Appendix: Recommendations that might have particular implications for service delivery

Guidance

Tables 1 and 2 below contain links to recommendations for pre‑hospital and hospital management of major trauma in the NICE guidelines on fractures (complex), major trauma, major trauma: service delivery and spinal injury that might have particular implications for service delivery. They do not list all the services needed to provide care for patients with major trauma.

The recommendations were reviewed by the guideline committee to identify those with an impact on services through:

timing – the timing an intervention should be given
destination of the patient – triaging decisions, initial destination or secondary transfer
availability of a service – the routine availability of an intervention
staff skills – expertise not routinely available.

The tables are arranged by clinical area, in alphabetical order.

**Table 1 Pre‑hospital management of major trauma: recommendations with implications for service delivery**
Clinical area	Interventions	Recommendations
Airway management	Basic airway manoeuvres and adjuncts	Major trauma recommendations 1.2.2 and 1.2.3
Airway management	Drug‑assisted rapid sequence induction of anaesthesia and intubation, delivered within 45 minutes of the initial call to the emergency services	Major trauma recommendations 1.2.1 and 1.2.3 Major trauma: service delivery (this guideline) recommendation 1.11.2
Airway management	Supraglottic devices	Major trauma recommendation 1.2.2
Chest trauma	Open thoracostomy	Major trauma recommendation 1.3.5
Chest trauma	Needle decompression	Major trauma recommendation 1.3.5
Chest trauma	Ultrasound performed by specialist team	Major trauma recommendation 1.3.2
Circulatory access	Peripheral venous access	Major trauma recommendations 1.5.15 and 1.5.16
Circulatory access	Intra‑osseous access	Major trauma recommendations 1.5.15 and 1.5.16
Fracture, open	Prophylactic antibiotic treatment, delivered as soon as possible and preferably within 1 hour of injury	Fractures (complex) recommendation 1.1.11
Fracture, pelvic	Pelvic binder application, including purpose‑made and improvised pelvic binders	Fractures (complex) recommendation 1.1.7
Spinal injury	In‑line spinal immobilisation	Spinal injury recommendations 1.1.2, 1.1.4, and 1.1.9
Spinal injury	Assessment using Canadian C‑spine rule	Spinal injury recommendations 1.1.5 and 1.1.6

**Table 2 Hospital management of major trauma: recommendations with implications for service delivery**
Clinical area	Interventions	Recommendations
Circulatory access	Peripheral intravenous access	Major trauma recommendation 1.5.17
Circulatory access	Intra‑osseous access	Major trauma recommendation 1.5.17
Documentation	Standardised documentation used throughout a trauma network	Major trauma: service delivery (this guideline) recommendations 1.7.1 and 1.7.2
Documentation	Pre‑alert information received by senior nurse or trauma team leader in the emergency department, who determines the level of trauma team response	Major trauma recommendation 1.8.4
Documentation	Documentation completed by designated member of trauma team and checked by trauma team leader	Major trauma recommendations 1.8.8 and 1.8.9
Haematology	Immediate haematology consultation for anticoagulation reversal	Major trauma recommendations 1.5.10 and 1.5.11
Haematology	Laboratory testing of coagulation to guide blood product protocol	Major trauma recommendation 1.5.27
Haematology	Plasma and red blood cells for fluid replacement	Major trauma recommendations 1.5.24 and 1.5.25
Information and support for patients, family members and carers	A healthcare professional to facilitate delivery of information	Major trauma recommendation 1.9.2 Major trauma: service delivery (this guideline) recommendation 1.6.3 Fractures (complex) recommendation 1.4.2 Spinal injury recommendation 1.8.2
Information and support for patients, family members and carers	A dedicated member of staff for unaccompanied children and vulnerable adults to contact next of kin and provide personal support	Fractures (complex) recommendation 1.4.5 Major trauma recommendation 1.9.5 Major trauma: service delivery (this guideline) recommendation 1.9.4 Spinal injury recommendation 1.8.6
Radiology, imaging	Immediate CT	Major trauma recommendation 1.4.5 and recommendation 1.5.31
Radiology, imaging	Whole‑body CT	Fractures (complex) recommendation 1.2.8 Major trauma recommendation 1.5.34
Radiology, imaging	Immediate eFAST (extended focused assessment with sonography for trauma)	Major trauma recommendation 1.4.4
Radiology, imaging	FAST (focused assessment with sonography for trauma)	Major trauma recommendation 1.5.29
Radiology, imaging	Ultrasound	Major trauma recommendation 1.4.6
Radiology, imaging	X‑ray	Major trauma recommendations 1.4.4 and 1.4.6 and recommendation 1.5.29
Radiology, imaging	Immediate radiology consultation to interpret results of imaging	Spinal injury recommendation 1.5.1
Radiology, interventional	Interventional radiology for haemorrhage control	Major trauma: service delivery (this guideline) recommendation 1.11.3 Fractures (complex) recommendation 1.2.16 Major trauma recommendations 1.5.40–1.5.43
Surgery	Damage control surgery	Major trauma recommendation 1.5.37
Surgery	Definitive surgery	Major trauma recommendations 1.5.38 and 1.5.39
Surgery	Immediate surgery to explore hard signs of vascular injury	Fractures (complex) recommendation 1.2.3
Surgery, neurosurgery and spinal	Specialist neurosurgical or spinal surgeon on call immediately for patients with a spinal cord injury	Spinal injury recommendations 1.6.1 and 1.6.2
Surgery, neurosurgery and spinal	Local spinal cord injury centre consultant	Spinal injury recommendation 1.6.3
Surgery, orthopaedic	Surgery for pilon fractures, performed within 24 hours of the injury	Fractures (complex) recommendation 1.2.32
Surgery, orthopaedic and plastic	Surgery performed concurrently by consultants in orthopaedic and plastic surgery to achieve debridement, fixation and cover of an open fracture	Fractures (complex) recommendation 1.2.27
Surgery, pelvic	Consultation with pelvic surgeon for unstable pelvic fracture	Fractures (complex) recommendation 1.2.18
Wound care	Negative pressure wound therapy for open fracture wounds	Fractures (complex) recommendation 1.2.31
Wound care	Photographs of open fracture wounds, taken in accordance with a protocol	Fractures (complex) recommendation 1.3.4