Speak Up! Have your say on the NICE guidance for Major Trauma

NICE GUIDANCE

A draft of the NICE guidance on assessment and management of major trauma was released this morning for stakeholder consultation.

If you work in a major trauma centre, in a trauma unit – or in any institution which might receive patients with major trauma injuries, YOU are a stakeholder and NICE wants to know what you think.

I’d strongly suggest having a look at the guidance yourself: there are three key documents to look at

1. a draft of the full guideline here

2. the key recommendations here

3. the evidence behind the recommendations (appendices) here

Here’s a quick overview of the key recommendations.

Airway

Prehospital RSI within 30mins of call to emergency services; use of supraglottic airways if RSI cannot be performed (and airway manoeuvres/adjuncts if SGA isn’t possible) then transport to major trauma centre for RSI if journey time is <60mins and nearest trauma unit for RSI if not.

Chest Injury

eFAST gets a mention for rule-in of pneumothorax (but not for ruling it out); decompression of suspected tension pneumothorax before imaging is only recommended if there is cardiovascular instability or respiratory compromise and open thoracostomy (rather than needle thoracostomy) is the advised approach when indicated.

Imaging wise, CXR and eFAST are mentioned as part of the primary survey but may be omitted in favour of thoracic CT in adults where there is no severe respiratory compromise and no haemodynamic instability (or a good response to initial resuscitation). Chest CT is not, we are reminded, the first line chest imaging technique in paediatric patients.

Haemorrhage

Simple dressings are the first line treatment, with tourniquets recommended for limb injuries where simple dressings cannot control haemorrhage.

Pelvic binders are only indicated where bleeding from a suspected pelvic injury is suspected; in this case purpose-made pelvic binders should be applied with improvised pelvic binders for children who are too small for commercially available products.

Tranexamic Acid

Give as soon as possible but not >3h beyond injury unless evidence of fibrinolysis is apparent.

Anticoagulant Reversal

Reverse ASAP in major haemorrhage: if you admit major trauma patients your trust should have a protocol for reversal of anticoagulation. Prothrombin complex concentrate is advised for patients requiring reversal of a Vitamin K agonist (warfarin, sinthrome etc) rather than FFP. A haematologist should be consulted for advice on other agents or in children.

Don’t reverse anticoagulation in patients who don’t have evidenced or suspected bleeding.

Major Haemorrhage Protocols

MHP activation should be triggered by physiological criteria (including haemodynamic status and response to initial volume resuscitation), rather than haemorrhagic risk tools applied at a single time point.

Circulatory Access

IO gets the thumbs-up: both pre-hospital and in-hospital peripheral IV is first line for adults with IO recommended as a backup in case of IV failure (pending central access in hospital); IO is offered as first line for children where IV is predicted to be difficult.

Volume Resuscitation

Take a restrictive approach until control of bleeding has been achieved.

Pre-hospital: titrate to palpable central pulse; in-hospital, the priority is haemorrhage control with volume titrated to maintain central circulation until control is achieved.

In the context of traumatic brain injury (TBI) with haemorrhagic shock, if TBI is the primary problem resuscitate less restrictively whereas if haemorrhagic shock is the dominant condition maintain a restrictive approach.

Which Fluids?

Pre-hospital: use crystalloid only if blood products are not available.

In-hospital: do not use crystalloid in patients who are bleeding.

Use a 1:1 blood:plasma ratio (1 unit blood: 1 unit plasma in adults; 1 part blood: 1 part plasma in children by weight)

Haemorrhage Protocols

You should have one for adults and one for children. Start with your standard protocol and then adjust once blood results are available as per haematology advice.

Haemorrhagic Imaging

If your patient is haemodynamically unstable, limit imaging to the minimum required to direct interventions.

In haemodynamically stable patients (or those responding to resuscitation), consider immediate CT.

Remember FAST does not exclude intraperitoneal or retroperitoneal haemorrhage; do not use FAST or other imaging before immediate CT and do not use FAST to determine need for CT.

Whole Body CT

Use CT head-pelvis in adults with blunt major trauma and suspected multiple injuries. Clinical examination and the CT scanogram can help direct need for limb imaging.

Do not routinely use whole body CT in children.

Damage Control Surgery

Use damage control surgery in patients who are haemodynamically unstable and not responding to resuscitation. In other patients definitive surgery may be more appropriate.

Interventional Radiology

Interventional radiology is indicated for the treatment of arterial bleeding from pelvic fractures unless open surgery is indicated for another reason. IR may also be useful in solid organ injuries (liver, spleen, kidneys) with arterial haemorrhage. IR may be used in conjunction with surgical techniques for arterial haemorrhage in “surgically inaccessible areas”. Endovascular stent grafts are indicated in blunt thoracic aortic injury.

KEEP PATIENTS WARM

Enough said.

Analgesia & Pain Relief

Assess pain regularly using appropriate pain scales both pre-hospital and in-hospital.

Titrated intravenous morphine is the first line drug for analgesia in major trauma with caution in the elderly and in circulatory shock with the intranasal route as an option where IV access has not been established.

Ketamine appears as a second-line analgesic agent.

Documentation

There is some structured guidance on documentation both pre-hospital and on arrival with a suggestion that a written summary containing information about diagnosis, management plan and expected outcome should be available within 24h, stored in the patient’s notes, aimed at the GP but written in plain English so as to be understandable by the patient and their family/carers.

Communication

Alongside recommendations for structured handover at all points of communication, NICE spends a few pages reminding us of the importance of communicating to the patient and to their relatives/carers. The paragraph below actually captures nicely the ethos of conversations we have with patients and their families in the ED:

Screen Shot 2015-08-07 at 10.10.48

So there you have it. As I alluded to at the start, these aren’t my opinions but the statements proposed by NICE as part of their major trauma guidance – and if you disagree or do things differently, they want to hear from you!

From my perspective, the only real sticking point is the choice of morphine as first line analgesic – I switched to fentanyl for most of the intravenous analgesia I prescribe a few years back and I find it more predictable and generally cleaner – I know I’m not alone.

Major Trauma - Courtesy of Janos Baombe

Major Trauma – Courtesy of Janos Baombe

There are also some great future research recommendations included, so if you are looking for an area of trauma in which to make a difference to patients… You have our support here at St Emlyn’s.

Nat

Before you go please don’t forget to…

18 Comments

  1. inseiffolliet

    The first two links don’t work for me.

    Reply
    1. Natalie May (Post author)

      Thanks for the heads-up – should work now (they work for me!)

      Reply
  2. Mark Lindham

    Daft as it may seem, it would be good to explicitly state that protocols for reversal of warfarin in adults should not require routine permission from a haemotologist for access to PCC. This still occurs in some places!

    Reply
    1. Simon Carley

      Gosh really? We have PCC in the resus room and whilst I have no problems phoning a friendly haematologist for advice on using it we don’t have to ask permission and have great support from Virchester’s haematology team.

      S

      Reply
  3. ketaminh

    thanks folks for nice review here!

    one thing that bugs me is the minor misreporting of the pneumothorax and open thoracostomy details in the draft.

    It reads like open thoracostomy is the universally preferred technique but thats not true. the main text of the draft indicates it is only for intubated patients, not spontaneously breathing patients who still require a chest drain. The bold type recommendations box lacks sufficient detail to clarify this distinction in clinical practice prehospitally.

    this point is often lost in translation and I am aware of a number of sentinel events in prehospital Australian care whereby well meaning registrars perform open thoracostomies on spont breathing awake patients..some who then deterioriate as a result of their new open pneumothoraces!

    Reply
    1. Simon Carley

      Inportant point Minh. I’ve not seen any do a finger thoracostomy on a spontaneously breathing patient yet (thankfully), though I have heard it suggested…. resulting in a Paddington moment of a very hard stare…. https://www.youtube.com/watch?v=q_XjlVrrU_A

      Reply
    2. Simon Carley

      Hi Minh,

      Good points.

      I’ve not seen awake finger thoracostmies done, but I have heard it suggested…… cue one of these https://www.youtube.com/watch?v=q_XjlVrrU_A

      Reply
  4. Paramedrusty

    Nice summary Nat
    Loving the fluids, less sure about the morphine, was hoping for more USS, and the “30 mins to RSI” is cooking up a storm locally as advanced care prehospital teams have been resisted for years.
    Loving the focus on communications: within the team, between teams and of course patients and relatives.
    Documentation standards will require a generational step change for compliance with these.
    Agree with Minh regarding the thoracostomy: PPV first should be unambiguous. On scene, a Paddington stare would be the lesser option below personal primary response to a prematurely wielded scalpel. But I’m considerably less enlightened than Simon.
    P

    Reply
    1. Simon Carley

      I hope the 30 mins to RSI (if adopted) allows us to make progress in Greater Virchester….

      Reply
      1. Paramedrusty

        Simon
        Hot debates on Twitter ongoing, many v strongly in favour, it’ll boil down to whether it’s a commissioned service. 30 mins to intervention means 20 min response-BASICS alone cannot do this. A capability/system needs designing & developing.
        I suspect Dr only model will be too expensive, so MICA style career development possibly on the horizon.
        Interesting times.
        R

      2. Simon Carley

        If London, Birmingham etc can do it…..

  5. Andy Thomas

    Cheers Nat and just to confirm titrate fluid to central pulse not radial in pre hospital setting

    Reply
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