Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 13 n Transfer to Definitive Care
The Advanced Trauma Life Support® course is
designed to train clinicians to be proficient in
assessing, stabilizing, and preparing trauma
patients for definitive care. Definitive trauma care,
whether support and monitoring in an intensive
care unit (ICU), admission to an unmonitored unit,
or operative intervention, requires the presence and
active involvement of a team of providers with the
skills and knowledge to manage the injuries sustained
by the trauma patient. If definitive care cannot be
provided at a local hospital, transfer the patient to
the closest appropriate hospital that has the resources
and capabilities to care for the patient. Ideally, this
facility should be a verified trauma center at a level
that is appropriate to the patient’s needs.
The decision to transfer a patient to another facility
depends on the patient’s injuries and the local
resources. Decisions about which patients need to be
transferred and when and how the transfer will occur
are based on medical judgment. Evidence supports the
view that trauma outcome is enhanced if critically
injured patients are treated in trauma centers. See
ACS COT Resources for Optimal Care of the Injured
Patient; Guidelines for Trauma System Development and
Trauma Center Verification Processes and Standards.
The major principle of trauma management is to do
no further harm. Indeed, the level of care of trauma
patients should consistently improve with each step,
from the scene of the incident to the facility that offers
the patient necessary and proper definitive treatment.
Determining the Need for
pAtient Transfer
The vast majority of patients receive their total care
in a local hospital, and movement beyond that point
is not necessary. It is essential that clinicians assess
their own capabilities and limitations, as well as those
of their institution, to allow for early differentiation
between patients who may be safely cared for in the
local hospital and those who require transfer for
definitive care.
hemodynamic abnormalities may be less obvious.
Therefore, diligence in recognizing the need for early
transfer is critical.
To assist clinicians in determining which patients
require care at a higher-level facility, the ACS Committee
on Trauma recommends using certain physiological
indices, injury mechanisms and patterns,
and historical information. These factors also help
clinicians decide which stable patients might benefit
from transfer. Suggested guidelines for interhospital
transfer when a patient’s needs exceed available
resources are outlined in n TABLE 13-1. It is important
to note that these guidelines are flexible and must
take into account local circumstances.
Certain clinical measurements of physiologic status
are useful in determining the need for transfer to an
institution that provides a higher level of care. Patients
who exhibit evidence of shock, significant physiologic
deterioration, or progressive deterioration in
neurologic status require the highest level of care and
will likely benefit from timely transfer (n FIGURE 13-1).
Stable patients with blunt abdominal trauma and
documented liver or spleen injuries may be candidates
for nonoperative management, requiring the immediate
availability of an operating room and a qualified surgical
team. A general or trauma surgeon should supervise
nonoperative management, regardless of the patient’s
age. If the facility is not prepared for urgent operative
intervention, these patients should be transferred to
a trauma center.
Patients with specific injuries, combinations of injuries
(particularly those involving the brain), and/or a
history indicating high-energy-transfer injury may be
at risk for death and are candidates for early transfer
to a trauma center. Elderly patients should be considered
for transfer for less severe injuries (e.g.,
multiple rib fractures and patients on anticoagula-
Transfer Factors
Patients who require prompt transfer can be identified
on the basis of physiologic measurements, specific
identifiable injuries, and mechanism of injury.
Patients with severe head injury (GCS score of 8 or
less) and hypotension are easily recognized and
warrant urgent transfer. However, the need to transfer
patients with multiple injuries without obvious
n FIGURE 13-1 Trauma teams rapidly assess patients to determine
the need for transfer to a higher level of care.
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