Transport Time
Patients meeting the criteria for major trauma should be triaged to the highest level of trauma care within 60 minutes transport time of the incident location.(7)In cases where a MTS is within the 60 minutes transport time, the patient should be taken to that service, bypassing all other hospitals in order to minimise the time from injury to specialised care.
Road transfer
Transport time by road will vary according to many factors including the time of day, traffic conditions and distance. Time will be calculated from loading the patient to the time of arrival at the receiving centre. Some flexibility in the 60-minute timeframe should be shown where a small increment added to transport time means that the patient is delivered to the appropriate facility for their care.In situations in which a patient is more than 60 minutes from an MTS, then the patient will be transported by road to the highest level of trauma care available within the 60-minute transport timeframe.
If a patient appears to be in immediate life-threat during transport, the patient is to be diverted to the nearest designated trauma service (of any level) for stabilisation, with subsequent transport to a MTS at the earliest appropriate time. An example of this would be a rapidly deteriorating patient with an urgent need for airway control or surgical control of bleeding.
Helicopter transfer
Image used with permission from Departemnt of Health, Victoria
Mobile Intensive Care Ambulance (MICA) flight paramedics carry and are able to administer blood products to all adult patients in the pre-hospital setting for patients presenting with haemorrhagic shock. Paediatric patients can also be administered blood products, but only after consultation with the patient’s guardians or medical consultation. In the case where all blood available has been utilised, consultation with the ARV coordinator for destination planning should occur (this may include diversion to a regional trauma service (RTS)). If the patient does not have signs of persisting hypovolaemic shock, they may be transported directly to an MTS.
ARV or PIPER Transfer
ARV or PIPER have access to a massive transfusion pack and this can be used for both road transfers or air transfers.
Persisting hypovolaemic shock
Image used with permission from Ambulance Victoria
If signs of shock are present, it is vital that non-hypovolaemic causes must be excluded, including neurogenic shock in spinal injuries as well as obstructive shock from possible tension pneumothorax and/or cardiac tamponade.
If the trauma patient has signs of hypotensive end-organ impact such as altered conscious state, marked pallor, clammy skin or has no response to initial crystalloid resuscitation (whilst balancing permissive hypotension principles) urgent management of hypovolaemic shock is required. Paramedics should consider availability of aeromedical resources and coordination with local health services for blood products or immediate haemostatic interventions, this should be organised via the AV clinician and ARV or PIPER.
For situations in which the patient is being transported by road and appears to be in an immediately life-threatening situation during transport, the patient is to be diverted to the nearest designated trauma service (of any level) for stabilisation, with subsequent transport to a MTS at the earliest appropriate time. Consultation with the Ambulance Victoria Clinician and interim health service should take place as soon as possible to ensure necessary arrangements are made prior to patient arrival, and for the subsequent retrieval and transfer.
Currently, all MICA Paramedics can administer packed red cell concentrate (PRCC) to major trauma patients presenting with a systolic blood pressure <70. Calcium gluconate is available for administration as required.
In patients requiring more than 4 units of PRCC, diversion to a RTS may be necessary in order to access additional blood products or other haemostatic interventions. This is dependent on health service capability, flight and landing logistics. For this to be considered, a RTS must have available surgical, operating theatre and blood bank capability and capacity. This will be determined and confirmed by the ARV or PIPER coordinator after consultation with the MFP crew, the AV clinician and RTS staff.
The patient will be transferred by road or aeromedical resource, whichever is most appropriate.
ARV or PIPER will also contact a nominated MTS to initiate early referral and case support between RTS clinicians and the MTS clinicians. The patient may be subsequently transferred for ongoing care.