• Use drug assisted RSI to secure the airway (see Emergency Anaesthesia).
• If RSI fails, use basic manoeuvres and adjuncts and / or supraglottic device to oxygenate until:
  
  • either a surgical airway or
  • assisted tracheal placement is performed.

• Perform CXR and/or eFAST in all patients with haemodynamic instability or severe respiratory compromise.
• Decompress the chest using an open thoracostomy followed by intercostal chest drain insertion.
• Cover open pneumothoraces.
• Perform immediate CT in patients with significant chest injury.

Please also refer to the NICE Guidelines on Major Trauma Initial Assessment and Initial Management.

Dressing and tourniquets

Use simple dressings with direct pressure to control external haemorrhage.

• In patients with major limb trauma use a tourniquet if direct pressure has failed to control haemorrhage.
• It may be appropriate to use a tourniquet first line in some situations (always note time tourniquet applied). A second tourniquet is sometimes required. Check the tourniquet after patient movement and consider replacing it with a pneumatic tourniquet following resuscitation.

Tranexamic acid (TXA)

• Administer TXA in patients with major trauma and active or suspected bleeding (SBP <90 and/or HR>110)
• Do not administer TXA if >3 hours after injury (unless hyperfibrinolysis is demonstrated on ROTEM).

Access

• Use peripheral intravenous access.
• If peripheral IV access fails, consider intra-osseous access while central access is being achieved. Avoid lower-limb IO if significant pelvic trauma.

Volume Resuscitation

• Restrict volume resuscitation in patients with active bleeding until haemorrhage control is achieved. Where time to definitive care is prolonged / delayed, balance the risks of permissive hypotension against blood loss.
• Haemorrhage control is the priority. Titrate volume to a central pulse.
• For patients with haemorrhagic shock and a traumatic brain injury (TBI):
• Restrict volume resuscitation if haemorrhagic shock predominates.
• Use a less restrictive approach if TBI predominates.
• DO NOT use crystalloids for patients with active bleeding where blood is available.
• Use a ratio of 1RBC:1FFP to replace volume remembering to include pre-hospital blood.
• Start with a fixed-ratio protocol for blood components and change to lab/ROTEM/VBG-guided once available.

• Limit imaging to CXR, Pelvis XR and FAST in patients not adequately responding to volume to direct early surgical intervention.
• A negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage.
• Use immediate CT in haemodynamically normal patients/volume responders.

Involve specialty consultants (Orthopaedics, Vascular, IR and General Surgery) ensuring joint decision making regarding the following definitive care principles:

• Consider damage control surgery in patients with instability who do not adequately respond to volume.
• Use definitive surgery in haemodynamically normal patients.
• Consider IR in patients with active arterial pelvic haemorrhage unless open surgery is required for other injuries.
• Consider IR in patients with solid organ arterial haemorrhage (spleen, liver or kidney).
• Consider a joint IR/Surgical strategy for inaccessible regions
• Consider an endovascular stent for patients with blunt thoracic aortic injury.

• Use intravenous morphine 1st line (5mg aliquots, reduced in elderly)
• Use intravenous ketamine second line (0.2-0.5 mg/kg)
• Consider intranasal fentanyl if IV access not established (up to 100mcg in two 1ml (50mcg) doses).

Use fluid warming devices, warm blankets and a Bair Hugger in all major trauma patients where haemorrhage is suspected or proven.