Major trauma is the leading cause of morbidity, mortality and reduction in quality of life in the under 40 age group.

The impact on healthcare costs is also significant, with lengthy hospital admissions, intensive care stays and rehabilitation (McCullough et al 2014).

Recently updated guidelines (NICE (2016) ) illustrate the extensive suite of knowledge and skills required in the provision of effective trauma care – care based on the best available evidence and provided systematically, with speed, accuracy and with good clinical judgement (Glen 2016). The provision of care supported by the best available research forms the basis to decreasing the impact of major trauma.

The NICE (2016) “Major trauma – assessment and management” guidelines focus on ten recommendations, with the overriding goal being to provide rapid, effective, and accurate care that targets life threatening conditions.

Here we provide a summary of each recommendation; however readers are encouraged to review the guidelines for an in depth understanding of their scope.

1.1 Immediate destination after injury

A major trauma centre is the optimal destination. However intermediate urgent care provision should be provided in regional settings until transfer to a major centre can occur.

1.2 Airway management

Airway management following trauma is acknowledged as extremely challenging. Rapid sequence induction (RSI) combining anaesthesia and intubation is the preferred method for airway management and ventilation for patients unable to manage their airway. If RSI is unsuccessful, basic airway management with the use of a supraglottic device is recommended until a surgical airway can be performed.

1.3 Chest trauma in a prehospital setting

Thoracic injuries are the leading factors in patient morbidity and mortality following trauma (Yamamoto 2005). Rapid clinical assessment to identify and manage pneumothorax is a key element in the guidelines. In the pre-hospital setting, tension pneumothorax should be managed rapidly, with the use of an IV cannula inserted into the second intercostal space. This is considered an adequate approach, however if the expertise is available, the performance of an open thoracostomy can be considered.

1.4 Chest trauma in hospital

In the hospital setting, the guidelines recommend open thoracostomy and chest drainage following imaging. However in cases of patient instability associated with respiratory distress or haemodynamic instability, chest decompression can be performed prior to imaging.

1.5 Management of haemorrhage

The guidelines recommend a straightforward approach to simple haemorrhages with the use of dressings and direct pressure. In addition, the use of tourniquets for limb trauma is recommended for life threatening blood loss, and pelvic binders for pelvic fractures.

For fluid replacement, IV access should be provided peripherally or intraosseously until central access can be obtained. Volume resuscitation and fluid replacement protocols should be developed in line with the guideline recommendations for both pre-hospital and in-hospital settings.

1.6 Reducing heat loss

Minimisation of heat loss to patients is a key element related to all trauma management.

1.7 Pain management

The use of a pain scale to regular monitor pain levels is recommended. IV morphine is recommended as first line analgesia with ketamine as second line treatment.

1.8 Documentation

Documentation is an essential element of best practice in major trauma both in the pre-hospital and in-hospital settings. Clinical documentation should cover airway, breathing, circulation, disability (neurological impairment), exposure and environment.

Recording and sharing of information must be structured, whether paper based or during handover. Ready access to the patient’s records is also essential. A written summary should also be provided to the patient’s GP within 24 hours of admission to hospital. This is essential in maintaining continuity of care.

Information provided to the family should be written in plain language and cover diagnosis, management plan and the expected outcome.

1.9 Information and support

Honesty, managing expectations and offering support are the three key elements necessary in communication with family members and carers and friends with frequent updates on patient status provided.

Patients should also be offered access to support, by family members, friends, or others, during their treatment, if deemed appropriate by the treating team. For vulnerable adults and children, a member of the staff should be allocated to provide support and to provide information.

1.10 Training and skills

Maintaining clinical skills is essential in the provision of care to ensure it is delivered safely, efficiently and effectively. Employers must support their trauma team in providing access to regular clinical updates and refresher training. Further education is also required for health professionals working with children, with a particular focus on child safety and managing family distress being of great importance.

Summary

The provision of care to patients impacted by major trauma must be based on the best available evidence and delivered systematically, efficiently and effectively. The NICE guidelines for “Major trauma – assessment and management” provide a structured approach in the delivery of this care.

It is critical that in both pre-hospital and in-hospital settings, policies and protocols developed for managing trauma patients reflect the best available evidence. Good patient outcomes are dependent on the strength of evidence available in the delivery of effective trauma management and care.




References:

1. Glen, J. (2016). Assessment and initial management of major trauma: summary of NICE guidance. BMJ, 353, 3051
2. Hodkinson, M. (2016). A critical review of NICE Guideline 39 – major trauma: assessment and initial management, Journal of Paramedic Practice, (8), 5
3. McCullough AL, Haycock JC, Forward DP, Moran CG. (2014). Early management of the severely injured major trauma patient, Br J Anaesth. 2014 Aug;113(2):234-41
4. NICE. (2016). NICE guidelines Major trauma: assessment and initial management https://www.nice.org.uk/guidance/ng39/chapter/recommendations
5. Yamamoto, I., Schroeder, C., Morley, D., Beliveau, C. (2005). Thoracic trauma: the deadly dozen, Crit Care Nurse Q, 28 (1), 22-40