Advanced Trauma Life Support ATLS Student Course Manual 2018

TREATMENT BEFORE TRANSFER 245
to provide definitive care. Frequently, CT scans done
before transfer to definitive care are repeated upon
arrival to the trauma center, making the necessity of a
pre-transfer CT questionable. Multiple scans result in
increased radiation exposure and additional hospital
costs as well as a delay in transfer to definitive care.
Treatment before Transfer
Patients should be resuscitated and attempts made
to stabilize their conditions as completely as possible
based on the following suggested procedure:
n FIGURE 13-2 Effective communication with the prehospital system
should be developed to identify patients who require the presence
of a doctor in the ED at the time of arrival.
procedures can be performed expeditiously, lifethreatening
injuries should be treated before patient
transport. This treatment may require operative
intervention to ensure that the patient is in the best
possible condition for transfer. Intervention before
transfer requires judgment.
After recognizing the need for transfer, expedite the
arrangements. Do not perform diagnostic procedures
(e.g., diagnostic peritoneal lavage [DPL] or CT scan) that
do not change the plan of care. However, procedures
that treat or stabilize an immediately life-threatening
condition should be rapidly performed.
Despite the principle that transfer should not be
delayed for diagnostic procedures, a significant portion
of trauma patients transferred to regional trauma
centers undergo CT scanning at the primary hospital,
thus leading to an increased length of stay before
transfer. In fact, research has shown that much of the
time delay between injury and transfer is related to
diagnostic studies performed despite lack of a surgeon
Pitfall
Delay in transfer of a
patient to definitive care
prevention
• Consider transfer early in
the assessment process.
• Quickly determine the
needs of the patient and
the capabilities of the
institution.
• Order only tests that will
identify life-threatening
injuries that can be
treated or stabilized
before transfer.
1. Airway
a. Insert an airway or endotracheal tube, if needed.
Establish a low threshold to intubate patients
with altered GCS, even above 8, when there is
concern for potential deterioration, and discuss
this decision with the receiving doctor.
b. Provide suction.
c. Place a gastric tube in all intubated patients
and in non-intubated patients with evidence
of gastric distention. Use judgment when
patients are agitated or intoxicated, as
this procedure can induce vomiting,
risking aspiration.
2. Breathing
a. Determine rate and administer supplementary
oxygen.
b. Provide mechanical ventilation when needed.
c. Insert a chest tube if needed. Patients with
known or suspected pneumothorax should
have a chest tube placed when they are being
moved by air transport.
3. Circulation
a. Control external bleeding , noting time of
placement when tourniquet is used.
b. Establish two large-caliber intravenous lines
and begin crystalloid solution infusion.
c. Restore blood volume losses using crystalloid
fluid and blood to achieve balanced
resuscitation (see Chapter 3: Shock) and
continue replacement during transfer.
d. Insert an indwelling catheter to monitor
urinary output.
e. Monitor the patient’s cardiac rhythm and rate.
f. Transport patients in late pregnancy, tilted
to the left side to improve venous return.
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