South East Scotland Major Trauma Guidelines- Use drug assisted RSI to secure the airway.
- 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.
Primary survey key principles
Warning
- Perform CXR and/or eFAST in all patients with haemodynamic instability or severe respiratory compromise.
- Decompress the chest using an open thoracostomy followed by intercostals chest drain insertion.
- Perform immediate CT in other patient with significant chest injury.
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Please also refer to the NICE guidelines on Major trauma: initial assessment and management. |
Dressings 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. A second tourniquet is sometimes required. Check the tourniquet after patient movement and consider replacing 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.
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.
- Use a ratio of 1RCC: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.
Imaging
- 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.
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Paediatrics Please also refer to the Royal College of Radiologist's guidelines for guidance on paediatric trauma. |
Definitive Care
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 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.
Disability
- Use intravenous morphine 1st line (5mg aliquots, reduced in elderly).
- Use intravenous ketamine 2nd line (0.2-0.5mg/kg).
- Consider intranasal ketamine if IV access not established (0.7mg/kg).
Environment