MEDEST

The National Institute for Health and Care Excellence (NICE) published a Guidelines Draft on Major Trauma. The great thing about is that everyone can consult the draft and send suggestion (but only if you work for a stackholder organization) about the recommendations and scientific evidences contained.
Consult the documents at the links below:

• Major trauma: assessment and initial management full guidelines
• Major trauma: assessment and initial management short version, just the recommendations
• Evidence in full (appendices)

Here are some highlights with a particular regard to pre-hospital environment recommendations:

Airway management

RSI and orotracheal intubation is the preferred method to manage airways (when compromised) in a trauma patient.

In prehospital setting RSI and OTI has to be performed on scene in less than 30 min from the initial call. Backup plan is SGA (in patients with reduced level of consciousness and no glottic reflexes) or basic airways maneuver plus adjuncts (patients with GAG reflexes still present), and transfer to Trauma Center (within 60 min) to manage airways. If Trauma Center is more than 60 minutes away, reach local hospital to perform RSI and than transfer the patient.

“The GDG had a strong belief that RSI of anaesthesia and intubation delivered by a competent person is the gold standard of care when maintaining the airway of both adults and children and made a recommendation for RSI of anaesthesia and
intubation accordingly.”

“The GDG suggested that the second best device for airway management was the supraglottic device. This device provides less protection than RSI of anaesthesia and intubation against aspiration; however this device provides greater protection than
basic airway adjuncts, and can be administered safely by in the pre-hospital environment by paramedics or physicians staff.”

“Supraglottic devices can only be used in patients without airway reflexes to avoid stimulating vomiting or laryngospasm,, and
are therefore only appropriate for use in patients with a reduced level of consciousness.”

“For patients with airway reflexes, where a supraglottic device cannot be used, the GDG recommended the use of basic airway manoeuvres and adjuncts until such time as RSI of anaesthesia and intubation is available.”

“The GDG therefore concluded that where possible, RSI should be delivered at scene and within a timeframe than minimised
pre-hospital time. Pre-hospitals systems should develop to make this widely available. Where pre-hospital RSI is not possible within a 30-minute window, the GDG recommended transporting the patient with supraglottic or basic airway adjuncts to a MTC within 60 minutes, otherwise to a TU”

Pre-hospital Tension Pneumothorax

• Closed pneumo

Perform chest decompression of a suspected tension pneumothorax only in haemodynamically unstable patients or in pts who have respiratory compromise.

Perform open thorachostomy to drain tension pneumothorax in haemodynamically unstable patients (preferred on simple needle decompression).

Simple open thorachostomy can be performed only in intubated (and positive pressure ventilated) patients. In all other cases insert a chest drain to prevent a sucking chest open wounds

• Open pneumo

No more vented or 3-sided occlusive dressing in open (sucking) pneumothorax: use a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting

“The GDG limited the recommendation to intervene to people who are haemodynamically unstable or have severe respiratory compromise. The GDG agreed that people who have signs of a tension pneumothorax but are haemodynamically normal can wait until hospital for a more definitive diagnosis and possible decompression.”

“Needle decompression is a simpler technique to perform than insertion of a chest drain but is associated with a number of complications. These include the cannula blocking, the catheter not being long enough and therefore, not penetrating the
thoracic parietal pleura, or incorrect placement of the needle, all of which result in the decompression not being successful. The GDG agreed by consensus that open thoracostomy is more effective and stable than needle decompression.”

“An open thoracostomy can only be used on intubated patients. A surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open. This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound”

“The GDG agreed that given the lack of evidence, no recommendation could be made around whether an occlusive dressing for an open pneumothorax should be vented or three-sided. Additionally, the GDG accepted there was no evidence to make a
recommendation around supplementing the dressing with a chest drain in the prehospital setting.The GDG decided through expert consensus to recommend using a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting. The GDG emphasised the importance of a ‘simple’ dressing that provides an airtight seal that is fast and straightforward to apply. The priority should be transporting the patient to a hospital where a chest drain can be inserted.”

Haemorrhage control

First line intervention is direct pressure with simple dressing.

If direct pressure failed use tourniquets (no difference between mechanical or penumatic ones) as backup method. Is controversial when tourniquets has to be used (as first line) over direct pressure

Use Tranexamic acid in suspected haemorrahagic patients as soon as possible but never beyond 3 hrs from trauma

“In the absence of any evidence in favour of haemostatic dressings, the GDG did not believe that they offered any improvement over and above standard dressings with direct pressure.”

“Whereas, immediate haemorrhage control can be achieved by direct pressure, the decision of when direct pressure should be
used over tourniquets was considered controversial as the GDG tried to weigh up the risk and cost of placing a tourniquet on a person who did not require it compared with those that do.”

Vascular access

In adults use IV access as first line and IO as rescue technique if IV failed

In children, when difficult vascular access is suspected, use IO access as first line technique

Fluid resuscitation

In pre-hospital environment the target for volume titration has to be maintaining a palpable central pulse (femoral or carotid)

In pre-hospital, if blood products are not available, small boluses of crystalloids are the preferred fluid volume replacement.

“The GDG discussed the situation when a pre-hospital practitioner is treating a patient in profound haemorrhagic shock but does not have access to blood products. In this case small boluses of crystalloids would be appropriate.”

Pain control

IV Morphine is the first line recommended agent. Ketamine (at pain relief doses) the second option.

Caution is recommended when Morphine is administered in a haemodinamically unstable patient.

Intranasal administration is the recommended route of administration when IV is not available.

“Two studies compared IV morphine with IV fentanyl and found no difference between the interventions for pain relief and adverse side effects.”

(Many) Things that I Like about these guidelines

1. The airway management approach! Totally agree on RSI and OTI as gold standard in trauma, and if performed, better be fast. The 30 min target is a quite fair indication but, as any other straight timing, depends on  the circumstances. The thing I appreciate is the idea of DO IT IN THE SHORTEST TIME POSSIBLE. Great. And if plan A (Ventilation+Oxygenation) fails? Plan B (Oxygenate) SGA and rush to TC, if close, or to any other trauma unit. And if for any reason placing a SGA is not possible? Use BVM and adjuncts and rush again. Love it!

2. Thoracostomy better than needle decompression, both in prehospital and in hospital, for tension pneumothorax drainage. We are all aware of the bunch of studies indicating as needle decompression is inadequate in most cases, and all the FOAMED drums are rumbling on these frequencies. But till now none (first of all the Archaic Trauma Life Support)  officially stated this in a guideline (that I’m aware to, at least). So WELCOME expert consensus of NICE GDG!

3. Simple occlusive dressing in open pneumo. Straight and simple.

4. The choice for prehospital fluid replacement goes on crystalloids only cause blood products are not available, but in the text is highlighted as both crystalloids and colloids are detrimental on coagulation process (so they are banned in hospital setting). The future is blood products even in prehospital environment!

(Few) Things that I don’t like about these guidelines

1. The choice of open simple thoracostomy just in intubated pts has to be more clearly highlighted. I suggest as an adjunct to main (yellow background) recommendation. And so as to be for thoracostomy plus chest drainage in non intubated pts.

2. Why they just mention Morphine (as opioid) for pain control and don’t include fentanyl in the main recommendation, if in the text is clearly indicated as all the available evidences show no differences between the two drugs in terms of clinical effects and adverse events? I think Fentanyl due to its wide diffusion (with great satisfaction) worths a mention!

Draft closes for comments on 21 of September.

Tags: emergency medicine, Guidelines, NICE, prehospital emergency medicine, trauma