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It Doesn’t Have To Be Traumatic
Dr Mattia Baldini discusses the key considerations for transferring patients with major trauma.
© UCL
In this step, Dr Mattia Baldini, Anaesthetic Registrar, London School of Anaesthesia, discusses the management of the major trauma patient in the context of critical care transfers.
The Basics
- Traumatic injuries are caused by the transfer of outside forces to the body and are broadly classified as blunt or penetrating.
- Major trauma is defined as an injury or combination of injuries that are life-threatening and could be life-changing because of potential long-term disability. This is associated with an Injury Severity Score (ISS) greater than 15.
Traumatic injury is the leading cause of death for people aged under 44 in the UK. For every trauma fatality between 3 – 4 patients survive with a serious or permanent disability.
Regional Trauma Systems
- Survival in major trauma is crucially linked to early recognition and intervention through timely transfer to a dedicated tertiary centre.
- Following the development of similar systems in the USA and elsewhere, in 2012 the UK set up its own major trauma network; this has led to significant improvement in outcomes.
In regional trauma systems, hospitals receiving trauma patients are designated as either:
- Major Trauma Centres (MTCs), which have resources to manage severely injured patients
- Trauma Units (TUs), which are responsible for the local management of patients with less severe injuries.
- An essential element to regional trauma systems is a close collaboration between ambulance services, TUs and MTCs in a region.
- Regional ambulance services use triage tools to decide which patients should be brought to TUs and which to MTCs, but as some injuries declare themselves over time and calculation of the ISS relies on in-hospital investigations, sometimes severely injured patients are initially brought to the local TU or to a district general hospital.
- Rarely, patients may self-present with severe injuries to these sites and require transfer to an MTC.
Indications For Transferring Between Hospitals
- Trauma patients initially managed in district general hospitals or TUs might need transfer to MTCs because of identification of injuries compatible with major trauma and/or the need for specific tertiary services including:
• Neurosurgery
• Cardiothoracic surgery
• Vascular surgery
• Burns
• Paediatric intensive care
- The trauma team leader at the MTC is an important contact for referral and discussion of such cases prior to transfer.
The Challenges
Expedited Transfer vs. Additional Investigation
Patient outcome is directly related to the time elapsed between the time of injury and definitive treatment. Avoid delaying transfer for additional tests or interventions that will not affect outcome as greatly as expediting a move.
Airway Management
Induction of general anaesthesia in the major trauma patient implies a high risk of:
o difficult direct laryngoscopy and/or mask ventilation
o spinal cord injury in the context of C-spine fracture
o aspiration of gastric content
o cardiovascular instability
The most commonly used modality to obtain a definitive airway is rapid sequence induction (RSI) with manual in-line stabilisation (MILS) of the C-spine (as pictured above) and is generally appropriate prior to transfer in the context of:
o Airway obstruction – especially burns patients with evidence of inhalational injury at high risk of rapidly progressing oedema and obstruction.
o Respiratory compromise (hypoxia and/or hypoventilation).
o Reduced or rapidly-deteriorating GCS or loss of laryngeal reflexes, in particular in patients with traumatic brain injury (TBI) where controlled ventilation is part of neuroprotective measures.
o The dangerously combative or uncooperative patient.
o Anticipated life-threatening deterioration en route.
Spinal Precautions
Spinal injury should be assumed in any patient who has sustained a significant blunt trauma, until clearance procedures have been completed. Note that C-spine injury cannot be ruled out clinically in patients who:
o Have sustained a significant closed head injury
o Are intoxicated or have reduced GCS from any other cause
o Have significant pain from other injury which “distracts” attention from the neck
In these cases different spinal precautions are employed, including collar and/or blocks for C-spine immobilisation and the use of a spinal board. This document provides more detail on spinal immobilisation.
Chest Drain Management
Insertion might have been performed for tension pneumothorax or massive haemothorax. If patients are invasively ventilated, insertion of a chest drain is often appropriate to prevent pneumothorax expansion during transfer.
While it might be appropriate to clamp chest drains during transfer between trolleys, stretchers or the scanning table, it is important that they are kept open and with the bottle below the level of the chest while in transit, in particular if airlifting is necessary. The drop in atmospheric pressure with increasing altitude can result in pneumothorax tensioning if the chest drain is kept closed.
It is important to consider the location of the chest drain during transfer, ensuring it is always visible and not kinked. You should be prepared to perform emergency decompression in case of failure.
Clot Dislodgement And Ongoing Bleeding
Any patient movement entails risk of dislodgement of the primary clot at the site of vascular injury. This is more significant as consumptive coagulopathy and fibrinolysis ensue. Effective (or sometimes over-enthusiastic) resuscitation with increase in systemic blood pressure can contribute.
To limit the risk of bleeding in the trauma patient, the following principles are important to consider during the journey to definitive treatment:
o Hypotensive resuscitation: volume replacement with blood products to achieve palpable central pulses and intact conscious level with systolic BP of 80-90mmHg (MAP of 50-60mmHg) until major bleeding has been stopped. This might not be appropriate for the patient with TBI (see below).
o Tranexamic acid administration (1g within 3 hours from injury followed by a further 1g according to local protocol).
o Prevention of hypothermia (part of the ‘lethal triad of trauma’ with coagulopathy and acidosis) via temperature monitoring, exposure limitation and active warming of the patient and blood products. Portable fluid warmers are available in some services.
Given the potential need for resuscitation during inter-hospital transfer, it is important to have adequate IV access (at least 2 large-bore IV – 14G or 16G) and to consider taking blood products that have already been issued for that patient.
In acute management of hypovolaemic shock the Hb might be falsely reassuring. The response to fluid challenge (in particular when only transient) as well as the trend in base excess and lactate are more helpful to judge volume resuscitation.
Blood gases and point of care thromboelastographic (TEG) tests may be useful prior to transfer to determine what products are needed to correct trauma-induced coagulopathy – but testing should not delay time-critical transfers.
Traumatic Brain Injury (TBI)
TBI requiring neurosurgical intervention is a common indication for secondary transfer of the trauma patient.
Blood pressure targets should be adjusted to maintain cerebral perfusion pressure (systolic BP 110–150 mmHg with MAP >90 mmHg) . If hypovolaemia from bleeding coexists (see above), the most appropriate BP target should consider the predominant problem.
Please see Step 4.3 for more on transferring with neuroprotection.
Practicalities
- A “pre-alert” should be issued to the emergency department of the receiving MTC so preparation can be undertaken in advance, including recruiting the trauma team. This is crucial when time-critical interventions are necessary on arrival, such as massive transfusion or neurosurgical decompression.
- Handover tools such as the mnemonic ATMIST (age, time of incident, mechanism of injury, injuries top-to-toe, vital signs and treatment), are useful to convey information quickly. Imaging should also be sent electronically to the receiving hospital in advance.
In summary, major trauma patients represent a challenging cohort of transfers given the potential for acute deterioration and the time-critical nature. This also means they can be life-saving and as such, unnecessary delays should be minimised.
© UCL
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