II. Indications: Decide early if transfer to Trauma Center is appropiate

  1. Among other criteria, Glasgow Coma Score <= 8 should be cared for at Trauma Center
  2. Focus on speed and efficiency
    1. Do just enough to allow safe transport to definitive care
  3. Call for transport early in course
    1. If available, a second provider in the Trauma Evaluation can break-off to contact the Trauma Center
    2. Relay a focused hand-off (MIST mnemonic: Mechanism, injuries, symptoms/signs, treatment)

III. Evaluation

  1. Perform Primary Survey and Secondary Survey
  2. Examine all areas (arm pits and back, Breasts, butt cheeks and sac)

IV. Imaging: Obtain focused imaging only (for stabilization only, not diagnosis)

  1. See Trauma Evaluation for imaging precautions
  2. Make electronic copies (e.g. CD) of all imaging to send with patient
  3. CT Head
    1. Indicated in Altered Level of Consciousness (evaluate for intracranial bleeding such as Epidural Hematoma)
    2. Obtain CT Cervical Spine at same time as CT Head (if indicated)
  4. Chest XRay
    1. Repeat again after intubation and Nasogastric Tube placement
  5. Consider Pelvic XRay (if suspicion of Fracture)
  6. Focused assessment sonography for Trauma (FAST)

V. Management: Focus on acute stabilization and Resuscitation to ensure safe transport

  1. Airway: RSI and Intubation (or surgical airway)
    1. Indicated in unstable airway, respiratory distress, Altered Mental Status (GCS <11)
    2. Secure an Advanced Airway prior to transport if any chance it will be needed en-route
      1. Definitive airway management is very difficult en-route (especially on air transport)
    3. Confirm Endotracheal Tube position (including with Chest XRay prior to transport)
    4. Ensure adequate Sedation and analgesia for transport
    5. Secure patient's hands with soft restraints to prevent self-extubation
  2. Chest Tubes (if indicated)
    1. Especially for air transport during which even a small Pneumothorax is likely to expand
  3. Vascular Access and Hemorrhage Management
    1. Secure intravenous lines (minimum of 2 lines, as large bore as possible)
    2. Write numbers (1, 2, 3) on the Intravenous Fluid bags (helps track total crystalloid administered)
    3. Start Blood Products prior to transfer if indicated OR
      1. Give transport paramedics blood to start if needed in route
      2. Use O- for women (or O- or O+ for men) if Transferring before type specific blood available
    4. Apply Tourniquets if needed to control life threatening bleeding
      1. See Tourniquet and Hemorrhage Management for precautions
  4. Major Fracture stabilization
    1. Pelvic stabilization (Pelvic Binder) for suspected Pelvic Fracture
    2. Splinting (large bulky splints to prevent Fracture movement in transport)
    3. Traction Splinting
  5. Avoid procedures that may be deferred to the accepting facility
    1. Avoid Fracture reduction that may be safely delayed
    2. Immediately reduce Fractures with neurovascular compromise or active bleeding
  6. Environment
    1. Maintain patient warmth (monitor patient Temperature)
  7. Tubes
    1. Orogastric Tube
    2. Foley Catheter (or Suprapubic Catheter)
  8. Other measures
    1. Consider Seizure Prophylaxis
    2. Tetanus prophylaxis
    3. Antibiotics if indicated

VI. Management: Transfer documentation

  1. Patient evaluation including SAMPLE History (including Anticoagulant use), dosing weight, Vital Signs, exam, GCS
  2. Imaging studies burned to CD or DVD as well as radiologist reports (if available)
  3. Diagnostic testing results (EKG, Labs)
  4. Interventions (medications, procedures)

VII. References

  1. (2016) CALS, 14th ed, I-6
  2. Herbert and Inaba in Herbert (2014) EM:Rap 14(3): 5-6
  3. Mell in Herbert (2015) EM:Rap 15(2): 1-2
  4. (2008) ATLS Manual, American College of Surgeons
  5. (2012) ATLS Manual, 9th ed, American College of Surgeons

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