Transport and destination hospital for patients with suspected multiple and/or severe injuries - a systematic review and clinical practice guideline update.

purposeOur aim was to update the evidence-based and consensus-based recommendations on criteria for transport and destination hospital for patients with suspected multiple and/or severe injuries based on available evidence. This guideline topic is part of the 2025 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

methodsMEDLINE and Embase were systematically searched to January/February 2024. Further literature reports were obtained from clinical experts. Randomised controlled trials (RCTs) or observational studies reporting risk-adjusted outcomes were included if they compared different transport strategies or destination hospitals for patients with (suspected) multiple and/or severe injuries. We considered patient-relevant outcomes such as mortality and neurological outcomes. Risk of bias was assessed at outcome level using ROBINS-I for observational studies and RoB 2 for RCTs. We conducted meta-analyses if possible; alternatively, we synthesised the evidence narratively. We used GRADE to rate the certainty of evidence. Expert consensus was used to develop recommendations and determine their strength.

resultsA total of 127 studies were identified. They addressed helicopter vs. ground emergency medical services (EMS) transport, ground EMS with vs. without a physician, on-scene time, and handover on arrival at the hospital. Studies on destination hospitals have compared trauma centres at different levels, the nearest hospital vs. higher-level trauma centres, or hospitals with specialised services for trauma patients in general or specific subgroups, among others. Four recommendations were modified and five additional recommendations were developed. The guideline panel rejected one proposed recommendation. All accepted recommendations (n=8) achieved strong consensus.

conclusionThe key recommendations are summarised as follows: 1. For the prehospital management of severe trauma, helicopter emergency medical services should be deployed, taking into account operational and tactical considerations. 2. Prolong the on-scene time only to perform indicated, stabilising therapeutic interventions. 3. For patients with penetrating or perforating torso trauma, keep the prehospital rescue time as short as possible. 4. Transport patients with severe blunt trauma primarily to a regional or supraregional trauma centre. 5. Transport patients with penetrating or perforating trauma to the nearest appropriate hospital capable of providing definitive haemorrhage control. 6. Patients with severe traumatic brain injury should primarily be transported to the nearest trauma centre with 24-hour availability of neurotraumatological expertise. 7. The following patients should be transported to a supraregional trauma centre: • Patients with unstable pelvic fractures and hemodynamic instability; • Patients with neurological deficits following spinal injury. 8. Use a standardized handover concept in the trauma bay.