Trauma Unit / LEH responsibilities prior to transfer

Consider leaving the patient on the ambulance scoop stretcher if the MTC transfer is imminent.  SAS to consider using the same crew for onward transfer.

<C> Treat with pressure / dressing / bandage /  tourniquets / haemostatics.

A Secure Airway.

B If indicated, decompress the chest with thoracostomy and/or intercostals drainage (using transport drains rather than underwater seal bottles if possible and available.

C Secure and tape IV access x2.

Do not waste time / delay transfer with arterial lines. Pelvic Binder as indicated. 

1g TXA if indicated.

Apply traction to femoral shaft fractures (use Kendrick splints as available).

H haemostatic resuscitation +/- Major Haemorrhage protocol as indicated.

D Prevent secondary brain injury.

E Use a Bair Hugger blanket or similar if hypothermic or shocked.  Immobilise / reduce fractures / dislocations. 

• CXR/Pelvis XR/FAST.
• A blood gas (venous or arterial).
• Urinary catheter where indicated.
• An orogastric or nasogastric tube in intubated patients.
• ECG (major chest injury or > 45 yrs old).

CT scans can considerably delay time to definitive care where it is not immediately available.  The TU TTL must balance the information gained form CT against delays to definitive care and it is perfectly acceptable to send a
patient to the MTC without imaging.  Prompt  immediate CT may be of overall benefit in many patients though a 5 minute verbal report is often all that is required before sending the patient.  It is not necessary to wait for the full written report before departure.

A structured checklist and standardised documentation is used for all transfers. The TU TTL should update the MTC TTL with clinical information and timings.  The SAS should still place a pre alert to the RIE within a 16 minute ETA. 

Patients who are peri-arrest with a positive FAST where a consultant surgeon and theatre are immediately available (within 30 minutes) should receive damage control intervention at the TU.  The TU consultant should then arrange for urgent transfer to the MTC post operatively.  Transfer patients immediately to the MTC if theatre or surgical staff are not readily available. 

Patients who are peri-arrest with penetrating trauma should undergo resuscitative thoracotomy at the TU.  If trained staff are not immediately available transfer to MTC.

Algorithm for network transfers

South East Trauma Network Head Injury Pathway

Time critical secondary transfer checklist

The patient may benefit from MTC care though care closer to home may be more appropriate and the following factors should be considered. Involve the patient and those close to them in any decision and/or any power of attorney. 

Considerations

• Are there treatment escalation plans and advanced directives to consider?
• Is there a pre-existing frailty (e.g. clinical frailty score ≥5)
• Does the patient have a traumatic brain injury assessed as an immediate threat to life or incompatible with good functional recovery AND where early limitation or withdrawal of therapy is being considered?

All other patients are suitable for MTC transfer under automatic acceptance.  This should be agreed by the senior ED physician. The treating team may decide that the patient should remain local. (Any case can always be discussion with the neurological registrar).

• Not to be used in the following patients
  • <65 years
  • learning disabilities
  • stable long term disabilities
• Score verified by 2 doctors (including 1 consultant)
• To score - Ask patients, carers, NOK, paramedics and care home staff regarding capability 2 weeks ago, not today.
• Patients acutely close to death or terminally ill score 9.
• Patients with mild, moderate and severe dementia map to scores of 5, 6 and 7 respectively.