Identification of Potential Major Trauma

 Vital signs

The first step to identifying potential major trauma is to assess the patient’s vital signs. In the inter-hospital setting, major trauma is recognised where an injured patient meets the following criteria3 4.
 



If the trauma patient has any one of the above signs present, then potential major trauma is identified and activation of early consultation and potentially retrieval should begin.


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Isolated head injury in older people

Where a person has an altered conscious state (GCS < 13) and is over 65 years of age and has sustained their injury as a result of a low fall (< 1 m) then the patient should be managed in or transferred to a metropolitan neurosurgical service (MNS) or MTS. If the patient is already being assessed in an MNS, then there is no requirement to transfer to an MTS. Data from the Victorian State Trauma Registry demonstrates that outcomes for this subset are comparable when care is delivered in an MNS as when provided in an MTS5.
 


 Injuries found or suspected


The presence of any one of the following physiological or anatomical injuries constitutes major trauma for the purpose of inter-hospital transfer6. These injuries cover threats to life, limb or eyesight.

All penetrating injuries

  • Excluding isolated/superficial limb injuries

Blunt injuries

  • Serious injury to a single region such that specialised care or intervention may be required, or that life, limb or long-term quality of life may be at risk
  • Significant injuries involving more than one body region

Specific injuries

  • Limb amputations or limb-threatening injuries
  • Serious crush injury
  • Major compound fracture or open dislocation
  • Fracture to two or more of the following: femur/tibia/humerus
  • Fractured pelvis

Specialised trauma transfer indications

There are certain indicators in the Specialist trauma guidelines whereby transfer to either an MTS or a specialised unit is necessary. The acute nature of these injuries often requires definitive specialist care with minimal delay.

Burns

  • Burns to more than 20% of the body for an adult or 10% for a child
  • Suspected respiratory tract burns
  • High-voltage electrical injury7

Specialised burns units providing optimal care for severely burned patients are situated at The Alfred (≥16yrs, adult) and the Royal Children’s Hospital (< 16yrs, paediatric). Trauma services at all levels may receive patients with major burns injuries for resuscitation and initial stabilisation. Staff should be familiar with the burns trauma transfer guidelines, which highlight the differences between patients requiring immediate transfer and those requiring non-urgent transfer. Advice and consultation can always be sought from ARV or PIPER.

Traumatic Brain Injury

  • Neurological deficits
  • Skull fracture
  • Abnormal CT scan findings

Spinal trauma

  • Significant spinal fracture
  • Minor spinal cord or nerve-root injury
  • Presence of neurological deficits

In isolated spinal cord trauma with neurological deficit, the patient should be transferred from a primary hospital (including an MTS) directly to the Victorian Spinal Cord Service at Austin Health at the earliest possible time and ideally in less than 6 hours. All spinal cord trauma in paediatric patients should be transferred and managed at the Royal Children's Hospital.

 

Paediatric trauma

  • Any of the above conditions when in children will initiate transfer
All paediatric major trauma is transferred to the Royal Children’s Hospital.

Obstetric trauma

  • Evidence of foetal distress and foetus beyond 24 weeks’ gestation.
  • Possibility of trauma to the uterus.
  • All obstetric major trauma patients should be transferred to the Royal Melbourne Hospital where they will have urgent obstetric assessment.

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 High-risk criteria

The presence of a high-risk mechanism of injury or a comorbid factor places the patient at risk of major trauma complications. Patients in this category should have a complete trauma evaluation conducted and be observed for a period of time.

If physiologically stable patients with only a high-risk mechanism of injury or a comorbid factor are triaged as major trauma patients, this may result in unnecessary over-triage.
If deterioration in a patient’s condition occurs, then ARV or PIPER should be contacted to discuss the case and possible activation of retrieval services and transfer to a MTS.

High-risk criteria for major trauma involves8:
 
  • ejection from a vehicle
  • motorbike rider or cyclist impact > 30 km/h
  • fall from a height  > 3 m
  • struck on the head by an object falling > 3 m
  • explosion
  • high-speed car accident > 60 km/h
  • pedestrian impact

AND
  • age < 10 or > 55
  • pregnancy
  • significant comorbidity
     

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