The arrival of an unstable trauma patient in the emergency department (ED) triggers a multitude of decisions. Among the most important of these is “where should the patient go next?” This decision must consider available data on the presence and magnitude of shock and the anatomic distribution of injuries, and it must balance the need for acquiring more information against the need for immediate action. The benefits, risks, and logistics of all available strategies should be known and optimized in advance. Once a transfer strategy is developed, its successful implementation will depend on effective coordination of a multidisciplinary trauma team and clear forward communication. This chapter focuses on the way critical decisions about the disposition of unstable patients are made, communicated, and executed under conditions of uncertainty and rapid change.