What are the key principles of initial assessment and management for a patient with suspected major trauma in primary care?

The key principles for initial assessment and management of a patient with suspected major trauma in primary care focus on rapid identification, immediate life-saving interventions, and prompt transfer to an appropriate specialist centre NICE NG39,NICE CKS,NICE NG40.

• Immediate Transfer to a Major Trauma Centre: Be aware that the optimal destination for patients with major trauma is usually a major trauma centre NICE NG39,NICE NG40. Spend only enough time at the scene to give immediate life-saving interventions before transfer NICE NG40. If a patient needs a life-saving intervention that cannot be delivered by the primary care team, they should be diverted to the nearest trauma unit if necessary, before onward transfer to a major trauma centre NICE NG39,NICE NG40. The referring professional should inform the destination hospital by phone of the impending transfer NICE CKS.
• Systematic Assessment (CABCDE): Record and assess catastrophic haemorrhage, airway with in-line spinal immobilisation, breathing, circulation, disability (neurological), and exposure and environment (ABCDE) NICE NG39.
• Key Assessment Points:
  • Mechanism of Injury: Identify how and when the injury occurred, especially dangerous mechanisms such as falls from height greater than 1 metre or 5 stairs, high-speed motor vehicle collisions, or ejection from a vehicle NICE CKS.
  • Level of Consciousness: Assess using the Glasgow Coma Scale (GCS) NICE CKS. A GCS score of less than 15 on initial assessment is a risk factor for intracranial complications NICE CKS.
  • Vital Signs: Look for hypoxia or signs of shock, such as tachycardia, hypotension, or reduced capillary refill time NICE CKS.
  • Specific Injury Signs: Examine for visible trauma to the scalp, skull, head, and neck NICE CKS. Assess for signs of basal skull fracture (e.g., clear fluid from ear/nose, periorbital haematoma, bleeding from ears, Battle's sign) NICE CKS. Assess for neck pain, tenderness, or inability to rotate the neck 45 degrees, which may indicate cervical spine injury NICE CKS.
  • Risk Factors for Complications: Identify risk factors for intracranial complications or cervical spine injury, including any loss of consciousness, post-traumatic seizure, persistent headache or vomiting, focal neurological deficit, or current anticoagulant medication NICE CKS.
• Immediate Life-Saving Interventions:
  • Haemorrhage Control: Use simple dressings with direct pressure to control external haemorrhage NICE NG39. For major limb trauma, use a tourniquet if direct pressure fails to control life-threatening haemorrhage NICE NG39. If active bleeding is suspected from a pelvic fracture after blunt high-energy trauma, apply a purpose-made pelvic binder or consider an improvised one if a purpose-made binder does not fit NICE NG39. Consider intravenous tranexamic acid as soon as possible in patients with active or suspected active bleeding NICE NG39.
  • Spinal Immobilisation: If a head injury presents with risk factors for cervical spinal injury (e.g., GCS less than 15, neck pain/tenderness, focal neurological deficit, paraesthesia), full cervical spine immobilisation should be attempted and maintained NICE CKS.
  • Minimising Heat Loss: Minimise ongoing heat loss in patients with major trauma NICE NG39.
  • Pain Management: Assess pain regularly using a suitable pain assessment scale NICE NG39. Use intravenous morphine as the first-line analgesic, adjusting the dose as needed NICE NG39. If intravenous access is not established, consider intranasal atomised diamorphine or ketamine NICE NG39.