To identify patients with major trauma who require immediate transfer to a major trauma centre, a pre-hospital major trauma triage tool should be used NICE NG40. This tool must include an assessment of the patient's physiology and anatomical injury NICE NG40. It should also consider the specific needs of high-risk populations, such as older patients, children, pregnant women, patients taking anticoagulants, and those with comorbidities NICE NG40. Patients on any anticoagulant medication should have a CT head scan within 8 hours of a head injury NICE CKS.
Key indicators for immediate transfer include:
- Physiological Compromise: This includes a depressed conscious level, such as a Glasgow Coma Scale (GCS) score of 8 or less, or a GCS less than 15 NICE NG232,NICE CKS. Signs of shock, such as tachycardia, hypotension, or reduced capillary refill time, also indicate the need for immediate transfer NICE CKS. Ventilatory insufficiency, hypoxaemia (PaO2 less than 13 kPa on oxygen), hypercarbia (PaCO2 more than 6 kPa), irregular respirations, or loss of protective laryngeal reflexes are critical indicators NICE NG232.
- Significant Anatomical Injuries: These include a suspected open or depressed skull fracture, or a tense fontanelle in a child NICE CKS. A suspected basal skull fracture, signs of a penetrating injury, or visible trauma to the scalp or skull are also important NICE CKS. In children under 1 year of age, a bruise, swelling, or laceration of more than 5 cm on the head warrants immediate transfer NICE CKS. Suspected cervical spine injury, indicated by midline cervical spine tenderness or an inability to rotate the neck 45 degrees to the left and right, is another key factor NICE CKS. Any focal neurological deficit also necessitates immediate transfer NICE CKS.
- Dangerous Mechanism of Injury: High-energy mechanisms of injury are significant indicators NICE CKS. These include falls from a height greater than 1 metre or 5 stairs, high-speed motor vehicle collisions (whether as a pedestrian, cyclist, or vehicle occupant), rollover motor accidents, ejection from a motor vehicle, accidents involving motorized recreational vehicles, bicycle collisions, or diving accidents NICE CKS.
- Other Important Factors: Any loss of consciousness or amnesia of the event, or any vomiting since the injury, should prompt consideration for transfer NICE CKS. Irritability or altered behaviour, particularly in infants and children aged under 5 years, is also a concern NICE CKS. Clinical concern about the diagnosis of head injury, ongoing concern by the person or their family/carers, or if a responsible adult cannot stay with the person for the first 24 hours after the injury, are also reasons for immediate transfer NICE CKS. Additionally, possible non-accidental injury, safeguarding concerns, or if a vulnerable person is affected, require immediate transfer NICE CKS.
Only enough time should be spent at the scene to provide immediate life-saving interventions NICE NG40. While the optimal destination is usually a major trauma centre, if a patient requires a life-saving intervention (such as drug-assisted rapid sequence induction of anaesthesia and intubation) that cannot be delivered by the pre-hospital team, they may be diverted to the nearest trauma unit for this urgent treatment before onward transfer NICE NG40,NICE NG39. Initial resuscitation and stabilisation, along with comprehensive monitoring, should be established before transfer to avoid complications during the journey NICE NG232. Patients with persistent hypotension despite resuscitation should not be transported until the cause is identified and they are stabilised NICE NG232.