Use drug-assisted rapid sequence induction (RSI) of anaesthesia and intubation as the definitive method of securing the airway in patients with major trauma who cannot maintain their airway and/or ventilation.

If RSI fails, use basic airway manoeuvres and adjuncts and/or a supraglottic device until a surgical airway or assisted tracheal placement is performed.

In patients with tension pneumothorax, perform chest decompression before imaging only if they have either haemodynamic instability or severe respiratory compromise.

Perform chest decompression using open thoracostomy followed by a chest drain in patients with tension pneumothorax.

Imaging for chest trauma in patients with suspected chest trauma should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area.

Consider immediate chest X‑ray and/or eFAST (extended focused assessment with sonography for trauma) as part of the primary survey to assess chest trauma in adults (16 or over) with severe respiratory compromise.

Consider immediate CT for adults (16 or over) with suspected chest trauma without severe respiratory compromise who are responding to resuscitation or whose haemodynamic status is normal (see also recommendation 1.5.34 on whole-body CT).

Consider chest X‑ray and/or ultrasound for first‑line imaging to assess chest trauma in children (under 16s).

Do not routinely use CT for first‑line imaging to assess chest trauma in children (under 16s).

Use simple dressings with direct pressure to control external haemorrhage.

In patients with major limb trauma use a tourniquet if direct pressure has failed to control life‑threatening haemorrhage.

Rapidly reverse anticoagulation in patients who have major trauma with haemorrhage.

Hospital trusts that admit patients with major trauma should have a protocol for the rapid identification of patients who are taking anticoagulants and the reversal of anticoagulation agents.

Use prothrombin complex concentrate immediately in adults (16 or over) with major trauma who have active bleeding and need emergency reversal of a vitamin K antagonist.

Do not use plasma to reverse a vitamin K antagonist in patients with major trauma.

Consult a haematologist immediately for advice on adults (16 or over) who have active bleeding and need reversal of any anticoagulant agent other than a vitamin K antagonist.

Consult a haematologist immediately for advice on children (under 16s) with major trauma who have active bleeding and may need reversal of any anticoagulant agent.

Do not reverse anticoagulation in patients who do not have active or suspected bleeding.

Use physiological criteria that include the patient’s haemodynamic status and their response to immediate volume resuscitation to activate the major haemorrhage protocol.

Do not rely on a haemorrhagic risk tool applied at a single time point to determine the need for major haemorrhage protocol activation.

For patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.

In pre-hospital settings, titrate volume resuscitation to maintain a palpable central pulse (carotid or femoral).

In hospital settings, move rapidly to haemorrhage control, titrating volume resuscitation to maintain central circulation until control is achieved.

For patients who have haemorrhagic shock and a traumatic brain injury:

In pre-hospital settings only use crystalloids to replace fluid volume in patients with active bleeding if blood components are not available.

In hospital settings do not use crystalloids for patients with active bleeding. For patients who do not have active bleeding, see the section on resuscitation in the NICE guideline on intravenous fluid therapy in adults in hospital and the section on fluid resuscitation in the NICE guideline on intravenous fluid therapy in children and young people in hospital for advice on tetrastarches.

For adults (16 or over) use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.

For children (under 16s) use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child’s weight.

Hospital trusts should have specific major haemorrhage protocols for adults (16 or over) and children (under 16s).

For patients with active bleeding, start with a fixed‑ratio protocol for blood components and change to a protocol guided by laboratory coagulation results at the earliest opportunity.

Imaging for haemorrhage in patients with suspected haemorrhage should be performed urgently, and the images should be interpreted immediately by a healthcare professional with training and skills in this area.

Limit diagnostic imaging (such as chest and pelvis X‑rays or FAST [focused assessment with sonography for trauma]) to the minimum needed to direct intervention in patients with suspected haemorrhage and haemodynamic instability who are not responding to volume resuscitation.

Be aware that a negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage.

Consider immediate CT for patients with suspected haemorrhage if they are responding to resuscitation or if their haemodynamic status is normal.

Do not use FAST or other diagnostic imaging before immediate CT in patients with major trauma.

Do not use FAST as a screening modality to determine the need for CT in patients with major trauma.

Use whole‑body CT (consisting of a vertex‑to‑toes scanogram followed by a CT from vertex to mid‑thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole‑body CT.

Use clinical findings and the scanogram to direct CT of the limbs in adults (16 or over) with limb trauma.

Do not routinely use whole‑body CT to image children (under 16s). Use clinical judgement to limit CT to the body areas where assessment is needed.

Use damage control surgery in patients with haemodynamic instability who are not responding to volume resuscitation.

Consider definitive surgery in patients with haemodynamic instability who are responding to volume resuscitation.

Use definitive surgery in patients whose haemodynamic status is normal.

For patients with major trauma, use intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.

If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamine.

Consider ketamine in analgesic doses as a second‑line agent.