Transfer to

Definitive
Care

Dr. Charles A Simanjuntak, dr, SpOT(K), FICS, MPd

FKIK Universitas Jambi
 Case Scenario

A 27-year-old male is brought to an 80-bed

rural hospital following an MVC.
The hospital has a CT scanner and
ultrasound capability, but no neurosurgical
facility.
Vitals: Systolic BP 80; shallow breathing;
and GCS score 6.
What are your concerns and priorities in
organizing transfer of this patient?
CharlesASjuntak, FKIK-Unja 2
Objectives

Identify injured patients who may

require transfer from the primary
facility to a trauma center.

Discuss the procedures for optimal,

safe patient transfer.

CharlesASjuntak, FKIK-Unja 3
 Transfer Principles

Know institutional capabilities.

Be prepared and anticipate patient needs.
Do no further harm.
Identify patients whose needs exceed local
resources.

CharlesASjuntak, FKIK-Unja
Transfer Principles

Perform only essential procedures.

Establish direct communication between
referring and receiving doctors.
Transport to closest, appropriate facility.
Use most appropriate mode of transport.

CharlesASjuntak, FKIK-Unja
Transfer Decisions

Whom do I transport?

Patients with multiple injuries

Patients whose needs exceed
institutional capabilities
Patients with comorbidities
Extremes of age
Preexisting disease

CharlesASjuntak, FKIK-Unja 6
CharlesASjuntak, FKIK-Unja 7
Transfer to Definitive Care:
Special Considerations(1)

Extreme age
Age > 55 is considered geriatric
trauma
Significant comorbidities
Anticoagulation therapy

Patients with any of these require

higher levels of trauma care

CharlesASjuntak, FKIK-Unja 8
Transfer to Definitive Care :
Special Considerations (2)

Solid Organ Injury

Large amount of hemoperitoneum
Contrast blush
Anticoagulation
Age > 55 years

Patients with any of these require

higher level trauma care
CharlesASjuntak, FKIK-Unja 9
 Pediatric Anatomic Indicators(1)
Penetrating injury to the head, neck or torso
Significant penetrating injury to the
extremities, proximal to the knee or elbow,
with neurovascular compromise
Visible crush of head, neck or torso
Abdominal tenderness, distention or seat belt
sign
Flail chest
Pelvic fracture

CharlesASjuntak, FKIK-Unja 10
Pediatric Anatomic Indicators(2)
Injuries to the extremities with
Visible crush or
Evidence of neurovascular compromise
Amputations proximal to the wrist or ankle
Fracture of 2 or more proximal long bones
(humerus or femur)
Signs and symptoms of spinal cord injury
Serious burns
2nd or 3rd degree burns over more than 10% of
total body surface area or
Involving face, airway, hands, feet, genitalia
CharlesASjuntak, FKIK-Unja 11
Pediatric Physiologic Indicators
Glasgow Coma Score of 13 or less
Loss of consciousness for greater than 5
minutes
Failure to localize pain (GCS motor score 4 or
less)
Evidence of poor perfusion
Weak distal pulse, pallor, cyanosis, delayed cap
refill, or tachycardia
Evidence of respiratory distress or failure
Stridor, grunting, retractions, cyanosis, hoarseness,
difficulty speaking
CharlesASjuntak, FKIK-Unja 12
Adult Anatomic Indicators(1)
Penetrating injury to the head, neck or
torso
Significant penetrating injury to the
extremities, proximal to the knee or
elbow, with neurovascular compromise
Visible crush of head, neck or torso
Abdominal tenderness, distention or seat
belt sign
Flail chest
Pelvic fracture (this does not include
isolated hip fractures)

CharlesASjuntak, FKIK-Unja 13
Adult Anatomic Indicators(2)
Injuries to the extremities with
Visible crush or
Evidence of neurovascular compromise
Amputations proximal to the wrist or
ankle
Fracture of 2 or more proximal long bones
(humerus or femur)
Signs and symptoms of spinal cord injury
Serious burns
2nd or 3rd degree burns over more than 10%
of total body surface area
Involving face, airway, hands, feet, genitalia
CharlesASjuntak, FKIK-Unja 14
Adult Physiologic Indicators
Glasgow Coma Score of 13 or less
Loss of consciousness for greater than 5
minutes
Failure to localize pain (GCS motor score 4
or less)
Respiratory rate less than 10 or greater than
29
Requires endotracheal intubation
Requires relief of tension pneumothorax
Pulse rate greater than 120 with evidence of
hemorrhagic shock
Systolic blood pressure less than 90 mm Hg
CharlesASjuntak, FKIK-Unja 15
Geriatric Indicators(1)

Geriatric trauma indicators are similar to

adult.

Differences are marked with an asterisk *

CharlesASjuntak, FKIK-Unja 16
 Geriatric Anatomic Indicators(1)
Penetrating injury to the head, neck or torso
Significant penetrating injury to the
extremities, proximal to the knee or elbow,
with neurovascular compromise
Visible crush of head, neck or torso
Abdominal tenderness, distention or seat belt
sign
Flail chest
Pelvic fracture (this does not include isolated
hip fractures)
Injury sustained in two or more body regions*

CharlesASjuntak, FKIK-Unja 17
Geriatric Anatomic Indicators(2)
Injuries to the extremities with
Visible crush or
Evidence of neurovascular compromise
Amputations proximal to the wrist or ankle
Fracture of 2 or more proximal long bones
(humerus or femur)
Signs and symptoms of spinal cord injury
Serious burns
2nd or 3rd degree burns over more than 10% of
total body surface area or
Involving face, airway, hands, feet, genitalia

CharlesASjuntak, FKIK-Unja 18
 Geriatric Physiologic Indicators(1)
Glasgow Coma Score of 13 or less
Glasgow Coma Score less than 15 with a known
or suspected traumatic brain injury*
Loss of consciousness for greater than 5 minutes
Failure to localize pain (GCS motor score 4 or
less)
Respiratory rate less than 10 or greater than 29
Requires endotracheal intubation
Requires relief of tension pneumothorax
Pulse rate greater than 120 with evidence of
hemorrhagic shock
Systolic blood pressure less than 100 mm Hg*
CharlesASjuntak, FKIK-Unja 19
Geriatric Mechanism Indicators(1)
Fracture of 1 or more proximal long bones
(humerus or femur) sustained in a motor
vehicle crash*
Pedestrian struck*
Falls from any height including standing
with evidence of a traumatic brain
injury*

CharlesASjuntak, FKIK-Unja 20
Special Considerations
Pregnancy
Co-morbid conditions
Cardiac or respiratory disease
Liver failure or cirrhosis
Insulin-dependant diabetes (Type 1)
Compromised immune system
Cancer, HIV, Transplant
Bleeding disorders or on anti-coagulants
Morbidly obese
CharlesASjuntak, FKIK-Unja 21
Five Exceptions to Mandatory Transport(1)
1. Medical necessity for initial assessment and
stabilization
2. Unsafe or medically inappropriate due to
adverse weather conditions or excessive
transport time
3. It would cause a shortage of local EMS
resources
4. No trauma center is able to receive and provide
care to the patient without undue delay
5. Before transport begins, the patient (or
parent/guardian) requests transportation to a
hospital that is not a trauma center

CharlesASjuntak, FKIK-Unja 22
Five Exceptions to Mandatory Transport(2)
1. It is medically necessary to transport the
patient to a hospital without a trauma
center for initial assessment and
stabilization before transfer.
These must be legitimate, immediately life-threatening
medical reasons.
Unable to open or maintain airway
Traumatic arrest
Uncontrollable external bleeding
EMS agency protocols should provide guidance on
when this is appropriate

CharlesASjuntak, FKIK-Unja 23
Five Exceptions to Mandatory Transport(3)
2. Unsafe or medically inappropriate due to
adverse weather conditions or excessive
transport time.

In cases of bad weather or when transport time to the nearest

trauma center is excessive, a patient may be better served
by stopping at the nearest hospital for stabilization and
transfer.
Consider other methods of transport, such as air
medical
Local and regional protocols should provide guidance
on when this is appropriate
Use your best professional
CharlesASjuntak, judgment
FKIK-Unja 24
Five Exceptions to Mandatory Transport(4)
3. It would cause a shortage of local resources.

Many EMS jurisdictions have limited resources equipment

and/or personnel to provide for the emergency
medical needs of their community. If transporting to a
trauma center causes a shortage of these resources, it
may be better to transport to the closest hospital where
transfer can be arranged.
Each community must assess its available resources,
including air medical services and mutual aid, to
understand when this exception applies.

CharlesASjuntak, FKIK-Unja 25
 Five Exceptions to Mandatory Transport(5)
4. No trauma center is able to receive and provide
care to the patient without undue delay.

This exception was originally intended to address situations where

trauma centers were diverting trauma patients. However,
with todays mature state and regional trauma systems, this is
mostly a thing of the past. Trauma centers avoid trauma
patient diversion.
If, for some unusual reason, a trauma center diverts your patient,
you must use your best judgment, along with guidance from
medical control, to determine the next best destination for
your trauma patient.

CharlesASjuntak, FKIK-Unja 26
Five Exceptions to Mandatory Transport(6)
5. Before transport of a trauma patient begins, the
patient requests to be transported to a hospital
that is not a trauma center. This request may
also be made by the parents / legal guardian of a
trauma patient who is a minor, or by a legal
representative of the patient.
Competent patients have the right to have input into
where they will receive treatment. EMS personnel
should attempt to convince the patient of the need
for treatment at a trauma center but should respect
the competent patients wishes.
CharlesASjuntak, FKIK-Unja 27
Transfer Decisions

Where should I send the patient?

Transfer to an institution capable of
providing equipment and resources
Transfer to an appropriate, qualified
physician who can:
Make the diagnosis
Treat the patients injuries
Provide commitment and resources

CharlesASjuntak, FKIK-Unja
Transfer Decisions

When should I transport the patient?

Transfer after life-threatening problems are
managed.
Transfer after disabling injuries are stabilized.
Transfer after arrangements are made.
Transfer before performing unnecessary tests
and procedures.

Avoid delay!

CharlesASjuntak, FKIK-Unja
 Transfer Decisions

How should I transport the patient?

Determine by:
Care required en route
Patient destination
Available resources
Existing transfer agreements

CharlesASjuntak, FKIK-Unja 30
CharlesASjuntak, FKIK-Unja 31
Summary

What is the problem?

Not all hospitals can care for all
trauma patients.
Who needs transfer?
Patient whose needs exceed local
resources.
Where should the patient be
sent?
Ideally, to a verified trauma center.
CharlesASjuntak, FKIK-Unja 32
Summary

When should they be

transported ?
After immediate, life-threatening
injuries are addressed.
How should the patient be
transported ?
According to patient need and
available resources
CharlesASjuntak, FKIK-Unja 33