How can I identify patients with major trauma who require immediate transfer to a trauma centre?

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 ¹. This tool must include an assessment of the patient's physiology and anatomical injury ¹. 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 ¹. Patients on any anticoagulant medication should have a CT head scan within 8 hours of a head injury ⁴.

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 ³,⁴. Signs of shock, such as tachycardia, hypotension, or reduced capillary refill time, also indicate the need for immediate transfer ⁴. 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 ³.
• Significant Anatomical Injuries: These include a suspected open or depressed skull fracture, or a tense fontanelle in a child ⁴. A suspected basal skull fracture, signs of a penetrating injury, or visible trauma to the scalp or skull are also important ⁴. In children under 1 year of age, a bruise, swelling, or laceration of more than 5 cm on the head warrants immediate transfer ⁴. 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 ⁴. Any focal neurological deficit also necessitates immediate transfer ⁴.
• Dangerous Mechanism of Injury: High-energy mechanisms of injury are significant indicators ⁴. 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 ⁴.
• Other Important Factors: Any loss of consciousness or amnesia of the event, or any vomiting since the injury, should prompt consideration for transfer ⁴. Irritability or altered behaviour, particularly in infants and children aged under 5 years, is also a concern ⁴. 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 ⁴. Additionally, possible non-accidental injury, safeguarding concerns, or if a vulnerable person is affected, require immediate transfer ⁴.

Only enough time should be spent at the scene to provide immediate life-saving interventions ¹. 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 ¹,². Initial resuscitation and stabilisation, along with comprehensive monitoring, should be established before transfer to avoid complications during the journey ³. Patients with persistent hypotension despite resuscitation should not be transported until the cause is identified and they are stabilised ³.