RCEM SLO 5 Roadmap: Achieving Paediatric Emergency Medicine Excellence for UK Trainees (2021 Curriculum)

RCEM SLO 5 Roadmap: Achieving Paediatric Emergency Medicine Excellence for UK Trainees (2021 Curriculum)

I. Strategic Overview: Defining and Assessing Paediatric Excellence (SLO 5)

The Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome 5 (SLO 5) defines the required competence for Emergency Medicine trainees in Paediatric Emergency Medicine (PEM). This outcome is comprehensive, demanding expertise in the care of children of all ages, across all stages of development, and explicitly including those with complex medical and social needs.[1] Achieving SLO 5 is not simply about clinical proficiency but requires integration across professional domains: evaluation, investigation, decision-making, safeguarding, resuscitation, and empathetic care for families and loved ones attending the Emergency Department (ED) [1].

1.1 SLO 5 Mandate: Scope and Key Capabilities (GMC and RCEM requirements)

SLO 5 encompasses a broad clinical and professional scope. Clinically, it involves mastery of Domain 2 capabilities, including history taking, diagnosis, medical management, prescribing safely, and using medical devices.[1] However, the scope extends significantly into non-clinical domains. Domain 3 requires understanding national legislation and the health service context [1], which is particularly relevant when navigating complex care pathways or legal frameworks, such as those governing mental capacity or safeguarding. Furthermore, Domain 5 capabilities in leadership and team-working are crucial for managing high-stakes paediatric cases, while Domain 7, covering safeguarding vulnerable groups, is a non-negotiable core requirement for all trainees.[1]

A crucial point of structural distinction exists between SLO 5 and SLO 3 (Adult Resuscitation). While SLO 3 provides detailed content on resuscitation and severe illness, the current Key Capabilities for SLO 5 are noted to lack this equivalent detail.[2] This structural distinction requires a deliberate approach by the trainee. Success in SLO 5 relies on the ability to transpose and apply high-level critical care skills acquired under SLO 3 onto paediatric physiology. This application must demonstrate nuanced judgement, focusing on the specific variables introduced by age—namely, correct age-appropriate equipment selection, accurate drug calculations based on weight [3], and utilizing developmental and age-specific assessment tools like the Paediatric Early Warning Score (PEWS), instead of relying on adult systems like NEWS. Therefore, the ultimate assessment emphasis in SLO 5 shifts from generic technical mastery to demonstrating applied paediatric clinical judgement and effective complexity management.

1.2 Programme of Assessment (POA) and WPBA Strategy

The RCEM 2021 Programme of Assessment (POA) mandates that trainees must continually provide evidence of activity in SLO 5 in each year of training.[4] This necessitates a proactive strategy to seek out and document workplace-based assessments (WPBAs), even during non-paediatric placements.

The curriculum specifies the use of a mixed economy of assessment tools to capture the breadth of SLO 5 capabilities.[5] High-fidelity scenarios are mandatory: trainees are expected to be observed in the resuscitation room and reflect on the feedback received regarding their assessment and management of critically unwell children.[1]

• Evaluation of Specialty Learning Event (ESLE): This tool is essential for documenting competence in leadership, especially when managing paediatric trauma or medical resuscitation.[1]

• Case-Based Discussion (CbD): CbDs are the ideal modality for demonstrating the management of complex, multi-system cases. They are particularly useful for showcasing advanced decision-making in areas such as safeguarding, ethical dilemmas (e.g., termination of resuscitation), or the longitudinal care planning for technology-dependent children.[1]

• Mini-CEX and DOPs (Direct Observation of Procedural Skills): These are best used for focused assessments of specific clinical skills, such as obtaining consent in an adolescent or performing an age-appropriate procedure.[1, 5]

• Multi-Source Feedback (MSF): MSF is critical for validating non-technical skills (NTS), such as effective communication with distressed families and robust collaboration within the multidisciplinary team (MDT), which includes acknowledging and acting upon the concerns raised by nursing staff.[6]

Furthermore, trainees are expected to develop teaching and leadership capabilities, demonstrating an ability to deliver effective feedback and set learning objectives.[4] A strategic approach to achieving this involves aligning teaching activities directly with PEM needs—for example, delivering a teaching session on paediatric triage algorithms or resuscitation human factors to junior colleagues or allied health professionals. Documenting this activity allows the trainee to efficiently gather evidence for multiple key capabilities simultaneously, covering both SLO 5 competence and broader Domain 5 (Leadership) requirements.

1.3 Quality Improvement (QI) and Portfolio Building

The GMC requires that QI capabilities are assessed annually and are demonstrably transferrable across training domains, replacing the previous single FRCEM Quality Improvement Project (QIP) essay.[4] For SLO 5, QI initiatives should be intrinsically linked to improving paediatric outcomes or safety in the ED setting.

Appropriate SLO 5 focused QI projects could include auditing department adherence to structured safeguarding checklists [7], measuring the efficacy of communication aids for non-verbal patients [8], or improving time-to-analgesia metrics for painful paediatric presentations (e.g., long bone fractures).

For strong portfolio building, documentation must extend beyond basic clinical cases. Trainees are advised to document a broad range of paediatric cases, specifically emphasizing reflection on difficult and complex situations.[9] Submitting reflections on cases involving medico-legal processes, coroner involvement, or complex family liaison is explicitly recommended.[10] This highlights that achieving expert standard in PEM involves the skilled management of significant non-clinical complexity, demonstrating professional judgment (GMC Domain 4) in the most challenging scenarios.

II. The RCEM Trainee Roadmap for PEM Competency

The formal Programme of Learning for SLO 5 defines mandatory placements, life support training, and the use of high-fidelity simulation necessary to develop the required clinical and professional competence.

2.1 Required Clinical Placements and Timeframes

The curriculum mandates a minimum of six months in PEM during intermediate training.[1] This period is essential for accumulating adequate exposure to the diverse range of paediatric presentations, from minor injury to critical illness.

Trainees must strategically utilize associated placements, such as Paediatric Intensive Care Unit (PICU) or General Paediatrics, to gather required WPBAs.[5] Given the rapid pace of rotation, advanced planning is required to ensure a comprehensive mix of assessment modalities—including CbDs, Mini-CEXs, DOPs, and ESLEs—are completed and signed off by both RCEM and RCPCH PEM consultants where possible.[5]

2.2 Essential Life Support and Professional Courses

Specific training courses are non-negotiable prerequisites for SLO 5 attainment:

• Advanced Life Support: Mandatory completion of Advanced Paediatric Life Support (APLS) or European Paediatric Advanced Life Support (EPALS) is required.[1]

• Neonatal Expertise: While optional, completion of Neonatal Life Support (NLS) is strongly recommended.[1] This training provides specialized skills for the neonate demographic, ensuring competence across the entire paediatric age range specified by SLO 5.

• Safeguarding Compliance: Mandatory completion of Safeguarding Level 1, 2, and 3 is foundational.[1]

• Spotting The Sick Child Module: Trainees must complete the "Spotting The Sick Child Online Module".[1] This popular and highly successful tool provides over five hours of clinical footage of real patients, allowing users to learn how to assess seven common, critical symptoms: difficulty in breathing, fever, rash, fits, dehydration, abdominal pain, and head injury.[11, 12]

2.3 Simulation, Team Leadership, and Human Factors

High-fidelity simulation is an integral, mandatory element of the SLO 5 Programme of Learning.[1] Trainees are required to engage in in situ simulation of PEM resuscitation scenarios and undergo simulation suite feedback specifically targeting paediatric resuscitation team leadership and human factors.[1]

Simulation training effectively addresses the inherent challenges of PEM. Paediatric critical illness is a low-frequency, high-stakes event in many EDs, meaning technical and complex procedural skills can be seldom-used.[13] High-fidelity simulation, which often uses computer-controlled mannequins to replicate life-like conditions and real-time physiological responses, directly closes this exposure gap. This training is also specifically designed to improve non-technical skills, including teamwork, communication, and critical thinking, often utilizing techniques such as video-assisted debriefings to maximize the learning transfer.[13, 14] The requirement for this structured simulation validates the importance of readiness for low-frequency emergencies and emphasizes that competence extends beyond individual technical skill to include effective multidisciplinary team coordination and leadership.[1, 15] Trainees are also expected to utilize relevant online modules, such as those provided by RCEM Learning, to supplement their knowledge base.[1]

III. Core Clinical Competency I: Paediatric Evaluation and Decision-Making

Excellence in PEM hinges on the rapid, structured evaluation of the acutely unwell child, followed by decisive action.

3.1 The Foundation: Rapid Primary Survey (ABCDE)

The foundation of assessing any deteriorating or critically ill patient, regardless of age, remains the standardized Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.[16] The core principles require continuous assessment, regular re-assessment after interventions, treating life-threatening problems before progressing, and ensuring appropriate help is called early.[16]

Central to this is the rapid, initial 30-second assessment, often referred to as "Look, Listen, and Feel." This brief overview is vital for identifying critical illness immediately.[16] The initial assessment should focus on:

• Look: Observing the child's general appearance, noting any signs of respiratory distress (e.g., recession or nasal flaring), or rash.[17] If the child can only speak in short sentences, this indicates potential breathing difficulties.[16]

• Listen: Identifying audible respiratory noises such as stridor, wheeze, or grunting.[17]

• Feel: Checking the temperature, pulse, and capillary refill time (CRT).[17] Oxygen saturations must be measured in any child showing signs of shock or respiratory distress.[17]

A common pitfall is delaying the physical assessment while attempting to console a distressed child. The expert approach necessitates beginning assessment via observation (Look/Listen) while the child is settling, often on a parent's lap, before proceeding to physical touch (Feel).[17]

3.2 Utilising Paediatric Early Warning Systems (PEWS)

PEWS is the national standardized system for identifying physiological deterioration in children.[18] The PEWS chart comprises multiple physiological parameters (Heart Rate, Respiratory Rate, CRT, etc.) that contribute to a numerical score.[18, 19] However, SLO 5 competence requires the trainee to understand and action all four mandated escalation triggers, demonstrating clinical sophistication beyond the numerical score alone.[18]

The four escalation triggers in the UK PEWS chart are:

1. PEWS Numerical Score: Activation based on physiological parameters reaching defined thresholds.

2. AVPU: A decreased level of consciousness (Alert, Voice, Pain, Unresponsive). Failure to respond to initial prompts is a clear marker of critical illness.[16, 18]

3. Clinical Intuition Trigger: This mechanism ensures that if a clinician has a concern not reflected in a low numerical score, that concern automatically triggers escalation. Staff are required to document the details of these concerns.[18] This institutionalizes the vital practice of professional judgment, particularly respecting the cumulative experience of senior nursing staff, who may voice concerns that "they just don’t look right".[6] Trainees must understand that listening to the nurses, and acting upon their worry, is integral to achieving safe practice.[6]

4. Parent Concern Trigger: This is an essential and independent route to escalation mandated by the RCPCH.[18] A concern voiced by a parent or carer must lead to escalation of care, regardless of the child's numerical score.[18]

3.3 Age and Developmental Stage Specific Assessment

Caring for children "at all stages of development" [1] requires adaptation of assessment and management techniques.

• Building Rapport: Essential soft skills include being able to connect with the child quickly. Knowledge of basic TV characters (Cocomelon, Bluey, Paw Patrollers) for younger children, and current culture (like Premier League football teams) for older children, can be highly effective distraction techniques that facilitate necessary clinical examination.[6]

• Procedural Comfort: When conducting painful or invasive procedures (DOPs), trainees must utilize age-appropriate comfort and distraction measures.[20] For infants, this includes skin-to-skin contact with the carer, swaddling, pacifiers, and pre-procedure sucrose.[20] For older children, distractions such as music, apps, toys, or engagement with a Child Life therapist are recommended.[20]

IV. Core Clinical Competency II: Leading Paediatric Resuscitation and Critical Care

The highest level of clinical competence in SLO 5 is demonstrated by the ability to lead resuscitation and manage the complex intersection of high-stakes medicine and ethical considerations.

4.1 Resuscitation Leadership and Protocols

Upon completion of higher training, the trainee must be an expert in assessing and managing all children and young adults, and specifically be able to lead a multidisciplinary paediatric resuscitation, including trauma.[1]

Effective leadership requires coordinating simultaneous interventions (e.g., assessment, monitoring, and obtaining intravenous access) and ensuring effective communication amongst the team using standardized tools such as SBAR (Situation, Background, Assessment, Recommendation) or RSVP (Reason, Story, Vital signs, Plan).[16] Crucially, the trainee must call for appropriate help early and integrate all team members into the management plan.[16]

Pharmacological management in paediatrics is uniquely challenging due to weight-based dosing. The trainee must utilize drug doses based on current Resuscitation Council UK (RCUK) Guidelines (2021) recommendations.[3] Specific attention must be paid to common critical care doses, such as Amiodarone, which is given as $5{\text{ mg kg}}^{-1}$ IV or IO bolus in arrest after the 3rd and 5th shocks, and Atropine, given at $20{\text{ mcg kg}}^{-1}$.[3] Neonatal care requires further specific knowledge, such as the recommendation for glucose at $2.5{\text{ mL kg}}^{-1}$.[3]

4.2 Ethical Considerations in Termination of Resuscitation (ToR)

Paediatric resuscitation involves navigating profound ethical dilemmas, particularly regarding the termination of resuscitative efforts (ToR). Ethical principles, including beneficence and non-maleficence, are critical in balancing the potential benefits of prolonged resuscitation against the harms, such as dysthanasia (prolonging the dying process), moral distress for the clinical team, and adverse neurological outcomes.[21, 22]

Prognostic indicators guide these difficult decisions. A lack of response to intensive resuscitation for greater than 10 minutes carries an extremely poor prognosis for survival, or survival without disability.[23] While this threshold provides guidance, the clinician must consider specific mitigating factors, such as severe prearrest hypothermia (e.g., near-drowning in icy water) or drug overdose, before determining whether to extend efforts.[23] If return of spontaneous circulation (ROSC) occurs at any time, even briefly, it may necessitate extending the resuscitative attempt.[23]

The trainee must demonstrate advanced ethical communication skills (GMC Domain 4). If the decision is made to stop resuscitation, compassionate communication with families is essential.[21, 22] The trainee must inform the parents and offer them the sensitive option of holding their child as care is withdrawn.[24] The expert trainee must be prepared to navigate scenarios such as "slow codes" and, when appropriate, exercise clinical directiveness in ToR decisions while maintaining a therapeutic relationship with the family to mitigate the harm of conflict.[21, 22, 25]

V. Domain Expertise: Safeguarding and Child Protection

Safeguarding vulnerable groups constitutes a fundamental, non-negotiable core capability within SLO 5 (Domain 7).[1]

5.1 Legal Requirements and Training

All trainees must complete the mandatory Safeguarding Level 1, 2, and 3 training.[1] Beyond individual competency, the curriculum requires understanding the relevant national documents and policies that govern child protection in the ED setting.[1]

The successful trainee must demonstrate an understanding of the roles of other critical external systems required for child protection. This includes Social Services (Children Social Care, CSC), the Police Child Protection and Domestic Violence Units, and community systems such as Health Visitors and Community Paediatricians.[1] Trainees must also be proficient in using the Child Protection Information Sharing (CP-IS) system to ensure prompt communication between the ED, primary care, and other protective services.[7]

5.2 Structured Decision-Making and Escalation

Decision-making in safeguarding must utilize structured tools, such as safeguarding checklists.[7] A core requirement is the ability to escalate concerns based on clinical judgment, even in the absence of absolute certainty.[7] This mandates a department culture that encourages a proactive and non-judgmental approach, ensuring staff who raise concerns are supported without fear of reprisal.[7]

The essential action, even when in doubt, is the immediate referral to paediatrics and Children Social Care.[7] Furthermore, the trainee must be prepared to handle complex discussions, including the ability to communicate with parents, informing them sensitively that a social services referral is being made, while avoiding accusatory language and focusing on the child's safety.[1, 7]

5.3 Documentation Standards and Medico-Legal Integrity

Safeguarding documentation requires rigorous adherence to specific standards that meet high medico-legal scrutiny. The integrity of the case record is paramount, particularly in cases that may involve medico-legal review or coroner involvement.[10]

Key standards for documentation include:

• Recording injuries accurately using diagrams and photographs when appropriate.[7]

• Noting the exact words used by caregivers when providing the history or explaining the mechanism of injury (MOI).[7] This captures subtle inconsistencies or changes in the narrative.

• Documenting the decision-making process, including who was consulted (e.g., Paediatric Consultant, CSC), what was discussed, and the actions taken (e.g., arrangements for follow-up appointments).[7]

The following structured checklist represents the non-negotiable requirements for safeguarding practice:

Safeguarding Documentation and Escalation Checklist

Action Area	RCEM Standard Requirement	Rationale (Medico-Legal)
Consultation/Referral	Document who was consulted (e.g., Consultant, Paediatrician, CSC), and the advice received.	Establishes multidisciplinary team coverage and validates shared decision-making.[7]
Injury Recording	Record injuries with diagrams and photographs (if appropriate).	Provides objective, forensic evidence of the injury pattern.[7]
Mechanism of Injury (MOI)	Note the exact words used by caregivers when describing the MOI.	Captures critical inconsistencies or shifts in the history provided.[7]
Escalation Rationale	Escalate based on clinical judgment, even without certainty; document the rationale.	Meets the curriculum mandate for proactive intervention based on suspicion.[7]

VI. Domain Expertise: Care for Children with Complex Needs

A central component of SLO 5 is the ability to assess and formulate management plans for children and young adults who present with complex medical and social needs.[1] This cohort represents a high proportion of ED users and presents unique challenges that require dedicated skills.[26]

6.1 Managing Intellectual and Developmental Disabilities (IDDs)

Children with Intellectual and Developmental Disabilities (IDDs) are among the highest users of emergency healthcare services.[26, 27] Their management is often complicated by communication, sensory, and behavioral challenges, leading to risks of negative experiences and outcomes.[26] Addressing this population directly relates to the curriculum's requirement to manage health inequalities; autistic people and individuals with learning disabilities are known to face disparities, increasing their risk of premature death from treatable causes.[28]

Achieving competence in this area requires the implementation of systemic accommodations, demonstrating a commitment to patient-centred care.[28] The ED environment must be adjusted to reduce overwhelming sensory input. This strategic adaptation ensures that vulnerable children receive equitable care, moving beyond mere clinical assessment to address the systemic barriers they face.

6.2 Practical Communication and Environmental Strategies

Effective communication is the cornerstone of managing children with complex needs. For non-verbal or autistic children, reliance on verbal language is insufficient. Trainees must be facile in utilizing Augmentative and Alternative Communication (AAC) methods.[8]

AAC encompasses all ways a person communicates besides talking, including sign language, gestures, the use of pictures, photos, objects, or dedicated electronic devices.[8] The required expert knowledge dictates the immediate implementation of "reasonable adjustments," similar to those utilized in special education, to facilitate interaction.[29] This includes employing visual supports, such as visual schedules or picture cards, as many autistic individuals process visual information more effectively than auditory input.[8]

Interaction techniques must be adapted:

• Language must be simplified, clear, and concise to reduce potential confusion.[8]

• The clinician must allow sufficient "wait time" for the child to process the request and formulate a response, resisting the natural urge to fill silences.[8]

• When situations become overwhelming, access to a quiet space or the use of sensory tools (e.g., ear defenders) should be part of the care plan.[30]

• During procedures, positive reinforcement, praise, and rewards linked to the child's specific interests can improve cooperation.[31]

6.3 The Technology-Dependent Child

The ability to manage children with technology dependence (e.g., home ventilators, tracheostomies, indwelling central lines, G/J tubes) is explicitly required by SLO 5.[1, 32] These presentations are typically high-acuity and require a rapid understanding of the child’s complex baseline physiology.

The initial assessment must prioritize troubleshooting potential equipment failure or managing intercurrent illness (e.g., fever/infection) superimposed on the baseline condition.[33] Key history points involve establishing the child’s stable ventilator settings and blood gas parameters.

Expert decision-making extends to disposition planning. Trainees must understand the stability criteria for transfer or discharge.[33] For instance, criteria for moving from intensive care to a general ward include: stable ventilator settings for at least one week, a matured tracheostomy stoma (more than one week old), no need for vasoactive drug support, and stable blood gases (e.g., $Pa{O}_2\ge 60\text{ mmHg}$ on $Fi{O}_2\le 0.4$).[33] Furthermore, protocols must address regionalization issues, determining whether transport should be to the closest ED or to a specialized paediatric center depending on the patient’s critical status and specific technological needs.[32]

VII. Professional Practice: Communication, Ethics, and Family Support

The final component of SLO 5 excellence involves mastering the non-technical skills required to manage the human context of paediatric emergencies, particularly dealing with crisis and grief.

7.1 Communicating Difficult News and Supporting Families in Crisis

A core requirement of empathetic care is acknowledging the stress of the ED experience. Trainees must validate the family’s decision to attend the ED and should never criticize or berate a family for seeking emergency care.[6] They must establish clear and timely communication, using structured models (SBAR/RSVP) for internal handovers and providing clear explanations to families.[16]

A major component of high-quality paediatric care is managing Family Presence During Resuscitation (FPDR). Policy guidance suggests that the presence of family members allows them to witness that all possible efforts are being made for their child, providing comfort and helping them gain a realistic view of the attempted resuscitation.[34] If FPDR is utilized, the trainee, acting as the team leader, must immediately allocate a dedicated staff member (often a nurse or social worker) to remain with the parents to support them through the process.[24]

7.2 Compassionate Care and Bereavement Support

When a child dies in the ED, the interaction between the healthcare team and the bereaved family has a profound, long-term impact on the grieving process.[35] Achieving SLO 5 competence requires leadership that extends to terminal and bereavement care excellence.

Key actions for compassionate care include:

• Demonstrating empathy, providing timely answers, and maintaining a clear understanding of the child’s unique medical situation.[35]

• Utilizing the child’s name consistently.[35]

• Alerting all appropriate local agencies (e.g., Acute Consultant Paediatrician on-call and Police Senior Investigating Officer, especially in cases of Sudden Unexpected Death in Infancy or Childhood, SUDIC).[24]

• Liaising with institutional Family Support Teams or dedicated resource centers to provide external resources for grief management.[35]

The expert trainee must demonstrate the capacity to maintain a therapeutic relationship with families, even when complex ethical decisions (such as ToR) lead to disagreement or conflict. This level of communication ensures that the emotional harms of conflict are mitigated for all parties involved, including the medical team.[25]

VIII. Conclusion and Recommendations

Attainment of RCEM SLO 5 represents achieving an expert level of capability in Paediatric Emergency Medicine. The curriculum demands that trainees integrate advanced critical care skills (from SLO 3) with domains unique to paediatric practice: developmental assessment, safeguarding, and profound communication skills.

The strategic requirements dictate a continuous, proactive approach to portfolio development, where trainees must gather evidence of Clinical Activity (CLA) and Quality Improvement (QI) in a broad range of paediatric cases across every year of training.[4, 9] Observation in the resuscitation room and specific feedback on leadership (ESLE/simulation) are mandatory checkpoints.[1]

Key Recommendations for Trainees:

1. Prioritize Non-Numerical Assessment: Trainees must actively document scenarios demonstrating professional judgment, specifically acting on the Clinical Intuition Trigger and the Parent Concern Trigger of the PEWS chart.[18] This validates the professional competence required beyond basic physiological scoring.

2. Rigorous Safeguarding Documentation: Treat all potential safeguarding cases as high-stakes medico-legal events. Non-negotiable practice includes utilizing structured checklists, escalating based on clinical suspicion rather than certainty, and meticulous documentation of the exact words used by caregivers and detailed photographic/diagrammatic evidence of injuries.[7]

3. Implement Systemic Accommodation: When managing children with complex needs or IDDs, the trainee must demonstrate the implementation of "reasonable adjustments." This involves utilizing visual supports and Augmentative and Alternative Communication (AAC) methods to overcome health inequalities and ensure patient-centred care.[8, 28]

4. Master Ethical Leadership: Critical care leadership must encompass the human factors of end-of-life care. Trainees must demonstrate expertise in compassionate communication, managing Family Presence During Resuscitation (FPDR), and navigating the complex ethical frameworks governing the termination of resuscitation.[21, 24, 34]

5. Utilize Simulation for Human Factors: Leverage high-fidelity simulation specifically to practice seldom-used skills and receive structured feedback on team leadership and communication during paediatric emergencies.[1, 13]

Achieving SLO 5 is ultimately defined by the trainee's capacity to manage not only the pathophysiology of illness but also the significant social, developmental, and ethical complexities inherent in caring for vulnerable children and their families.

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1. SLO 5 - Care for children of all ages in the ED, at all stages of ..., https://rcemcurriculum.co.uk/care-for-children-in-the-ed/

2. EM Curriculum - RCEM, https://rcem.ac.uk/em-curriculum/

3. Paediatric emergency algorithms & resources - Resuscitation Council, https://www.resus.org.uk/sites/default/files/2022-03/RCUK%20Paediatric%20emergency%20algorithms%20and%20resources%20Mar%2022%20V1.pdf

4. RCEM Generic Specialty Learning Outcomes V.5 - RCEMCurriculum, https://rcemcurriculum.co.uk/wp-content/uploads/2021/05/Appendix-4-Generic-SLO-Curriculum-Supporting-Material.pdf

5. The Paediatric Emergency Medicine handbook A practical guide for trainees at any level, from initial interest to CCT - RCPCH, https://www.rcpch.ac.uk/sites/default/files/2021-11/PEM_Training_guide_v_1_11_21.pdf

6. The Whole* of PEM, in One Blog - RCEMLearning, https://www.rcemlearning.co.uk/foamed/the-whole-of-pem-in-one-blog/

7. Detection and Management of Non-Accidental Injury (NAI) in Infants ..., https://somersetsafeguardingchildren.org.uk/detection-and-management-of-non-accidental-injury-nai-in-infants-rcem-guidance/

8. Autism communication strategies - LeafWing Center, https://leafwingcenter.org/autism-communication-strategies/

9. SLO 5: Care for Children of All Ages in the ED cesr Pathway, https://cesrportfolio.co.uk/blogs/slo-5-cesr-pathway-uk

10. Emergency medicine | GMC, https://www.gmc-uk.org/cdn/documents/sat---ssg--emergency-medicine-2021-curriculum---dc13727_pdf-87179601.pdf

11. Spotting the sick child - online learning - RCPCH, https://www.rcpch.ac.uk/resources/spotting-sick-child-online-learning

12. Spotting the Sick Child: Home, https://spottingthesickchild.com/

13. Pediatric Resuscitation Training through Simulation Programs - Children's Mercy, https://www.childrensmercy.org/health-care-providers/refer-or-manage-a-patient/educational-offerings/simulation-training/

14. Enhancing Pediatric Emergency Care in Low-Resource Settings Through Simulation-Based Training: A Narrative Review - PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC12220881/

15. Paediatric Emergency Medicine (PEM) Simulation Day - HEE East of England website, https://heeoe.hee.nhs.uk/emergency_medicine/simulation/paediatric-emergency-medicine-simulation-day

16. The ABCDE Approach | Resuscitation Council UK, https://www.resus.org.uk/library/abcde-approach

17. Managing the unwell child - PMC - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC3960691/

18. UK Paediatric Early Warning Systems (PEWS) | RCPCH, https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems

19. Pediatric Early Warning Score (PEWS) - MDCalc, https://www.mdcalc.com/calc/3901/pediatric-early-warning-score-pews

20. Clinical Practice Guidelines : Communicating procedures to children, https://www.rch.org.au/clinicalguide/guideline_index/Communicating_procedures_to_families/

21. Ethics in the Emergency Department: Withholding or Terminating Resuscitation - PubMed, https://pubmed.ncbi.nlm.nih.gov/40742225/?utm_source=SimplePie&utm_medium=rss&utm_campaign=pubmed-2&utm_content=1zOrwYPa_1RS6jdZ9VLHcTFM_z0nKGv5xC17ijJBVjdDspZQ-I&fc=20220524062322&ff=20250731173358&v=2.18.0.post9+e462414

22. Ethics in the Emergency Department: Withholding or Terminating Resuscitation - Health Sciences Research Commons - The George Washington University, https://hsrc.himmelfarb.gwu.edu/gwhpubs/7520/

23. Part 2: Ethical Aspects of CPR and ECC | Circulation - American Heart Association Journals, https://www.ahajournals.org/doi/10.1161/circ.102.suppl_1.i-12

24. Timeline: The Emergency Department - The Resuscitation - RCEMLearning, https://www.rcemlearning.co.uk/modules/the-sudic-protocol/lessons/clinical-assessment-42/topic/timeline-the-emergency-department-the-resuscitation/

25. Part 3: Ethics: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care | Circulation, https://www.ahajournals.org/doi/10.1161/CIR.0000000000001371

26. Seeking Care for Children with Intellectual and/or Developmental Disabilities in the Emergency Department: A Mixed Methods Systematic Review of Parents' Experiences and Information Needs - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC11194008/

27. Care for children with disabilities in emergency departments | OAEM - Dove Medical Press, https://www.dovepress.com/seeking-care-for-children-with-intellectual-andor-developmental-disabi-peer-reviewed-fulltext-article-OAEM

28. Caring for patients with learning disability, autism or complex needs in the ED - RCEM, https://rcem.ac.uk/on-demand/caring-for-patients-with-learning-disability-autism-or-complex-needs-in-the-ed/

29. Supports, Modifications, and Accommodations for Students - Center for Parent Information and Resources, https://www.parentcenterhub.org/accommodations/

30. Autism and communication - National Autistic Society, https://www.autism.org.uk/advice-and-guidance/topics/about-autism/autism-and-communication

31. Educator Strategies for Developmental delay | AllPlay Learn, https://www.allplaylearn.org.au/early/educator/developmental-delay/

32. Guidelines for Prehospital Pediatric Protocol Development, https://emscimprovement.center/documents/1378/5-Guidelines_for_Prehospital_Pediatric_Protocol_Development.pdf

33. Technology-dependent children - PMC - PubMed Central - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC7335821/

34. Publication: Presence of family members at the clinical emergency of children and babies, https://www.resus.org.uk/library/publications/publication-presence-family-members-clinical-emergency

35. Communication with families, https://emscimprovement.center/documents/1009/Communication_with_families_chapter.pdf

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Silver Trauma: Best Practice for Ax & Mx in the ED

 

Silver Trauma: Best Practice for Assessment and Management in the Emergency Department

Executive Summary

This document provides a comprehensive briefing on the assessment and management of "Silver Trauma"—significant injury in patients aged 65 and over. This patient demographic now constitutes the majority of major trauma cases in the UK, frequently presenting after low-energy falls (<2 metres). The core challenge lies in their diminished physiological reserve, multiple comorbidities, and polypharmacy, which blunt the typical signs of severe injury, leading to systemic under-triage, delayed diagnosis, and disproportionately high morbidity and mortality.

The fundamental principle of care is a shift from an injury-centric to a patient-centric, holistic model. Key best practices include mandatory triage modification with early senior clinician involvement, universal screening for frailty (Clinical Frailty Score) and delirium (4AT test), and the adoption of modified physiological thresholds for shock. A Systolic Blood Pressure < 110 mmHg, a Heart Rate > 90 bpm, or a venous lactate > 2.5 mmol/L are critical indicators of occult hypoperfusion requiring aggressive intervention.

Management requires a multidisciplinary team (MDT) approach initiated in the Emergency Department, incorporating geriatric principles into the standard trauma survey. This includes proactive management of geriatric syndromes (summarised by the PINCHME mnemonic: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment), optimised analgesia with a focus on regional blocks, and a low threshold for comprehensive CT imaging. The use of structured screening tools, such as the 'Shake, Rattle, Rock and Roll' assessment, is advocated to detect occult truncal and head injuries. This integrated pathway aims to address the patient's intrinsic vulnerability concurrently with their acute injuries, thereby improving outcomes and ensuring they receive safe, high-quality, and dignified care.

1. Definition and Classification

Silver Trauma is a distinct clinical entity defined as significant injury or suspected major trauma occurring in patients aged 65 and over [1, 7]. Specific local guidelines may use a higher threshold of >70 years, or >65 years with a Rockwood Clinical Frailty Score (CFS) of ≥ 5 [39]. Others propose defining this group as those in their predicted last 10 years of life, which in Devon would be 75 years of age.

It is distinguished from trauma in younger cohorts by several key factors:

• Low-Energy Mechanisms: Seemingly minor mechanisms, such as a fall from standing height (<2 metres), are the most common cause of major injury (Injury Severity Score [ISS] >15) [8, 30, 40].
• Atypical Presentations: Age-related physiological changes, comorbidities (e.g., chronic hypertension), and polypharmacy (e.g., beta-blockers) blunt the classic physiological responses to trauma, masking signs of shock and severe injury [1, 8, 30]. Patients with chronic pain or cognitive decline may not present as expected, and the only clue to a fracture may be a loss of function, increased distress, or delirium.
• Holistic Nature: The patient's pre-injury state—including frailty, comorbidities, and cognitive function—is often a more significant determinant of outcome than the injury itself. Silver trauma is best conceptualised as a complex geriatric syndrome presenting with trauma [1, 9, 30, 41].

The core philosophy of management is to "treat patients with injuries and not injuries on patients" [41].

2. Epidemiology & Aetiology

• Incidence: Patients aged 65 and over are the fastest-growing demographic within the UK Major Trauma Network and represent the majority of major trauma patients [2, 30]. In one NHS trust, 70% of major trauma patients across specialities are aged 70 or over. These patients experience longer hospital lengths of stay and higher morbidity and mortality rates.
• Age and Frailty: Frailty is a superior predictor of outcomes than chronological age alone [12, 30]. The International Consortium on Health Outcome Measures defines older age as the last ten years of life before regional life expectancy, which may vary from 70 in parts of Northern England to 80 in parts of London [30].
• Aetiology: The most common mechanism of injury is a fall from standing height (<2m), which has surpassed road traffic collisions (RTCs) and accounts for the highest ISS and mortality rates [2, 8, 30, 40]. Venous tears are more common than visceral injury from low-energy mechanisms.
• Predisposing Factors: Declining proprioception and loss of protective reflexes lead to a higher rate of truncal injuries. Deconditioning leads to skeletal mineralisation loss. Assessment must extend beyond the injury to consider medical and social causes of the fall, including frailty, infection, cardiac events, neurological conditions, iatrogenic causes, neglect, and polypharmacy.
• Pathology and Injury Patterns: Skeletal and head injuries are the most common [8, 30]. Older people have a relative reduction in connective tissue in bone, meaning energy is not dissipated as effectively, leading to fractures from low-energy mechanisms.
  • Head Injuries: Intracranial haemorrhage (ICH) can be occult and well-compensated initially. A drop in GCS is often a later sign than in younger patients [41].
  • Truncal Injuries: The pattern is often determined by the fall mechanism:
    • Fall onto bottom (axial loading): Multi-level insufficiency fractures of the lumbar and thoracic spine.
    • Fall to side (hip and shoulder loading): Pubic rami and sacral alar fractures.
    • Fall forwards/backwards (head and C-spine loading): Intracranial haemorrhage and C-spine hyperflexion injuries [40].
  • Limb Injuries: Classic patterns include 'fall onto outstretched hand' (Colles' fracture) and ankle or hip fractures, with the knee usually preserved.

3. Pathophysiology and Clinically Relevant Anatomy

The ageing process involves the replacement of active parenchymal cells with inactive interstitial cells, leading to a loss of functional reserve and a decline in organ function [41]. This is a critical factor in the high morbidity and mortality observed in silver trauma [1, 4].

System	Age-Related Change	Clinical Implication in Trauma
Musculoskeletal	Osteoporosis and reduced bone mineral density. Degenerative changes (osteoarthritis, osteophytes) and conditions like Parkinsonism lead to rigidity and fixed flexion deformities.	Increased susceptibility to fractures from low-energy forces. Rigid structures (e.g., cervical spine) are more likely to fracture as they cannot absorb kinetic energy through flexion/extension [9, 41].
Respiratory	Increased chest wall rigidity, loss of respiratory muscle mass, reduced alveolar gas exchange surface area, and blunted central responses to hypoxia and hypercapnia.	Reduced compliance requires harder work for inspiration. Increased risk of fatigue and earlier onset of hypercapnic (Type II) respiratory failure, especially with chest wall injury. Simple rib fractures can have severe consequences [7, 41].
Cardiovascular	Myocardium replaced by collagen/fat, leading to stiffer ventricular walls and decreased cardiac reserve. Stiffening blood vessels, desensitised baroreceptors, and impaired autonomic function. Reduced atrial pacemaker cells lower resting and maximum heart rate. Atherosclerosis impairs organ blood flow.	Limited ability to increase cardiac output in response to shock. Blunted tachycardic response to hypovolaemia. Baseline hypertension means a "normal" BP (e.g., 120/80) may represent shock. Increased risk of severe organ injury with moderate hypotension [1, 6, 8, 41].
Neurological	Cerebral atrophy causes stretching and tautness of bridging subdural veins.	Increased risk of subdural haematoma from minor tearing forces after a fall. Increased intracranial space may delay symptoms, leading to a higher presenting GCS for a given injury severity [41, 44].

4. Clinical Assessment: Modified Trauma Survey

The standard CABCDE primary survey remains the foundation of care but requires significant modification to account for age-related changes and atypical presentations [15, 18, 41]. Senior clinician review (registrar or above) is triggered by the presence of high-risk features.

4.1. Catastrophic Haemorrhage

• Early Control: Identify and control overt bleeding immediately (e.g., scalp lacerations, epistaxis, long bone fractures) [41].
• Anticoagulation: Immediately identify anticoagulant and antiplatelet use. These patients are at high risk for catastrophic haemorrhage. Initiate reversal protocols early based on clinical suspicion, particularly with head injury, without waiting for laboratory confirmation [1, 6, 20, 28]. Administer Tranexamic Acid (TXA) to all bleeding trauma patients unless contraindicated [20, 21].

4.2. A Airway and Cervical Spine Control

• Airway Assessment: Be vigilant for obstruction from false teeth, friable tissue, and secretions. Weak respiratory muscles and a poor cough reflex increase risk [22, 28, 41]. Noisy breath sounds or paradoxical chest movements indicate obstruction [22]. Advanced airway management may be challenging due to obesity, altered dentition, and reduced neck movement (LEMON predictors) [18, 41].
• Cervical Spine Control:
  • Maintain a high index of suspicion for C-spine injury in any patient >65 with trauma to the head, face, or neck, or a high-energy mechanism [41]. Neck pain is a high-risk feature.
  • Minimal Movement Philosophy: Rigid collars are often poorly tolerated and may cause harm (pressure sores, increased ICP, aspiration). If a collar cannot be applied safely due to deformities (e.g., kyphosis), support the neck in its current position with rolled blankets or blocks [22, 41].
  • Clearance: CT is the imaging modality of choice for C-spine clearance in patients >65 [3, 41].

4.3. B Breathing and Ventilation

• Assessment: Record respiratory rate (RR), SpO2, and inspired O2. Rates >20 bpm may indicate distress, while <12 bpm can signify fatigue [22, 28]. Tachypnoea is often the first sign of developing shock.
• Key Injuries: Simple rib fractures can have grave consequences due to reduced physiological reserve [7, 28]. Maintain a low threshold for chest imaging.
• Oxygen Therapy: For major trauma, initially provide high-flow oxygen. For patients at risk of hypercapnic respiratory failure (e.g., severe COPD), target SpO2 of 88-92% once ABG results are available. Otherwise, target 94-98% [41].

4.4. C Circulation and Haemorrhage Control

• Recognising Shock: This is a primary failure point. The typical tachycardic response is often blunted or absent due to medications (beta-blockers, calcium channel blockers) or pacemakers.
  • Modified Vital Sign Thresholds: Act on subtle signs. A Systolic Blood Pressure < 110 mmHg or a Heart Rate > 90 bpm should be considered clinically significant and trigger aggressive resuscitation [1, 38, 40, 41, 42]. Some guidelines use a threshold of HR > 100 bpm.
  • A "normal" blood pressure of 120/80 may represent shock in a patient with baseline hypertension [8, 22, 28].
• Occult Hypoperfusion: Do not rely on vital signs alone. Routinely use objective markers:
  • A venous lactate > 2.5 mmol/L should be considered indicative of haemorrhage until proven otherwise [6, 38, 41, 42]. Some guidelines use a lower threshold of >2.0 mmol/L.
  • Base Excess (BE) is another critical marker [6].
• Haemorrhage Assessment: Examine for all potential bleeding sources. Use eFAST to "rule in" but not exclude significant injury [41]. Perform an Aortascan if a ruptured AAA is on the differential.
• Coagulopathy & Hypothermia:
  • Hypothermia Prevention: This is mandatory. Use warm blankets, Bair Huggers, and warmed IV fluids to maintain a core temperature between 36–37.4°C [19, 28, 41].
  • Fluid Resuscitation: Restrict crystalloid infusions. For haemorrhagic shock, activate the massive transfusion protocol and use blood products (e.g., 1:1:1 ratio) [41].

4.5. D Disability (Neurological Status)

• Neurological Assessment: Record GCS, pupil size, and reactivity. A GCS < 15 should not be assumed to be the patient's baseline without collateral history. Escalate immediately for new or worsening neurological signs [22].
• Cognitive and Delirium Screening:
  • This is a cornerstone of best practice. Any degree of cognitive impairment, acute or chronic, is a high-risk feature.
  • Screening Tools: The 4AT test is the recommended tool for delirium screening in all patients ≥65 [15, 16]. A score ≥4 indicates possible delirium/cognitive impairment [15]. The Abbreviated Mental Test Score (AMTS) should also be completed [22, 41].
  • Delirium Prevention & Management: Delirium is a medical emergency. Immediately implement delirium reduction strategies using the PINCHME mnemonic to address common causes [28, 41]:
    • Pain: Ensure adequate multimodal analgesia. Use the PAINAD scale for patients with cognitive impairment.
    • Infection: Screen for underlying infection (e.g., UTI, pneumonia).
    • Nutrition & Hydration: Provide food and fluids as soon as possible.
    • Constipation: Consider prophylactic laxatives with opiates. Check for urinary retention.
    • Hydration: (Covered under Nutrition & Hydration).
    • Medication: Conduct medicines reconciliation. Ensure time-critical drugs (e.g., for Parkinson's) are given on schedule.
    • Environment: Involve family, ensure patient is comfortable, and provide glasses and hearing aids.

4.6. E Exposure and Environment

• Hypothermia: Remove wet clothes and actively warm the patient [28, 41].
• Skin Integrity: Perform a full skin assessment, paying attention to pressure areas (occiput, sacrum, heels), especially under collars or splints [22, 41].
• Secondary and Tertiary Survey for Occult Injury: A formal head-to-toe secondary survey is mandatory. All falls, including ‘non-injury falls’, must be screened for trauma. Evidence of two or more injuries is a high-risk feature.
  • The ‘Shake, Rattle, Rock and Roll’ approach is advocated as a quick and reproducible screening assessment for occult injury in supine patients.
    • Shake: The patient is asked to actively shake their head. Asymmetric neck movement or pain should be assessed further. Then ask them to move both arms and legs, looking for pain.
    • Rattle: The patient is asked to take a deep breath in and cough. If pain-free, the chest is gently compressed anteriorly and bilaterally, screening for pain.
    • Rock: The pelvis is gently rocked bimanually at the iliac crests. This rotates the lumbar spine and loads the pelvis to unmask pain.
    • Roll: Gently roll each hip in turn (most easily done at the foot), then roll the patient on their side and palpate along the vertebrae.
  • A repeat tertiary survey, extending the assessment to 'Shake, Rattle, Rock and Roll with Stretch and Stroll', should be performed 24 hours after admission to re-review for missed or evolving injuries.

5. Key Investigations

5.1. Imaging

A low threshold for comprehensive imaging is crucial, as clinical examination is unreliable for excluding severe occult injuries [1, 24].

• Computed Tomography (CT):
  • Timing: Major trauma patients should have their CT scan started within 1 hour of arrival [24, 25]. Pre-existing renal disease should not delay a life-saving trauma CT scan [25].
  • Whole Body CT (WBCT): A "pan-scan" from vertex to pelvis is indicated for patients with high-energy mechanisms, haemodynamic instability, or suspicion of injury to more than one body region [28, 41].
  • Silver Trauma Pan-Scan: A modified non-contrast WBCT can be considered to reduce contrast load if there is no shock and a suspicion of multiple injuries [40]. If shock without an apparent cause is present, a contrast pan-scan is wise.
  • Focused CT:
    • Head: Recommended for any patient ≥65 with LOC or amnesia, or any patient on anticoagulants/antiplatelets after a head injury [3, 41, 42].
    • C-Spine: The imaging modality of choice for any patient ≥65 with suspected cervical spine injury [3, 28, 41]. A low threshold should exist for adding CT C-spine to a CT head scan.
• Plain Film Radiography: Has a limited role. C-spine X-rays have low sensitivity and are not recommended as first-line [3, 41]. Supine chest X-rays have low sensitivity for pneumothorax and rib fractures [41].
• Ultrasound:
  • eFAST: Should be used to "rule in" significant injury, not exclude it [41].
  • Chest Ultrasound: Superior to supine CXR for detecting pneumothorax [41].

5.2. Laboratory Investigations

• Arterial/Venous Blood Gas: Essential for assessing lactate, base excess, pH, PaO2, and PaCO2 to guide resuscitation [6, 41].
• Standard Trauma Bloods: Full blood count, urea & electrolytes, liver function tests, coagulation screen (including INR and fibrinogen), and Group & Save [41]. A haemoglobin drop of 15 g/L or more is a high-risk feature.
• Cardiac Markers: High-sensitivity troponin if an acute coronary syndrome is suspected as a precipitant for the fall [41].

6. Treatment and Management

6.1. The Holistic and Multidisciplinary Approach

Time-critical single-organ interventions are rarely required; the focus is on early comprehensive review and a holistic approach.

• Early MDT Involvement: Effective management requires an MDT approach commencing in the ED, including Emergency Medicine, Geriatrics (Care of the Elderly), Specialist Nursing, Pharmacy, Physiotherapy, and Occupational Therapy [8, 22].
• Comprehensive Geriatric Assessment (CGA): Geriatrician assessment is required within 72 hours for Major Trauma Centre admissions, but best practice dictates early involvement in the ED to guide care plans, cognitive assessment, and medication management [1, 9, 29].
• Patient-Centred Care: Adopt a ‘What matters most to you’ approach to focus on immediate patient goals, maintain motivation, and shape rehabilitation outcomes.
• Silver Trauma Admission Care Bundle: This framework ensures all aspects of holistic care are addressed:
  • Dignity, autonomy, and independence
  • Analgesia and Nausea Control
  • Bone protection
  • Collateral History
  • Constipation and Urinary Retention
  • Delirium Screen (and PINCHME)
  • Falls / Polypharmacy review (STOPP/START toolkit) [30, 41]
  • Fit to Sit and early mobilisation
  • Fluids, Blood products, and Anticoagulation management
  • Nutrition
  • OT & Physiotherapy review
  • Skin care / pressure areas
  • Treatment Escalation Plan (TEP)
  • Tertiary survey
  • VTE prophylaxis

6.2. Analgesia

Effective pain management is critical to prevent delirium and facilitate mobilisation [23].

Medication Class	Best Practice/Modification in Silver Trauma	Rationale
Acetaminophen	Consider reduced maximum daily dose for patients aged over 80 years.	Reduced drug clearance necessitates dose reduction [23].
Systemic Opioids	Fentanyl preferred initially. Use low starting doses and titrate slowly.	Minimises haemodynamic depression and CNS/respiratory side effects. Slower clearance of other opioids [23, 41].
Regional Analgesia	Mandate use of Ultrasound-Guided Nerve Blocks (UGNBs), e.g., Fascia Iliaca Block for hip/femur fractures.	Provides rapid, sustained, non-systemic pain relief; reduces opioid reliance and subsequent delirium risk [23, 27, 41].
NSAIDs	Use with extreme caution or avoid entirely.	High risk of renal and gastrointestinal injury [23, 41].
Skeletal Muscle Relaxants	Avoid entirely.	High anticholinergic effects increase the risk of delirium [23].

6.3. Management of Specific Injuries

• Head Injury: Management focuses on preventing secondary brain injury (avoiding hypoxia and hypotension). Prognosis is significantly worse with increasing age; early and honest discussions about goals of care are vital [41, 44].
• Fragility Fractures (e.g., #NOF): Require an integrated orthogeriatric care model with surgery within 36 hours [31, 41].
• Spinal Injuries: Conservative management with collars requires a careful risk/benefit assessment due to risks of pressure injury, aspiration, and delirium. Patients must not be nursed on dynamic pressure-reducing air mattresses [22].
• Rib Fractures: Require aggressive pain management (consider epidural for ≥4 fractures) and chest physiotherapy to prevent pneumonia [41, 43].

7. Complications

Vigilance for complications is essential, as deterioration can be rapid.

7.1. Complications of the Condition

Complication	Key Features & Management
Delirium	Common and serious. Prevent and manage by addressing PINCHME factors. Avoid ward moves where possible as this can worsen delirium [8, 30, 41].
Venous Thromboembolism (VTE)	High risk due to immobility. Requires risk assessment and appropriate prophylaxis [41].
Infection	High risk of hospital-acquired pneumonia and UTIs. Infection is a common precipitant for delirium [28, 41].
Autonomic Dysreflexia	Life-threatening emergency in spinal cord injury, often triggered by bladder/bowel distension. Presents with sudden hypertension and bradycardia [22].
Pressure Ulcers	High risk due to immobility, poor nutrition, and fragile skin. Requires vigilant skin care [22, 41].

7.2. Complications of Treatment

• Immobilisation: Prolonged bed rest or collar use increases the risk of delirium, VTE, pneumonia, aspiration, and pressure sores [22, 41].
• Pharmacological:
  • Opiates: Risk of respiratory depression, sedation, constipation, and delirium [41].
  • Benzodiazepines: Can cause prolonged sedation and increase delirium risk [41].
  • NSAIDs: Risk of acute kidney injury and GI bleeding [41].
• Catheterisation: Increases risk of UTI, which can trigger delirium. Remove as soon as no longer required [22].

References

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Appendix: Example Electronic Health Record (EHR) Documentation

Silver Trauma Assessment (.SILVERTRAUMA) ED Provider Note

TIME OF ASSESSMENT: PATIENT IDENTIFIERS: Name, DOB, Hosp No.

HISTORY OF PRESENTING COMPLAINT:

• Mechanism of Injury: [ ] Fall <2m (standing height), [ ] Fall >2m, [ ] Fall downstairs, [ ] RTC, [ ] Pedestrian vs. Vehicle, [ ] Other: ______
• Time of Injury: ______
• Loss of Consciousness: [ ] Yes, [ ] No, [ ] Unknown
• Amnesia: [ ] Yes, [ ] No, [ ] Unknown
• Pre-event symptoms: [ ] Dizziness, [ ] Chest Pain, [ ] Palpitations, [ ] SOB, [ ] Focal neurology, [ ] None reported
• Long lie suspected: [ ] Yes, [ ] No, [ ] Unknown

PAST MEDICAL HISTORY:

• [ ] Hypertension, [ ] IHD, [ ] Heart Failure, [ ] AF, [ ] CVA/TIA, [ ] COPD, [ ] Diabetes, [ ] CKD, [ ] Cancer, [ ] Dementia, [ ] Parkinson's Disease

MEDICATIONS:

• Anticoagulant/Antiplatelet: [ ] None, [ ] Warfarin (last INR: __), [ ] Apixaban, [ ] Rivaroxaban, [ ] Dabigatran, [ ] LMWH, [ ] Aspirin, [ ] Clopidogrel
• Rate/Rhythm Control: [ ] Beta-blocker, [ ] Calcium Channel Blocker, [ ] Digoxin
• Time-critical meds (e.g., Parkinson's) due: Yes/No, Time: _____

FUNCTIONAL & SOCIAL HISTORY:

• Accommodation: [ ] Own home, [ ] Sheltered, [ ] Residential/Nursing Home
• Pre-injury Mobility: [ ] Independent, [ ] Stick, [ ] Frame, [ ] Chairbound, [ ] Bedbound
• Clinical Frailty Score (CFS): ______ (1-9)
• Collateral history from: [ ] Family, [ ] Carer, [ ] Paramedics, [ ] Not available

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EXAMINATION (C-ABCDE Approach):

• Catastrophic Haemorrhage: [ ] None. [ ] Active, controlled.
• Airway: [ ] Patent and self-maintained. [ ] Concerns (e.g., secretions, stridor).
• C-Spine: [ ] No tenderness. [ ] Midline tenderness. [ ] Immobilised (Collar/Blocks/Minimal Movement).
• Breathing: RR: __, SpO2: __% on __ O2. [ ] Symmetrical chest expansion. [ ] No respiratory distress. [ ] Signs of distress/injury present.
• Circulation: HR: __, BP: /. [ ] Warm & well-perfused. [ ] Signs of shock (cool, clammy).
• Disability: GCS: E__V__M__ = __/15. Pupils: __mm, PERL. Blood Glucose: __. Gross neurology intact.
• Cognitive Screen: 4AT Score: ______ ([ ] Alert, [ ] AMT4: __/4, [ ] Attention test passed, [ ] Acute change/fluctuating course).
• Exposure: Temp: __°C. Full secondary survey performed.
• Injuries identified: ______________________

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INVESTIGATIONS:

• ECG: [ ] Sinus Rhythm. [ ] AF. [ ] Other: ______
• VBG/ABG: pH: __, Lac: __, BE: __, pCO2: __, pO2: __
• Bloods: Pending / Reviewed. Key results: Hb __, Plt __, INR __, Creatinine __
• Imaging Requested: [ ] CT Head, [ ] CT C-Spine, [ ] CT Chest/Abdo/Pelvis (Trauma Pan-Scan), [ ] X-Rays: _____
• Imaging Results: ______________________

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MEDICAL DECISION MAKING & PLAN: Impression: ___ year old patient with Silver Trauma secondary to ______. Key issues identified are ________________.

Problem Synthesis & Risk Assessment: The patient presents with significant injuries following a low-energy mechanism. The blunted physiological response (HR/BP) relative to their likely baseline and comorbidities suggests a high risk of occult injury and decompensation. Lactate is ___, indicating potential hypoperfusion. The CFS is ___, indicating significant frailty. The 4AT score of ___ suggests underlying cognitive impairment and/or acute delirium, which complicates assessment and increases risk of adverse outcomes. The patient is on ______ (anticoagulant), increasing haemorrhage risk.

Differential Diagnosis:

• Traumatic: Occult intracranial/thoracic/abdominal haemorrhage, further occult fractures.
• Medical Precipitant: ACS, arrhythmia, sepsis (UTI/Pneumonia), PE, stroke, hypoglycaemia, postural hypotension.

Plan:

1. Resuscitation: IV access established. Targeted fluid resuscitation based on lactate/BE. TXA administered. Anticoagulation reversal with ______ initiated. Active warming measures in place.
2. Analgesia: Multimodal approach. Regional block (e.g., FICB) performed for ______ fracture. Low-dose IV Fentanyl for breakthrough pain.
3. Investigations: Awaiting CT results. Serial VBG for lactate clearance.
4. Holistic/Geriatric Care:
   • Delirium Prevention (PINCHME): Pain managed. Infection screen sent (Urine/CXR). IV hydration commenced. Bowel/bladder plan initiated. Medication reconciliation in progress. Patient's glasses/hearing aids requested.
   • Treatment Escalation Plan (TEP): Discussion initiated regarding ceilings of care and resuscitation status.
5. Referrals & MDT Communication:
   • Admit under: [ ] Trauma & Orthopaedics, [ ] General Surgery, [ ] Acute Medicine
   • Referral to: Geriatrics (Care of the Elderly) for co-management and CGA. Pharmacy for medication review.
   • Disposition: For admission to ______ ward for ongoing care and MDT management. Critical care consultation if required.

Provider: _______________ GMC: _______ Date/Time: ________

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