So NICE has published it’s guidelines on ‘Major trauma; assessment and initial management’, obviously it would be ideal for you to run through the full document yourself but to give you a flavour of the key points that we think will affect our practice here are what we consider to be the headlines;
So the guideline is split up into 10 major sections and we’ll take the key points from each 1 by 1….
1. Immediate destination after injury
Nothing major here but that the optimal destination for patients with major trauma is the major trauma centre, only exceptional circumstances or locations should they first go to the trauma unit for urgent treatment. A reasonable example would be inadequate airway management where local expertise at a trauma unit is required to secure the airway where it would be unsafe to convey the patient further to an MTC.
2. Airway management in pre-hospital and hospital settings
When an RSI is indicated this should be performed as soon as possible and within 45 minutes of the initial call to emergency services and preferably at the scene of the incident.
Transport the patient to a major trauma centre for RSI providing the journey time is 60 minutes or less & only divert to a trauma unit for RSI before onward transfer to if a patent airway can’t be maintained or the journey time is greater than 60 minutes.
3. Management of chest trauma in pre-hospital settings
Regarding eFAST; only to be used if specialist team can utilise without delaying onwards transfer, beware that negative eFAST doesn’t rule out a pneumothorax.
Only perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise and open thoracostomy instead of needle decompression should be used where expertise is available. Followed by a chest drain via the thoracostomy in patients who are breathing spontaneous (I’m not sure but it seems from the guidelines that this is recommended to be placed prehospitally).
Beware of conversion of an open pneumothorax to a tension once decompressed.
4. Management of chest trauma in hospital settings
In tension pneumothorax perform chest decompression before imaging only if they have haemodynamic instability or severe respiratory compromise (this is a strange one as a tension pneumothorax would be defined by haemodynamic instability or severe respiratory compromise….)
Consider CXR/eFAST as part of the primary survey assess chest trauma in adults with severe respiratory compromise.
Do not routinely use CT for 1st line imaging to assess chest trauma in children (under 16′s).
5. Management of haemorrhage in prehospital and hospital settings
Regarding pelvic binders; if active bleeding is suspected from a pelvic fracture after a high energy trauma apply a purpose made binder or consider an improvised binder only if the purpose made binder does not fit.
Use TXA as soon as possible in patients with major trauma and active or suspected bleeding but not more than 3 hours after injury unless there is evidence of hyperfibrinolysis.
Rapidly reverse anticoagulation in patients who have major trauma and active or suspected active bleeding; use prothrombin complex concentrate immediately for active bleeding needing reversal if vitamin K antagonists.
Fluid resuscitation should be with blood products. In pre-hospital settings only use crystalloids to replace fluid volume in patients with active bleeding if blood components are not available and once in hospital do not use crystalloids for patients with active bleeding.
In pre-hospital settings, titrate volume resuscitation to maintain a palpable central pulse (carotid or femoral).
In hospital settings, move rapidly to haemorrhage control, titrating volume resuscitation to maintain central circulation until control is achieved and use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.
Limit diagnostic imaging (such as chest and pelvis X‑rays or FAST [focused assessment with sonography for trauma]) to the minimum needed to direct intervention in patients with suspected haemorrhage and haemodynamic instability who are not responding to volume resuscitation.
Use interventional radiology techniques in patients with active arterial pelvic haemorrhage unless immediate open surgery is needed to control bleeding from other injuries.
6. Reducing heat loss in prehospital and hospital settings
Minimise ongoing heat loss in patients with major trauma.
7. Pain management in pre-hospital and hospital settings
Use intravenous morphine as the first‑line analgesic in major trauma and adjust the dose as needed to achieve adequate pain relief and if i.v. access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamine.
Consider ketamine in analgesic doses as a second‑line agent.
8. Documentation in prehospital and hospital settings
The trauma team leader should be easily identifiable to receive the handover and the trauma team ready to receive the information.
Produce a written summary, which gives the diagnosis, management plan and expected outcome.
9. Providing support
If the patient agrees, invite their family member, carer or friend into the resuscitation room. Ensure that they are accompanied by a member of staff and their presence does not affect assessment, diagnosis or treatment.
10. Training and skills
So lastly the guidelines state as you might expect that all staff should be up to date with this guideline and should have up to date training for the interventions that they are required to deliver.
So as previously mentioned these are just a handful of the points and guidance contained within the document. Make sure you have a look through it yourself here and we’ll release a podcast summing up these points in the next week or so.