Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 13 n Transfer to Definitive Care
table 13-1 rapid triage and transport guidelines (continued)
SECONDARY
SURVEY
FINDING
INTERVENTIONS AND ADJUNCTS TO
BE PERFORMED AT LOCAL FACILITY
CONSIDER
TRANSFER?
Neck
Hematoma, crepitus, midline
tenderness or deformity
CT scan c
Y
Chest
Multiple rib fractures, flail chest,
pulmonary contusion, widened
mediastinum, mediastinal air
CXR, FAST c , CT scan c
Y
Abdomen Rebound, guarding FAST, DPL a , CT scan c Y
Perineum/
Rectum/Vagina
Laceration
Proctosigmoidoscopy c , speculum
examination c
Y
Neurologic Deficit Plain films c , CT scan c , MRI c Y
Musculoskeletal
Complex or multiple fractures or
dislocations or bony spine injuries
Extremity xrays c , spine xrays c , or CT scan c
Y
Other Factors
Age, multiple comorbidities,
pregnancy, burn
Note: Evaluate and make the decision to transfer within first 15–30 minutes of trauma team leader arrival.
a. Perform only if it affects the decision to transfer.
b. Patients with GCS scores 9–13 may require intubation, depending on clinical circumstances and discussion with accepting doctor.
c. Perform only in hemodynamically stable patients for whom the results will affect the decision to transfer or the care provided before transfer.
tion therapy) because of their limited physiologic
reserve and potential for comorbid illnesses.
Obese patients rarely require transfer specifically
because of their weight except in extreme cases in
which CT scans cannot be obtained due to the patient’s
size or special equipment is required for an operative
procedure. The difficult airway often associated with
obesity may warrant early intubation before transfer
when there is a risk that mental status or respiratory
status may deteriorate during transport.
Abuse of alcohol and/or other drugs is common
to all forms of trauma and is particularly important
to identify, because these substances can alter pain
perception and mask significant physical findings.
Alterations in the patient’s responsiveness can be
related to alcohol and/or drugs, but cerebral injury
should never be excluded as a potential cause of mental
status change, even in the presence of alcohol or drugs.
If the examining doctor is unsure, transfer to a higherlevel
facility may be appropriate.
Death of another individual involved in the traumatic
incident suggests the possibility of severe, occult injury
in survivors. In these cases, a thorough and careful
evaluation of the patient is mandatory, even when
there are no obvious signs of severe injury.
Timeliness of Transfer
Patient outcome is directly related to the time elapsed
between injury and properly delivered definitive care.
In institutions without full-time, in-house emergency
department (ED) coverage, the timeliness of transfer
depends partly on how quickly the doctor on call can
reach the ED. Consequently, trauma teams should
develop effective communication with the prehospital
system to identify patients who require a doctor to be
present in the ED at the time of arrival (n FIGURE 13-2).
In addition, the attending doctor must be committed
to respond to the ED before the arrival of critically
injured patients.
The timing of interhospital transfer varies based on
transfer distance, available skill levels of transferring
personnel, circumstances of the local institution, and
the interventions required before safely transferring
the patient. If resources are available and the necessary
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