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Trauma

About

What is covered

This pathway covers the:
  • assessment and initial management of major trauma, including airway management, chest trauma, haemorrhage, pain and temperature control
  • assessment and initial management of spinal injury
  • assessment and management of complex and non-complex fractures
  • organisation and delivery of major trauma services.
Recommendations apply to children, young people and adults unless otherwise specified. The pathway covers pre-hospital and hospital settings.

Updates

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Assessment and management of major trauma including spinal injury, open fractures, pelvic fractures, limb and joint fractures in pre-hospital and hospital settings.

What is covered

This pathway covers the:
  • assessment and initial management of major trauma, including airway management, chest trauma, haemorrhage, pain and temperature control
  • assessment and initial management of spinal injury
  • assessment and management of complex and non-complex fractures
  • organisation and delivery of major trauma services.
Recommendations apply to children, young people and adults unless otherwise specified. The pathway covers pre-hospital and hospital settings.

Sources

The NICE guidance that was used to create the pathway.
Major trauma: service delivery (2016) NICE guideline NG40
Pre-hospital initiation of fluid replacement therapy in trauma (2004) NICE technology appraisal guidance 74
Translaryngeal tracheostomy (2013) NICE interventional procedure guidance 462
Low-intensity pulsed ultrasound to promote fracture healing (2010) NICE interventional procedure guidance 374
Ambu aScope2 for use in unexpected difficult airways (2013) NICE medical technology guidance 14
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technology guidance 3

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Some recommendations on management depend on whether the growth plate of the injured bone has closed (skeletal maturity). The age at which this happens varies. In practice, healthcare professionals use clinical judgement to determine whether a bone is skeletally mature. When a recommendation depends on skeletal maturity this is clearly indicated.
In the non-surgical orthopaedic management of unimalleolar ankle fractures:
  • advise immediate unrestricted weight-bearing as tolerated
  • arrange for orthopaedic follow-up within 2 weeks if there is uncertainty about stability
  • advise all patients to return for review if symptoms are not improving 6 weeks after injury.
If treating an ankle fracture with surgery, consider operating on the day of injury or the next day.
Assess whether the person is at high, low or no risk for cervical spine injury using the Canadian C-spine rule as follows:
  • the person is at high risk if they have at least one of the following high-risk factors:
    • age 65 years or older
    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example, diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
    • paraesthesia in the upper or lower limbs
  • the person is at low risk if they have at least one of the following low-risk factors:
    • involved in a simple rear-end motor vehicle collision
    • comfortable in a sitting position
    • ambulatory at any time since the injury
    • no midline cervical spine tenderness
    • delayed onset of neck pain
  • the person remains at low risk if they are:
    • unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high-risk factors)
  • the person has no risk if they:
    • have one of the above low-risk factors and
    • are able to actively rotate their neck 45 degrees to the left and right.
Be aware that applying the Canadian C-spine rule to people under 16 is difficult and the child's developmental stage should be taken into account.
Assess the person with suspected thoracic or lumbosacral spine injury using these factors:
  • age 65 years or older and reported pain in the thoracic or lumbosacral spine
  • dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
  • pre-existing spinal pathology, or known or at risk of osteoporosis – for example steroid use
  • suspected spinal fracture in another region of the spine
  • abnormal neurological symptoms (paraesthesia or weakness or numbness)
  • on examination:
    • abnormal neurological signs (motor or sensory deficit)
    • new deformity or bony midline tenderness (on palpation)
    • bony midline tenderness (on percussion)
    • midline or spinal pain (on coughing)
  • on mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).
NICE has produced a pathway on osteoporosis.
Be aware that assessing people under 16 with suspected thoracic or lumbosacral spine injury is difficult and the child's developmental stage should be taken into account.
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 life-threatening haemorrhage.
Make eye contact and be in the patient's eye line to ensure you are visible when communicating with this person to avoid them moving their head.
Assess the person for spinal injury, initially taking into account the factors listed below. Check if the person:
  • has any significant distracting injuries
  • is under the influence of drugs or alcohol
  • is confused or uncooperative
  • has a reduced level of consciousness
  • has any spinal pain
  • has any hand or foot weakness (motor assessment)
  • has altered or absent sensation in the hands or feet (sensory assessment)
  • has priapism (unconscious or exposed male)
  • has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.
NICE has produced a pathway on metastatic spinal cord compression.
For people under 16 use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child's weight.
For people aged 16 and over use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.
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.
Use intravenous tranexamic acidAt the time of publication (February 2016), tranexamic acid did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. 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.
Minimise ongoing heat loss in patients with major trauma.
A radiologist, radiographer or other trained reporter should deliver the definitive written report of emergency department X-rays of suspected fractures before the patient is discharged from the emergency department.
Follow a structured process when handing over care within the emergency department (including shift changes) and to other departments. Ensure that the handover is documented.
Ensure that all patient documentation, including images and reports, goes with patients when they are transferred to other departments or centres.
For patients who are being transferred from an emergency department to another centre, provide verbal and written information that includes:
  • the reason for the transfer
  • the location of the receiving centre and the patient's destination within the receiving centre
  • the name and contact details of the person responsible for the patient's care at the receiving centre
  • the name and contact details of the person who was responsible for the patient's care at the initial hospital.
The use of spinal immobilisation devices may be difficult (for example in people with short or wide necks, or people with a pre-existing deformity) and could be counterproductive (for example increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated or distressed people, including children, think about letting them find a position where they are comfortable with manual in-line spinal immobilisation.
When carrying out full in-line spinal immobilisation in people aged 16 and over, manually stabilise the head with the spine in-line using the following stepwise approach:
  • Fit an appropriately sized semi-rigid collar unless contraindicated by:
    • a compromised airway
    • known spinal deformities, such as ankylosing spondylitis (in these cases keep the spine in the person's current position).
  • Reassess the airway after applying the collar.
  • Place and secure the person on a scoop stretcher.
  • Secure the person with head blocks and tape, ideally in a vacuum mattress.
When carrying out in-line spinal immobilisation in people under 16, manually stabilise the head with the spine in-line using the stepwise approach above and consider:
  • involving family members or carers if appropriate
  • keeping infants in their car seat if possible
  • using a scoop stretcher with blanket rolls, vacuum mattress, vacuum limb splints or Kendrick extrication device.
If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamineAt the time of publication (February 2016), neither intranasal diamorphine or intranasal ketamine had a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information..
Consider ketamine in analgesic doses as a second-line agent.
For the initial management of pain in young people and adults with suspected long bone fractures of the legs (tibia, fibula) or arms (humerus, radius, ulna), offer:
  • oral paracetamol for mild pain
  • oral paracetamol and codeine for moderate pain
  • intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
Consider NSAIDs to supplement the pain relief described above except for frail or older adults.
Use intravenous opioids with caution in frail or older adults.
Do not offer NSAIDs to frail or older adults with fractures.
For the initial management of pain in children with suspected long bone fractures of the legs (femur, tibia, fibula) or arms (humerus, radius, ulna), offer:
  • oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
  • intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Be aware that the optimal destination for people with major trauma is usually an MTC. In some locations or circumstances intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network.
For people with major trauma or spinal injury, use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
For recommendations on the initial pharmacological management of pain in adults with suspected low-energy pelvic fractures, see the NICE pathway on hip fracture.
For patients with suspected high-energy pelvic fractures, use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
For people with suspected open fractures, use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
Offer medications to control pain in the acute phase after spinal injury.
If possible, record information on whether the assessments show that the person's condition is improving or deteriorating.
Ensure that pre-hospital documentation, including the recorded pre-alert information, is made available to the trauma team quickly and placed in the patient's hospital notes.
When needed for distal radius fractures, perform surgery:
  • within 72 hours of injury for intra-articular fractures
  • within 7 days of injury for extra-articular fractures.
When needed for re-displacement of distal radius fractures, perform surgery within 72 hours of the decision to operate.
For patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.
Use drug-assisted RSI of anaesthesia and intubation as the definitive method of securing the airway in patients with major trauma who cannot maintain their airway and/or ventilation.
If RSI fails, use basic airway manoeuvres and adjuncts and/or a supraglottic device until a surgical airway or assisted tracheal placement is performed.
One member of the trauma team should be designated to record all trauma team findings and interventions as they occur (take 'contemporaneous notes' ).
The trauma team leader should be responsible for checking the information recorded to ensure that it is complete.
Address issues of non-accidental injury before discharge in people with femoral fractures. This is particularly important for people who are not walking or talking. For more information, see the NICE pathway on when to suspect child maltreatment.
Use whole-body CT (consisting of a vertex-to-toes scanogram followed by a CT from vertex to mid-thigh) in people aged 16 and over with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole-body CT.
Use clinical findings and the scanogram to direct CT of the limbs in people aged 16 and over with limb trauma.
Do not routinely use whole-body CT to image people under 16. Use clinical judgement to limit CT to the body areas where assessment is needed.
Produce a written summary, which gives the diagnosis, management plan and expected outcome and:
  • is aimed at and sent to the patient's GP within 24 hours of admission
  • includes a summary written in plain English that is understandable by patients, family members and carers
  • is readily available in the patient's records.

Glossary

American Spinal Injury Association
Bispectral Index
amputation when there is time to delay decision but reconstructive surgery is not involved in the decision
electroencephalography
extended focused assessment with sonography for trauma
focused assessment with sonography for trauma
rapid sequence induction
trauma audit and research network
Medical Research Council
major trauma centre
major trauma centres
non-steroidal anti-inflammatory drugs
picture archiving and communication system

Paths in this pathway

Pathway created: February 2016 Last updated: April 2016

© NICE 2016

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