Overview & Aetiology
History is crucial — a medical event (e.g. cardiac arrest whilst driving) may have preceded the trauma. This determines treatment priority:
- Primary cause medical → follow standard ALS algorithm.
- Primary cause trauma (or concomitant) → treat the precipitating cause / life-threatening injury first (e.g. defibrillate VF, control catastrophic haemorrhage).
Priorities & the De-emphasis of Compressions
Why compressions are not the first priority in TCA: in a normovolaemic medical arrest, compressions are the priority because there is blood to move. In TCA the heart is frequently empty (hypovolaemia) or its filling/output is mechanically obstructed (tension pneumothorax, tamponade) — compressing an empty or obstructed heart circulates little or nothing. Correcting the reversible cause therefore takes priority over compressions and ALS drug administration in the immediate moment.
HOTT is treated according to clinical priority, not a fixed sequence. Undertake only essential lifesaving interventions on scene. If the patient shows any signs of life (pulse, chest rise, breathing effort, movement, eye opening, or a shockable rhythm), prioritise rapid transfer or rendezvous with enhanced/critical care — do not delay for spinal immobilisation.
HOTT — The Four Reversible Causes
Commonest causes of TCA. Address concurrently, based on clinical priority — not sequentially.
- Pelvic splint/binder — stabilised at the earliest possible opportunity, preferably before the patient is moved. Assess the pelvis by inspection/MOI only — do not manipulate it to test for fracture. If the patient is entrapped, the binder is applied when this can be done with minimal handling — often after extrication.
- Long bone / limb fracture reduction & splinting — in the critical patient, long bone fractures are splinted en route, not delayed on scene. Effective splinting generally means realigning gross deformity first — restoring length/angulation reduces ongoing bleeding into the tissues and can restore compromised distal circulation. Check and document motor/sensation/circulation (MSC) in all four limbs before and after any manipulation.
Blunt Traumatic Cardiac Arrest
- HOTT + high-quality airway management take priority; treat by clinical priority, not sequence.
- Active bleeding, significant hypovolaemia, or suspected tamponade → transfer rapidly. Surgery is often the only definitive treatment.
- Refer to Termination of Resuscitation guidance, which also applies in blunt TCA (full ToR criteria not reproduced in this sheet — check current JRCALC guideline).
Penetrating Traumatic Cardiac Arrest
- Do not delay on scene — perform interventions en route wherever possible.
- Rapid transport to nearest MTC (or TU if necessary) — but consider crew safety in a moving vehicle.
- Request enhanced/critical care early; do not delay departure from scene waiting for them.
- Volume resuscitation en route where possible — do not delay to obtain IV access. Rapid conveyance is often the intervention that saves the patient.
Post-ROSC Destination
- ROSC after TCA → convey to MTC, unless airway/ventilation or haemorrhage cannot be safely managed.
- TCA secondary to hanging/asphyxiation may be preferentially treated at an MTC — follow local trauma network guidance.
Enhanced Interventions Beyond Paramedic Scope
These are not NWAS paramedic-scope interventions. They're included so you recognise what critical care/HEMS teams may do on arrival, and can pre-empt the request and hand over accurately.
Bilateral (finger) thoracostomy
An open surgical decompression at roughly the 4th–5th intercostal space, anterior/mid-axillary line — blunt dissection into the pleural space without necessarily inserting a chest drain. Used by critical care/HEMS clinicians because needle decompression has a documented high failure rate for evacuating pneumothorax and haemothorax in TCA. Increasingly performed bilaterally and proactively when thoracic trauma can't be excluded, often before advanced airway management.
Resuscitative (clamshell) thoracotomy
Physician-led procedure, mainly for penetrating trauma with a short down-time. Broad sequence: bilateral thoracostomies first → clamshell thoracotomy if no ROSC → pericardiotomy to release tamponade → inspection/repair of cardiac wounds → internal cardiac massage / aortic compression / volume resuscitation. Very limited role in blunt trauma.
Prehospital blood products
Most UK HEMS/critical care services now carry packed red cells (typically group O), and some carry lyophilised plasma (LyoPlas) or FFP, for haemorrhagic shock and TCA. Calcium is often given alongside transfusion because citrate in blood products can cause hypocalcaemia. Evidence on survival benefit over crystalloid in this setting is mixed — a major UK RCT (RePHILL) did not demonstrate clear superiority over saline for its primary outcome, though blood products remain in routine critical-care use, particularly for longer transport times.
What I Can Actually Do On Scene
- Rapid ABC / HOTT-focused assessment, prioritised by clinical urgency
- External haemorrhage control: pressure, tourniquet, haemostatic dressing
- Pelvic splint/binder — stabilised at earliest opportunity, no manipulation to assess
- Realignment of deformed limb fractures before splinting, with MSC checks
- Early TXA administration
- Stepwise airway management within scope; ventilation
- Needle decompression of suspected tension pneumothorax
- Chest compressions — resumed as crew numbers allow, deprioritised (not omitted) while treating reversible causes
- Early, non-delaying request for enhanced/critical care
- Rapid conveyance to MTC / nearest appropriate centre per local trauma network
Sources for This Sheet
- JRCALC — Advanced Life Support, §12 Trauma (G0120, v19.83, updated 12 Aug 2026) — provided source text, used directly.
- JRCALC — Trauma Emergencies in Adults – Overview (G0540, v34.57, updated 15 Apr 2026) — provided source text, used directly for pelvic/limb haemorrhage control and splinting.
- Resuscitation Council UK / European Resuscitation Council Guidelines 2025, Special Circumstances (traumatic cardiac arrest, HOTT) — paraphrased, badged separately, not JRCALC.
- Published literature on prehospital thoracostomy, resuscitative thoracotomy, and prehospital blood products (bilateral thoracostomy failure rates of needle decompression, RT technique, RePHILL trial, UK HEMS blood product surveys) — background/awareness only, not a protocol source.
Learning sheet only — not a clinical protocol. Verify against current JRCALC / NWAS guidance.
JRCALC G0120 v19.83 · RCUK/ERC Guidelines 2025