Recommendations for research

The guideline committee has made the following recommendations for research.

1 Point-of-care coagulation testing

What is the clinical and cost effectiveness of point‑of‑care coagulation testing using rotational thromboelastometry (ROTEM) or thromboelastography (TEG) to target treatment, compared with standard laboratory coagulation testing?

Why this is important

More rapid treatment of coagulopathy could reduce mortality from haemorrhage, which is the main cause of death in patients with major trauma. Point‑of‑care ROTEM and TEG are complex diagnostic tools used to detect coagulopathy. They are used successfully in surgery and intensive care settings. It is thought they might also be effective in targeting treatment for coagulopathy in the resuscitation room.

Point-of-care ROTEM and TEG are faster to perform than standard laboratory tests and enable an earlier transition from an initial fixed‑ratio protocol to a protocol guided by laboratory coagulation results. These results can be updated as often as every 15 minutes, which could enable treatment to be adjusted rapidly and targeted effectively. This could result in reduced use of blood components and other treatments for coagulopathy.

The costs of point‑of‑care ROTEM and TEG could be offset by the changes in management they lead to, which could be life‑saving, and by avoidance of unnecessary transfusions.

2 Lactate level for monitoring severity of shock

Is lactate monitoring in patients with major trauma clinically and cost effective?

Why this is important

In current practice, treatment for hypovolaemic shock is guided by the patient's haemodynamic levels, including heart rate and blood pressure. However, haemodynamic levels such as blood pressure tend to change late and correct early, so may not accurately indicate continuing shock. Research has found a strong correlation between lactate levels and the presence of shock. Lactate level may therefore be a more responsive indicator of shock that could be used to guide treatment.

3 Morphine compared with ketamine for first‑line management of pain

Is morphine clinically and cost effective compared with ketamine for first‑line pharmacological pain management (in both pre‑hospital and hospital settings) in patients with major trauma?

Why this is important

The use of opioids as first‑line analgesics after major trauma is well established but has been associated with negative side effects. Consequently, intravenous ketamine in sub‑anaesthetic doses is often used for analgesia in pre‑hospital and hospital settings. Some studies have suggested that intravenous morphine in combination with ketamine provides more effective analgesia than morphine alone. However, there is little evidence from well‑controlled trials that directly compares the effectiveness and side effects of morphine and ketamine.

4 Warming in patients with major trauma

Is warming clinically and cost effective in patients with major trauma? If so, which groups of patients will benefit from warming and what is the best method of warming?

Why this is important

After major trauma, patients are often exposed to adverse weather conditions and are at risk of developing hypothermia, which is associated with worse outcomes including higher mortality. However, there is uncertainty about the clinical benefit of warming patients and whether all groups of patients would benefit from warming. In addition, there is a wide range of methods used for warming and little evidence showing their comparative effectiveness, particularly in pre‑hospital settings.