2.6 Resuscitation, Trauma and Crisis Management
Last updated
Last updated
Diagnostic Approach
Initial assessment: Confirm hypoxia (SpO₂ < 90%) and evaluate airway patency.
Differential diagnosis:
Airway obstruction, atelectasis, bronchospasm, pneumothorax, aspiration, or hypoventilation.
Equipment issues: Misplaced ETT, circuit disconnection, or oxygen delivery failure.
Investigations: ABG (PaO₂), chest X-ray, bronchoscopy (if necessary).
Resuscitative Management
Immediate actions:
100% oxygen and optimize ventilation.
Verify airway patency (suction, reposition, or reintubate if needed).
Treat underlying cause:
Bronchodilators for bronchospasm.
Chest drain for pneumothorax.
Suction for secretions or aspiration.
Increase FiO₂ and PEEP for atelectasis.
Diagnostic Approach
Initial assessment: Identify low ETCO₂ (< 35 mmHg).
Differential diagnosis:
Hyperventilation (manual or mechanical), low cardiac output, pulmonary embolism, or air embolism.
Investigations: ABG (PaCO₂), assess ventilatory settings, and rule out hemodynamic instability.
Resuscitative Management
Address ventilation: Reduce tidal volume or respiratory rate.
Treat underlying cause:
Volume resuscitation for low cardiac output.
Address pulmonary embolism with anticoagulation or thrombolysis.
Manage air embolism with left lateral decubitus and Trendelenburg positions.
Diagnostic Approach
Initial assessment: Identify high ETCO₂ (> 45 mmHg).
Differential diagnosis:
Hypoventilation, high metabolic rate (e.g., sepsis, malignant hyperthermia), or equipment failure.
Investigations: ABG (PaCO₂), inspect ventilator circuit and tubing.
Resuscitative Management
Increase minute ventilation: Increase respiratory rate or tidal volume.
Treat underlying cause:
Address circuit obstruction.
Administer dantrolene for malignant hyperthermia.
Diagnostic Approach
Initial assessment: Identify rate and rhythm on ECG.
Differential diagnosis:
Pain, anxiety, hypovolemia, anemia, hyperthermia, sepsis, or arrhythmias.
Investigations: ECG, ABG, electrolytes, hemoglobin, and temperature.
Resuscitative Management
Treat underlying cause:
Fluid bolus for hypovolemia.
Analgesics for pain, anxiolytics for anxiety.
Electrolyte correction for abnormalities.
Manage arrhythmias:
SVT: Vagal maneuvers, adenosine.
VT: Amiodarone or synchronized cardioversion.
Diagnostic Approach
Initial assessment: Confirm rate and rhythm on ECG (< 60 bpm).
Differential diagnosis:
Vagal stimulation, beta-blocker use, electrolyte imbalance, or high spinal block.
Investigations: ECG, ABG, and serum electrolytes.
Resuscitative Management
Atropine: 0.5 mg IV (repeat up to 3 mg).
Escalation: Epinephrine infusion or temporary pacing for refractory cases.
Treat underlying cause: Reversal of vagal stimulation or electrolyte correction.
Diagnostic Approach
Initial assessment: Confirm MAP < 65 mmHg or significant drop from baseline.
Differential diagnosis:
Hypovolemia, sepsis, anaphylaxis, or cardiogenic shock.
Investigations: ABG, electrolytes, and echocardiography.
Resuscitative Management
Fluids: Crystalloid boluses to restore intravascular volume.
Vasopressors: Phenylephrine, ephedrine, or norepinephrine as needed.
Treat underlying cause: Antibiotics for sepsis, epinephrine for anaphylaxis.
Diagnostic Approach
Initial assessment: Confirm BP > 140/90 mmHg or significant rise from baseline.
Differential diagnosis:
Pain, anxiety, hypervolemia, or pheochromocytoma.
Investigations: ECG, ABG, and assess analgesia/anesthesia depth.
Resuscitative Management
Optimize anesthesia depth: Increase volatile agent or administer opioids.
Short-acting antihypertensives: Esmolol, labetalol, or nitroglycerin.
Diagnostic Approach
Initial assessment: Confirm elevated peak inspiratory pressure (> 30 cmH₂O).
Differential diagnosis:
Obstruction (e.g., ETT kinking, secretions), bronchospasm, reduced compliance (e.g., pneumothorax, ARDS).
Investigations: Inspect ventilator settings, auscultate lungs, consider chest X-ray.
Resuscitative Management
Treat obstruction: Suction secretions, reposition ETT, or remove obstruction.
Bronchodilators: For bronchospasm.
Reduce tidal volume: Optimize ventilation for reduced compliance.
Chest drain: For tension pneumothorax.
Presenting Features
Early Symptoms:
Neurological: Circumoral numbness, metallic taste, tinnitus, dizziness, agitation.
Cardiovascular: Hypertension and tachycardia.
Progression:
Severe neurological: Seizures, altered consciousness, coma.
Cardiovascular collapse: Bradycardia, hypotension, arrhythmias, asystole.
Diagnosis
Clinical diagnosis based on timing of symptoms following local anesthetic administration.
Correlate dose and site of administration with known toxic thresholds.
Short-Term Management
Stop Local Anesthetic Administration Immediately.
Airway and Breathing: Secure airway, provide 100% oxygen, and manage seizures with benzodiazepines (e.g., midazolam).
Circulation:
Initiate lipid emulsion therapy (e.g., Intralipid 20%): 1.5 mL/kg bolus followed by infusion (0.25–0.5 mL/kg/min).
Manage arrhythmias with amiodarone (avoid lignocaine and vasopressin).
Advanced Cardiac Life Support (ACLS) if cardiac arrest occurs.
Airway Management
Prioritize securing the airway early
Consider early intubation if there are signs of respiratory compromise or altered mental status
Seizure Management
Administer benzodiazepines (e.g., midazolam) as first-line treatment
Avoid propofol in patients with cardiovascular instability
Cardiovascular Support Modifications
Avoid high doses of epinephrine (use smaller doses: <1 mcg/kg)
Consider vasopressin as an alternative vasopressor
Be prepared for prolonged resuscitation efforts
Avoid calcium channel blockers and beta-blockers
Lipid Emulsion Therapy (a critical addition to standard ALS)
Initial bolus: 1.5 mL/kg of 20% lipid emulsion over 1 minute
Followed by infusion: 0.25 mL/kg/min for at least 10 minutes after hemodynamic stability
Can repeat bolus 1-2 times for persistent cardiovascular collapse
Maximum recommended dose: approximately 10-12 mL/kg
CPR Modifications
Consider extended CPR duration (LAST-related cardiac arrest may require prolonged resuscitation)
More frequent rotation of chest compressors to maintain high-quality CPR
Post-Resuscitation Care
Extended monitoring period (at least 12-24 hours)
Watch for recurrence of toxicity
Referral Management
Transfer to intensive care for monitoring and management of ongoing complications.
Neurological or cardiac follow-up if prolonged toxicity or arrest occurred.
Presenting Features
Early signs: Rapidly increasing end-tidal CO₂, tachycardia, and muscle rigidity (especially masseter).
Later signs: Hyperthermia, acidosis, hyperkalemia, rhabdomyolysis, and cardiac arrhythmias.
Diagnosis
Clinical diagnosis based on presentation and triggering agents (e.g., volatile anesthetics, suxamethonium).
Confirm with creatine kinase levels, hyperkalemia, metabolic acidosis.
Definitive testing: Caffeine-halothane contracture test (post-crisis).
Short-Term Management
Discontinue Triggering Agents Immediately.
Administer Dantrolene: 2.5 mg/kg IV bolus, repeat as necessary (up to 10 mg/kg).
Cooling Measures: Active cooling with ice packs, cold IV fluids, or cooling blankets.
Supportive Care:
Treat acidosis with bicarbonate.
Correct hyperkalemia (e.g., calcium gluconate, insulin-dextrose infusion).
Manage arrhythmias (avoid calcium channel blockers).
Referral Management
Transfer to ICU for ongoing monitoring and supportive care.
Genetic counseling and referral for family screening.
Presenting Features
Acute Onset: Hypotension, bronchospasm, urticaria, angioedema, facial swelling, gastrointestinal symptoms.
Severe cases: Cardiovascular collapse, airway obstruction.
Diagnosis
Clinical diagnosis based on rapid onset and characteristic symptoms.
Confirm with serum tryptase levels (within 1–6 hours of reaction).
Short-Term Management
Adrenaline (Epinephrine):
IM: 0.5 mg (repeat every 5 minutes as needed).
IV for refractory cases (titrated doses).
Airway and Breathing: Ensure airway patency and administer 100% oxygen.
Circulation: IV fluids (crystalloid or colloid) to support perfusion.
Adjunctive Medications:
Antihistamines: Chlorphenamine IV.
Corticosteroids: Hydrocortisone IV.
Bronchodilators for bronchospasm (e.g., salbutamol nebulizer).
Referral Management
Admission to ICU for observation (minimum 4–6 hours).
Referral to an allergist for identification of the causative agent and long-term management.
Presenting Features
Prolonged muscle paralysis and inability to breathe following suxamethonium administration.
Delayed recovery of spontaneous ventilation post-procedure.
Diagnosis
Clinical diagnosis based on delayed neuromuscular recovery.
Confirm with dibucaine number test for pseudocholinesterase activity.
Short-Term Management
Support Ventilation:
Mechanical ventilation until spontaneous recovery.
Airway Protection: Ensure secure airway with intubation if required.
Monitor Neuromuscular Function: Use nerve stimulator to assess recovery.
Referral Management
Genetic counseling for inherited pseudocholinesterase deficiency.
Inform future care providers to avoid suxamethonium.
MILS physically restricts cervical extension and neck flexion, worsening laryngoscopy grade by approximately 1 level and reducing mouth opening by ~10mm. This makes direct laryngoscopy more challenging.
MILS fundamentally alters intubation dynamics:
Increased lifting force needed for laryngoscopy
Higher risk of dental damage due to altered force vectors
Increased difficulty in supraglottic device placement
Approximately 20% reduction in first-pass success rates
30% increase in time to successful intubation
Evidence shows paradoxical effects on cervical spine movement:
Reduces gross neck movement
Increased subaxial movement (especially C3-C5) due to greater force required
Potential for increased pressure transmission to unstable segments
Net movement may exceed that seen with careful unrestrained laryngoscopy
Technical considerations for laryngoscopy under MILS:
Video laryngoscopes with hyperangulated blades provide superior views
However, tube delivery more challenging due to acute angle
Bougie use more difficult due to restricted manipulation space
Standard Macintosh technique requires significant modification
MILS technique variations affect airway management:
Bimanual technique (thumbs on mastoids, fingers on vertebrae) most stable
Single-handed technique allows more space but less control
Assistant position critical - ideally at head of bed
Communication essential between airway operator and assistant
Impact on airway strategy:
Lower threshold for awake techniques
Need for extended pre-oxygenation due to longer intubation times
Rescue techniques more challenging
Front-of-neck access may be complicated by assistant's hands
Consider releasing MILS in can't intubate, can't oxygenate scenario
Team considerations:
Assistant fatigue during prolonged attempts can compromise stabilization
Clear communication needed regarding timing of laryngoscopy
Explicit plan for MILS release if emergency airway needed
Second assistant often required for optimal equipment handling
* Core physiological targets for preventing secondary brain injury:
Cerebral Perfusion Pressure (CPP) >60mmHg (CPP = MAP - ICP)
ICP <20-25mmHg
PaO2 >13kPa (100mmHg)
PaCO2 4.5-5.0kPa (tight control)
SaO2 >97%
Systolic BP >90mmHg (unless contraindicated)
Temperature 36-37°C
Blood glucose 4-10 mmol/L
Sodium 140-145 mmol/L
ICP management principles:
First-tier interventions: head up 30°, neck in neutral position, adequate sedation, osmotherapy (mannitol/hypertonic saline), CSF drainage if available
Second-tier interventions: hyperventilation (temporary), barbiturate coma, decompressive craniectomy
Avoid: neck vein compression, prolonged Valsalva, unnecessary stimulation
Monitor: pupillary responses, GCS, focal deficits, vital signs
Airway management considerations:
Early intubation for GCS ≤8 or deteriorating GCS
RSI with full preparation and skilled operator
Maintain MAP during induction (ready vasopressors)
Avoid succinylcholine if >48hrs post-injury (↑K+ risk)
Opioid pretreatment to blunt response to laryngoscopy
Ensure ETCO2 35-40mmHg immediately post-intubation
Avoid nasal intubation with base of skull fractures
Ventilation strategy:
Volume-controlled ventilation preferred
PEEP 5-10cmH2O (balance recruitment vs ICP effect)
Target PaO2 >13kPa without excessive FiO2
Avoid routine hyperventilation
Consider permissive hypercapnia if concurrent chest injury
Sedation and paralysis:
Adequate sedation essential (propofol/midazolam)
Regular sedation holds for neurological assessment if stable
Paralysis if required for ICP/ventilator synchrony
Consider EEG monitoring during deep sedation
Systemic management:
Careful fluid balance (avoid hypo/hypervolemia)
Isotonic crystalloids (avoid glucose-containing fluids)
Maintain euglycemia
Active temperature management
DVT prophylaxis (mechanical initially)
Early enteral nutrition if possible
Monitoring and investigations:
Arterial line essential
Consider ICP monitoring for GCS ≤8
Regular blood gases, electrolytes, glucose
Repeat CT scanning for deterioration
Regular pupillary assessment
Consider jugular bulb oximetry
Specific considerations for non-trauma intracranial events:
SAH: nimodipine, strict BP control
Stroke: BP targets depend on intervention plan
Tumour: consider steroid requirement
Status epilepticus: aggressive anticonvulsant strategy"
Classification Framework and Initial Approach:
Shock defined as inadequate tissue perfusion/oxygenation
All types share end pathway of cellular dysfunction
Initial assessment: Airway, Breathing, Circulation
Early monitoring: arterial line, continuous ECG, regular blood gases
Basic investigations: FBC, coagulation, lactate, troponin, chest X-ray
Consider point-of-care ultrasound/echo early
Assessment of response to initial fluid challenge guides management
Hypovolaemic Shock:
Causes: hemorrhage, GI losses, burns, dehydration
Features: tachycardia, hypotension, poor peripheral perfusion, reduced urine output
Management priorities:
Stop ongoing losses (surgery, hemostasis) Replace volume (blood products in hemorrhage, crystalloid in dehydration) Massive transfusion protocol activation if needed Target Hb >80 g/L, platelets >50, normal coagulation Consider TXA in trauma (within 3 hours) Avoid over-resuscitation once hemorrhage controlled
Distributive Shock:
Causes: sepsis (commonest), anaphylaxis, neurogenic, endocrine
Features: usually warm peripheries, increased CO, low SVR
Septic Shock Management:
Early broad-spectrum antibiotics (<1 hour) Source control Initial fluid resuscitation (30ml/kg) Early noradrenaline via central access Consider vasopressin as second-line Steroids if refractory to vasopressors Regular reassessment of fluid status
Anaphylactic Shock:
IM adrenaline immediate priority Remove trigger if obvious Large volume fluid resuscitation Consider IV adrenaline infusion if refractory
Neurogenic Shock:
Maintain MAP with fluids and vasopressors Consider bradycardia management Avoid over-hydration
Cardiogenic Shock:
Causes: MI, end-stage heart failure, myocarditis, arrhythmia
Features: pulmonary edema, raised JVP, cool peripheries
Initial Assessment:
12-lead ECG Urgent echo Serial troponins BNP if diagnosis unclear
Management Strategy:
Treat underlying cause (PCI for MI) Careful fluid assessment Consider inotropes (dobutamine first-line) Early mechanical circulatory support assessment Manage arrhythmias Consider pulmonary artery catheter Early specialist referral
Obstructive Shock:
Causes: tension pneumothorax, cardiac tamponade, massive PE
Features: specific to cause but include raised CVP
Tension Pneumothorax:
Immediate needle decompression Formal chest drain Positive pressure ventilation with caution
Cardiac Tamponade:
Urgent pericardiocentesis Surgery if traumatic Careful fluid resuscitation
Massive PE:
Consider thrombolysis Surgical embolectomy in select cases Anticoagulation timing important IVC filter if contraindication to anticoagulation
Monitoring Response to Treatment:
Clinical markers:
Mental status Urine output Peripheral perfusion Blood pressure response
Laboratory markers:
Lactate clearance Base deficit ScvO2 if central access
Advanced monitoring:
Cardiac output monitoring Mixed venous saturation Central venous pressure trends Dynamic indices of fluid responsiveness
Special Considerations:
Mixed shock states common:
Sepsis with myocardial depression Trauma with neurogenic component Cardiogenic shock with secondary distributive features
Mechanical ventilation effects:
Positive pressure affects venous return May unmask hypovolaemia Careful PEEP titration needed
Timing of interventions:
Some require immediate action (tension pneumothorax) Others need careful planning (mechanical support)
End-organ protection:
Renal replacement timing Brain protection strategies Ventilation strategies Stress ulcer prophylaxis
Team Approach:
Early specialist consultation
Clear communication of treatment goals
Regular team reassessment
Documentation of response to interventions
Consider early ICU involvement
Clear escalation pathway
End-of-life discussions if appropriate
Initial Assessment and Preparation:
Evaluate patient status and urgency level
Early activation of massive transfusion protocol if needed
Position patient optimally (supine, trendelenburg if tolerated)
Prepare resuscitation fluids/blood products
Gather all necessary equipment before starting
Consider ultrasound availability immediately
Ensure adequate lighting and assistance
Peripheral IV Access - First Priority:
Two large-bore (14-16G) cannulae initially
Optimal sites: antecubital fossa, forearm vessels
Use tourniquet despite poor veins
Maximum 2 attempts per practitioner
Consider forearm cutdown if experienced
IO access if peripheral attempts fail after 2-3 minutes
Intraosseous (IO) Access:
Sites: proximal tibia (first choice), proximal humerus, distal tibia
Can deliver all resuscitation fluids/medications
Flow rates up to 100ml/min with pressure
Complications: compartment syndrome, osteomyelitis
Maximum 24-48 hour placement
Consider early replacement with definitive access
Central Venous Access:
Femoral approach preferred in shock (landmarks preserved)
Internal jugular if femoral contraindicated/failed
Subclavian last resort in coagulopathy
Always use ultrasound guidance if available
Large bore (at least 8.5Fr) triple lumen
Consider MAC line or rapid infusion catheter
Strict aseptic technique despite urgency
Ultrasound Technique Optimisation:
Use high-frequency linear probe
Ensure adequate gel and pressure
Visualise vessel in both short and long axis
Confirm venous vs arterial with compression
Dynamic needle tip visualization
Consider out-of-plane approach in emergency
Adjunctive Measures:
Consider local vasodilators (GTN paste, warm packs)
Vein illumination devices if available
Use of pressure bags for rapid infusion
Early consideration of fluid warmers
Regular reassessment of access adequacy
Document access attempts and sites
Special Circumstances:
Trauma: avoid sites of potential injury
Burns: consider escharotomy for access
Coagulopathy: compression available sites only
Obesity: longer catheters, ultrasound essential
Pediatrics: IO early if peripheral access difficult
Team Considerations:
Clear communication of strategy
Most experienced operator for difficult access
Parallel processes (e.g., IO while preparing CVC)
Regular reassessment of need for escalation
Early anaesthetic/surgical involvement if needed
Clear handover of access sites/attempts
Indications for Arterial Cannulation:
Continuous blood pressure monitoring in unstable patients
Need for frequent blood gas sampling (>4/day)
During vasoactive drug administration
Major surgery with anticipated hemodynamic instability
Cardiac output monitoring via pulse contour analysis
Unreliable NIBP (arrhythmias, severe vasoconstriction)
Requirement for beat-to-beat analysis
Arterial Line Technical Aspects:
Site selection considerations:
Radial first choice (collateral circulation) Femoral for backup/cardiac output monitoring Brachial/axillary rarely indicated Dorsalis pedis/posterior tibial if required
Equipment requirements:
20G catheter standard (larger for femoral) Dedicated pressurized flush system Non-compliant tubing Appropriate transducer height/zeroing
Maintenance:
Regular sterile site inspection Flush system maintenance Waveform analysis Regular damping assessment
Central Venous Access Essential Functions:
Administration of:
Vasoactive medications Hypertonic solutions TPN Irritant drugs
Hemodynamic monitoring:
CVP measurement ScvO2 sampling Central venous temperature
Rescue access in arrest
Extended venous access for:
Antibiotics Multiple infusions Blood products
CVC Technical Considerations:
Site selection based on:
Urgency of insertion Coagulation status Infection risk Duration of anticipated use Operator experience
Insertion technique:
Mandatory ultrasound guidance Full aseptic technique Correct position confirmation CXR post internal jugular/subclavian
Line selection:
Number of lumens needed Duration of anticipated use Need for specific therapies (dialysis) Consider antimicrobial coating
Monitoring Capabilities:
Arterial:
Systolic/diastolic/mean pressures Pulse pressure variation Systolic pressure variation Waveform analysis End-organ perfusion assessment
Central venous:
Static CVP measurements Dynamic CVP changes Mixed venous saturations Central temperature
Complications Management:
Arterial:
Thrombosis Digital ischemia Infection Bleeding (especially if coagulopathic) Pseudoaneurysm formation
Central venous:
Immediate: pneumothorax, arterial puncture, arrhythmia Early: malposition, bleeding, air embolism Late: infection, thrombosis, stenosis
Prevention strategies:
Regular assessment of ongoing need Early removal when not required Strict aseptic maintenance Daily line site review Regular system integrity checks
Role in Specific Conditions:
Septic shock:
ScvO2 monitoring CVP trends during fluid resuscitation Multiple access for antibiotics/pressors
Respiratory failure:
Frequent blood gas analysis Assessment of tissue perfusion
Cardiac conditions:
Beat-to-beat BP monitoring Cardiac output assessment Response to interventions
Major trauma:
Large-bore access Transfusion capability Coagulation management
Quality and Safety Considerations:
Documentation requirements:
Insertion details Regular site checks Complications Ongoing indication review
Training needs:
Competency assessment Regular updates Complication management
Protocol development:
Insertion bundles Maintenance care Removal criteria
Audit requirements:
Infection rates Complication rates Compliance with bundles
Future Developments:
Non-invasive cardiac output monitoring
Continuous non-invasive BP measurement
Advanced waveform analysis
Infection reduction strategies
New coating technologies
Alternative access devices"
Relevant Anatomy:
Radial Artery:
Courses lateral to flexor carpi radialis Superficial in anatomical snuffbox Modified Allen's test assesses ulnar collateral flow Usually 2-4mm diameter
Femoral Artery:
Lateral to vein below inguinal ligament Usually 6-8mm diameter Located beneath fascial layers
Ultrasound Appearance:
Arteries: round, pulsatile, non-compressible Small diameter vessels require high-frequency probe Depth typically 2-10mm (site dependent) Document presence of variants/anatomical abnormalities
Indications:
Absolute:
Requirement for continuous BP monitoring Frequent blood gases (>4/day) Intraoperative monitoring in major surgery
Relative:
Use of vasoactive drugs Cardiac output monitoring Unreliable NIBP readings Anticipated deterioration Requirement for beat-to-beat analysis
Contraindications:
Absolute:
Local infection Inadequate collateral circulation Raynaud's phenomenon Previous arterial surgery at site
Relative:
Coagulopathy Peripheral vascular disease Previous lines at same site Proximal AV fistula
Complications & Prevention:
Immediate:
Arterial spasm - gentle technique Pain - adequate local anaesthetic Haematoma - careful compression Failed puncture - ultrasound guidance
Early:
Disconnection - secure connections Line displacement - appropriate fixation Dampening - regular system assessment Air embolism - maintain closed system
Late:
Infection - sterile technique/maintenance Thrombosis - regular flushing Ischaemia - early recognition Pseudoaneurysm - careful removal technique
Prevention Strategies:
Ultrasound guidance Aseptic technique Regular site inspection Early removal when not required
Insertion Technique:
Preparation:
Full consent process Equipment check Patient positioning Aseptic technique Assistant availability
Procedure:
Site cleaning (2% chlorhexidine) Local anaesthetic infiltration Ultrasound identification of vessel Single-wall puncture technique Guidewire insertion if using Seldinger Catheter threading Secure fixation
Initial Setup:
Pressurised flush system (300mmHg) Non-compliant tubing Appropriate transducer height System zeroing Waveform analysis
Monitoring Requirements:
Immediate:
Waveform characteristics Comparison with NIBP Flush test Site inspection
Ongoing:
Regular site inspection System integrity checks Dampening assessment Regular zero calibration Comparison with NIBP
Maintenance:
Sterile dressing changes Flush system checks Line securing Regular need assessment
Documentation Requirements:
Procedure Note:
Indication Consent process Site and approach Ultrasound use Local anaesthetic used Number of attempts Complications Confirming tests
Ongoing Documentation:
Daily site inspection System integrity Waveform quality Dressing changes Regular need review
Removal Documentation:
Reason for removal Technique used Haemostasis achieved Post-removal checks Any complications
Quality Assurance:
Audit Requirements:
Success rates Complication rates Infection rates Documentation compliance
Training Needs:
Competency assessment Regular updates Supervision requirements
Protocol Development:
Insertion bundles Maintenance care Removal criteria Emergency procedures"
Relevant Anatomy:
Internal Jugular Vein (IJV):
Lateral to carotid artery within carotid sheath More superficial and lateral than artery Variable size with respiration/position Anatomical landmarks: sternocleidomastoid borders
Subclavian Vein:
Runs beneath clavicle Continuation of axillary vein Fixed to surrounding tissue (remains patent in hypovolaemia) Landmarks: junction first rib/clavicle
Femoral Vein:
Medial to artery below inguinal ligament More superficial above saphenofemoral junction Landmarks: femoral pulse and inguinal ligament
Ultrasound Anatomy:
Veins: compressible, non-pulsatile Color flow helps identify vessels Anatomical variants common Depth varies by site/patient
Indications:
Administration of:
Vasoactive drugs Parenteral nutrition Concentrated solutions Multiple infusions
Monitoring:
CVP measurement ScvO2 sampling Right heart catheterization access
Emergency Access:
Rapid volume replacement Cardiac arrest Drug administration
Other:
Poor peripheral access Temporary cardiac pacing Renal replacement therapy Plasmapheresis
Contraindications:
Absolute:
Local infection Thrombosis at insertion site SVC obstruction (upper body lines)
Relative:
Severe coagulopathy Anatomical distortion Previous lines/surgery Contralateral pneumothorax High ventilation pressures
Complications & Prevention:
Immediate:
Arterial puncture - ultrasound guidance Pneumothorax - avoid subclavian if inexperienced Air embolism - Trendelenburg position Arrhythmias - avoid deep insertion Nerve injury - careful technique
Early:
Bleeding - correct coagulopathy Malposition - CXR confirmation Haematoma - careful compression Line occlusion - proper flushing
Late:
Central line infection - sterile technique/bundles Venous thrombosis - early removal Central vein stenosis - site rotation Catheter erosion - correct tip position
Prevention Strategies:
Full barrier precautions Ultrasound guidance mandatory Correct positioning Experience-appropriate site selection Regular review of ongoing need
Insertion Technique:
Preparation:
Full consent process Coagulation status check Equipment preparation Patient positioning Assistant availability Ultrasound setup
Procedure:
Cap, mask, sterile gown/gloves Large sterile field 2% chlorhexidine skin prep Local anaesthetic Ultrasound-guided vessel identification Seldinger technique Guidewire length control Dilator careful use Line insertion to correct depth Suture securing
Initial Checks:
Blood aspiration all ports Flush all lumens Secure connections Sterile dressing CXR if appropriate
Monitoring Requirements:
Immediate Post-insertion:
Vital signs CXR for position (thoracic lines) Site inspection Line function check
Ongoing:
Daily site inspection Line necessity review Dressing integrity Port access sterility Function checks
Maintenance:
Regular flushing Sterile port access Dressing changes Suture inspection Clinical need review
Documentation Requirements:
Procedure Note:
Indication Informed consent Site and approach Ultrasound use Local anaesthetic Number of attempts Complications Line type/length Tip position
Ongoing Documentation:
Daily site review Line necessity Dressing changes Infection monitoring Port access log
Bundle Compliance:
Hand hygiene Maximum barrier precautions Chlorhexidine skin prep Optimal site selection Daily review of necessity
Quality Assurance:
Training Requirements:
Competency assessment Supervision levels Regular updates Complication management
Audit Points:
Success rates Complication rates Infection rates Bundle compliance Documentation standards
Protocol Development:
Insertion guidelines Maintenance procedures Removal criteria Emergency protocols
Regular Review:
Technique updates Equipment changes Staff competency Outcome monitoring
Principles of Ultrasound Imaging and Safe Use for Vascular Access
Ultrasound imaging is widely used to improve the success and safety of vascular access procedures. Understanding the principles of ultrasound and adhering to safety practices are essential for optimal outcomes.
A. Ultrasound Physics
Sound Waves: High-frequency sound waves (2–15 MHz) are transmitted into tissues.
Echo Generation: Tissue interfaces reflect these waves back to the transducer.
Image Formation: The ultrasound machine interprets returning echoes to create a real-time image.
B. Modes of Imaging
B-Mode (Brightness Mode):
Provides a two-dimensional grayscale image, commonly used for vascular access.
Color Doppler:
Identifies blood flow direction and velocity to differentiate arteries from veins.
Power Doppler:
Enhances sensitivity to flow but lacks directional information.
C. Transducers
Linear Transducer:
High-frequency (7–15 MHz) for superficial structures, ideal for peripheral vascular access.
Curvilinear Transducer:
Low-frequency (2–5 MHz) for deeper structures, used for central venous access.
D. Image Optimization
Depth: Adjust to ensure the target vessel is visible in the center of the field.
Gain: Modify brightness to enhance contrast between tissues.
Focus: Position the focal zone at the level of the target vessel for clarity.
A. Preparation
Ensure patient comfort and appropriate positioning.
Use sterile techniques to minimize infection risk.
B. Vessel Identification
Arteries vs. Veins:
Arteries are pulsatile, non-compressible, and exhibit high flow on Doppler.
Veins are compressible, non-pulsatile, and show low flow on Doppler.
Visualize surrounding structures to avoid inadvertent injury.
C. Needle Guidance
Out-of-Plane Technique:
The needle crosses the ultrasound beam perpendicularly, appearing as a bright dot.
In-Plane Technique:
The needle is aligned with the beam, showing the entire length for precise guidance.
A. Infection Control
Use sterile probe covers and ultrasound gel.
Disinfect the transducer and equipment after each use.
B. Mechanical Safety
Pressure Application: Avoid excessive pressure that could distort vessel anatomy or cause discomfort.
C. Energy Safety
ALARA Principle: (As Low As Reasonably Achievable)
Minimize power output and scan duration to reduce thermal and mechanical effects.
D. Ergonomics
Position the ultrasound machine, operator, and patient to prevent operator fatigue and optimize visualization.
Increased Success Rates: Particularly in difficult venous access scenarios.
Reduced Complications: Minimizes arterial puncture, pneumothorax, and hematoma formation.
Real-Time Guidance: Allows dynamic visualization of needle advancement and vessel entry.
Learning Curve: Proficiency requires training and practice.
Equipment Dependence: Image quality depends on the operator's skill and machine settings.
Patient Factors: Obesity, edema, or vessel spasm can reduce visibility.
The principles of ultrasound imaging, including sound physics, image optimization, and transducer selection, underpin its effective use in vascular access. Adhering to safety protocols ensures patient comfort, minimizes complications, and maximizes the success of procedures. Regular training and practice enhance proficiency and confidence in using ultrasound for vascular access.
Safe Transfusion Practices
Safe transfusion practices ensure the effective use of blood and blood products while minimizing risks. This involves understanding the composition and indications for blood products, adhering to storage and handling protocols, and following local regulations.
A. Red Blood Cells (RBCs)
Composition: Packed red cells with minimal plasma.
Indications:
Severe anaemia.
Acute blood loss with compromised oxygen delivery.
Risks:
Hemolytic reactions.
Iron overload with repeated transfusions.
B. Fresh Frozen Plasma (FFP)
Composition: Plasma containing clotting factors.
Indications:
Coagulopathy due to liver disease, DIC, or massive transfusion.
Replacement of specific clotting factors when concentrates are unavailable.
Risks:
Allergic reactions.
Volume overload.
C. Platelets
Composition: Concentrated platelets in a small plasma volume.
Indications:
Thrombocytopenia with bleeding or prior to invasive procedures.
Platelet dysfunction due to drugs or inherited disorders.
Risks:
Febrile reactions.
Alloimmunization.
D. Cryoprecipitate
Composition: Concentrated fibrinogen, factor VIII, von Willebrand factor, and factor XIII.
Indications:
Hypofibrinogenemia.
DIC or major hemorrhage requiring fibrinogen replacement.
Risks:
Similar to plasma products, with added risk of volume overload.
E. Albumin and Other Plasma Derivatives
Composition: Purified albumin solutions or specific factors (e.g., prothrombin complex concentrates, IV immunoglobulin).
Indications:
Volume expansion, hypoalbuminemia, or replacement of specific deficiencies.
Risks:
Allergic reactions, fluid overload.
A. Storage Guidelines
Red Blood Cells:
Store at 2–6°C in monitored refrigerators.
Shelf life: 35–42 days depending on the anticoagulant.
Platelets:
Store at 20–24°C with gentle agitation.
Shelf life: 5–7 days.
Fresh Frozen Plasma and Cryoprecipitate:
Store at -18°C or lower.
Thaw at 37°C before use; use within 24 hours of thawing.
Albumin and Derivatives:
Store as per product-specific guidelines, usually at controlled room temperature.
B. Handling Practices
Verification: Ensure proper labeling, matching patient and product identifiers.
Transport: Use insulated, validated containers to maintain temperature during transfer.
Expiry: Discard expired or compromised products according to protocols.
C. Minimizing Waste
Return unused units promptly to storage.
Avoid unnecessary thawing or prolonged exposure to room temperature.
A. State, Territory, and Local Protocols
Follow guidelines from national bodies such as the National Blood Authority (NBA) in Australia.
Adhere to hospital-specific transfusion policies, which include:
Indications for blood product use.
Documentation and consent requirements.
Management of adverse reactions.
B. Transfusion Checklist
Pre-Transfusion Testing:
Crossmatch and blood group verification.
Patient Identification:
Use two independent identifiers to ensure correct patient-product matching.
Informed Consent:
Discuss benefits, risks, and alternatives with the patient.
Administration:
Initiate transfusion under supervision, monitoring for adverse reactions.
Use appropriate infusion equipment, such as a blood filter.
C. Managing Adverse Reactions
Immediate Actions: Stop the transfusion and assess the patient.
Notify the Blood Bank: Return the blood unit and accompanying samples for testing.
Documentation: Record details of the reaction and management steps.
Regular training for healthcare providers on transfusion protocols.
Audits to ensure adherence to best practices.
Encourage reporting of near-misses and adverse events to improve systems.
Safe transfusion practices hinge on understanding the indications and risks of blood products, maintaining strict storage and handling protocols, and adhering to state and local guidelines. Robust training and monitoring ensure patient safety and system-wide efficiency.
Approach to Managing Major Haemorrhage
Managing major haemorrhage is a time-critical process aimed at preventing shock, preserving organ perfusion, and addressing the underlying cause of bleeding. A structured, multidisciplinary approach is essential for optimizing outcomes.
1. Immediate Assessment and Recognition
Recognize Early Signs:
Hypotension, tachycardia, reduced urine output, and altered mental state.
Signs of ongoing blood loss (e.g., visible bleeding, hematoma expansion).
Trigger Major Haemorrhage Protocol (MHP):
Activate hospital-wide response, ensuring rapid access to blood products and support teams.
2. Airway, Breathing, Circulation (ABC)
Airway and Breathing:
Secure the airway if the patient is obtunded or at risk of aspiration.
Provide high-flow oxygen to optimize tissue oxygenation.
Circulation:
Establish large-bore intravenous or intraosseous access.
Initiate rapid fluid resuscitation with warmed crystalloids if necessary while preparing blood products.
3. Haemodynamic Stabilization
Control Bleeding:
Direct pressure, tourniquets, surgical intervention, or endovascular techniques (e.g., embolization).
Consider tranexamic acid (TXA) within 3 hours of bleeding onset to reduce mortality.
Volume Replacement:
Use blood products in a balanced ratio (e.g., 1:1:1 of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets).
Avoid excessive crystalloids to minimize dilutional coagulopathy and hypothermia.
Massive Transfusion Protocol (MTP):
Ensure early delivery of blood products through predefined MTP pathways.
4. Monitor and Manage Coagulopathy
Point-of-Care Testing:
Use thromboelastography (TEG) or rotational thromboelastometry (ROTEM) to guide blood product administration.
Correct Coagulopathy:
Administer fibrinogen concentrate or cryoprecipitate if fibrinogen levels are low (<1.5 g/L).
Provide calcium to correct hypocalcemia from citrate in transfusions.
Address acidosis and hypothermia to maintain clotting efficiency.
5. Continuous Monitoring and Assessment
Reassess Regularly:
Monitor vital signs, urine output, lactate, and hemoglobin levels.
Reevaluate bleeding control measures and response to interventions.
Prevent and Manage Complications:
Monitor for transfusion reactions, electrolyte disturbances, and organ dysfunction.
6. Definitive Treatment of the Underlying Cause
Surgical Intervention:
Control hemorrhage through laparotomy, thoracotomy, or other procedures.
Interventional Radiology:
Angiography and embolization for non-compressible or inaccessible bleeding.
Pharmacological Support:
Use vasoactive drugs for hemodynamic support if needed.
7. Post-Resuscitation Care
ICU Admission:
Close monitoring of organ function and coagulation.
Gradual correction of any residual coagulopathy or anemia.
Debrief and Documentation:
Review protocol adherence, outcomes, and team performance.
This comprehensive approach emphasizes rapid response, teamwork, and tailored management to optimize survival and recovery.
Personnel, Equipment, and Drugs Required for Crisis Management
Effective crisis management in the perioperative setting requires a prepared and well-coordinated team, appropriate equipment, and readily available medications. This ensures timely and efficient response to life-threatening events.
A. Leadership and Communication
Team Leader:
Typically the anaesthetist managing the crisis.
Coordinates the response, assigns roles, and makes critical decisions.
Key Roles:
Airway manager: Ensures patency and ventilation.
Circulation manager: Manages IV access, fluids, and drugs.
Scribe: Documents events, interventions, and times.
B. Support Staff
Nurses: Administer drugs, manage equipment, and assist with resuscitation.
Surgeons: Address surgical complications or assist in crisis management (e.g., hemorrhage control).
Additional Specialists: Cardiologists, intensivists, or other consultants based on the crisis.
C. Communication Experts
Facilitate internal communication within the team and external communication with ICU or other facilities if transfer is required.
A. Airway Management
Face masks, oral and nasopharyngeal airways.
Supraglottic devices (e.g., LMA).
Laryngoscopes and video laryngoscopes.
Endotracheal tubes (various sizes).
Cricothyroidotomy and tracheostomy kits for CICO situations.
Oxygen delivery systems (e.g., bag-valve-mask, ventilators).
B. Circulatory Support
Intravenous access equipment: Cannulas, central line kits, pressure bags.
Monitoring equipment: ECG, blood pressure cuffs, SpO2, and end-tidal CO2 monitors.
Defibrillator with external pacing capability.
C. Hemodynamic Support
Fluid administration sets and rapid infuser systems.
Arterial line kits for invasive blood pressure monitoring.
D. Emergency Monitoring
Capnography for respiratory crises.
Portable ultrasound for vascular access or cardiac evaluation.
E. Miscellaneous
Suction devices with Yankauer and flexible suction catheters.
Warmers for fluids and patient temperature maintenance.
Point-of-care testing devices for blood gas analysis, lactate, and glucose.
A. Airway and Breathing Support
Induction Agents: Propofol, thiopentone, ketamine.
Neuromuscular Blockers: Succinylcholine, rocuronium.
Reversal Agents: Sugammadex, neostigmine, glycopyrrolate.
B. Circulatory Support
Vasopressors: Epinephrine, phenylephrine, norepinephrine, vasopressin.
Inotropes: Dobutamine, dopamine.
Antiarrhythmics: Amiodarone, adenosine, magnesium sulfate.
C. Hemodynamic and Volume Resuscitation
Fluids: Crystalloids (normal saline, Ringer’s lactate), colloids, blood products (RBCs, FFP, platelets).
Antifibrinolytics: Tranexamic acid for bleeding crises.
D. Respiratory Crises
Bronchodilators: Salbutamol, ipratropium bromide.
Steroids: Hydrocortisone, dexamethasone.
E. Anaphylaxis Management
Epinephrine (IM or IV), antihistamines (chlorpheniramine, diphenhydramine), and corticosteroids.
F. Malignant Hyperthermia
Dantrolene, cooling equipment, and bicarbonate.
G. Sedation and Analgesia
Benzodiazepines (midazolam), opioids (fentanyl, morphine).
A. Cardiac Arrest
Immediate access to advanced cardiac life support (ACLS) medications and defibrillation.
B. Hemorrhagic Shock
Massive transfusion protocol equipment, including rapid infusers and cross-matched blood.
C. Difficult Airway
Complete difficult airway trolley, including fiberoptic scopes and CICO kits.
Crisis management algorithms (e.g., ACLS, anaphylaxis, malignant hyperthermia).
Posters or electronic references for rare emergencies.
Preparedness for crises involves assembling a skilled and coordinated team, having the right equipment and medications immediately available, and using structured algorithms for management. Regular training and simulation ensure readiness for effective crisis resolution.
Role of Disaster Management Protocols and Mobilizing Resources
Disaster management protocols provide structured frameworks for effective, coordinated responses to emergencies involving mass casualties or resource constraints. They ensure rapid mobilization of available resources, minimize chaos, and maximize patient outcomes.
Role of Disaster Management Protocols
Preparedness and Planning:
Establish clear procedures for communication, resource allocation, and role assignments.
Conduct regular disaster drills and simulations to identify gaps and enhance readiness.
Predefine triage systems (e.g., START triage) to prioritize care based on severity and survivability.
Coordination and Communication:
Designate command and control centers for centralized decision-making.
Ensure seamless communication between hospitals, emergency services, and government agencies.
Implement real-time information systems to monitor resource availability and patient distribution.
Efficient Resource Utilization:
Deploy protocols to manage limited resources, such as blood products, ventilators, and operating rooms.
Emphasize equitable resource distribution to prevent depletion in critical areas.
Flexibility and Scalability:
Enable protocols to adapt to different disaster scenarios (natural disasters, pandemics, mass shootings).
Activate additional surge capacity, such as field hospitals and temporary care centers.
Psychological Support and Safety:
Incorporate measures for staff mental health support and safety.
Address the psychological impact on patients and their families.
Mobilizing Available and Limited Resources
Personnel:
Deploy available healthcare providers and reassign roles based on skills (e.g., generalists assisting specialists).
Call in additional staff, including volunteers and off-duty personnel.
Use telemedicine to extend specialist availability.
Facilities:
Convert non-traditional spaces (e.g., gyms, schools) into triage or treatment centers.
Optimize hospital bed allocation by discharging stable patients and using step-down units.
Establish field hospitals near disaster sites for initial stabilization.
Equipment and Supplies:
Implement inventory protocols to ration critical supplies (e.g., PPE, medications).
Share resources across regions through mutual aid agreements.
Use alternatives or substitute therapies when standard resources are unavailable (e.g., split ventilators).
Triage and Patient Flow:
Apply triage systems to prioritize care for patients most likely to benefit.
Decentralize patient load by transporting stable patients to less affected facilities.
Expedite diagnostic and treatment pathways to manage high patient volumes efficiently.
Community Engagement:
Involve community organizations for logistical support (e.g., transport, shelter, food).
Educate the public on self-care measures and disaster response plans.
After-Action Reviews:
Conduct post-event evaluations to refine protocols and improve future responses.
Update stockpiles, infrastructure, and staff training based on lessons learned.
A well-organized disaster management protocol enhances resilience, ensures optimal use of scarce resources, and promotes the safety of both patients and responders during crises.
Generic Transfer Principles:
Risk/benefit assessment for all transfers
Stabilization before transport when possible
Appropriate team composition and experience
Standard monitoring requirements
Equipment redundancy planning
Clear communication pathways
Documentation completeness
Time-critical vs routine transfer considerations
Road Transfer Specific Challenges:
Environmental:
Traffic conditions/delays
Weather impact on road conditions
Journey time variability
Vibration effects on patient/equipment
Limited space in vehicle
Clinical:
Motion sickness effects on team
Patient accessibility during transit
Equipment security concerns
Monitoring interference from vehicle
Logistical:
Vehicle availability/preparation
Fuel management
Route planning
Rest stops for long transfers
Advantages:
Door-to-door capability
Flexible routing
Lower cost
Easier abort options
Less weather dependency
Air Transfer Specific Challenges:
Physiological:
Altitude effects (reduced PaO2)
Expansion of air-filled spaces
Motion sickness more common
Temperature regulation
Dehydration risk
Equipment:
Weight restrictions
Power supply limitations
Equipment certification requirements
Interference with aircraft systems
Calibration at altitude
Clinical:
Limited access to patient
Noise limiting communication
Confined space for interventions
Vibration effects on procedures
Logistical:
Weather dependencies
Landing site availability
Cost implications
Crew duty time restrictions
Ground transfer requirements
Equipment Considerations:
Road:
Power supply reliability
Equipment securing
Access to spare equipment
Interference from vehicle electrics
Air:
Aviation authority approval
Electromagnetic compatibility
Pressure effects on pumps
Battery duration requirements
Weight restrictions
Staff Considerations:
Road:
Driver training requirements
Motion sickness management
Rest periods for long transfers
Team rotation for extended journeys
Air:
Altitude physiology training
Aviation medicine knowledge
Emergency procedures familiarity
Communication in noise
Flight safety responsibilities
Clinical Limitations:
Road:
Prolonged transfer times
Limited intervention space
Vehicle motion effects
Weather/traffic delays
Air:
Altitude restrictions for some conditions
Limited emergency landing options
Confined space procedures
Weather limitations
Pressurization requirements
Documentation Requirements:
Road:
Journey times/delays
Traffic conditions
Rest stops
Vehicle checks
Air:
Flight plan details
Altitude restrictions
Pressurisation details Aviation authority requirements
Emergency Management:
Road:
Multiple stop options
Alternative routes
Backup vehicle availability
1. Initial Assessment and Stabilization
Determine Need for Transfer:
Identify gaps in current facility capabilities (e.g., specialty care, advanced imaging, or interventional procedures).
Consider patient prognosis and transfer risks versus benefits.
Stabilize the Patient:
Secure airway, breathing, and circulation.
Initiate resuscitation as needed (e.g., fluid therapy, vasopressors).
Address life-threatening issues (e.g., control bleeding, decompress pneumothorax).
Establish Monitoring:
Continuous monitoring of vital signs, oxygenation, and end-tidal CO₂.
Invasive monitoring if required (e.g., arterial line, central venous line).
2. Communication and Coordination
Contact Receiving Facility:
Identify an appropriate facility capable of managing the patient’s condition.
Speak directly with the accepting clinician to provide a detailed handover:
Patient’s clinical status and interventions.
Reason for transfer and ongoing treatment plan.
Confirm bed availability and acceptance of the patient.
Inform Key Stakeholders:
Notify patient’s family about the transfer decision, rationale, and destination.
Obtain informed consent for transfer, where possible.
Engage Transport Team:
Contact a specialized critical care transport team (e.g., road, air, or retrieval services).
Provide details of the patient’s clinical status and equipment needs.
3. Preparation for Transport
Documentation:
Ensure transfer documentation is complete, including:
Patient’s medical records, imaging, and test results.
Transfer letter outlining patient condition, interventions, and care requirements.
Include medication chart and ongoing treatment instructions.
Equip Transport:
Prepare necessary medications (e.g., sedation, vasopressors, emergency drugs).
Ensure transport equipment is functional (e.g., portable ventilator, defibrillator).
Staffing:
Assign appropriate personnel based on patient needs (e.g., intensivist, critical care nurse, paramedic).
4. During Transport
Continuous Monitoring:
Monitor vital signs, oxygenation, and invasive parameters during transit.
Respond to changes in patient condition promptly.
Communication:
Maintain communication with the receiving facility, providing updates as needed.
Notify receiving facility of estimated arrival time and any changes en route.
5. Handover at Receiving Facility
Provide Detailed Handover:
Summarize patient’s clinical course, interventions, and current status.
Handover monitoring equipment, medications, and documentation.
Assist Transition of Care:
Ensure patient is safely transferred to the receiving team and critical care environment.
6. Post-Transfer Review
Debrief the Team:
Review the transfer process to identify challenges and opportunities for improvement.
Audit and Feedback:
Record transfer details and outcomes for quality assurance and future planning.
Safe Transfer of Critically Ill Patients
The safe transfer of critically ill patients is a complex process requiring meticulous planning, appropriate personnel, and specialized equipment to maintain patient stability and safety during transport. The ANZCA, ACEM, and CICM PG52 Guideline (2024) provides a structured approach to ensure best practices in patient transfers.
Critically ill patients may require transport in three key settings:
Pre-hospital Transport: Retrieval from out-of-hospital settings (e.g., roadside, private dwelling).
Inter-facility Transport: Transfer between healthcare facilities when the referring hospital lacks necessary diagnostic, therapeutic, or intensive care capabilities.
Intra-facility Transport: Movement within a hospital (e.g., from ED to ICU, to imaging, or theatre).
Continuity of Care: The level of care during transport should equal or exceed that at the referral site.
Minimal Clinical Team Transfers: Reducing handovers ensures continuity of management and minimizes information loss.
Timely Response: Initiating transport should not be delayed unnecessarily. In emergency cases, retrieval should proceed even if the receiving facility is yet to be confirmed.
Patient Communication: Where possible, patients (or carers) should be informed about their transport and destination.
Centralized Clinical Coordination: Involves dedicated teams (e.g., retrieval services) to provide logistical and medical support.
Reliable Communication: Between referring and receiving teams, transport crew, and emergency services to ensure smooth handovers.
Complete Transport Record: Includes pre-, intra-, and post-transport assessments, interventions, medications, and adverse events.
Electronic Documentation: Preferred for accuracy, legal compliance, and quality assurance.
Audit & Review: Regular case reviews, morbidity/mortality meetings, and benchmarking ensure continuous improvement.
Risk Management: Identifying potential transport risks (e.g., equipment failure, team fatigue) and implementing mitigation strategies.
Appropriately Trained Transport Team:
At least one critical care doctor or anaesthetist.
A trained nurse or paramedic with advanced airway, circulation, and ventilation management skills.
Credentialing & Scope of Practice:
Staff should have formal training in transport medicine.
Specific expertise for paediatric, neonatal, bariatric, or ECMO patients.
Fatigue Management:
Adherence to rest policies for retrieval personnel.
Optimal Patient Resuscitation Before Transfer:
Secure airway, breathing, and circulation (ABC) before transport.
Ensure intravenous access is patent and secured.
Checklist Use:
A structured pre-transport checklist reduces errors and ensures readiness.
Minimum Equipment Standards:
Ventilators, defibrillators, infusion pumps, portable ultrasound.
Adequate oxygen supply (with at least 50-100% buffer).
Continuous Monitoring:
Mandatory for all transports: ECG, BP, SpO₂, EtCO₂ (if intubated), temperature.
Additional for inter-facility transport: Glucose, urine output, pain score, point-of-care ultrasound.
Road Transport: Preferred for short-distance transfers with stable patients.
Air Transport (Helicopter/Fixed-wing):
Indicated for long-distance transfers or when urgent intervention is required.
Requires pressurization considerations for patients with pneumothorax, air embolism.
Crew must be trained in aeromedical retrieval hazards (hypoxia, vibration, noise, cold stress).
Structured Handover: Use of ISBAR (Introduction, Situation, Background, Assessment, Recommendation) format.
Ongoing Patient Care: Ensure the receiving team is fully briefed on transport events, interventions, and new management needs.
The safe transport of critically ill patients requires meticulous planning, trained personnel, appropriate equipment, and structured communication. Adhering to PG52 (2024) guidelines ensures patient safety and minimizes adverse transport-related events.