Summary of NICE Guidance
- Take the patient to a trauma centre
- Use RSI to secure the airway where needed within 45 mins of call
- If RSI fails use basic airway manoeuvres and adjuncts and/or a supraglottic
device
- Assess for PTX clinically and perhaps use USS (eFAST) though can be false negative.
- Chest decompression with suspected tension PTX only if haemodynamic instability or severe respiratory compromise.
- Open thoracostomy instead of needle decompression preferred then chest drain via the thoracostomy in patients who are breathing spontaneously
- Observe for recurrence of Tension PTX
- Open PTX the cover with occlusive dressing and observe for recurrence of Tension PTX
Imaging chest trauma
- Consider CXR and eFAST and then CT chest. Not routine in children
- Use whole-body CT (vertex-to-toes scanogram followed by a CT
from vertex to mid-thigh) in adults (16 or over) with blunt major trauma and
suspected multiple injuries.
- Patients should not be repositioned during
whole-body CT.
Haemorrhage
- Use simple dressings with direct pressure to control external haemorrhage.
- Major limb trauma use a tourniquet if direct pressure has failed and life-threatening haemorrhage.
- If active bleeding is suspected from a pelvic fracture after blunt high-energy
trauma apply a purpose-made pelvic binder or consider an improvised pelvic binder, but only if a purpose-made binder does not fit.
- Use intravenous tranexamic acid as soon as possible in patients with major
trauma and active or suspected active bleeding. Do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma unless there is evidence of hyperfibrinolysis.
Anticoagulant reversal
- Rapidly reverse anticoagulation in patients who have major trauma with
haemorrhage.
- Use prothrombin complex concentrate immediately in adults (16 or over) with
major trauma who have active bleeding and need an emergency reversal of a
vitamin K antagonist. Do not use plasma to reverse a vitamin K antagonist in patients with major
trauma.
- Do not reverse anticoagulation in patients who do not have active or suspected
bleeding. Take haematology advice.
- Use physiological criteria and response to immediate volume resuscitation to activate the major haemorrhage protocol. Do not rely on a haemorrhagic risk tool applied at a single time point to determine the need for major haemorrhage protocol activation.
- For IV access with major trauma in pre-hospital settings use peripheral intravenous access or if peripheral intravenous access fails, consider intra-osseous access
Volume Resuscitation
- Patients with active bleeding use a restrictive approach to volume
resuscitation until definitive early control of bleeding has been achieved.
- 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.
- For patients who have haemorrhagic shock and a traumatic brain injury:
if haemorrhagic shock is the dominant condition, continue restrictive volume
resuscitation or if traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion.
- In pre-hospital settings only use crystalloids to replace fluid volume in patients
with active bleeding if blood components are not available.
- In hospital settings do not use crystalloids for patients with active bleeding
- For adults (16 or over) use a ratio of 1 unit of plasma to 1 unit of red blood cells
to replace fluid volume.
- For children (under 16s) use a ratio of 1 part plasma to 1 part red blood cells,
and base the volume on the child's weight.
Damage control surgery
- Use damage control surgery in patients with haemodynamic instability who are
not responding to volume resuscitation.
- Consider definitive surgery in patients with haemodynamic instability who are
responding to volume resuscitation.
- Use definitive surgery in patients whose haemodynamic status is normal.
References