Level 1 of 6Core
Transfer of the critically ill patient
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Transfer is an intervention with an indication, a therapeutic window, a side-effect profile and contraindications: if you cannot state in one sentence what the patient gains at the destination, the indication is not established. Decide time-critical (expanding extradural haematoma, aortic dissection, STEMI for primary intervention, torrential variceal haemorrhage, stroke inside the thrombectomy window, limb ischaemia — the clock is the treatment, correct only what will kill in the vehicle) versus stabilise-first (most renal replacement and poisoning referrals — all the risk lies on the road, full preparation mandatory).
- Danger signs — do not depart until corrected: airway not patent or protected, GCS ≤8, agitation needing restraint; SpO2 below 92% despite FiO2 ≥0.6, dependence on non-invasive ventilation, an undrained pneumothorax of any size, a briskly bubbling chest drain; systolic below 90 mmHg or MAP below 65 mmHg, a pressure held only by a titrated vasoactive infusion, or uncontrolled haemorrhage. A shock index above 0.9 suggests occult hypovolaemia; above 1.0 predicts need for transfusion.
- 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 (treat above 6.0 with any ECG change before movement), sodium below 120 mmol/L (predicts seizure), and a rhythm requiring cardioversion or pacing. Capillary glucose below 4 mmol/L in an adult, 3 mmol/L in a child, 2.6 mmol/L in a neonate; core temperature below 35°C or above 40°C.Not available at your setup — Arterial blood gas, Serum electrolytes.
- Grade oxygenation by the 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.
- The child compensates and then crashes: hypotension in a child is pre-terminal — 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 tachypnoeic child heralds arrest. The neonate presents with apnoea, bradycardia, poor perfusion, hypothermia and hypoglycaemia. The pregnant patient beyond 20 weeks: treat unexplained hypotension first with left lateral tilt of 15–30 degrees.
- 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 the current number, because by the time the criteria are met the journey may no longer be survivable. Record the level of care (0–3); it must never fall during transfer, and the trip to the CT scanner carries an adverse event rate comparable to interhospital transport.
Manage now— do this, in order
- The four rules: 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, inability to clear secretions, facial or airway burns, or a predicted trajectory towards these — intubation in a moving vehicle has a markedly higher failure rate, so decide liberally and early. RSI: ketamine 1–2 mg/kg IV (agent of choice in shock); propofol 1–2 mg/kg IV adult (0.5–1 mg/kg in shock or the elderly); fentanyl 1–3 micrograms/kg IV; rocuronium 1–1.2 mg/kg IV (lasts 45–70 minutes — relaxation lasts the journey); never suxamethonium in hyperkalaemia, burns over 24 hours old, denervation or crush injury.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 tube: uncuffed internal diameter (mm) = age/4 + 4 (cuffed = age/4 + 3.5), oral length (cm) = age/2 + 12, newborn oral length (cm) ≈ weight in kg + 6. Decompress the stomach and send tested portable suction with every patient with reduced conscious level, vomiting or airway bleeding.Doctor / Nurse
- Calculate the oxygen on paper: cylinder contents (litres) ≈ gauge pressure (bar) x water capacity (litres); requirement (litres) = flow rate (L/min) x journey time (min) x 2 — a hand-ventilated adult at 15 L/min for a realistic 90 minutes needs 2,700 litres. Achieve the target saturation (94–98%, or 88–92% at risk of hypercapnic failure) before departure on the device that will actually be used; NIV is generally not deliverable in transport — wean, intubate, or do not travel yet. Drain any pneumothorax before departure (mandatory before air transfer), never clamp a chest drain, and carry a self-inflating bag-valve-mask with reservoir — it needs neither oxygen nor electricity.Not available at your setup — Chest drain / tube thoracostomy.
- 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 where cardiac dysfunction, severe malnutrition or DKA is suspected). Control haemorrhage before travel — direct pressure, splintage, reversal of anticoagulation, 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. Never transport a titrated vasopressor on a gravity-driven infusion.Doctor / NurseNot available at your setup — Infusion pump, Central venous access. 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 BP recorded every 5 minutes is a compromise and never a safe technique.
- Check capillary glucose immediately before departure and record it with the time — never accept a value from an hour before. 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; never give 50% glucose to a child. Draw up seizure drugs within arm's reach: lorazepam 4 mg IV in adults (0.1 mg/kg, maximum 4 mg, in children) or midazolam 10 mg buccal (0.3 mg/kg, maximum 10 mg, in children); second-line levetiracetam 60 mg/kg IV (maximum 4.5 g) or phenytoin 20 mg/kg IV at no more than 50 mg/min (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 — one documented systolic below 90 mmHg approximately doubles mortality in traumatic brain injury — 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.
- If anything goes wrong in transit, STOP THE VEHICLE first — assessment, auscultation, cannulation, intubation and chest compressions all fail at speed. 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; for cardiac arrest get the patient flat on a firm surface — adrenaline 1 mg IV in the adult, 0.01 mg/kg (0.1 mL/kg of 1:10,000) in the child. Compressions on a moving trolley do not perfuse.Doctor / Nurse
| RSI drug | Adult | Paediatric | Note |
|---|---|---|---|
| Ketamine | 1–2 mg/kg IV | 1–2 mg/kg IV | Choice in shock |
| Propofol | 1–2 mg/kg IV (0.5–1 in shock/elderly) | 2–3 mg/kg IV | Avoid if unstable |
| Fentanyl | 1–3 micrograms/kg IV | 1–2 micrograms/kg IV | Omit or halve in shock |
| Rocuronium | 1–1.2 mg/kg IV | 1 mg/kg IV | Onset 45–60 s, lasts 45–70 min |
| Suxamethonium | 1–1.5 mg/kg IV | 2 mg/kg IV (infants) | Never in hyperkalaemia, burns >24 h, denervation, crush |
| Pre-departure correction | Regimen |
|---|---|
| Hyperkalaemia | Calcium gluconate 10% 10–30 mL IV over 5–10 min (paediatric 0.5 mL/kg, max 20 mL); 10 units soluble insulin in 25 g glucose IV over 15–30 min; nebulised salbutamol 10–20 mg; recheck K and glucose before departure |
| Aortic dissection | Labetalol 5–10 mg IV boluses then 2–8 mg/min, or esmolol 0.5 mg/kg then 50–200 micrograms/kg/min — target HR <60/min, systolic 100–120 mmHg |
Refer / escalate
Refer early and on trajectory rather than the current number — consider transplantation, thrombectomy, neurosurgery, dialysis or intervention before 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), weighing the one-to-several-hour delay of retrieval against the harm of an under-equipped journey.
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