Patient Retrieval / Transport
Definition
Principles
Job of
retrieval
team
Patient
Retrieval
Answer
Format
Mode of
transport
Procedures
PreHospital
Process whereby medical teams are transported from central hospital to peripheral areas with intention of treating, stabilising and tetrieval
and transport of patients from remote locations to 1Y hospital treatment site
Prehospital transport: 1Y
Interhospital transport: 2Y
Provide best possible are with exposing patient to least possible risk
Transfer and transit are times of greatest risk
Level of medical care should always be retained / increased at each transfer
Utilising peripheral location staff as transport escorts may significantly affect level of care at that location
Adverse events: in 70%; 45% equipment, 25% vascular line, 25% patient instability; 20% cardiac patients require intervention during transfer
(RF: prev cardiac arrest, post-thrombolysis, MI, requiring IV INF)
Provide rural practitioners with information and advice network, bed-finding facility
Communicate – transferring / accepting hospital / unit / team – ensure have all info
Transporting team
Relatives and patient
Correct choice of patient – is it indicated? Benefits > risks; appropriate care must not be available at referring hospital
Correct choice of transport – weather conditions, terrain, distance
Correct choice of team – staff on transport should be appropriate to retrieval; experienced staff (doctor familiar with resus, A, ventilation,
other organ support; nurse / technician / paramedic familiar with medical procedures and equipment); consider personal comfort and safety
Equipment – electronic equipment with own battery power; separate sources for O2 and suction; BVM; defib; ECG; oximeter; ETCO2; cardiac;
BP; thermometer; ventilator; fluid pumps; drugs (full resus drugs, draw up anticipated drugs); O2 (take 2-3x supply anticipated); ETT (removed
gass from cuff on ascent, instil on descent, or fill with water); emergency airway kit; pleural drainage equipment; infusion pumps;
pericardiocentesis equipment; sharps disposal box; urinary catheter and bag; NGT and bag; gloves, dressing etc…; splints; torch, safety glasses
Transit to patient
Prepare patient on arrival – STABLE = sugar, T, airway, BP, labs, emotional support
Full assessment and investigations; careful stabilisation of patient (SBP >100, HR <120, CRT, UO, vol deficit, ongoing bleeding, GCS, #’s,
pneumo/haemothorax); if likely airway compromise / resp failure, intubate pre-transfer
Secure airway, ventilation, O2, catheters, tubes, trains (Heimlich valve on chest drain), art lines (decr battery requirement than NIBP); IVA (x2
large bore); sedation / analgesia; anti-emetic; anti-convulsant (phenytoin loading helpful for motion sickness); IVF (correct deficit prior to
leaving, will need flushes, adequate supplies of fluids); fracture sites (splinted, haemorrhage controlled, self contained traction); spinal injuries
(C spine precautions); temp
Re-assessment prior to transfer; liase again with accepting team, ensure bed ready and where transporting to
Anticipate problems –
Loading and unloading: removal of lines, thermal insult
Effect of altitude: decr PiO2 – at risk if decr SaO2, decr Hb, incr O2 requirements, fixed CO; need supplementations +/- cabin
pressurisations; in severe disorders may not be able to fly at sea level cabin altitudes, which will incr
turbulence, flying time and fuel consumption
Dysbaria – in skull # with aerocoele, recent GUT stureus, bowel obstruction, mediastinal emphysema, bullae in emphysema,
Pneumothorax (Consider prophylactic ICC drain), penetrating eye inj, decompression illness; effects ETT, IV bags (IV line
stops / slows at altitude, frequent flushes required, colostomy bags, drains; limb swelling beneath plaster casts;
acceleration / deceleration; electromagnetic interference
Decr humidity – humidify gases
Decrease T, darker, noisier, vibrations, space and lighting limitation
Noise, vibration, G forces: harmful to vascular anastomoses <14/7, pneumothoraces <10/7, hypoV; worsen ain, cause bleeding;
makes procedurs hard, obscure alarms, make examination hard
Vital signs: more difficult to monitor
Staff problems: sickness, sinus/ear pressure
Special considerations: air embolism / eye injury / HI (aerocoele, CSF rhinorrhoea) / # (rebleeding; G forces on C spine) / decompression
sickness / ACS – travel lower
Weather conditions
Defib: movement artefact will make it difficult to sync; consult pilot before giving DC shock
Transfer patient – continuing care during transfer
Direct handover – including communication with family, referring hospital, ED consultant, patient
Documentation and audit – pre-transfer condition; investigations accompany patient
Helicopter: indications: trauma score <12, SBP <90, RR <10 / >35, HR <60 / >120, unresponsive to verbal stimuli
P – flexible landing (closer to hospital, reaches inaccessible areas), medium distances (50-200km or road time >1-2hrs – will halve
transit time in this circumstances), can reach isolated areas (eg. Mountainous); less turbulence than fixed wing; faster to
mobilise than fixed wing
C – more expensive, louder, more vibration, less space, mild complications of altitude, more weather dependent (eg poor
vis); slower to mobilise than road; slower speed than fixed wing; usually not pressurised; T control difficult; safety
considerations on approach; more dangerous to crew; relatively contraindicated in bronchopleural fistula, bowel
surgery <10/7, active GI bleeding, vascular anastomosis <14/7; communication only via headset
Fixed wing: P – cheaper, quieter, smoother, more space, long distances (>200km or road transport time >3hrs or helicopter flight
time >1hr); fastest speed; better T control than helicopter; <900km will be unpressurised at 3000m, >900km will be
pressurised up to 8000m
C – need landing strip, more complications of altitude, need ambo to transport from strip, slower to arrange; vibration
dependent on weather conditions; more dangerous to crew; relatively contraindicated in bronchopleural fistula,
bowel surgery <10/7, active GI bleeding, vascular anastomosis <14/7
Road: P – quicker to arrange; good <50km; less dangerous to crew; no complications of altitude; cheap
C – slower at longer distances, need road access
Stay and Play – procedures dangerous in pre-hospital environment; if long transfer time, stabilise pre-transport (esp do all procedures pretransfer if via air)
Load and Go – preferred if short transfer time; stabilise en route
Decision influenced by: probability of benefit vs harm from intervention, time to ED, skill level of operator, equipment available
Of Benefit: early defib (1min delay = 10% incr mortality)
needle decompression of pneumothorax
basic airway
nitrates / GTN / CPAP in LVF (improve recovery and mortality)
thrombolytics for MI with long transport time (decr time to thrombolysis by 30-45mins; 15-30% false positives, 5% false
negatives)
RSI if long transport time
Neonatal
transfer
ALS in SOB (decr mortality 2%, improve rate of recovery)
ECG pre-hospital (get ECG 30mins earlier, show dynamic changes; adds 5mins to scene time)
disposition prediction (80% sens, 90% spec)
early access to EMS, lay CPR, early ACLS care, airway management, prompt surgery in multi-trauma
? benefit: RSI in trauma (equivocal evidence from Brain Trauma Foundation in 2007; incr hypoxia, worse outcome but not necessarily
causal, decr other aspects of care)
lights and sirens
medical staff on helicopters (of more benefit is specific training)
No benefit: IVF in trauma (NICE guidelines: only give if no radial pulse in penetrating thorax trauma, then give 250ml boluses; give in
trauma if transport time >60mins and haemorrhage controlled; do not delay transportation to hospital)
IVA with scene delays (incr scene time by 3mins, incr infection)
C spine clearance
ALS in major trauma or GCS <9 (incr mortality and morbidity, OPALS Major Trauma Study)
pre-hospital cooling (no difference to in-hospital cooling)
Beware: hypoglycaemia - at birth, BSL 60-70% maternal level, but falls within 1-2hrs; always give dextrose containing fluids before and during
transport (10% dextrose 80ml/kg/day); check BSL Q15-30minly intially
hypothermia – provide neutral thermal environment; aim 36.5-37.5 PR; dry thoroughly to prevent evaporative heat loss, place on
prewarmed surface (conductive), increase room temp (convective), clothe (radiative)
hypoxemia – resp distress syndrome (ground glass on CXR, air bronchograms; use CPAP at 4-6cm; give surfactant through ETT)
persistent pul HTN of newborn (caused by meconium aspiration, hypothermia, sepsis; have labile oxygenation despite good
ventilation due to RL shunt of blood through PDA / PFO; diagnosed by >10% differences in sats between R hand and L
foot; treat with intubation, 100% O2, correction of acidosis, IVF and inotropes if needed, maintenance of normal Hct,
correction of metabolic abnormalities, NO INH)
cyanotic congenital heart disease (RL shunting suggestive if PaO2 <100mmHg of ABG despite 100% O2 given; reopen PDA with
PGE1 0.05mcg/kg/min titrating up to 0.1mcg/kg/min; give O2, supportive, ETT)
Hypotension – usually 2Y to hypoV, CCF, sepsis; BP will drop late, so look for other signs; 10ml/kg N saline bolus, PRBC if anaemic,
dobutamine 5mcg/kg/min if CCF
Infection - signs may be non-specific; give broad spectrum Abx (eg. Ampicillin + gentamicin); give if prem as infection may be cause of preterm
labour (?Grp B strep)
Notes from: Dunn, Cameron, TinTin, computer notes