Improving EMS Trauma Triage

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Improving EMS Trauma Triage

• A Project of the
• Florida Department of Health
• Division Of Emergency Medical Operations
• Office of Trauma in Cooperation With The
• Emergency Medicine Learning Resource Center
  (EMLRC)

2
Disclaimer

• This training program is not intended to replace
  or function as local emergency medical services
  treatment or transport protocol. For specific
  protocol guidance, contact your system EMS
  medical director.

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Improving EMS Trauma Triage

• Faculty
• Joe Nelson, DO, MPH
• EMS Medical Director
• Bureau of EMS
• Florida DOH
• Tallahassee, Florida
• Patricia Byers, MD, FACS Associate Professor,
  University of Miami Ryder Trauma Center Miami,
  Florida

• Grant Project Coordinators
• Susan McDevitt, RN, MSN, MBA, MS, FACHCA
  Director, Office of Trauma Executive Director
  Community Health Nursing
• Florida DOH
• Tallahassee, Florida

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Objectives

• Upon Completion of This Program the EMT/Paramedic
  Will
• Understand of the need and methodology for a
  rapid assessment of the trauma patient.
• Understand the importance of accurate trauma
  triage to an appropriate destination, especially
  in the rural setting.
• Have a basic understanding of the
  characteristics/capabilities of various levels of
  Trauma Centers.

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Objectives

• Upon Completion of This Program the EMT/paramedic
  Will
• Be able to apply decision-making aids to
  recognize need for transport a Trauma Center.
• Will be able to identify critical interventions
  on scene and during transport.
• Will understand advantages and disadvantages
  emergency ground vs. air transport.

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Introduction

• Each year, over 160,000 lives in the United
  States are lost due to trauma.
• Trauma is the leading cause of death and
  disability in children and young adults.
• The risk of death is significantly lower when
  care is provided in a trauma center than in a
  nontrauma center.

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Role of Prehospital Care

• The Emergency Medical Services system
  provides the first link
  to improved patient outcome.
• Goal delivery of trauma victims to definitive
  care sites within the golden hour.
• Rural EMS Services are challenged to provide
  timely trauma triage stabilization.

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Making a Difference

• Appropriate actions and triage decisions in the
  field can decrease in-hospital stay and the
  burden of injury.
• For example, a single episode
  of hypotension in the patient
  with traumatic brain injury
  doubles mortality.

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Trauma Centers Save Lives

• 15-19 reduction in injury-related mortality with
  trauma system implementation.
• Risk of death was decreased by 25 when care is
  provided at trauma centers.

• 678,000 injury victims across the nation have
  benefited from evaluation and treatment in a
  regional trauma center.

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Triage to a Trauma Center

• Currently, appropriate pre-hospital triage to a
  trauma center occurs in 33-71 percent of cases.
• A reasonable EMS system goal for appropriate
  trauma center triage rate is 65 percent.

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The Need For Accurate Triage

• Especially acute in the rural setting.
• In Florida more than 95 of the citizens have
  access to a trauma center by ground or air
  evacuation in less than 85 minutes.
• Transport decision must be made early in rural
  setting due to prolonged transport times.

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Barriers to Rural Trauma Care

• Delay in discovery of the victim or accident.
• Time lag for notification of 911.

• Prolonged time for prehospital mobilization and
  response.
• Prolonged scene time.
• Extended pre-hospital transport.

EMERGENCY TRAUMA CENTER
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Rural Trauma Challenges

• 2005 Florida Department of Health sponsored study
  A Comprehensive Assessment of the Florida Trauma
  System (Flint L. Orban B, Durham R, et al).
• Counties in Florida without trauma centers had
  the highest fatality rates.
• Study Focused on rural counties in northwestern
  Florida and the Panhandle.

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Scene Size up

• Personal safety BSI
• Scene Safety
• Safety of you and your partner
• Safety of patient and bystanders
• High index of suspicion

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Do You Need Help?

• Determine the total number of patients
• If you MIGHT need help - request it early
• Begin triage
• Minimize scene time

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Mechanism of Injury (MOI)

• Can help you focus on suspected injuries
• Helps to guide the assessment
• Trauma triage tools combined with paramedic
  judgment have been demonstrated to have the
  greatest predictive value in identifying
  seriously injured patients

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Significant Mechanism of Injury

• Ejection from vehicle
• Death in same
• passenger
• compartment
• Roll-over of vehicle
• High-speed vehicle collision
• Vehicle-pedestrian collision

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Significant Mechanism of Injury

• Falls greater than 20 feet Adults
• Falls greater than 10 feet Children
• Motorcycle crash

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Hidden Injuries

• Seat belts
• If buckled, may have produced injuries
• If patient had seat belt on, it does not mean
  they do not have injuries
• Airbags
• May not be effective without seat belt
• Patient can hit wheel after deflation
• Lift the deployed airbag and look at the steering
  wheel for deformation

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Child Safety Seats

• Injury patterns with airbags.
• Proper use in vehicles with airbags.
• For older children, The lap
  belt should fit snug and low
  over the upper thighs.
  If it rides up on
  the abdomen,
  it could cause serious injuries
  in a crash.

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Additional Infant Child Considerations

• Falls gt10 feet
• Bicycle collision
• Vehicle in medium speed collision

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Initial Assessment

• Goal-to identify and treat immediate,
  life-threatening conditions.
• General impression.
• Evaluate mental status (AVPU) and ABCs.
• Take C-spine control or delegate to someone while
  you continue the assessment.
• Age gt 55 or lt 16 special caution

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CNS Trauma Center Transport

• Adults
• Best Motor Response (BMR) lt 5 (less than
  localizing pain)
• GCS lt 12 independent of other criteria
• Pediatric
• Any altered mental status (including loss of
  consciousness) other than amnesia
• Adult or Pediatric
• Paralysis, loss of sensation, suspicion of spinal
  cord injury

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Assess Airway

• Responsive patient
• Talking or crying open airway
• Check for signs of inadequate breathing
• Unresponsive patient
• Open airway by appropriate means
• Check for signs of inadequate breathing

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Airway Trauma Center Transport

• Adults/Children
• ACTIVE airway assistance
  required (i.e., more than supplemental O2
  without airway adjunct)

CAUTION
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Airway Treatment

• GCS lt8, severe facial or cervical injury,
  respiratory insufficiency
• Patients without airway need emergency intubation
  with in line traction
• Alternative airway techniques
• needle cricothyroidotomy
• esophageal obturator types-combitube
• Confirm tube placement

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Assess Breathing

• Assess rate and depth
• Look for equal chest rise and fall
• Use high flow O2 by Non Re-breather oxygen mask
  for patients with inadequate breathing
• For adults breathing lt8 bpm or gt24 bpm, consider
  assisting ventilations with BVM
• Ventilate at age-appropriate rate for any
  patients not breathing

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Breathing Trauma Center Transport

• Adult patients with sustained respiratory rate
  less than 10 per minute or greater than 29 per
  minute.
• Pediatric patients breathing assistance beyond
  supplemental O2 and one-time need for suctioning
  without airway adjunct.

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Breathing Treatment

• All trauma patients should have oxygen therapy
• May need supplemental breathing with bag valve
  mask
• Tension pneumothorax should be relieved primarily
  by decompression
• Monitor O2 saturation  
• Sucking chest wound partially occlusive
  dressing
• Flail chest bulky dressing taped to chest wall

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Assess Circulation

• Assess pulse
• Look for and control
  external bleeding
• Assess skin color, moisture and temperature

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Circulation Trauma Center Transport

• Adult shock
• No radial pulse AND heart rate gt 120 OR
• BP lt 90 systolic
• Sustained heart rate gt 120 with radial pulse
  and BP gt 90 systolic

CAUTION
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Circulation Trauma Center Transport

• Pediatric shock
• No palpable pulses OR
• Weak carotid or femoral pulse OR
• Systolic BP lt 50
• Good carotid or femoral pulse with absent distal
  pulses OR
• Systolic BP 50-90

CAUTION
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Circulation Treatment

• Control bleeding
• Tourniquet as a last resort
• Splint deformities of extremities
• Large bore IVs in uninjured
  extremities
• Prehospital controversy
• Field resuscitation of intravascular
  volume
• MAST

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Rapid Trauma Assessment

• Continue spinal stabilization
• Reconsider transport decision
• Assess mental status
• Rapid Head to toe survey to rule out
  immediate life threats

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Head and Neck

• Assess the head, inspect and palpate for injuries
  or signs of injury
• Assess the neck, inspect and palpate
  for injuries or signs of
  injury
• Apply cervical spinal immobilization collar

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Head and Neck Trauma Center Transport

• Adult/Pediatric
• Paralysis, loss of sensation, suspicion of spinal
  cord injury
• Penetrating injury to head, neck, torso,
  excluding superficial wounds
• Pediatric patient who is not awake and appropriate

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Head and Neck Treatment

• IMMOBILIZATION
• C-collar
• Long spine board
• Control bleeding

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Chest Assessment

• Assess the chest
• Inspect
• Palpate
• Auscultative
  exam with
  stethoscope

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Chest Trauma Center Transport

• Any penetrating injury, especially sucking chest
  wound
• Flail chest
• Difficulty breathing or hypoxia (Low oxygen
  saturation) with evidence chest trauma
• Hoarseness or subcutaneous
  emphysema

CAUTION
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Chest Trauma Center Transport

• Suspected pneumothorax (especially tension
  pneumothorax)
• Tracheal deviation
• Difficulty breathing
• Chest Pain after trauma

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Chest Treatment

• Seal sucking chest wounds immediately
• Treat Flail Chest immediately
• Treat pneumothorax only if tension pneumothorax
  is suspected
• Monitor O2 saturation

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Abdomen Pelvis Assessment

• Assess the abdomen, inspect and palpate for
  injuries or signs of injury.
• Assess the pelvis, inspect and palpate for
  injuries or signs of injury.
• Include inspection of perineal (genital) area if
  mechanism warrants exam.

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Abdomen and Pelvis Trauma Center Transport

• Any penetrating injury, especially evisceration
• Any Rigidity or Tenderness with palpation
• Unstable pelvis Crepitus or pain with palpation
• Blood noted upon inspection of perineal area
• Visible seat belt marks or contusions with
  tenderness

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Abdomen and Pelvis Treatment

• Treat for shock
• Reevaluate upper abdominal injuries for chest
  involvement
• Cover eviscerations with moist sterile dressing
• MAST suit may be useful for unstable pelvic
  fractures

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Extremities Back Assessment

• Assess all four extremities, inspect palpate
  for injuries or signs of injury
• Examine pulses, motor sensory function
• Roll patient with spinal precautions assess
  posterior body, inspect palpate, examining for
  injuries or signs of injury

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Extremities and Back Trauma Center Transport

• Amputation proximal to wrist or ankle
• Degloving injury or flap avulsion gt 5 inches
• Multiple long bone fracture sites
• Single long bone fracture site due to MVC
• Single long bone fracture site due to fall from
  gt 10 feet

CAUTION
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Extremities and Back Treatment

• Splint during transport if possible
• Document pulse, motor and sensation before and
  after splinting
• Apply gentle traction to fracture or dislocation
  ONLY if pulses are absent
• Ice packs and
  elevation to injured
  extremity, if possible

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Skin Trauma Center Transport

• Adults gt 15 BSA 2nd and 3rd degree burns
• Pediatric gt 10 BSA 2nd 3rd degree burn
• Third-degree burns greater than 5 of the body
  surface area in any age group
• Second or third-degree thermal
  or chemical burns involving
  vital areas

CAUTION
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Skin Trauma Center Transport

• Electrical burns, including lightning injury
• Burns associated with other significant major
  injury or pre-existing
  disease
• Burn injury with
  inhalation injury

CAUTION
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Skin Treatment

• Burn dressings
• Treat for shock
• IV volume replacement
• Do NOT rupture blisters
• Do NOT put ointment,
  etc. on burns

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Detailed Physical Exam

• Look for medical identification devices
• Assess baseline vital signs
• Assess patient history (SAMPLE)
• On blood thinners?
• Perform a detailed physical examination

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On-going Assessment

• Unstable patient, repeat and record vital signs
  at a minimum every 5 minutes
• Reassess mental status
• Reassess airway
• Monitor breathing rate
  and quality
• Reassess circulation
• Re-establish patient
  priorities

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Helicopter Use

• Call air transport early with accurate patient
  condition evaluate weather
• Notify receiving hospital by radio with
  information which allows them to prepare
• Intubation and vent support
• Thoracostomy tubes
• O Negative
  blood
• Operating room
  readiness

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Indications for Helicopter Use

• Prolonged transport time
• Lengthy extrication
• Poor access to patient
• Multiple patients
• Anticipated need of whole blood
• Multi-system trauma requiring
  rapid surgical
• intervention

CAUTION
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Summary

• Rural Trauma Triage presents special challenges
• Accuracy is needed to get the patient transported
  to an appropriate Trauma Center
• A rapid, thorough exam is necessary
• Do only critical interventions on scene
• When indicated, call helicopter early

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Bibliography

• Anderson Ronald, Trunkey Donald, et al. U.S.
  Trauma Center Crisis Lost in the Scramble for
  Terror Resources. 2004. National Foundation for
  Trauma Care Irvine, CA
• Flint L. Orban B, Durham R, et al.
• A Comprehensive Assessment of the Florida
  Trauma System. 2005. University of South
  Florida, University of Florida, Office of Trauma,
  Florida Department of Health, Division of
  Emergency Medical Operations.
• Florida Adult Trauma Scorecard Methodology. 2005.
  Ch 64E-2.017 Florida Administrative Code.
• Florida Pediatric Trauma Scorecard Methodology.
  2005. Ch 64E-2.0175 Florida Administrative Code.
• MacKenzie Ellen J., et al. A National Evaluation
  of the Effect of Trauma-Center Care on
  Mortality. N Engl J Med 2006354366-78.
• Ma MH, MacKenzie EJ, Alcorta, R, Kelen GD.
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  major trauma patients. J Trauma 1999
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• Petersen Scott R. Interfacility Transfer of
  Injured Patients Guidelines for Rural
  Communities. 2002. American College of Surgeons
  Committee on Trauma. Chicago, IL.
• United States. CDC Acute Injury Care Research
  Agenda Guiding Research for the Future. 2005.
  Office of Statistics and Programming, National
  Center for Injury Prevention and Control, Centers
  for Disease Control and Prevention. Atlanta, GA
• United States. EMT-Basic National Standard
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  Administration. Washington, DC.
• United States. Paramedic National Standard
  Curriculum. 1998. United States Department of
  Transportation National Highway Traffic Safety
  Administration. Washington, DC.
• United States. Trauma System Agenda For The
  Future. 2002. American Trauma Society and U.S.
  Department of Transportation, National Highway
  Traffic Safety Administration. Washington, DC.