Major trauma

Any person, 16 years and over, presenting with blunt, penetrating, or other traumatic mechanism resulting in an actual or potential life or limb-threatening injury. Excludes major burns.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
Suspected C-spine injury	All trauma patients should be treated as having a spinal injury until proven otherwise Stabilise the C-spine with in-line immobilisation and/or foam collar (appendix)

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning Do not perform head tilt and do not insert a nasopharyngeal airway, if there is any possibility of a fractured base of skull or nasal bone fracture

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated Apply oxygen
Tension pneumothorax Asymmetrical chest movement Unilateral or decreased breath sounds	Perform chest decompression, if trained
Open pneumothorax Open, sucking chest wound	Cover with non-porous dressing taped on 3 sides only. Remove immediately if respiratory status deteriorates
Flail chest Paradoxical chest wall movement Respiratory distress Hypoxia Severe pain	Exclude pneumothorax

Circulation

Assessment	Intervention
Signs of external bleeding	Control external bleeding using direct pressure and/or elevation In cases of limb haemorrhage, i.e. arterial bleeding, use a tourniquet, or keep in situ if applied pre-hospital, until advised by the trauma team
Perfusion (capillary refill, skin warmth and colour) Pulse rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG
IVC and/or pathology	Insert 2 large bore (18 gauge) IV cannulas, if trained If unable to obtain IV access, consider intraosseous, if trained If ongoing haemodynamic instability, escalate as per local CERS protocol for advice regarding blood products and activation of Critical Blood Loss or Massive Transfusion Protocol or Code Crimson and give tranexamic acid, 1 g IV, once only See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of Hartmann’s or sodium chloride 0.9% IV/intraosseous bolus Warmed fluids are preferred Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved
Pelvic injury	Consider pelvic binder if signs of shock, severe pain or high risk mechanism. High risk mechanism may include: crush injury high speed, rollover or lateral impact MVA ejection from a vehicle, partial or complete vehicle vs pedestrian death in the same vehicle See pelvic binder appendix
Long bone injury	Apply a splint to any long bone injuries

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated If reduced GCS or unable to recall events, commence A-WPTAS. See specific treatment section
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Aim for normothermia If hypothermic, initiate slow re-warming with blankets, forced air device, warm IV fluids or blood Measure core temperature if actively warming
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, including estimated blood loss
NBM	NBM until medical review
Nausea and/or vomiting	If present, see nausea and/or vomiting section
Gastrointestinal	Consider insertion of IDC if required and not contraindicated

Glucose

Assessment

Intervention

BGL

Measure BGL If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria): give 40% glucose gel, up to 15 g, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake: give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose 200 mL by IV infusion over 15 minutes, once only if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes If the patient is unconscious or peri-arrest: give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis if delay in IV access, give glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Focused assessment

Complete a secondary survey focused assessment.

Precautions and notes

• Be aware of distracting painful injuries that may mask other and more serious injuries.
• Tachycardia may not occur in athletes, elderly patients, those taking beta blocker agents or those suspected of spinal cord injury.
• Be aware of severe injury in elderly patients with a low mechanism of injury.
• Early use of blood products, if available, remains the optimal resuscitation fluid for the hypovolaemic patient. Escalate as per local CERS protocol.
• Where blood is not available, or delayed, IV Hartmann’s solution is the preferred alternative for the initial resuscitation of the hypovolaemic trauma patient. IV sodium chloride 0.9% may be used as an alternative, however, large volumes may result in metabolic acidosis. Small volumes of fluid resuscitation are preferred, i.e. permissive hypotension, rather than aggressive fluid resuscitation.
• Tranexamic acid is recommended in shocked trauma patients within 3 hours from the time of injury.

Interventions and diagnostics

Specific treatment

Limb threatening injury

• Neutral alignment
• Apply splint
• Elevate the limb
• Perform neurovascular limb observations.

Open fractures

• Irrigate with sodium chloride 0.9% and apply a compress soaked in sodium chloride 0.9%.
• Do not reposition protruding bone ends.
• Stabilise limb.
• Escalate care urgently as per local CERS protocol.

Amputation or partial amputation

• If the digit, tissue or limb has been completely amputated:
  • Wrap the amputation in gauze soaked with sodium chloride 0.9%.
  • Place in a clean bag, and then in another bag with ice slurry.
  • Do not sit the amputation directly in the ice slurry.
• If partial amputation:
  • Perform neurovascular exam.
  • Irrigate with sodium chloride 0.9% and apply dressing soaked in sodium chloride 0.9%.
• Escalate care urgently as per local CERS protocol.

Suspected mid-shaft femur fracture

• Stabilise with traction splint. Perform neurovascular observations pre and post splinting.
• Consider hip fracture (suspected) protocol.

Impaled objects

• Stabilise object. Do not remove.

Open abdominal injuries

• Cover exposed viscera with moist saline packs.

Head injury

• Repeat A-WPTAS if the score is less than 18/18.

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Tetanus

If patient has a ‘tetanus-prone’ wound, consider giving a tetanus booster vaccine.

• Diphtheria and tetanus (ADT booster) vaccine should be given as per the Australian Immunisation Handbook Guide for tetanus prophylaxis in wound management.
• If ADT booster is not available then diphtheria/tetanus/pertussis (Boostrix) vaccine can be used.
• If no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine: refer to medical or nurse practitioner or nurse immuniser.
• If pregnant or breastfeeding: dTpa vaccine (diphtheria-tetanus-acellular pertussis) is recommended. Refer to medical or nurse practitioner or nurse immuniser.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• Formal police blood alcohol level, if applicable
• FBC, UEC, coags, lipase, group and hold, VBG with lactate
• Consider alerting blood bank simultaneously
• Female of childbearing age: urine or serum βHCG

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au