist within a group and which we can draw upon to support one another and achieve our common goals. If you like, it’s the “glue” that holds society together, and it plays an integral part in wellbeing, team efficiency, improved patient outcomes, and reduced burnout. Getting to know the person behind the job role helps improve how we work together as a team and leads to long-term gains, but for these initiatives to be successful, they need to be senior-led.

The NHS is a richly diverse workplace, and interacting with people from varied backgrounds broadens your outlook and fosters greater inclusivity by exposing you to different viewpoints. This ultimately leads to better patient outcomes by improving communication (adapting your language and being sensitive to cultural norms), reducing health inequalities through increased awareness of systemic barriers, enhancing cultural competence, and creating a more compassionate clinical environment. A win-win!

To read more about this movement, click here https://www.civilitysaveslives.com.

Managing Trauma in a DGH – Dr Cat Hearnshaw and Dr Jon Riley

This session was presented by speakers from DGHs in the East Midlands, about 30 minutes from the Major Trauma Centre.

They presented an interesting case series of four children with handlebar injuries, seen over a few months, and all managed in different ways. The pathway was different for each one. This was very relatable for those of us working in Trauma Units!

We can all take this back to our own Trauma Units to improve the care of Children and Young People with trauma.

Hypothermic Cardiac Arrest – Dr Patrick Davies, PICU Consultant, NUH

In this talk, we learnt about “very cold humans”.

Did you know that 11.8°C is the lowest temperature survived by any human?!

Our heart stops because of the progressive impairment of our voltage-gated sodium, potassium and calcium channels. The action potential duration and QT interval progressively lengthen as our sino-atrial node is suppressed at lower temperatures. At <30°C, it may fail, and at 20-24°C, we become asystolic.

At 13^°C, our brain stops working.

The colder you are, the longer you can survive cardiac arrest. You have 3 minutes of brain function at 100% metabolism, and essentially, the faster you cool, the more time you can buy yourself.  However, getting this cold rapidly enough is difficult in the UK climate.

We were reminded that brain temperature is not the same as core temperature. There are purpose-made devices that can be used on scene and beyond to achieve rapid brain cooling, e.g., the aptly named “RhinoChill”.

That’s all very well and good for your brain, but how about the rest of our body?

Hutchinson et al found that hypothermic children with severe TBI have worse survival rates than normothermic patients (doi: 10.1056/NEJMoa0706930). And so, warming these patients is an integral part of the resuscitation.

Patrick pointed out that passive warming methods (covering with blankets, drying patients, reducing air flow and warming the environment) only work if you are generating heat, i.e. they are methods that stop heat loss, but don’t generate heat for you, and patients certainly aren’t generating any heat whilst they are in arrest.

This is why we require active warming methods (hot water bottles, heated ventilator gases, warmed IV fluids, cavity heating, ECMO (extracorporeal warming).

We should be aiming for a 1-degree increase per hour (0.5-2 °C).

We were reminded of the phenomenon of “afterdrop,” in which a patient’s core body temperature continues to fall even after they’ve been removed from the cold environment and after rewarming has begun. This is because you initially vasoconstrict in the cold environment, then vasodilate as you warm up, causing cold, acidic, hypoxic blood from the limbs to move centrally, then leading to a further drop in core temperature. This can lead to cardiac instability or even arrest, so be wary that active rewarming isn’t occurring too quickly.

PEM Adventures with Dr Dani Hall, Dr Kat Priddis, Dr Rachael Mitchell, Dr Sarah Davies, Dr Constantinos Kanaris, Dr Arun Gulati and Dr Victoria Meighan

Narrated by our very own Dr Dani Hall, the team took us through a simulated journey with Ian, a 7-year-old boy who has sustained severe burns and potential blast injuries. There was a focus on clinical and non-technical aspects.

From a clinical perspective, key points in management in such a case are:

C: Consider major haemorrhage in such trauma.

A: This should be presumed to be difficult – video laryngoscopy is valuable and likely to increase the success of intubation.

c: Manual in-line stabilisation is important but can be challenging, especially when the airway is ‘difficult’. (Link to Mr Patel’s talk…)

B: As part of the breathing assessment, POCUS can be helpful. B lines can be seen in blunt thoracic trauma from pulmonary contusions or blast lung. 3 or more B lines per rib space are sensitive but not specific for interstitial fluid and may represent blast lung or contusion, but 6 or more B lines per rib space are sensitive and specific for contusion.

When ventilating such patients, generally aim for low tidal volumes (6mL/kg), permissive hypercapnia (titrate pCO2 to maintain pH >7.15-7.20), and a longer Ti (1.2 seconds).

C: Burn size is often overestimated – use an appropriate tool to help you! Burns over 15% TBSA trigger burns-related fluid resuscitation. Evidence for coefficients to use in calculations varies so use your local guidance.

D: Burns are painful. Ensure adequate analgesia. Ketamine and Fentanyl are good options.

Cyanide toxicity is a distinct possibility where there has been a house fire. The clinical picture is one of a worsening lactic acidosis with high venous oxygenation. Hydroxycobalamin is the best treatment option. Remember to look at the carboxyhaemoglobin on the gas, too, and treat CO poisoning as required!

E: Ensure appropriate temperature management with the use of a Bair Hugger and warmed fluids. 

Microaggressions can affect team dynamics and clinical performance. Use tools like LIFT to call them out for a safer, more respectful working environment.

Shamelessly flying the flag for the DFTB PEM MSc in association with QMUL, from left to right, Dr Arun Gulati, Dr Marius Constantin, Dr Sandi Angus, Dr Demetris Athanasiou, Dr Tasnim Ransome, and Dr Wei Kang Yap. Find out more about the MSc here https://www.qmul.ac.uk/postgraduate/taught/coursefinder/courses/paediatric-emergency-medicine-online-msc/.