Interhospital transport of the stable, yet critically injured patient to provide optimal care has become common practice. Morbidity and mortality rates are decreased when critically injured patients are provided with the advantages of a dedicated trauma center and tertiary care. With the advances in prehospital care and the superior training of our ambulance and aeromedical prehospital care providers, the benefits of transport clearly outweigh the risks.
High speed travel, enlarging populations and the risky behavior adopted by our society now present the frequent need to transport critically injured and unstable trauma patients from smaller facilities to advanced trauma centers. The ultimate goal is the provision of optimal care for each injury, and therefore, special attention to details is required to protect both the patient and the transferring physician.
Transport to a regional trauma center is often required for evaluation and intervention for neurosurgical injury. The currently accepted guidelines for management of the severe head injury patient were described by the Brain Trauma Foundation in 1995. The recommendations for prevention of secondary brain injury should be given special emphasis when transporting the unstable neurosurgical patient. The most common causes of secondary brain injury are hypotension and hypoxia. Care must be taken to avoid even brief episodes of hypotension or falling oxygenation. Aggressive volume resuscitation aimed at euvolemia is essential. The added use of vasopressors and inotropes to support a mean arterial pressure > 70 mm Hg in tandem with euvolemia may decrease secondary brain injury. Early intubation for severe head injury (Glasgow Coma Scale score # 8) and supplemental oxygenation to maintain pulse oximetry > 95% also prevent further injury and should be maintained throughout transport. These steps, along with computed tomographic (CT) evaluation and the availability of neurosurgical care for space occupying lesions, provide the best outcome for the head injured patient. Transport should not be delayed for CT evaluation, which in most cases should be obtained at the receiving facility.
Truncal injuries frequently require transport to a tertiary care facility, often before complete stability can be achieved. Thoracic decompression should be performed before transport; however, definitive thoracotomy can usually be delayed with rapid transport and ongoing resuscitation.
Blunt abdominal trauma resulting in ongoing intra-abdominal hemorrhage may require a large volume of blood and significant postoperative resources, available only at large centers. Complex liver fractures are representative of this type of trauma. Ongoing volume resuscitation using blood products during rapid transport is usually adequate. Some patients may require "damage control" laparotomy with compression packing and direct transfer from the operating theater.
Complex pelvic fractures result in large volume blood loss and often require external fixation and arteriography for hemorrhage control. Pneumatic antishock garment inflation aids in temporary compression to help limit hemorrhage during transport.
In preparing for the transport of unstable trauma patients, the referring physician must assure and document many criteria: 1) Acknowledgment of hemodynamic compromise and steps at resuscitation. Resuscitation should begin prior to transport and should be continued during transportation. This frequently requires the most rapid form of transport available. 2) Complete evaluation of pretransfer neurological status and assurance of prevention of progression due to secondary neurologic injury. 3) Documentation of the need for transport and the patient and family's understanding, if possible. 4) It is imperative that the referring physician communicate directly with the receiving physician. This communication should include the current condition of the patient and the acknowledgment of instability. This communication should be well documented.
Often an unstable trauma patient must be transported. Provision of ongoing resuscitation, trained transport staff, pretransport identification of instability and communication should allow for optimal patient outcome and protection of the referring physician and institution.
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