TRAUMA TRIAGEAmy Gutman MD

EMS Medical Director

ALS / BLS Continuing Education

prehospitalmd@gmail.com

Objectives

Historical development of triage

Relationship between triage & development of trauma systems

How changes in triage affect resources

Review Region V Trauma Triage Guidelines

“Those who cannot remember the past are condemned to repeat it.” ~George Santayana

The “Disease” of Trauma

Leading killer in US of persons <44 yo, however: Life or limb-threats in 10% of all

trauma pts 150,000 deaths annually 44,000 MVC 28,000 GSW

Most expensive “disease” in terms of lost wages, initial care, rehabilitation & lifelong maintenance

Triage

French: “to sort, cull or select”

Evaluation & classification of casualties initially for evacuation & treatment of battlefield wounded

Greatest good for greatest number

Prior to 1700s rank trumped injury

Napoleonic Wars Baron Dominique–Jean Larrey was

Napoleon’s Surgeon Major during Rhine Campaign (1792-1798)

Developed “Flying Ambulance” (1797) to transport wounded off battlefield

Goal was treatment within 24 hrs Rescue casualties based on injury not rank Immediate treatment Transport to 1st line hospitals

Baron Pierre Percy developed alternative “Casualty Transport System” to transport surgeons & supplies to patient 1st “Mobile Hospitals”

American Civil War

1847: Congress authorizes 1st commissions for medical officers

1861: Battle of Bull Run Medical corps dysfunction

○ Too few ambulances○ Minimal organization○ Casualties not evacuated for days

Prompted 1862 appointment of 1st Surgeon General Bill Hammond

1862: 2nd Battle of Bull Run Dr Letterman appointed Medical

Director Army of Potomac Revised ambulance core

Jonathan Letterman MD

“ Napoleonic” casualty care

Transferred all medical care to Army Medical Corps

Reformed medical supply distribution

Triage by Medical Corps provided 1st prehospital standards of care

3 Tiered Evacuation System Field Dressing / Aid Station Field Hospital / MASH Unit Large Hospitals

World War I Collecting Zone

Advanced field aid stations

Evacuating Zone Clearing Hospital

Distributing Zone Rest Stations

Transport based upon “self-evacuation” ability

○ “Lyers” vs “Walkers”

“Casualty Clearing Hospitals” MASH “Specialty” Surgeons: Abdominal,

Orthopedics, Plastics Minimum10% operative rate

World War II

Radio communications

Resuscitation

Antibiotics

1st Air Transport

Development of Echelon System

WWII Echelon System

1st Echelon: “Physician First” Treat & Street after emergent

procedures No holding capacity but could treat

300-500 wounded simultaneously

2nd Echelon: Secondary triage 72 hour holding OR Capable Supported 3-9 Aid Stations

WWII Echelon System

3rd Echelon Combat Support Hospitals / MASH

units Advanced care capable of facility rapid

evacuation

4th Echelon Full spectrum of hospitals with

rehabilitation capabilities outside combat zone

Definitive care Limited to no mobility

Korean War

Increased use of aeromedical transport

Directly transported most seriously injured patients, bypassing “inappropriate” facilities

Trauma-Related Deaths*

*Includes environmental & post-operative complications

War # / 1000

Mexican 104

Civil 71

Spanish-American 34

WWI 17

WWII 0.6

Patient Outcomes & Time to Definitive Care

War Time Mortality

WWI 12-18 hrs 8.5%

WWII 6-12 hrs 5.8%

Korea 2-4 hrs 2.4%

Vietnam 65 mins 1.7%

Civilian Trauma System Evolution

1966 NHTSA “White Paper” Highway Safety Act of 1966 “Accidental Death and Disability: The Neglected Disease of Modern Society”

detailed MVC pts dying from initial trauma & inadequate prehospital care 1st statewide prehospital system in 1969 in Maryland

1971 Illinois Trauma Program Trauma center categorization Advanced communications Safer ambulance designs Improved prehospital training Trauma Registry development / CQI

1973-1976 ACS publishes “Optimal Hospital Resources for Care of the Injured Patient”

resulting in the Emergency Medical Services Act

Civilian Trauma System Evolution

1990: ACS “Trauma Care Systems Planning & Development

Act” established guidelines, funding & state-level leadership for trauma system development

1992“Model Trauma Care System Plan” introduced concept of

“Inclusive” vs “Exclusive” SystemsAssumes all acute care facilities are part of a larger

integrated systemTiered approach based on known quantity of available &

invariable resources

“Exclusive” Trauma Systems

Centralizes all injuries regardless of severity to tertiary centers

Excludes acute care facilities with variable capabilities

Over-triage to avoid under-triage

Problems Payer mix Triage based on likelihood of admission

vs tiered resource utilization Non-participation of uncategorized

facilities Lack of MCI training

Trauma Triage Leads to Trauma Care Systems

CDC / ACS / NHTSA Trauma Triage Guidelines assist providers in triaging pts to the proper facility

Guidelines offer pt-specific destination criteria for definitive treatment

Development of a Trauma Care System integrates prehospital & hospital care to reduce cost, time to OR / ICU, & mortality

Elements of a Functional Trauma

System Defined Need, Authority & Legislation

Standardized Care with Adaptive Changes Based Upon Resources

Tiered Triage Based on Injury Severity, With Mechanisms to Bypass Lower Echelons

Rapid Transport & Concurrent Treatment Utilizing Standardized Care

Integration of Advanced Technology

Commitment to Training

Outcomes Driven Model

Triage Tools Problems

“One Size Fits All” No, it doesn’t Populations & resources vary & change

Mature & busy systems have better outcomes

Incident influences outcomes

Changes in triage absolutely affect system resources & patient outcomes

Triage Tools

START

Trauma Index

Trauma Score / RTS

CRAMS Score Circulation, Respiration, Abdomen, Motor,

Speech

Prehospital Index

Trauma Triage Rule

Kampala Triage

Anatomically based global severity scoring system that classifies each injury in every body region according to its severity on a 6 point scale: 1 = Minor 2 = Moderate 3 = Serious 4 = Severe 5 = Critical 6 = Maximal (unsurvivable)

9 body regions: Head Face Neck Thorax Abdomen Spine Upper Extremity Lower Extremity External & other

Take highest AIS each of the 3 most severely injured body regions, square each AIS & add the 3 squared numbers together ISS = A2 + B2 + C2

ISS scores ranges from 1 to 75 AIS 0-5 for each category

If any of the 3 scores is a 6, the score is automatically set at 75

Since a score of 6 indicates futility of further medical care in preserving life, this generally means a cessation of further care

Abbreviated Injury Scale (AIS) Injury Severity Score (ISS)

A major trauma requiring a Trauma Center is defined as an ISS > 15

ACS Field Triage Decision Scheme

Physiologic Criteria

Anatomic Criteria

Mechanism Criteria

Age & Co-morbidities

“When In Doubt Take To A Trauma Center” Criteria

Physiologic Criteria (Vitals)

1st triage step identifies pts at high risk of suffering from severe injuries: Hypovolemic shock Neurogenic shock Cardiogenic shock Traumatic brain injury

However, critical injuries resulting in “shock” may not be reflected early in vitals due to physiologic compensation

“Do not pass “GO”, Do not collect $100”

Anatomic Criteria

2nd step evaluates injuries related to anatomical location

Penetrating trauma may cause significant injury dependent on area Proximal long bone fractures, pelvic

fractures & amputations all cause major bleeding

Skull fractures place pt at risk due to bleeding & increased ICP

Paralysis indicative of spinal trauma

Mechanism of Injury

Significant mechanism of injury often assoc with internal injuries masked by early physiologic compensation

Mechanism alone not enough to determine triage destination

Special Considerations

Use of anticoagulants (clopidogrel, aspirin, warfarin, NSAIDs)

Bleeding disorder (i.e. hemophiliacs)

Special Popuations Geriatrics (>70) Pediatrics Pregnancy

○ Physiologic changes: increased CO & TBV, hypercoagulability○ High risk of abruption with “minor” trauma

Provider impression Sick vs Not Sick? Not Sick with high potential for Sick?

Densmore. Outcomes and delivery of care in pediatric injury. J Ped Surg. 2006.

PURPOSESite of care must be correlated with outcomes to design

effective pediatric trauma care systems

Results80,000 injury cases in 27 statesGrouped by age, ISS & site of care89% received care outside of children's hospitals If 0-10 yrs with ISS >15, mortality, LOS & charges all

significantly higher in adult hospitals

CONCLUSIONSYounger & seriously injured children have improved outcomes in

children's hospitals

Caterino. Modification of Glasgow Coma Scale criteria for injured elders. Acad Emerg Med. 2011

CONCLUSIONS52,412 pts In elders, mortality & TBI increased with GCS decreasing

from 15 to 14 & 14 to 13 In adults, mortality did not increase with the GCS drop-offs

Trauma & Co-Morbidities

0

10

20

30

40

50

60

None One Two Threeor More

Avg. Age vs. #Medical Problems

0

10

20

30

40

50

60

None One Two Threeor

More

ICU Admit % vs. #Medical Problems

Trauma & Co-Morbidities

00.5

11.5

22.5

33.5

44.5

5

None One Two Threeor More

Mortality % vs. #Medical Problems

Appendix J: Air Medical Transport Protocols

Does not require Med Control approval, but does require oversight

Nearest Appropriate Facility: Uncontrolled airways unless ALS can intercept in a more timely

fashion Arrest due to blunt trauma

Air Medical Transport If meets specific criteria & scene arrival time to arrival time at

nearest appropriate hospital, including extrication time > 20 mins Location, weather or road conditions preclude ground ambulance Multiple casualties exceed capabilities of local agencies

Appendix J: Air Medical Transport Protocols Patient Conditions

Physiologic Criteria Unstable vitals (SBP <90, RR >30 or <10)

Anatomic Criteria Spinal cord injury

Severe Blunt Trauma: ○ Head Injury (GCS <12)○ Severe chest, abdominal or pelvic injuries excluding simple hip fractures

Burns: ○ >20% BSA 2nd or 3rd degree burns○ Airway, facial or circumferential extremity○ Associated with trauma

Penetrating injuries of head, neck, chest, abdomen or groin

Amputations of extremities, excluding digits

Appendix J: Air Medical Transport Protocols Patient

Conditions Special Conditions considered in

decision to request air medical transport, but not automatic or absolute

MVC Ejected Death in same compartment Pedestrian struck & thrown >15 ft, or

run over

Significant Medical History Age >55 or <10 Significant coexistent illness Pregnancy

Cudnik. Prehospital factors associated with mortality in injured air medical patients. PEC. 2012

BACKGROUND: Air medical transport provides rapid transport to definitive care. Overtriage & the

expense & transportation risks may offset survival benefits

RESULTS: 557 pts transported by air to a level 1 trauma center. Majority were male (67%),

white (95%) with an injury rurally. Most injuries were blunt (97%), & pts had a median ISS of 9. Overall mortality 4%

Most common reasons for air transport were MVC with high-risk mechanism (18%), MVC speed >20 mph (18%), GCS <14 (15%), & LOC >5 mins (15%)

Factors with high mortality: age >44 yrs, GCS <14, SBP <90 mmHg & flail chest Most common trauma indicators resulting in death, receipt of blood, surgery, ICU

admission included EMS ETI, >2 fractures of humerus/femur, neurovascular injury, cranial crush or penetrating injury, failure to localize to pain on examination, GCS <14

CONCLUSIONS Few prehospital criteria assoc with clinically important outcomes in helicopter-

transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated & developed

1,200 trauma admits/year

Pts w/ ISS >15 (240 total or 35 pts/surgeon)

Immediate surgical capability available

In-house trauma surgeon

General surgery residency program or trauma fellowship

Research

No minimum patient criteria

Surgical capability available in a “reasonably acceptable time”

General surgeon present at resuscitation

Desirable to have residents

No research minimum

LEVEL I TRAUMA CENTER LEVEL II TRAUMA CENTER

Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation

Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation

Level III “Community” Trauma Center Specialized ED with majority of

subspecialties on-call

Level IV Rural community hospitals No immediate surgical

interventions available Stabilize & transfer

Uncategorized Essentially a Level IV not

participating in ACS classification “Free-standing” EDs

Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation

Specialty Centers Neurocenters Burn Centers Pediatric Trauma Hyperbaric Medicine Microsurgery

Most have “Medical Specialties” certified by Joint Commission MICU CICU / Cath Lab Stroke Centers

MA State Trauma Centers

Region I Baystate (Level 1 Adult & Pediatric);

Springfield Berkshire Medical Center (Level 2 Adult

& Pediatric); Pittsfield

Region II UMass Memorial (Level 1 Adult Trauma

& Pediatric); Worcester

Region III Anna Jaques Hospital (Level 3 Adult);

Newburyport Beverly Hospital (Level 3 Adult);

Beverly Caritas (Level 3 Adult); Methuen Salem Hospital (Level 3 Adult); Salem Lawrence General Hospital (Level 3

Adult); Lawrence     Lowell General Hospital (Level 3 Adult);

Lowell)

Region IV Beth Israel (Level 1 Adult); Boston BMC(Level 1 Adult & Pediatric); Boston      Brigham & Women’s (Level 1 Adult);

Boston            Boston Children’s (Level 1 Pediatric);

Boston         Lahey Clinic (Level 2 Adult); Burlington      Massachusetts General (ACS Level 1 Adult &

Pediatric); Boston           Tufts / NEMC (Level 1 Adult & Pediatric);

Boston

Region V No verified ACS Trauma Centers

Rhode Island Rhode Island Hospital (Level 1 Adult);

Providence Hasbro Hospital (Level 1 Pediatric); Providence

Mass ACS Verified Trauma Centers

Quality Improvement (CQI / QA)

Data & Trauma Registry Data retrieval system for trauma

patient information Used to evaluate & improve the

trauma system as well as provide individual feedback

CQI Examine system performance to

improve outcomes Evaluate calls to determine if

standard of care met Relies upon accurate & complete

documentation

Transport Decisions

Should be based upon “evidence-based” criteria

Can critical problems be managed en-route

Use Medical Control early & often

Summary

The lessons of battlefield medicine created civilian trauma systems

Triage tools best understood within the context of the type of system they serve

As field resources change so must trauma systems

References

Bucher. Does Your Patient Need A Trauma Center? EMS World. 2011

Loftus. Banner Good Samaritan Medical Center. Statewide Trauma Rounds, 2007.

Bledsoe. Essentials of Paramedic Care. 2006. OEMS Prehospital provider Protocols. March 2012. Mosby, Brady, Caroline. Prehospital Care Textbooks.

“Trauma” References cited throughout presentation.