HEMS with blood delivery capacity
_{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.