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Level 2 of 6Must-remember

Transfer of the critically ill patient

Assess, manage and stay safe — enough on its own

The card — assess, manage, caution

Assessment— look, ask, measure

  • State the indication in one sentence: transfer is an intervention with an indication, a therapeutic window, a side-effect profile and contraindications — if you cannot say what the patient gains at the destination, the indication is not established.
  • Classify the transfer: primary (scene to first hospital), secondary or interhospital (upward for a specialist intervention or higher level of care, lateral for capacity, downward for repatriation), intrahospital (to radiology, theatre or an interventional suite — the most underestimated, with identical physiological risk), or retrieval (a specialist team comes to the patient).
  • Decide time-critical versus stabilise-first: in the time-critical transfer (expanding extradural haematoma, aortic dissection, ST-elevation infarction for primary intervention, torrential variceal haemorrhage, stroke inside the thrombectomy window, limb ischaemia) the clock is the treatment and only the abnormalities that will kill the patient in the vehicle are corrected; in the stabilise-first transfer (most renal replacement and poisoning referrals, endoscopy once bleeding has settled) all the risk lies on the road and full preparation is mandatory.
  • Airway: danger signs are an airway not patent, not protected, or maintained only by positioning or continuous suctioning; GCS ≤8; and agitation requiring restraint.
  • Breathing: SpO2 below 92% despite FiO2 ≥0.6, dependence on non-invasive ventilation or a high-flow device the transport environment cannot reproduce, an undrained pneumothorax of any size, or a briskly bubbling chest drain.
  • Circulation: systolic blood pressure below 90 mmHg or mean arterial pressure below 65 mmHg, a pressure maintained only by a titrated vasoactive infusion, or uncontrolled haemorrhage; shock index (rate divided by systolic pressure) above 0.9 suggests occult hypovolaemia and above 1.0 predicts need for transfusion.
  • Bedside glucose and temperature: capillary glucose below 4 mmol/L in an adult, below 3 mmol/L in a child, below 2.6 mmol/L in a neonate; core temperature below 35°C or above 40°C — repeat the glucose within minutes of departure and never accept a value from an hour before.
  • Neurology: ongoing or recurrent seizures, new focal deficit, pupillary asymmetry, posturing; GCS ≤8 indicates inability to protect the airway and a fall of ≥2 points is significant regardless of the absolute value.
  • Blood results that forbid departure until corrected: arterial pH below 7.2, base deficit above 6 mmol/L, lactate above 4 mmol/L, potassium above 6.5 mmol/L (or any potassium with ECG change — treat above 6.0 mmol/L before movement), sodium below 120 mmol/L which predicts seizure, and a rhythm requiring cardioversion or pacing.Not available at your setup — Arterial blood gas. electrolytes
  • Oxygenation grading: PaO2/FiO2 ratio below 40 kPa (300 mmHg) mild, below 27 kPa (200 mmHg) moderate, below 13.3 kPa (100 mmHg) severe — below 200 mmHg transport equipment will often fail to maintain oxygenation.Not available at your setup — Arterial blood gas.
  • Early warning scores: NEWS2 aggregate 5 or more, or any single parameter scoring 3, denotes risk of deterioration and ≥7 high risk; qSOFA ≥2 of 3 (respiratory rate ≥22/min, systolic ≤100 mmHg, altered mentation) marks infection at risk of poor outcome.
  • The child compensates and then crashes: hypotension in a child is a pre-terminal sign, so watch respiratory rate, work of breathing, capillary refill and alertness — a previously distressed child who becomes quiet is exhausted, not settled, and a falling respiratory rate in a child who was tachypnoeic heralds arrest.
  • The neonate presents with apnoea, bradycardia, poor perfusion, hypothermia and hypoglycaemia rather than localising signs; the TRIPS score (temperature, respiratory status, systolic BP, response to noxious stimuli, scored before and after transport) predicts 7-day mortality and intraventricular haemorrhage.
  • Other physiologies that change the assessment: the elderly deteriorate with blunted tachycardia and present with delirium rather than dyspnoea, at high risk of pressure injury and hypothermia; the pregnant patient beyond 20 weeks develops aortocaval compression when supine, so unexplained hypotension is treated first by left lateral tilt of 15-30 degrees; the patient with chronic obstructive pulmonary disease may deteriorate from uncontrolled oxygen rather than too little, with drowsiness and a flapping tremor.
  • Record the level of care (0-3): 0 ward, 1 ward with critical care advice, 2 single-organ support, 3 advanced respiratory support or two or more organs supported — this defines the monitoring and escort standard, and the level of care must never fall during transfer.
  • Ask the governing question: not is this patient stable now, but will this patient still be adequately supported at the worst moment of the journey, with only the equipment being carried — and refer on trajectory rather than on the current number, because by the time the criteria are met the journey may no longer be survivable.

Management— do this, in order

  • Stabilise before you move, and move before you are forced to — deterioration in transit is usually deterioration present and unaddressed at departure; prepare for the worst moment of the journey, carry two of anything whose failure would be critical (cannulae, cylinders, people, tubes, batteries), and do not let the level of care fall during the journey.
  • Secure the airway BEFORE departure in any patient with GCS ≤8, a deteriorating conscious level, an inability to clear secretions, facial or airway burns, or a predicted trajectory towards any of these — intubation at the roadside or in a moving vehicle has a markedly higher failure and complication rate, so decide liberally and early.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • Rapid sequence induction doses: ketamine 1-2 mg/kg IV adult and paediatric (agent of choice in shock); propofol 1-2 mg/kg IV adult (0.5-1 mg/kg in shock or the elderly), 2-3 mg/kg IV paediatric; fentanyl 1-3 micrograms/kg IV adult, 1-2 micrograms/kg IV paediatric; rocuronium 1-1.2 mg/kg IV adult, 1 mg/kg IV paediatric (onset 45-60 s, duration 45-70 min); suxamethonium 1-1.5 mg/kg IV adult, 2 mg/kg IV in infants.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • After intubation: record the tube length at the lips, secure with ties rather than tape alone, confirm by bilateral chest movement, auscultation and a sustained capnograph waveform, and re-confirm after every change of surface or position; paediatric uncuffed internal diameter (mm) = age/4 + 4 (cuffed = age/4 + 3.5), oral length (cm) = age/2 + 12, and in the newborn oral length (cm) is approximately weight in kg + 6.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • Decompress the stomach in the intubated, obstructed, vomiting or obtunded patient, and send tested portable suction with every patient who has a reduced conscious level, vomiting or airway bleeding.
  • Achieve the target saturation before departure on the device that will actually be used in transit: 94-98% for most patients, 88-92% for those at risk of hypercapnic respiratory failure; non-invasive ventilation is generally not deliverable in transport, so a patient whose oxygenation depends on it is weaned beforehand, intubated, or not transferred yet.
  • Drain any pneumothorax before departure and mandatorily before air transfer; a chest drain is never clamped, and the seal stays upright, below the level of the chest and secured to the trolley.Doctor / NurseNot available at your setup — Chest drain / tube thoracostomy.
  • Calculate the oxygen on paper: cylinder contents (litres) is approximately gauge pressure (bar) x water capacity (litres), and requirement (litres) = flow rate (L/min) x journey time (min) x 2 — so a hand-ventilated adult at 15 L/min on a journey realistically taking 90 minutes needs 15 x 90 x 2 = 2,700 litres; add driving-gas consumption for a pneumatically driven ventilator, verify the gauges personally, and carry a self-inflating bag-valve-mask with reservoir, which needs neither oxygen nor electricity.
  • Two functioning large-bore cannulae, flushed and secured with transparent dressings so the site stays visible, are the minimum; correct hypovolaemia before movement with balanced crystalloid 250-500 mL boluses in adults and 10 mL/kg boluses reassessed after each in children (10 mL/kg rather than 20 mL/kg where cardiac dysfunction, severe malnutrition or diabetic ketoacidosis is suspected).Doctor / Nurse
  • Control haemorrhage before travel with direct pressure, splintage, reversal of anticoagulation, correction of coagulopathy and tranexamic acid where indicated — adult 1 g IV over 10 minutes then 1 g over 8 hours; paediatric 15 mg/kg (maximum 1 g) then 2 mg/kg/h — and transfuse to a safe margin before departure rather than relying on the destination.Doctor / NurseNot available at your setup — Blood & blood products.
  • Vasoactive drugs go by syringe pump through a dedicated line, ideally central, with invasive arterial monitoring: noradrenaline 0.05-0.5 micrograms/kg/min, adrenaline 0.05-0.5 micrograms/kg/min, dobutamine 2.5-10 micrograms/kg/min; keep diluted, labelled bolus vasopressors within reach — metaraminol 0.5-1 mg IV, ephedrine 3-6 mg IV, or phenylephrine 50-100 micrograms IV.Doctor / NurseNot available at your setup — Infusion pump.
  • Without a pump the honest options are retrieval by a team that has one, delay until the vasopressor can be weaned, or definitive treatment where the patient lies — a burette giving set (60 drops/mL) with one person assigned solely to the infusion and blood pressure recorded every 5 minutes is a compromise and never a safe technique.Doctor / Nurse
  • Check capillary glucose immediately before departure and record it with the time: treat hypoglycaemia with 10% glucose 100-200 mL IV in adults (or 20% glucose 75-100 mL) and 10% glucose 2 mL/kg IV in children and neonates, rechecking after 10-15 minutes.Doctor / Nurse
  • Draw up seizure drugs and keep them within arm's reach: lorazepam 4 mg IV in adults (0.1 mg/kg, maximum 4 mg, in children), or midazolam 10 mg buccal in adults (0.3 mg/kg buccal or intranasal, maximum 10 mg, in children) where there is no access; second-line levetiracetam 60 mg/kg IV (maximum 4.5 g) or phenytoin 20 mg/kg IV at no more than 50 mg/min in adults and 1 mg/kg/min in children.Doctor / Nurse
  • For raised intracranial pressure: nurse head-up at 30 degrees if blood pressure allows, keep the neck straight with loose tube ties, maintain normocapnia (end-tidal CO2 4.0-4.5 kPa verified against an arterial gas), avoid any episode of hypoxaemia or hypotension, and carry osmotherapy for pupillary change — mannitol 20% 0.25-1 g/kg IV over 15 minutes, or hypertonic saline 2.7-3% 2-5 mL/kg IV.Doctor / NurseNot available at your setup — Arterial blood gas.
  • For hyperkalaemia before movement: calcium gluconate 10% 10-30 mL IV over 5-10 minutes (paediatric 0.5 mL/kg, maximum 20 mL), then 10 units of soluble insulin in 25 g glucose IV over 15-30 minutes and nebulised salbutamol 10-20 mg, and recheck potassium and glucose before departure; for aortic dissection control rate and pressure first with labetalol 5-10 mg IV boluses then 2-8 mg/min, or esmolol 0.5 mg/kg then 50-200 micrograms/kg/min, targeting heart rate below 60/min and systolic pressure 100-120 mmHg.Doctor / NurseNot available at your setup — Serum electrolytes.
  • Treat pain, nausea and agitation before departure — morphine 2-5 mg IV titrated in adults (0.1 mg/kg in children), ondansetron 4 mg IV (0.1 mg/kg, maximum 4 mg), or cyclizine 50 mg IV — and maintain sedation for the intubated patient by infusion (propofol 1-4 mg/kg/h, midazolam 0.02-0.2 mg/kg/h, fentanyl 0.5-3 micrograms/kg/h) with intermittent rocuronium 0.15 mg/kg to prevent coughing and dyssynchrony.Doctor / NurseNot available at your setup — Infusion pump.
  • If anything goes wrong in transit, STOP THE VEHICLE first — assessment, auscultation, cannulation, intubation and chest compressions all fail at speed — then hand-ventilate with a self-inflating bag and work through DOPES, switch to the second cylinder for oxygen exhaustion, flatten the trolley and give fluid plus a bolus vasopressor for hypotension, use the second cannula or intraosseous access if access is lost, and for cardiac arrest get the patient flat on a firm surface with adrenaline 1 mg IV in the adult or 0.01 mg/kg (0.1 mL/kg of 1:10,000) in the child.Doctor / Nurse

Caution— what harms

  • Never move a patient whose airway is not secured when it should be: loss of the airway in a patient moved without it secured is the single most lethal transfer event and the classic preventable death.
  • Never transport a patient dependent on a titrated vasopressor on a gravity-driven infusion: a bump raises driving pressure and delivers a bolus, a kink delivers nothing, and with a drug of one to two minutes half-life and a steep dose-response curve the result is alternating hypertensive surges and profound hypotension.Not available at your setup — Infusion pump.
  • Never clamp a chest drain, and never travel with an undrained pneumothorax — it must be drained before departure and mandatorily before air transfer, because at a cabin altitude of 8,000 feet (about 565 mmHg) trapped gas expands by roughly one third.Not available at your setup — Chest drain / tube thoracostomy.
  • Never rely on non-invasive ventilation in transit — it is generally not deliverable, so wean, intubate, or do not travel yet.
  • Never accept a glucose value from an hour before, particularly after insulin-dextrose, in the sedated patient in whom hypoglycaemia is silent, and in every child; and check capillary glucose in every neurological change before attributing anything to the primary disease.
  • Never give 50% glucose to a child — it is hyperosmolar and sclerosant; use 10% glucose 2 mL/kg IV.Doctor / Nurse
  • Never do arithmetic in a moving vehicle: establish and record the weight first (recent parental report, length-based resuscitation tape, or weight in kg is approximately (age in years + 4) x 2 for children aged 1-10 years) and write every dose in both milligrams and millilitres in advance.
  • Never treat the monitor: palpate a central pulse — oximetry is unreliable in motion, vasoconstriction, hypothermia and carbon monoxide poisoning (where it reads falsely normal), oscillometry fails in a moving vehicle, and an implausible reading in a patient who looks well is artefact.
  • Never assume a normal blood pressure in a child means a well child: hypotension in a child is pre-terminal, and bradycardia, apnoea, hypothermia and hypoglycaemia are how the neonate presents.
  • Never give suxamethonium in hyperkalaemia, burns more than 24 hours old, denervation or crush injury, and avoid propofol in the unstable patient because of vasodilatation and myocardial depression (halve it, 0.5-1 mg/kg, in shock or the elderly); remember rocuronium 1-1.2 mg/kg lasts 45-70 minutes, so relaxation lasts the journey.Doctor / Nurse
  • Never let a single episode of hypotension pass unnoticed in brain injury: in the traumatic brain injury literature one documented episode of systolic blood pressure below 90 mmHg approximately doubles mortality, because autoregulation is impaired and cerebral perfusion is pressure-passive.
  • Never transfer purely for capacity without recognising what you are doing: transfer because no bed exists locally carries all the risk and none of the therapeutic benefit, and is the least defensible category — as is the transfer made because the clinician was anxious rather than because a capability was absent.
  • Never let lights and sirens substitute for preparation: they shorten journeys only marginally while increasing acceleration forces and collision risk.
  • Never under-prepare the intrahospital journey: the trip to the CT scanner carries an adverse event rate comparable to interhospital transport despite the far shorter distance, because preparation is typically less rigorous.

Refer / escalate

Refer early and on trajectory rather than on the current number — consider transplantation, thrombectomy, neurosurgery, dialysis or intervention before the poor-prognosis criteria are met — and request a specialist retrieval team for the most unstable patients (particularly the vasopressor-dependent patient with no syringe pump, the marginal airway, and every neonate), accepting that retrieval typically delays departure by one to several hours and weighing that delay against the harm of an under-equipped journey.

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