Airway management

• If there is potential that the patient’s airway may deteriorate, then intubation prior to retrieval should be discussed with the ARV coordinator.
• Always have emergency airway equipment available.

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Fluid resuscitation

Avoidance of hypovolaemia in trauma is a cornerstone of management. A balanced approach to fluid replacement is important, especially in establishing early treatment goals (25, 26). Permissive hypotension is a recognised fluid resuscitation plan; it acknowledges the goal of end organ perfusion whilst avoiding haemodilution. Therefore, perfusion targets are patient dependent, however, acceptance of values below normotension are appropriate. If in any doubt, always call ARV for further guidance ^{(27, 28)}.

Resuscitation goals:

• The main goal of fluid resuscitation in trauma is to preserve vital organ function until bleeding can be controlled.
• The assessment of hypovolaemic shock is difficult during the early phase of major trauma care. The clearest signs of end-organ hypoperfusion include decreased urine output, acidosis, altered conscious state and elevated lactate level.
• In immediate trauma care aim for a blood pressure above 80-90 mmHg systolic, with a MAP of 50-60mmHg, until bleeding has been controlled in the setting of no clinical evidence of traumatic brain injury (TBI). In the presence of likely TBI, GCS<8, a MAP of more than 80mmHg is recommended.
• Blood pressure goals for penetrating trauma or uncontrollable haemorrhage are generally lower than for blunt trauma in the absence of a major head injury. (SBP values less than 90 mmHg may be acceptable if cerebral perfusion is maintained – that is, if conscious state is normal.) Early consultation about such patients is required.
• If possible, all blood/fluid administered to a major trauma patient should be warmed with a fluid warmer.

The main causes of shock in trauma patients are summarised below:

• Hypovolaemic shock – from obvious external blood loss or concealed internal blood loss.
  • External haemorrhage.
  • Chest – massive haemothorax.
  • Abdominal/pelvic cavities.
  • Retroperitoneum.
  • Femoral and other long bone fractures.
• Obstructive shock – due to impaired filling or obstructed outflow to/from the heart.
  • Tension pneumothorax/haemothorax.
  • Pericardial tamponade.
• Distributive Shock – due to relative hypovolaemia, pathological redistribution of intravascular volume
  • Neurogenic shock, a subset of distributive shock, occurs due to loss of sympathetic vascular tone, which may occur in spinal lesions at or above the sixth thoracic vertebral level.
• Cardiogenic Shock – direct trauma to cardiac tissue
  • Cardiac contusion
  • Ventricular rupture

Crystalloid fluids

Initial treatment of hypovolaemia with crystalloid fluids (normal saline) is acceptable, however should be administered in small bolus volumes, targeting the permissive hypotension values, with an initial maximum volume of 1000-1500ml. If perfusion targets are not met, contact ARV for further support ^{(8, 29)}.

Colloids

Colloids are not generally recommended in the early treatment of major trauma ^{(8, 28)}.

Blood products

After initial resuscitation, administration of packed red blood cells (PRBC) is advised. If greater than two units of PRBC are required, specialist consultation is recommended via ARV to guide ongoing resuscitation. The use of a balanced transfusion protocol (PRBC, plasma, platelets) is advised. The use of tranexamic acid and calcium supplementation should also be considered here.

Where massive transfusion is required (more than five units of blood in under four hours), blood product administration should be guided by the Critical bleeding massive transfusion guideline published by the National Blood Authority ⁽³⁰⁾. Urgent blood products can be organised for delivery via AV or the ARV team prior to departure.

Tranexamic Acid (TXA)

The early administration of TXA is recommended for patients with significant blood loss (31, 32).

• Administered within 3 hours of insult
• Consult ARV for further guidance.

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Analgesia

Titrated narcotic analgesia is the initial approach to pain management in trauma. Intravenous administration is the most effective route. Administer as per local protocols and titrate to effect. Analgesia should be administered prior to wound or fracture care as treatment and dressing of wounds or fractures can be particularly painful.

• Prophylactic antiemetic administration prior to transfer and retrieval is recommended.

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Fractures and dislocations

Limb fractures – closed:

• Assess and record neurovascular status.
• Straighten/align the limb.
• Apply a splint in an anatomical position.
• Continue to regularly monitor neurovascular status.
• If neurovascular compromise is evident arrange an urgent orthopaedic consultation or retrieval/transfer.

Limb fractures – open:

• As per closed limb fractures above.
• Administer IV antibiotics (cephazolin).
• For grossly contaminated wounds or delayed presentation (more than eight hours) use piperacillin + tazobactam or ticarcillin + clavulanate. For patients with a penicillin allergy, consult ARV.
• Perform a simple emergency department wound cleanse by removing any easily identified foreign objects or contamination (do not actively wash out the wound).
• Apply a saline-soaked gauze dressing and bandage then leave it intact.
• Organise an immediate orthopaedic consultation or activate urgent transfer/retrieval.

Note: if definitive management occurs more than six hours after injury the likelihood of chronic infection is significantly increased, therefore immediate transfer to a destination where early definitive management can be undertaken is imperative.

Joint dislocation:

• Joint dislocation may be associated with a fracture or may be mistaken for a juxta-articular fracture – always obtain an x-ray before management.
• Neurovascular structures are at risk. Always assess and record the findings including time of injury.
• Reduce dislocated joints if possible and splint.
• Monitor the patient’s neurovascular status after reduction.
• An open dislocation requires the same antiseptic precautions as an open fracture.
• Arrange immediate orthopaedic consultation.

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Prevent hypothermia

Preventing hypothermia is a vital aspect of trauma care. It is important to maintain normothermia ⁽³⁴⁾. Ensure the patient does not lose excess heat due to exposure or wounds. Ensure all wounds are covered.

• Administer warmed IV fluids; cover the patient with extra warm blankets as well as keeping the room warm (a general guide is that if clinical staff are comfortable, it’s likely to be too cold for a trauma patient). If available, the use of a forced air-warming machine is encouraged. Ensure wound care is attended to prior to commencement. Avoid moist dressings when using a forced air-warming machine due to evaporative cooling effects.
• Re-assess the patient and room temperature at regular intervals while awaiting the retrieval team.

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In-dwelling catheter

When clinically indicated, a urinary catheter should be inserted, and urine output measured hourly. The desired urine output for adults is 0.5–1.0 mL/kg/hr. Consider utilising a leg bag for urine containment as this is easier to package and reduces the risk of pressure area development.

• A urinalysis should be performed also to check for blood. Discoloured, brown urine may indicate myoglobinuria, a sign of rhabdomyolysis.

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Monitoring

Continuously monitor the heart rate, respiration rate, blood pressure, oxygen saturation and ETCO2 at 15-minute intervals or more frequently if indicated. Utilise electronic monitoring if available. All monitoring should be continued and documented until the retrieval team arrives. A baseline ECG should be taken prior to transfer if time permits and facilities exist.

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Pathology tests

When clinically indicated, pathology tests should be taken for FBE (full blood examination), UEC (urea, electrolytes, and creatinine) and glucose. Bedside/point-of-care testing is useful. Serial blood gas assessment of pH, haemoglobin and lactate levels provides good monitoring of tissue oxygenation, circulatory status, and response to resuscitation.

• Coagulation studies and group and crossmatch should be taken if there is a high index of suspicion for major injuries requiring further care. Isolated results from single blood tests may be misleading and results should be considered in the context of the whole patient and trended results where available.

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X-ray or eFAST scan

Baseline chest and pelvis x-rays are performed in the primary survey. Consider further diagnostic imaging if available and indicated. Do not transport an unstable trauma patient to an imaging facility unless absolutely essential.

• Consider the need for eFAST (Extended Focused Assessment with Sonography in Trauma) if available. eFAST is used primarily to detect the presence of fluid (presumed to be blood) in five areas – pericardial, pleural, perihepatic, perisplenic, and pelvic. It is more accurate than any physical examination finding for detecting intra-abdominal injury. It should only be carried out by staff who have been trained to do so.
• In haemodynamically stable patients, eFAST is delayed until the secondary survey and is ideally performed by a second operator while the remainder of the secondary survey is completed.

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Naso/orogastric tube (N/OGT)

All patients should be kept nil orally in the initial post-resuscitation phase of injury. The potential for a base of skull fracture in poly-trauma should be considered as a relative contraindication in the decision to insert an NGT (35). An OGT may be inserted following consultation and under direct visualisation.

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Wound care

In a major trauma patient, early wound closure (pre-transfer) is not a priority.

• Remove gross contamination and irrigate the wound.
• Gain haemostasis through pressure and elevation where possible.
• Simple dressings with saline, gauze, combine and moderate compression bandages are generally adequate.
• Do not routinely administer antibiotics for wound care.
• Suture simple wounds if time allows.

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Tetanus immunisation

Tetanus immunisation should be updated in the case of significant or contaminated wounds. Tetanus immunoglobulin should be given to patients who have not received a complete primary immunisation ⁽³⁶⁾.

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Antibiotics

Routine IV antibiotic administration is not recommended in major trauma, however, is indicated in open fractures (see limb fractures above).

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Reassess

The importance of frequent reassessment cannot be overemphasised. Patients should be re- evaluated at regular intervals as deterioration in a patient’s clinical condition can be swift. This will be evident in their vital signs and level of consciousness.

If in doubt, <C> ABCDE.