CASE 23

Incident

A 56-year-old woman has collapsed and presented by ambulance to a general hospital without on-site neurosurgical support. On admission, she was deeply unconscious and required intubation and ventilation in the Emergency Department. Examination findings at that time revealed bilateral brisk reflexes, hypertension (BP 180/100 mmHg) and small, non-reactive pupils. A CT head scan has now been arranged, which will require the patient to be transported to the radiology department, which is located on another level of the hospital building.

Relevant information

▪ Regional resources: Neurosurgical centre 300 km (185 miles) away

Questions

23.1 Outline your plan for safe patient transfer to and from the radiology department.

23.2 What does the CT head scan reveal? What should now occur?

23.3 Outline how the inter-hospital transfer of this patient to the neurosurgical receiving hospital 300 km (185 miles) away differs from the previously required intra-hospital transfer for CT head scan.

Discussion

23.1 Intra-hospital transport of critically ill patients occurs frequently. Transports are usually required to facilitate critical investigations and interventions or to move the patient from one critical-care area (e.g. Emergency Department) to another (e.g. ICU). Critically ill patients with minimal or no physiologic reserve undergoing such transports are at risk of clinical deterioration and adverse events are well reported ¹.

To minimise potential adverse events, a structured approach for all intrahospital critical-care transports is required. Intrahospital transport guidelines and protocols may vary regionally. A broad outline is detailed below.

Risk–benefit assessment

Patients undergoing invasive ventilation and who require high levels of intensive care support should not be transported for non-urgent interventions or investigations. In this scenario, the need for urgent imaging, potential intervention and ongoing care outside the Emergency Department clearly supports the requirement for patient transport.

Patient stabilisation

• Although acute threats to life have been addressed, a definitive diagnosis is unclear. Further investigation is therefore required before any therapeutic options (if any) are considered. Thus, in this scenario, patient transport for definitive investigation can be considered part of the stabilisation process. Prolonged periods of time in the Emergency Department performing multiple invasive procedures and attempting complete physiologic normalisation are not appropriate.

• Clinical reassessment should occur swiftly, systematically and, whenever possible, with the patient already supported by the equipment that will be used during transport.

• The airway should be checked and secured, endotracheal suction performed, ventilation and oxygenation optimised, adequate and patent vascular access secured and drainage devices measured and emptied. Sedation and analgesic requirements should be addressed and any drugs required for transport (including additional infused agents) pre-drawn and labelled for immediate use.

• Neuroprotective care should be provided, despite the current undifferentiated nature of the presentation (see Case 10). Specifically, hypotension, progressive hypertension, hypoxia and hypercarbia or hypocarbia should be aggressively avoided.

• Ensure that the patient clinical record remains with the team caring for the patient at all times.

Communication and coordination

Handover of care

• This will be required if the transport team are not the team currently caring for the patient. Clinical handover should be between nominated team leaders and be clear, concise, structured and documented.