The use of a checklist for the initial management of MTTA and MHP to ensure the process is streamlined led by the trauma team leader. This would help to reduce the cognitive load that is often presented to the team leader. This would also help direct junior team members that may not have significant experience in the initial management of major trauma.

In addition to the above, a checklist for the initial management of the major trauma patient is being created to ensure that clinicians are aware of both primary and secondary transfers. The contact details for the MTC (Adults and Paediatrics) were also included in this document. The main purpose of this document was for clinicians who may not be aware of the locally agreed protocol and to gain an overall understanding of how major trauma was managed.

Intended outcomes

1. The earlier recognition of the haemorrhaging patient with appropriate activation of the MHP

2. Limiting the over-reliance on Haemoglobin levels alone

3. Recognition of the importance of base excess and lactate levels for both diagnosis of tissue shock and assessment of adequate resuscitation

4. Ensuring that the principles of balanced transfusion are followed

5. Early use of TXA (unless contraindicated)

6. Awareness of the elderly trauma patient (not initially presenting as initial trauma)

7. a greater understanding of the need for dedicated trauma imaging to ensure that occult injuries are not missed.

8. Recognition that physiological deterioration as a consequence of active bleeding is less tolerated at the extremes of age, including in the pregnant trauma patient

Evidence: Before the start of the study, a pilot study was carried out to assess the pre-existing knowledge and awareness of the indications for MHP and MTTA. These responses were gathered from a cohort of clinicians of varying levels of seniority. The use of descriptive factors was used to evaluate the basic understanding of what would be the triggers for activation of MHP and MTTA. It was interesting

of trauma is particularly concerning with the walking trauma patient. There is also the need to establish Geriatric Trauma Protocols (GTP). This is a recognition that trauma to an altered physiology results in significant morbidity and mortality.

With regards to the self-presenting/NWAS presentation not considered initially as major trauma, the nursing staff would perform the initial triage. The nursing staff are trained to assess if the patients trigger the criteria for ‘silver trauma’ hence requiring a primary survey. Based on NICE guidelines, if there has been a significant mechanism of injury then the need for a primary survey would also be highlighted. Once triaged, the nursing staff highlights the aforementioned senior doctor in charge of the department. The clinician performing the primary survey has to be at a Registrar level and above with appropriate ATLS/ETC/APLS training. Based on the findings from the primary survey, the patient continues to be managed in the major area or gets transferred to the Resus area of the ED.

At the time of undertaking this project, the trust trauma guidelines were being updated. This enabled our project in highlighting the importance of trauma resuscitation. There was also a middle-grade teaching session on trauma-induced coagulopathy in addition to acute traumatic coagulopathy. This was well received amongst colleagues supported by the written formal feedback post-session.

We also introduced a new algorithm for the initial management of the Major trauma patient presenting to our ED. This was designed to ensure that the responsible clinician irrespective of the grade was aware of the accepted pathway. The contact details for the trauma coordinators for both the regional paediatric and adult MTCs were included in the document.

This pathway underwent clearance from the clinical governance before being incorporated into clinical practice and was included in the Major Trauma documentation for our Trust.

In addition to the wide dissemination of both these checklists and pathways, they were included in the monthly newsletter. This would reach a wider audience with the eventual aim of reducing the cognitive load and streamlining major trauma management. The importance of damage-controlled resuscitation was further

resuscitation measures. We have all gained an understanding of the deleterious nature of crystalloid resuscitation and as noted in the newer versions of ATLS, this is being phased out in clinical use. In some mature trauma systems, the use of crystalloid is completely phased out as the risk of complications as resultant of volume resuscitation outweigh any benefits.

The response with regards to factors that would trigger the MHP was also studied. This was to understand the recognition from clinicians of the importance of haemodilution in acute blood loss. The reliance on heart rate and blood pressure in the activation of the MHP has been proven to be outdated. This is particularly important at the extremes of age where the physiological reserves are depleted. There is increasing recognition that base excess and lactate are more sensitive in the context of acute blood loss with a resultant shock state (1). The value of the venous blood gas which forms the immediate investigation in most ED Resus settings is comparable to the results obtained from arterial blood gas. Part of the problem with the activation of MHP is the presumed waste that is associated with it, this has been discussed in more detail in the discussion section. It can be understood that if packed red cells or blood products are wasted this would cause considerable to the clinician.

The importance of initial management of a major trauma patient is of utmost importance. There are several potential considerations here. As described in other sections within this article, working as a middle grade require competency in managing major trauma patients. The level of confidence of the individual clinicians was assessed with follow-up plans to include regular trauma simulation scenarios as part of a teaching programme. These clinicians must be aware and updated on any changes to the management. A potential source of new information was identified as having links/updates on the monthly ED Newsletter. The basic management of trauma care has remained unchanged however with time and newer ATLS-based guidance fine-tuning is required.

As previously mentioned, our hospital is a Major Trauma Unit and not a Major Trauma Centre, it is important to note that approximately 50% of clinicians would consider undertaking the initial major trauma care before assessing

scenarios with the implementation of the tools as a result of this study. From the clinicians’ perspective, 89% (8/9) of the respondents felt that with the use of MHP and MTTA protocol has reduced the cognitive load whilst managing major trauma. There was an improvement in the level of confidence of clinicians in the initial management of major trauma from 52.9 % to 89% highlighting that with the appropriate trauma management education the confidence of clinicians can be improved. 89% of the clinicians found that the concept of primary and secondary transfer was clearer based on our transfer protocol. There was also greater awareness of damage-controlled resuscitation from 56% to 89%. There was interest from several levels of clinicians who were very keen to learn about how major trauma is managed. 78% of the respondents felt more confident in the management of the multiply injured patients.

Trauma Cell: The NWAS has a dedicated ‘Trauma Cell’ (2) which a specialist helpdesk co-located in the control room. This is staffed by advanced paramedics that deal with resource allocation, advice and pre-alerting of the major trauma centres. They have their own set of criteria that are used to direct patients to the appropriate level of care deemed necessary at the time.

can help direct the resuscitation effort with transfusion of the appropriate blood and blood products. Our hospital uses ROTEM as part of VHA and is available on request. VHA such as the use of ROTEM and TEG can confer additional benefits when compared to the standard coagulation assays [7].

In MTC, trauma care is streamlined with consultant-led care from the outset all the way through to recovery which has been proven to be beneficial for in-patient morbidity and mortality. However, in the non-MTC setting, this may not necessarily be the case leading to variability in the care thereby hampering the patient’s recovery. There is a need for robust processes to ensure that the same level of care is given to patients irrespective of the grade of the clinician and timing of the day among other key factors.  It has to be acknowledged that the number of cases of major trauma with ISS>15 would be considerably higher in the MTC setting compared to their counterparts. The composition of the major trauma team is also noted to vary between MTC and non-MTC settings. In developed major trauma systems like the LMTS, there is an immediate consultant presence from the different specialities. At its inception, the trauma team should involve members who are ATLS/APLS/ETC providers as the minimum at a registrar level as above. In time-critical scenarios, informed and appropriate decisions need to be made early on in the patient’s journey to optimise the intended outcomes. The presence of senior decision-makers at the time when the patient is received can help to mobilise resources earlier for definitive management. This can be in the realms of IR+DCS or DCS/ICU, being particularly important in out of hours when it can considerably longer period. In high-volume MTCs with the presence of dedicated trauma consultants this is a possibility, however, may not necessarily apply to non-MTC settings due to a variety of logistical reasons.

Changes as a result of the Project

• Introduction to the Major Trauma Development board as part of the major improvement project
• Incorporation into the Major Trauma documentation
• Greater discussion and awareness of the role of early DCR and Haemorrhage Control
• Garnered significant interest amongst clinicians at all levels of seniority

• Hands-off aseptic approach unless TCA when handover
• Clear documentation of attending trauma team members in major trauma booklet (both adult and paediatric)
• Early and appropriate analgesia is to be given to all trauma patients, and liaise with anaesthetic teams if any additional concerns including depressed GCS.
• Ensure that CT Polytrauma is carried out at the earliest as an adjunct to the primary survey for identification of injuries, if a pre-alert is received- inform radiology
• If concerns of active intra-abdominal bleeding, consider triple-phase CT B+CAP or Angiogram + Dual porto-venous phase (Liaise early with Radiologist)
• Early mobilisation of blood and blood products through activation of the MHP
• Use of ROTEM as an adjunct to haemostatic resuscitation
• Limit excessive handling of patients (especially in the context of suspected spinal/pelvic fractures)

Acknowledgement: We would like to take this opportunity to thank all the staff members working across different clinical settings that enable the safe management of the major trauma patient.