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NICE Trauma Guidance Summary 2016

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.
  • 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.

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