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A draft of the NICE guideline on major trauma assessment and initial management, published in August 2015. It covers recommendations for managing chest trauma, haemorrhage, documentation, and information and support for patients and their families. The guideline aims to improve outcomes for major trauma patients by providing evidence-based guidance on best practices.
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Major trauma: assessment and initial management: NICE guideline short version
Major trauma: assessment and initial management: NICE guideline short version
This guideline covers the care of people with major trauma in pre-hospital and hospital settings. It includes recommendations on managing: the airway chest trauma haemorrhage shock temperature pain. The guideline does not cover people with burns, spinal injuries (see the draft NICE guideline on spinal injury) or complex fractures (see the draft NICE guideline on fractures [complex]). Who is it for? People with major trauma, their families and carers. Healthcare professionals and practitioners who provide care for people with major trauma in pre-hospital and hospital settings. This version of the guideline contains the recommendations, context and recommendations for research. The Guideline Committee’s discussion and the evidence reviews are in the full guideline. Other information about how the guideline was developed is on the project page. This includes the scope, and details of the Guideline Committee and any declarations of interest. 2 3
Major trauma: assessment and initial management: NICE guideline short version
People have the right to be involved in discussions and make informed decisions about their care, as described in Your care. Using NICE guidelines to make decisions explains how we use words to show the strength of our recommendations, and has information about safeguarding, consent and prescribing medicines. Recommendations apply to both children (under 16s) and adults (over 16s) unless otherwise specified.
3 The NICE draft guideline on trauma: service delivery contains a 4 recommendation for ambulance and hospital trust boards, medical directors 5 and senior managers on drug-assisted rapid sequence induction of 6 anaesthesia and intubation. 7 1.1.1 Use drug-assisted rapid sequence induction (RSI) of anaesthesia 8 and intubation as the definitive method of securing the airway in 9 patients with major trauma who cannot maintain their airway and/or 10 ventilation. 11 1.1.2 If RSI fails, use basic airway manoeuvres and adjuncts and/or a 12 supraglottic device until a surgical airway or assisted endotracheal 13 placement is performed. 14 Airway management in pre-hospital settings 15 1.1.3 Aim to perform RSI at the scene of the incident and within 16 30 minutes of the initial call to the emergency services. 17 1.1.4 If RSI cannot be performed at the scene: 18 consider using a supraglottic device if the patient's airway 19 reflexes are absent
Major trauma: assessment and initial management: NICE guideline short version 1 use basic airway manoeuvres and adjuncts if the patient’s 2 airway reflexes are present or supraglottic device placement is 3 not possible 4 transport the patient to a major trauma centre for RSI provided 5 the journey time is less than 60 minutes 6 otherwise divert to a trauma unit for RSI before onward transfer.
8 1.2.1 Use clinical assessment to diagnose pneumothorax for the purpose 9 of triage or intervention. 10 1.2.2 Consider using eFAST (extended focused assessment with 11 sonography for trauma) to augment clinical assessment only if a 12 specialist team equipped with ultrasound is immediately available 13 and onward transfer will not be delayed. 14 1.2.3 Be aware that a negative eFAST of the chest does not exclude a 15 pneumothorax. 16 1.2.4 Only perform chest decompression in a patient with suspected 17 tension pneumothorax if there is haemodynamic instability or 18 severe respiratory compromise. 19 1.2.5 Use open thoracostomy instead of needle decompression if the 20 expertise is available. 21 1.2.6 Observe patients after chest decompression for signs of recurrence 22 of the tension pneumothorax. 23 1.2.7 In patients with an open pneumothorax: 24 cover the open pneumothorax with a simple occlusive dressing 25 and 26 observe for the development of a tension pneumothorax.
Major trauma: assessment and initial management: NICE guideline short version 1 1.4.3 Do not apply a pelvic binder unless active bleeding from a pelvic 2 fracture is suspected. 3 1.4.4 Apply a purpose-made pelvic binder in people with haemodynamic 4 instability and suspected pelvic fractures following blunt high- 5 energy trauma. 6 1.4.5 Consider an improvised pelvic binder in children with 7 haemodynamic instability and suspected pelvic fractures following 8 blunt high-energy trauma if they are too small to fit a purpose-made 9 pelvic binder. 10 Haemostatic agents in pre-hospital and hospital settings 11 1.4.6 Use intravenous tranexamic acid^1 as soon as possible in patients 12 with active or suspected active bleeding. 1.4.7 Do not use intravenous tranexamic acid 1 13 more than 3 hours after 14 injury unless there is evidence of hyperfibrinolysis. 15 Anticoagulant reversal in hospital settings 16 1.4.8 Rapidly reverse anticoagulation in patients who have major trauma 17 with haemorrhage. 18 1.4.9 Hospital trusts that admit patients with major trauma should have a 19 protocol for the rapid reversal of anticoagulation agents. 20 1.4.10 Use prothrombin complex concentrate immediately in adults with 21 major trauma who have active bleeding and need emergency 22 reversal of a vitamin K antagonist. 23 1.4.11 Do not use plasma to reverse a vitamin K antagonist. (^1) At the time of consultation (August 2015), tranexamic acid did not have a UK marketing authorisation for use in children and young people for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.
Major trauma: assessment and initial management: NICE guideline short version 1 1.4.12 Consult a haematologist immediately for advice on adults who have 2 active bleeding and need reversal of any anticoagulant agent other 3 than a vitamin K antagonist. 4 1.4.13 Consult a haematologist immediately for advice on children with 5 major trauma who have active bleeding and may need reversal of 6 any anticoagulant agent. 7 1.4.14 Do not offer anticoagulant reversal to patients who do not have 8 active or suspected bleeding. 9 Activating major haemorrhage protocols in hospital settings 10 1.4.15 Use physiological criteria that include the patient's haemodynamic 11 status and their response to immediate volume resuscitation to 12 activate the major haemorrhage protocol. 13 1.4.16 Do not rely on a haemorrhagic risk tool applied at a single time 14 point to determine the need for major haemorrhage protocol 15 activation. 16 Circulatory access in pre-hospital settings 17 1.4.17 For circulatory access in patients with major trauma in pre-hospital 18 settings: 19 use peripheral intravenous access or 20 if peripheral intravenous access fails, consider intra-osseous 21 access. 22 1.4.18 For circulatory access in children with major trauma, consider intra- 23 osseous access as first-line access if peripheral access is 24 anticipated to be difficult. 25 Circulatory access in hospital settings 26 1.4.19 For circulatory access in patients with major trauma in hospital 27 settings: 28 use peripheral intravenous access or
Major trauma: assessment and initial management: NICE guideline short version 1 Haemorrhage protocols 2 1.4.28 Hospital trusts should have specific major haemorrhage protocols 3 for adults and children. 4 1.4.29 For patients with active bleeding, start with a fixed-ratio protocol for 5 blood products and change to a protocol guided by laboratory 6 coagulation results at the earliest opportunity. 7 Haemorrhage imaging 8 1.4.30 Limit diagnostic imaging (such as chest and pelvis X-rays or FAST 9 [focused assessment with sonography for trauma]) to the minimum 10 needed to direct intervention in patients with suspected 11 haemorrhage and haemodynamic instability who are not 12 responding to volume resuscitation. 13 1.4.31 Be aware that a negative FAST does not exclude intraperitoneal or 14 retroperitoneal haemorrhage. 15 1.4.32 Consider immediate CT for patients with suspected haemorrhage if 16 they are responding to resuscitation or if their haemodynamic 17 status is normal. 18 1.4.33 Do not use FAST or other diagnostic imaging before immediate CT. 19 1.4.34 Do not use FAST as a screening modality to determine the need for 20 CT. 21 Whole-body CT 22 1.4.35 Use whole-body CT (consisting of a vertex-to-toes scanogram 23 followed by a CT from vertex to mid-thigh) in adults with blunt major 24 trauma and suspected multiple injuries. 25 1.4.36 Use clinical findings and the scanogram to direct CT of the limbs in 26 adults with limb trauma.
Major trauma: assessment and initial management: NICE guideline short version 1 1.4.37 Do not routinely use whole-body CT to image children. Use clinical 2 judgement to limit CT to the body areas where assessment is 3 needed. 4 Damage control surgery 5 1.4.38 Use damage control surgery in patients with haemodynamic 6 instability who are not responding to volume resuscitation. 7 1.4.39 Consider definitive surgery in patients with haemodynamic 8 instability who are responding to volume resuscitation. 9 1.4.40 Use definitive surgery in patients whose haemodynamic status is 10 normal. 11 Interventional radiology 12 The NICE draft guideline on trauma: service delivery contains a 13 recommendation for ambulance and hospital trust boards, medical directors 14 and senior managers on interventional radiology and definitive open surgery. 15 1.4.41 Use interventional radiology techniques in patients with active 16 arterial pelvic haemorrhage unless immediate open surgery is 17 needed to control bleeding from other injuries. 18 1.4.42 Consider interventional radiology techniques in patients with solid- 19 organ (spleen, liver or kidney) arterial haemorrhage. 20 1.4.43 Consider a joint interventional radiology and surgery strategy for 21 arterial haemorrhage that extends to surgically inaccessible 22 regions. 23 1.4.44 Use an endovascular stent graft in patients with blunt thoracic 24 aortic injury.
27 1.5.1 Minimise ongoing heat loss in patients with major trauma.
Major trauma: assessment and initial management: NICE guideline short version 1 Recording information in pre-hospital settings 2 1.7.1 Record the following in patients with major trauma in pre-hospital 3 settings: 4
Major trauma: assessment and initial management: NICE guideline short version 1 1.7.5 The trauma team leader should be easily identifiable to receive the 2 handover and the trauma team ready to receive the information. 3 1.7.6 The pre-hospital documentation, including the recorded pre-alert 4 information, should be quickly available to the trauma team and 5 placed in the patient’s hospital notes. 6 1.7.7 Assess and record the items listed in recommendation 1.7.1, as a 7 minimum, for the primary survey. 8 1.7.8 One member of the trauma team should have designated 9 responsibility for completing all patient documentation. 10 1.7.9 The trauma team leader should be responsible for checking the 11 information recorded to ensure it is complete. 12 Sharing information in hospital settings 13 1.7.10 Follow a structured process when handing over care within the 14 emergency department (including shift changes) and to other 15 departments. Ensure that the handover is documented. 16 1.7.11 Ensure that all patient documentation, including images and 17 reports, goes with the patient when they are transferred to other 18 departments or centres. 19 1.7.12 Provide a written summary within 24 hours of admission, which 20 gives the diagnosis, management plan and expected outcome and 21 is: 22 aimed at the patient’s GP 23 written in plain English 24 understandable by patients, family members and carers 25 updated whenever the patient’s clinical circumstances change 26 readily available in the patient’s records 27 sent to the patient’s GP on discharge.
Major trauma: assessment and initial management: NICE guideline short version 1 1.8.7 For a child or vulnerable adult with major trauma, enable their 2 parents or carers to remain within eyesight if appropriate. 3 1.8.8 Work with family members or carers of children and vulnerable 4 adults to provide information and support. Take into account the 5 age, developmental stage and cognitive function of the child or 6 vulnerable adult. 7 1.8.9 Include siblings of a child with major trauma when offering support 8 to family members or carers. 9 Providing information 10 1.8.10 Explain to patients, family members and carers what is happening 11 and why it is happening. Provide: 12 information on known injuries 13 details of immediate investigations and treatment, and if possible 14 include time schedules 15 information about expected outcomes of treatment, including 16 time to returning to usual activities and the likelihood of 17 permanent effects on quality of life, such as pain, loss of function 18 or psychological effects. 19 1.8.11 Provide information at each stage of management (including the 20 results of imaging) in face-to-face consultations. 21 1.8.12 Document all key communications with patients, family members 22 and carers about the management plan. 23 Providing information about transfer from an emergency department to 24 a ward 25 1.8.13 For patients who are being transferred from an emergency 26 department to a ward, provide written information that includes: 27 the name of the senior healthcare professional who spoke to 28 them in the emergency department
Major trauma: assessment and initial management: NICE guideline short version 1 how the hospital and the trauma system works (major trauma 2 centres, trauma units and trauma teams). 3 Providing information about transfer from an emergency department to 4 another centre 5 1.8.14 For patients who are being transferred from an emergency 6 department to another centre, provide verbal and written 7 information that includes: 8 the reason for the transfer, focusing on how specialist 9 management is likely to improve the outcome 10 the location of the receiving centre and the patient's destination 11 within the receiving centre 12 the name and contact details of the person responsible for the 13 patient's care at the receiving centre 14 the name of the senior healthcare professional who spoke to 15 them in the emergency department.
17 Recommendations for ambulance and hospital trust boards, and senior 18 managers 19 1.9.1 Provide each healthcare professional and practitioner within the 20 trauma service with the training and skills to deliver, safely and 21 effectively, the interventions they are required to give, in line with 22 the NICE guidelines on non-complex fractures, complex fractures, 23 major trauma and spinal injury assessment.
Major trauma: assessment and initial management: NICE guideline short version 1 2. What would help users overcome any challenges? (For example, existing 2 practical resources or national initiatives, or examples of good practice.)
4 In its 2010 report Major trauma care in England the National Audit Office 5 estimated that there are 20,000 cases of major trauma per year in England. 6 Each year 5,400 people die of their injuries and many others sustain 7 permanent disability. Every trauma death costs the nation in excess of £0. 8 million and every major injury £50,000. 9 Regional trauma networks were developed across England from April 2012. 10 Within these networks major trauma centres provide specialised care for 11 patients with multiple, complex and serious major trauma injuries, working 12 closely with local trauma units. 13 The initial assessment of a patient with major trauma is directed at rapid 14 identification of life-threatening or life-changing injuries. Clinicians conduct a 15 rapid primary survey using a prioritising sequence, such as
Major trauma: assessment and initial management: NICE guideline short version
2 The Guideline Committee has made the following recommendations for 3 research.
5 What is the clinical and cost effectiveness of point-of-care coagulation testing 6 using rotational thromboelastrometry (ROTEM) or thromboelastography (TEG) 7 to target treatment, compared with standard laboratory coagulation testing? 8 Why this is important 9 More rapid treatment of coagulopathy could reduce mortality from 10 haemorrhage, which is the main cause of death in patients with major trauma. 11 Point-of-care ROTEM and TEG are complex diagnostic tools used to detect 12 coagulopathy. They are used successfully in surgery and intensive care 13 settings. It is thought they might also be effective in targeting treatment for 14 coagulopathy in the resuscitation room. 15 Point-of-care ROTEM and TEG are faster to perform than standard laboratory 16 tests and enable an earlier transition from an initial fixed-ratio protocol to a 17 protocol guided by laboratory coagulation results. These results can be 18 updated as often as every 15 minutes, which could enable treatment to be 19 adjusted rapidly and targeted effectively. This could result in reduced use of 20 blood products and other treatments for coagulopathy. 21 The costs of point-of-care ROTEM and TEG could be offset by the changes in 22 management they lead to, which could be lifesaving, and by avoidance of 23 unnecessary transfusions.
25 Is lactate monitoring in patients with major trauma clinically and cost effective? 26 Why this is important 27 In current practice, treatment for hypovolaemic shock is guided by the 28 patient’s haemodynamic levels, including heart rate and blood pressure.
