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NICE issues raft of guidelines to ‘standardise’ trauma care

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The National Institute for Health and Care Excellence has issued guidance on key areas of trauma care, with recommendations on stopping life-threatening bleeds and improving communication.

The five guidelines, published this week by NICE, cover fractures, complex fractures, spinal injury assessment, major trauma and major trauma services.

Professor Mark Baker, director of the NICE Centre of Clinical Practice, said: “Major trauma remains the most common cause of death in patients under 40 years of age in the UK.”

“The techniques we adopt across England are inconsistent. They must be improved”

Karim Brohi

NICE highlighted that over 1,500 trauma patients died every year from severe bleeding and recent research had shown that some did not receive optimal blood transfusion treatment in England and Wales.

The new suite of trauma guidance includes recommendations on the best method to stop bleeding in different injuries and which are most effective for the situation – for example, at the scene of an accident – said the institute.

It stated that “simple dressings with direct pressure to control external haemorrhage” should be used to manage haemorrhage in pre‑hospital and hospital settings.

In patients with major limb trauma use, a tourniquet should be used if direct pressure has failed to control life‑threatening haemorrhage, said the guidance.

It added that intravenous tranexamic acid should be used “as soon as possible” in patients with major trauma and active or suspected active bleeding – but not more than three hours after injury unless there was evidence of hyperfibrinolysis.

“Major trauma remains the most common cause of death in patients under 40 years of age in the UK”

Mark Baker

Other sections cover the reversal of anticoagulation, circulatory access, fluid replacement, pain management and use of major haemorrhage protocols in hospitals.

The guidance also gives recommendations about how best to locate the site of the bleed so surgeons can operate quickly to stop it.

Professor Karim Brohi, chair of trauma sciences at Queen Mary University of London and deputy chair of the NICE guideline project executive team, said: “Stopping a patient from bleeding is vital for their survival, yet the techniques we adopt across England are inconsistent. They must be improved.

“The new NICE trauma guidelines are based upon the latest scientific evidence,” he said. “They will bring clarity to this challenging area of trauma care and undoubtedly save lives.”

In addition, NICE noted that every year in Britain, three in 100 people suffered a fracture, some of whom may require urgent treatment to save the limb.

The two fracture guidelines, also published this week, aim to clarify when minimal medical intervention is the best option.

They also include specific recommendations that will help clinicians effectively manage open fractures – where the bone tears through the skin – said NICE.

All five trauma guidelines feature recommendations to promote better communication.

Mark Baker

Mark Baker

Mark Baker

They suggest a designated point of contact within the trauma team for the patient, their family members and carers.

They also set an aim for the trauma team to give the patient’s GP a written summary including diagnosis, management plan and expected outcome, within 24 hours of admission.

Together these new NICE trauma guidelines give a wide-range of recommendations based upon the latest evidence, said NICE.

They will support trauma teams across the country, promoting high quality, patient-focused care as standard, it added.

Mr David Skinner, emeritus consultant in emergency medicine and chair of the guideline project executive team, said: “The recommendations in these new NICE guidelines will introduce the latest in evidence-based care across the entirety of our national trauma network.”

In 2010 a report by the National Audit Office found the management of major trauma patients was inadequate in England and called for a service overhaul.

It led to the development and implementation of countrywide major trauma networks – groups of hospitals centred around 27 major trauma centres that are equipped to provide the specialist care.

About the fracture guideline

  1. Three in 100 people in Britain will suffer a fracture each year and four out of 10 people will have at least one fracture in their lifetime.
  2. Many non-complex fractures get better with a cast or simple splint, but others have the potential for complications. We need to achieve a balance to ensure those serious fractures are not missed, but those simpler ones are not over-treated.
  3. The guideline gives recommendations on; initial pain management and immobilisation, acute stage assessment and diagnostic imaging, management in the emergency department, ongoing orthopaedic management, documentation and information / support for people with non-complex fractures and their families and carers.

About the complex fracture guideline

  1. A complex fracture is a severe break of the bone. The bone may break into multiple pieces and cause damage to the surrounding skin and muscle.
  2. Complex fractures make up the minority of the 1.8 million fractures that occur in England each year, but take a long time to heal and can cause disability. They are a large burden on healthcare resources.
  3. The guideline gives recommendations on; management in pre-hospital settings, immediate destination for people with suspected complex fractures, initial assessment and management in acute care, imaging and haemorrhage control of pelvic fractures, management of open fractures, management plan and referral for adults with pilon fractures and children with intra-articular distal tibia fractures, documentation and information / support for people with non-complex fractures and their families and carers.

About the spinal injury assessment guideline

  1. Spinal injury usually involves a fracture of the neck or back, which sometimes leads to nerve damage (spinal cord injury) and paralysis.
  2. Approximately 1,000 people sustain a new spinal cord injury each year in the UK and there is an estimated 50,000 people living with paralysis in the UK and Ireland.
  3. This guideline gives recommendations on; assessment and management in pre-hospital settings, pain management in pre-hospital and hospital settings, immediate destination after injury, emergency department assessment and management, diagnostic imaging, communication with tertiary services, early management in the emergency department after traumatic spinal cord injury, information and support for patients, family members and carers, and documentation in pre-hospital and hospital settings.

About the major trauma guideline

  1. Major trauma constitutes injuries which are life-threatening and may result in permanent disability.
  2. The most common cause of major trauma is road traffic accidents.
  3. This guideline gives recommendations on; immediate destination after injury, airway management in pre-hospital and hospital settings, management of chest trauma in pre-hospital settings, management of chest trauma in hospital settings, management of haemorrhage in pre-hospital and hospital settings, reducing heat loss in pre-hospital and hospital settings, pain management in pre-hospital and hospital settings, documentation in pre-hospital and hospital settings, information and support for patients, family members and carers, and training and skills.

About the major trauma services guideline

  1. Immediate management of major trauma patients costs the NHS between £0.3-0.4bn per year.
  2. The Trauma Audit and Research Network (TARN) 2015 audit has shown that since the introduction of MTNs, the chance of surviving major trauma has improved by 50% in England.
  3. This guideline gives recommendations on; pre-hospital triage, transferring patients with major trauma, pre-alert procedures, procedures for receiving patients in trauma units and major trauma centres, transfer between emergency departments, organisation of hospital major trauma services, documentation, monitoring and audit, information and support for patients, family members and carers, training and skills, and access to major trauma services.
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