Category: Trauma

The vast majority of non-major trauma pelvic fractures presenting to Calderdale & Huddersfield A&E will be fragility fractures in elderly patients — almost exclusively:

Isolated pubic rami fractures (anterior ring, FFP-I)
Pubic rami fractures with concurrent non-displaced sacral fracture (FFP-II)

These represent 84% of all elderly pelvic fractures nationally, and virtually all are non-operative injuries by definition. The remaining cases are a small minority and are addressed in the referral criteria below.

01-Jun-2026

Toddlers Fracture

Toddlers Fractures

Typically occur between 9months and 4yrs of age.
After a low energy twisting injury, such as;
- Slipping and twisting while walking/running/jumping
- Leg caught when sliding off parent/chair/toy
Clinical Features:
- Wont put foot down
- Not walking
- Often little tenderness
- Gentle twist of ankle and knee will be painful
Xray features:
- Spiral fracture tibia (often seen best on lateral view

01-Jun-2026

Major Haemorrhage Protocol

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MHP

Remember:

Do the Basics – don’t forget ABCD
Inform Transfusion and get someone to run a G&S sample down
FFP can take up to 45min and platelets come from Leeds
If you no longer need the MTP – inform transfusion and return products ASAP

22-May-2026

Penthrox (Methoxyflurane)

Penthrox is an inhaled, patient controlled analgesic for use with moderate to severe acute pain associated with trauma. Not to be used in atraumatic pain, chronic pain, children or pregnancy.

Rapid onset of analgesia lasting 25-60 minutes depending on rate and depth of inhalation. Wears off 10 minutes after last inhalation.

Contraindications (CHECK ALLL FM):

18-May-2026

Rabies [notifiable disease]

Recent Incident: Bat contact was not recognised (effectively touching a bat without gloves means treatment is recommended)

Important: Rabies Vaccine is in short supply and we must do a UKHSA risk assessment. Call RIgS 09:30-17:00 7 days, OR complete Form

Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.

In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.

Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.

Risk Assessment

To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]

Exposure Category

Combined Country/Animal & Exposure Risk

Treatment

Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.

If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)

You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]

IN HOURS 08:30AM-5PM PLEASE CALL PHARMACY TO INFORM THEM TO EXPECT A DELIVERY OF IMMUNOGLOBULIN SO THIS CAN BE SEGREGATED FOR THE CORRECT PATIENT. PLEASE ASK TO SPEAK TO THE RESPONSIBLE PHARMACIST CRH (4218/4279) HRI (2422/7123)

Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400

20-Apr-2026

ASPEN Collar fitting

Fitting ASPEN collars is import – for both the comfort and function of the collar. The DENS study has been looking at the effectiveness on collars in peg fractures. Preliminary results suggest limited benefit, which made be due to the fact the many patients remove the collar early as not comfortable.

APSEN Training Video

ASPEN VISTA (adjustable) – Coming Soon

16-Mar-2026

Cervical Spine Clearance in the trauma patient

Although in ED we cannot prevent the primary injury, our objective is to recognise and prevent secondary injury. Through the use of the agreed standards

Standards:

Spinal protection must remain in place if an injury is suspected/identified, or until it is excluded via an established protocol.
- Unless a senior clinician has clearly documented a decision, immobilisation not in the patients best interest.
Assessment of the whole spine should be performed and documented where injury is suspected.
If abnormal clinical signs are found, complete neurological examination must be performed and documented.
If spinal injury identified OR abnormal neurological signs consistent with spinal cord injury are found, immediate discussion with and referral to a centre capable of emergency spinal surgery must occur.
Significant spinal injury is excluded following either:
- Normal clinical examination in an awake and orientated patient with no clinically significant distracting injury OR illness is present; the patient can concentrate on and reliably report neck findings. (in line with Canadian C-Spine rules)
- Completion of spinal imaging protocols (standard 6).
Imaging protocols:
- Thoracic and lumbar spine scans should be obtained according to major trauma protocols.If a cervical spine injury is suspected, thin slice CT scanning from occiput to T4, including sagittal and coronal reconstructions should be performed without delay.If whole-body CT (WBCT) for trauma is necessary, this should include the cervical spine if injury is suspected.
- An initial report of spine clearance imaging should be available before the patient leaves the Emergency Department.

Option	Scenario		Action
1	This investigation demonstrates an injury that may affect spinal stability. (see Notes)		Continue spinal protection and seek advice from an appropriate clinical team.
2	This scan is of good quality and there are no comorbidities confounding its interpretation. No features of instability, such as fracture, haematoma or joint disruption are seen.	Patients with NO acute neurological symptoms/signs on examination or mobilisation.	Spinal protection may be removed.
		Patient who HAS acute neurological symptoms/signs on examination or mobilisation.	Continue spinal protection and seek advice from an appropriate clinical team.
		Unconscious OR unable to Co-Operate with examination (see Notes)	Spinal protection can be removed with caution providingConsultant Radiology report & No evidence of acute neurological deficitIt must be recognised there is a <1% chance of unrecognised injury. ANY evidence of neurological deterioration should be re-immobilised pending MRI
3	Whilst there are no obvious features of spinal instability, the CT scan is either not of good quality and/or there are comorbidities confounding its interpretation.		Continue spinal protection until MRI is performed and report available.

Magnetic Resonance Imaging is necessary when the following are present:

Suspected cord injury
Ambiguous CT scans, as per option 3 of standard 6
Inability to assess patient, as per option 2 standard 6
Ankylosed spines with negative or indeterminate CT appearances for fracture
Contraindications to ionising radiation, for example in pregnancy

Notes:

Option 1 Standard 6: Certain Spinal injuries may be combatable with removal of protection on agreement of the base speciality consultant:
- Facet joint fractures of the thoracic and lumbar spine
- Spinous process fractures
- Wedge compression fracture with loss of vertebral body height of less than 25%
- Type 1 odontoid fracture
- End-plate fracture
- Transverse process fracture
- Trabecular bone injury
- Osteophyte fracture, excluding corner or teardrop fractures
- Isolated avulsion fractures
Option 2 Standard 6: Management of Unconscious or patients unable to fully co-operate with clinical exanimation is recognised as significant challenge. With advances in CT the number of significant injuries missed is very low <1%. However, there are significant risks associated with prolonged immobilisation, especially for frail patients who are more likely to fall into this group.

This pragmatic approach is in line with BOA-Standards, however, it must be recognised there is a chance of deterioration. If ANY evidence of neurological deficit the patient should be re-immobilised and reassessed for further imaging.

Complications of prolonged use of Immobilisation:

Impaired venous drainage and increased intracranial pressure
Difficult laryngoscopy and intubation
Increased risk of aspiration and ventilator-associated pneumonia
Difficult central venous cannula insertion
Increased risk of central venous cannula associated blood stream infections
Increased risk of pulmonary thromboembolism
Pressure necrosis leading to ulceration
Inability to provide good oral care
Failed enteral nutrition, gastrostasis and reflux
Restricted physiotherapy

Reference:

NICE Spinal Injury – https://www.nice.org.uk/guidance/ng41
BOA Standard C-Spine Clearance- https://www.boa.ac.uk/static/1e3aff2a-576f-484b-ab21ec91300678cf/BOAST-Cervical-Spine-Clearance.pdf
C-Spine Clearance Unconscious patient UHW – https://www.rightdecisions.scot.nhs.uk/media/2106/clearance-of-the-cervical-spine-in-the-unconscious-adult-patient.pdf
Morris CG, McCoy EP, Lavery GG. Spinal immobilisation for unconscious patients with multiple injuries. BMJ. 2004 Aug 28;329(7464):495-9. doi: 10.1136/bmj.329.7464.495. Erratum in: BMJ. 2004 Oct 2;329(7469):773. McCoy, E P [corrected to McCoy, E]. Erratum in: BMJ. 2004 Sep 18;329(7467):673. PMID: 15331475; PMCID: PMC515204.

08-Feb-2026

Hip Dislocation – Flowchart

Dislocation of a Native Hip

Uncommon – High-Energy injury
All patients presenting with a suspected native hip dislocation following trauma (including falls from standing) must have a primary survey done to assess for other injuries.
Early Senior input (if not trauma team) and Resus
Neurovascular status of the affected limb must be assessed and documented.

Dislocation of Prosthetic Hip

Relatively common and frequently low energy
All patients should be assessed with low threshold to treat as trauma
- Remember the biggest cause of ISS >15 Major Trauma in UK is older patients falling from standing height
Neurovascular status of the affected limb must be assessed and documented.
If there is neurovascular compromise then move to Resus and inform ED senior

28-Dec-2025

Minimal and Moderate Paediatric Sedation

The depth and type of sedation required in children depends on the procedure to be carried out. With the exception of procedures expected to cause pain most procedures in the Paediatric Emergency Department will not require pharmacological agents.

Painful procedures preformed for children in the ED are usually done with Ketamine Sedation for which there is a separate pathway – Ketamine Sedation

Minimal and Moderate Sedation

Minimal – Drug induced calm, the patient is awake and responds to verbal commands but may have impairment of cognition and coordination.

Moderate – Drug induced depression of consciousness but patients respond purposefully to verbal commands or tactile stimulation.

Prior to consideration of drugs for painless procedures please consider consider alternative strategies. There are playspecialists at both sites between 8am and 8pm most days! If play therapists aren’t available consider the use of favourite songs, distraction toys, and of course the modern day all-in-one fix of a phone/tablet with the child’s favourite show!

The help of an experienced nurse and capable parent cannot be underestimated. You should consider the use of intranasal fentanyl (see guideline) on presentation for more painful conditions, as well as paracetamol and ibuprofen.

You might diminish the pain on infiltration of (warmed) local anaesthetics by injecting slowly and using a fine gauge needle. If oral sedation is to be considered oral Chloral Hydrate or Buccal Midazolam should be considered, neither of these require cannulation.

Who can preform minimal/moderate sedation?

Senior medical staff (ST3+) with paediatric life support training
Must have done at least 6 months of anaesthetics/ICU
Familiar with giving medication of choice
Must have at least 2 staff members – someone to perform sedation, someone to monitor the patient
Department must be safe – Senior ED Clinician in charge (Consultant or Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time

Benzodiazepine and chloral both have very variable effects in children and careful consideration of an alternative plan should be made. Can imaging be delayed until a play-therapist is present? Could they be bought into PAU for their imaging requirements? Can a specialist attend to clean and suture a wound under ketamine instead of just cleaning the wound and dressing?

Contraindications

Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:

Abnormal airway – including large tonsils or craniofacial anomalies e.g. receding jaw, stiff neck, restricted mouth opening, very large head
Raised intra cranial pressure or depressed conscious level
History of obstructive sleep apnoea
Major organ dysfunction including congenital cardiac anomalies
Moderate to severe gastro oesophageal reflux disease
Neuromuscular disorders
Bowel obstruction
Intercurrent respiratory tract infection
Known allergy to sedative drug / previous adverse reaction
Multiple trauma
Refusal by parent / guardian / child
Corrected age < 1 year because of severe prematurity
ASA 3 or more

Fasting

For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
Apply the 2-4-6 fasting rule for sedation in the ED unless child in significant distress and all other distraction and environmental alterations have been attempted.
- 2 hours for clear fluids
- 4 hours for breast milk
- 6 hours for solids and formula milk

Medications

Chloral Hydrate

Oral – give 45-60 minutes before procedure, it has an unpleasant taste but can be mixed with blackcurrant squash

Dose: –

Minimal Sedation: 30-50 mg/kg Maximum 1g

Moderate Sedation: 100mg/kg Maximum 2g

Side Effects

Gastric irritation including nausea and vomiting reported.

Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

There is NO reversal agent available

Buccal Midazolam

Buccal: Give 15 minutes pre-procedure and give half the dose into each side of the mouth