In February 2016, the National Institute for Health and Care Excellence (NICE) published clinical guideline NG39, which focuses on the care of major trauma patients in England. The guideline provides recommendations for the initial assessment and management of major trauma patients in both the pre-hospital and in-hospital phase, and the flow of these patients through trauma networks. NG39 (NICE, 2016a) is supported by NG40: major trauma service delivery (NICE, 2016b) and a number of other specific guidelines on fracture management, complex fractures and the management of spinal injuries. This article focuses on reviewing and critical appraisal of the recommendations (Box 1) for pre-hospital care, the impact of these on the paramedic profession and ambulance services, and the future of major trauma care in England. It does not consider the specific care of burns patients, paediatrics or the elderly, as sub-sets of major trauma.
This guidance (NG39) has been developed in response to a report by the National Audit Office (NAO) (2010), in conjunction with a National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2007), both of which focused on the treatment and outcomes for patients suffering with major traumatic injuries. Since the publication of such reports, trauma care services in England have undergone a period of significant development and change, which has seen the growth of trauma networks and re-organisation of NHS services to provide regional major trauma centres, supported by a network of outlying trauma units.
McCullough et al (2014) identify that major trauma is one of the leading causes of death in the under 40 years age group, and has a significant impact on morbidity. This is further compounded by the NAO (2010), who estimated 20 000 cases of major trauma per annum, resulting in approximately 5 400 deaths. The Trauma Audit and Research Network (TARN) have more recently estimated 12 500 people die from injury per annum (TARN, 2016); however, there is no breakdown as to death from major trauma injury. Although relatively small numbers when considering the number of pre-hospital to hospital admissions, the care input required by patients with major trauma is astronomical, with often long intensive care admissions, coupled with input from multiple specialities and protracted rehabilitation. The NAO (2010) estimated a burden of £0.3–£0.4 billion per annum, whereas NCEPOD (2007) estimated the cost at £1.2 billion per annum. However, since the publication of such reports, there has been no further research or statistical analysis of data to better understand the burden of trauma care today, which is likely to have significantly changed given the redevelopment of major trauma services over recent years. This must be considered a priority for research in order to further understand the impact of service development, injury prevention and the impact of major trauma care.
During the development of a NICE clinical guideline, an expert panel review all available evidence from detailed literature searches, and consider consensus opinion where evidence is lacking. Over 140 references are listed as part of NICE clinical guideline 39 (NICE, 2016a); however, The Lancet (2016) state that little clinical evidence exists to support the statements in the guideline. It is recognised by NICE (2016a) that further research is required into particular areas of the guidance, such as temperature management, the use of volume replacement in pre-hospital care and the use of analgesic agents. Although randomised control trials are considered gold standard, it is not always possible to conduct this type of research into procedures and practices, especially where mortality and morbidity are greatly affected. Therefore, consensus and expert opinion is essential in producing guidance for clinicians and systems alike. The author welcomes the introduction of the NICE (2016a) guidance as a pivotal step towards further improving trauma care in England, and developing the paramedic profession.
The decision of where to take a major trauma patient can be difficult for the pre-hospital clinician. The shift to regional major trauma centres (MTC) and trauma networks in 2012 led to the reduction of 193 trauma units to 22 major trauma centres (Dixon, 2014; NHS Choices, 2014). However, there are still significant regional variations in access to major trauma centres, as seen in Figure 1, with prolonged journey times, compounded by poor infrastructure in more rural locations. This has led to the concept of pit-stopping at a trauma unit (TU), for immediate stabilisation prior to onward transfer to definitive care at an MTC. This is dependent upon local protocols, however it is supported by the NICE guidance (NICE, 2016a) and Dixon (2014). NICE (2016b) also stipulate that ambulance Trusts should provide a triage tool for major trauma, to aid decision-making, supported by expert clinical advice, training and audit. The first major trauma decision tool was developed by the London Trauma Office and London Ambulance Service (NHS Confederation, 2010), and has since been adapted for use across the country. Regular update training is required, together with clinical support to enable paramedics and pre-hospital clinicians in decision-making. All ambulance Trusts should now have an adapted major trauma decision tool, and locally agreed and commissioned protocols for the triage of major trauma patients to the most appropriate centre, which may include the concept of pit-stopping at a TU for stabilisation. Where transport times to an MTC are prolonged, there should be an emphasis on providing critical interventions on scene, with less time-critical interventions being provided during transport (Harmsen et al, 2015).
Recommendation 1.2—airway management
It is widely recognised that airway management in trauma can be challenging (Deakin et al, 2010). The findings of the NCEPOD (2007) report suggest that one in eight patients arrived at hospital with a partial or fully occluded airway, and that general pre-hospital airway management was poor. However, these conclusions were based upon hospital case notes, and the report lacked significant input from ambulance Trusts and paramedics as the main providers of pre-hospital trauma care.
NG39 (NICE, 2016a) stipulates that rapid sequence induction (RSI) with the use of drugs to facilitate anaesthesia and intubation should be the definitive method of managing airway and ventilation in the obtund trauma patient. This supports the findings of NCEPOD (2007), which recommended the provision of anaesthesia in pre-hospital practice. However, neither stipulate the clinical grade required to facilitate RSI and airway control. It is therefore reasonable to consider that with the advent of specialist paramedics, drug-assisted airway management could be included in the paramedic scope of practice. It is interesting to note that NICE (2016a) recommend RSI on scene within 45 minutes of the initial 999 call time. However, where RSI cannot be achieved, the recommendation is to transport the patient to an MTC capable of RSI where the journey time is ≤60 minutes, diverting to a TU where the journey time is ≥60 minutes with an unprotected airway. This disparity could cause confusion to pre-hospital clinicians when deciding upon the most appropriate course of action for the patient. However, it is imperative that the airway is managed appropriately, with waveform capnography monitored as standard (Deakin et al, 2010). Clinical support should be considered where journey times exceed 60 minutes and definitive airway control is needed.
Recommendation 1.3—management of chest injuries
The management of chest trauma in the NICE (2016a) guidance predominantly focuses on the identification and management of pneumothorax and tension pneumothorax. Thoracic injuries account for a significant proportion of deaths from trauma-related injuries (Yamamoto et al, 2005) and are considered to have a significant impact on the patient and mortality and morbidity. It is important to note that there are a significant number of chest injuries that can result from blunt and penetrating trauma, some of which can be immediately life-threatening (Schoucoff and Rodriguez, 2011). This article does not consider the cause of injury, nor the pathophysiology pertaining to pneumothorax.
The diagnosis of an underlying pneumothorax, whether simple or tension, relies on the findings of clinical assessment (Schouchoff and Rodriguez, 2011) and this is advocated by NICE (2016a). Some of the signs and symptoms commonly reported in the literature include absent or reduced breath sounds, increased jugular venous pressure, hypotension, tachycardia, hypoxia and difficulty breathing (Dominguez et al, 2013). There is an emerging use of ultrasound to diagnose pneumothorax, especially by the use of enhanced care teams; however, negative findings do not necessarily exclude the presence of a pneumothorax, and the emphasis is placed on rapid clinical assessment (NICE, 2016a).
Where a clinician suspects a tensioning pneumothorax, characterised by cardiovascular and respiratory compromise, rapid chest decompression is indicated and advocated in this patient group by NICE (2016a), current UK clinical practice guidelines (Association of Ambulance Chief Executives (AACE), 2013) and in a consensus statement by the Faculty of Pre-hospital Care (Lee et al, 2007). This is normally achieved by the placement of a 14 g intravenous cannula through the second intercostal space, as described by Dominguez et al (2013) and Lee et al (2007). It is widely evidenced that this method does not often adequately decompress the chest, and is prone to a number of complications (Mistry et al, 2009; Dominguez et al, 2013). NICE (2016a) do not stipulate a method of decompression; however, it is identified that open thoracostomy be performed if the expertise is available. At present, this is not currently an independent skill for paramedics in the UK (Mistry et al, 2009). It is interesting to note that the consensus statement endorsed by the Faculty of Pre-hospital Care outlines that the evidence of benefit of thoracostomy is poor, and that needle chest decompression is normally adequate, despite the complications listed. The author would argue that this is dated evidence, and superseded by the NICE (2016a) guidance.
Anecdotally, the author has utilised a number of new generation devices, specifically designed for chest decompression, which consist of a larger, 12 g cannula and substantially longer needle. The author acknowledges that there are advantages and disadvantages to both the devices used, and does not advocate one device over another. It is likely that as more evidence becomes available, such devices will become standard equipment for the paramedic management of tension pneumothorax, which is supported by Ball et al (2010), who identify an increased success rate of needle decompression when a larger alternative to a 14 g cannula is used. Until such a time of change, clinicians should continue to follow local guidelines and protocols for the management of these patients, giving due consideration to enhanced care teams to deliver thoracostomy in the deteriorating patient.
Recommendation 1.5—management of haemorrhage
In recent years there have been a number of developments in the management of catastrophic haemorrhage, as lessons learnt from the military are adapted for use in civilian medicine (Rowell, 2013). The guidelines on management of haemorrhage are relatively simple: use dressings and direct pressure to control bleeding, with the use of tourniquets for life-threatening blood loss in extremity limb trauma (NICE, 2016a). These are not new lessons, nor new guidelines to paramedics, and the use of specialist dressings and tourniquets has been commonplace for a number of years. The use of pelvic binders is further advocated by NICE (2016a) where the clinician suspects pelvic injury or risk of bleeding from such an injury. This is often based upon assessment of the mechanism of injury and clinical findings. The use of tranexamic acid is also advocated within 3 hours of initial injury, as part of a package of care for haemorrhage control (CRASH-2 Collaborators, 2011).
The guidelines around volume and fluid resuscitation are changing, and this is reflected in both NICE (2016a) and AACE (2013), and there appears to be a wide and varied evidence base in the available literature. In a review of the literature, Geeraedts et al (2015) found that the relationship between pre-hospital fluid and mortality remains unclear and the authors go on to state that a tailored approach to fluid therapy may be more beneficial than the previous guidance to rapidly infuse fluid.
There remains much debate over the choice of fluid, but it is apparent that blood products and plasma are becoming more and more available to pre-hospital clinicians, delivered by enhanced care teams, normally operating on a Helicopter Emergency Medical Service. In the absence of blood products, the author advocates adherence to NICE (2016a) guidance, in restricting volume replacement to maintain central pulses, placing emphasis on basic haemorrhage control. This is succinctly summarised by the AACE (2013)UK Ambulance Services Clinical Practice Guidelines (Figure 2).
Recommendation 1.6—temperature management
Coagulopathy, associated with acidosis and hypothermia, is known to dramatically increase mortality from trauma (Hayes et al, 2002), which can be exacerbated by significant blood loss and poor management. It is therefore important for paramedics and pre-hospital clinicians to consider methods to reduce heat loss and promote warming of the patient from point of assessment to delivery at definitive care. There are multiple methods that can be used, including blankets, specially designed heat mattresses, thermoplastic scoop stretchers and the increasing use of bubble wrap. These methods are known to anecdotally prevent heat loss and maintain core body temperature, although a randomised control trial is needed to establish the best methods of heat loss prevention.
Recommendation 1.7—pain management
It is essential that pain is managed adequately in pre-hospital care, for both assessment and humanitarian reasons (Adams and Field, 2001). Where practical, a pain assessment should be undertaken at the earliest opportunity, in order to guide clinicians in providing adequate levels of analgesia (Muntlin Athlin et al, 2015). As described by Hodkinson (2016), paramedics should be aware of the different pain assessment techniques, employing the most appropriate to each given situation.
Controversially, NICE (2016a) advocate the use of intravenous morphine as a first-line analgesic in the pre-hospital phase, with ketamine as a second-line agent. Although morphine is a strong opioid analgesic, the peak effect is not reached for 10–15 minutes post administration. Morphine can also have profound effects on the respiratory, cardiovascular and neurological systems, depressing respiratory rate, inducing hypotension and altering mental status (Richards, 2009). In a trauma patient, these adverse effects can be disadvantageous. AACE (2013) administration guidelines also list a number of cautions for the use of morphine, which include patients with chest injuries and head-injured patients. This could be considered confusing for paramedics, and gives rise to the potential for patients to receive inadequate analgesia. Therefore, morphine may not be the most suitable analgesic in the first-line management of traumatic injuries. Ketamine, a strong dissociative anaesthetic agent, which has analgesic properties in low doses, could therefore be a preferable option as a first-line analgesic (Richards, 2009). Ketamine is considered to be respiratory and cardiovascular stable, maintaining the patient's own airway reflexes. Ketamine has a relatively rapid onset with short duration and this can be beneficial when needing to package a patient and apply traction. With the emergence of specialist paramedic practice, the use of ketamine is becoming more widespread and will continue to be developed in pre-hospital practice. Jennings et al (2011) identify that it is a safe drug for paramedics to carry and administer, and it is likely that in the future it will be more commonplace in pre-hospital care.
There are a number of other analgesic options emerging in the paramedic profession, including the use of inhaled methoxyflurane and the use of the intranasal route (Hodkinson, 2016). More research and evidence is required into these options prior to any recommendations being made, and this is acknowledged by NICE (2016a).
Recommendation 1.8—documentation
One of the key failings of pre-hospital care reported by NCEPOD (2007) was the lack of clear, concise documentation by pre-hospital care providers. It must be considered, however, that the findings of NCEPOD (2007) were largely based upon hospital care records, with no input from ambulance services. The NAO (2010) also recommended improvements in documentation of major trauma care across both pre-hospital and in-hospital care. NICE (2016b) recommend a standardised format to documentation, which is further compounded by NICE (2016a), which provides a standard template for the recording and handover of information. The basis for documenting clinical findings follows an airway, breathing, circulation, disability, exposure approach, and therefore mirrors clinical assessment. Findings can be succinctly documented and the author regularly adopts this approach in his own professional practice.
The handover at a receiving TU or MTC is a vital aspect of patient care and continuing the patient's experience in the emergency department, and is documented to have an impact on mortality (Loseby et al, 2013). A structured approach should be adopted, using a standardised format, and as such, the author advocates that listed in the NICE (2016a) guidance (Box 2). This loosely follows and builds upon the ATMIST (Age, Time of incident, Mechanism of injury, Injuries suspected, Signs, Treatment given) concept, described in detail by Loseby et al (2013).
Recommendation 1.10—training and skills
Skill retention and regular training is an important aspect of a trauma system, and to this end, NICE (2016a) recommend healthcare professionals operating within the system to be trained in the necessary skills to deliver safe, timely and effective care. This has a number of training implications for ambulance services, which must take responsibility for providing regular clinical updates and refresher training. However, it is a requirement of paramedics to maintain their own professional development, as outlined by the Health and Care Professions Council (2014). Therefore, paramedics should be proficient in the assessment and management of major trauma patients, which includes skills such as basic and advanced airway management, intravenous and intraosseous access, fluid therapy, analgesia administration, needle chest decompression and triage of patients to the most appropriate centre. Together with NICE NG39, clinicians should be aware of NG40 (major trauma service delivery) and the guidance on fractures, complex fractures and spinal injury (NICE, 2016a; 2016b).
Conclusions
These new sets of guidelines from NICE (2016a) are a welcome addition for ambulance services and the paramedic profession alike, bringing a standardised approach to major trauma care and service delivery across England. There are still a number of steps required in order to improve the access and standards of major trauma care, but it is vitally important to remember how far the ambulance service and trauma networks have come since the NCEPOD (2007) and NAO (2010) reports.
As with a large number of pre-hospital procedures, processes and treatments, more research is required in order to better understand the effects on patient outcome, although the author recognises that this can be limited. Paramedics and pre-hospital clinicians should continue to strive to deliver the exemplary levels of major trauma care that are seen day-in day-out, while utilising the recommendations developed by NICE.
Key Points
Conflict of interest: none declared