Introduction

There are many factors which result in a large portion of major trauma patients requiring transfer for definitive care at a MTS. Some of these factors include geographical location, severity of injury and trauma system knowledge and understanding.

 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 criteria (3, 4).
 

INTER-HOSPITAL VITAL SIGNS MAJOR TRAUMA
AGE Term – 3 Months 4-11 Months 1-4 Years 5-11 Years 12-15 Years 16 years and over
RR >60 >50 >40 >30 >30 <10 or >30
HR <100 or >180 <100 or >180 <90 or >160 <80 or >140 <60 or >130 <60 or >120
BP sys <50 <60 <70 <80 <90 <90
SpO2 <90% <90% <90% <90% <90% <90%
GCS <15 <15 <15 <15 <15 <13

If the trauma patient has one or more of the above signs present, then potential major trauma is identified, and activation of early consultation should begin including consideration for retrieval (5).

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 due to 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 a 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 MTS (4, 6).

Major trauma after a near hanging incident

Historically this cohort of patients received care at a MTS, however, current evidence indicates there is no mortality benefit for patients treated at a MTS, similarly there is no statistical improvement in functional outcomes of patients treated at a MTS. This patient subset can most likely be managed safely at a non-MTS. It is recommended that ARV is still contacted, however, the increasing likelihood is that most patients will not require a transfer to a MTS (7).

 


 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 transfer. These injuries cover threats to life, limb, or eyesight (1, 8).

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 a MTS or a specialised unit is necessary. The acute nature of these injuries often requires definitive specialist care with minimal delay.

Burns

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

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 and should 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 a MTS) directly to the Victorian Spinal Cord Injury 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.


 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.

High-risk criteria for major trauma involves(9):

  • 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 < 16 or > 55
  • Pregnancy
  • Significant comorbidity

If deterioration in a patient’s condition occurs, then ARV or PIPER should be contacted to discuss the case and activation of retrieval services and transfer to a MTS.

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