Field Triage of Trauma Patients

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Field Triage of Trauma Patients

• Gregory J Jurkovich, MD
• Chief of Trauma
• Harborview Medical Center
• Professor of Surgery
• University of Washington

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Goal

• Get the right patient. . .
• To the right hospital. . .
• In the right amount of time.

Patient destination based upon medical
appropriateness
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• Transfer of trauma patients to designated trauma
  centers has been shown to improve outcomes
• West JG, et al., Arch Surg, 1979
• West JG, et al., Arch Surg, 1983
• Shackford SR, et al., J Trauma, 1986
• Waddell TK, et al., J Trauma, 1991
• McKenzie et al, NEJM, 2006

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• Improved outcomes have also been associated with
• Institutional volume
• Smith SF, et al., J Trauma, 1990
• Per-surgeon volume
• Konvolinka CW, et al., Am J Surg, 1995
• Severity of injury encountered by attending
  surgeons
• Richardson JD, et al., J Trauma, 1998

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Triage

• Undertriage 5
• Failure to transport major trauma patients to a
  trauma center
• Often a political issue
• Overtriage 30-50
• Transporting minimally injured trauma patients to
  a trauma center
• Often a financial / resource issue

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Major Trauma Patient

• ISS gt 15 frequently used
• Correlates well with mortality over a broad range
  of ages and injuries
• Knudson MM, et al., Arch Surg, 1994
• Buckley SL, et al., J Pediatr Orthop, 1994
• Gustilo RB, et al., Orthop, 1985
• Jones JM, et al., J Trauma, 1995
• Shedden PM, et al., Pediatr Neurosurg, 1990
• Chen RJ, et al., Eur J Surg, 1995
• Cant be calculated in the prehospital setting

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Major Trauma Definitions

• Injury Severity Score
• ISS (nISS) gt 15
• ISS gt 9
• Death
• Resource Need
• ED to OR direct triage
• ED to Angio direct triage
• ICU care needed ?
• Blood products in first 24 hours ?

Not much data currently available on resource use
criteria
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Trauma Scores

• Trauma Index
• Kirkpatrick JR, Youmans RL, J Trauma, 1971
• Trauma Score / Revised Trauma Score
• Champion HR, et al., Crit Care Med, 1981
• Champion HR, et al., J Trauma, 1989
• CRAMS scale
• Gormican SP, Ann Emerg Med, 1982
• Prehospital Index
• Koehler JJ, et al, Ann Emerg Med, 1986
• Trauma Triage Rule
• Baxt WG, et al., Ann Emerg Med, 1990

Each with limitations, lacking clear superiority
over others
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Key Problematic Issues in Trauma Triage

• Definition of Major Trauma Patient
• Patients who benefit from Level I care?
• Resource use criteria? ISS criteria?
• Best Outcome Measures (Mortality,?)
• Trauma Team Activation Indicators
• Secondary Triage
• Validation of Trauma Triage Tool
• Data Linkage

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System Designs Influence Field Triage

• No system big problems
• Exclusive system all trauma going to a few
  hospitals?
• Inclusive system field triage key to preventing
  delays secondary triage

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A MODEL TRAUMA SYSTEM
Severe Injuries
15
Rehabilitation
85
Moderate Injuries
Acute Care
Minor Injuries
Prehospital Care
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Resource Consumption
193
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Annual Crash Distribution
Based on NASS/CDS 1995-2003 Annual Averages
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Figure 1 Trauma Centers All Levels
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History of ACS Field Triage Criteria


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• 1976 First version Optimal Hospital
  Resources for Care of the Seriously Injured
  NO PRE-HOSPITAL OR TRIAGE GUIDELINES.
• 1979 Second version Hospital and Prehospital
  Resources for Optimal Care of the Injured
  Patient Appendix E
• 1983 Third version. Appendix F covered triage
  guidelines but was never published in the ACS
  bulletin

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1979 ACS Bulletin Appendix D E

• Guidelines for inter-hospital transfer
• Domains
• System-specific injuries
• Late sequelae

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Early versions of field triage 1980 - Champion et
al, J Trauma 8(4) 207 Resource
Document 1987 1990 1999
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1990 The Orange Book. New Title. Revised
triage scheme

• RTS, PTS added

• proximal penetrating injuries added

• Burns gt 15, face airway changed to 10 or
  inhalational injuries

• Pelvic fx, limb paralysis, proximal amps added

• Vehicular deformity decreased from 30 to 20

• Intrusion from 18/24 to 12

• Auto - ped from 20 to 5 mph

• MCC 20 mph or separation

• psychotics co-morbidities added

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Trauma Triage 2007
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Field Triage Revision Meetings 2005-06

• CDC
• NHTSA
• ACEP
• ACS COT

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My thanks to

• E. Brooke Lerner, Ph.D.
• Robert McKersie, MD
• Jeff Salomone, MD
• Mark C. Henry, MD
• Steward Wang, MD
• Robert E. OConnor, M.D., MPH

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2007 ACS Field Triage Decision Scheme Retained
the step approach to field triage Aware of
overtriage harm
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Step 1 Physiologic Criteria

• GCS lt 14 or
• Systolic BP lt 90 or
• Respiratory rate lt10 or gt29 (lt20 in infant lt one
  year)

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Step 1 Physiologic Criteria

• Drop RTS scoring. It is seldom used, it is
  redundant to measure, and it is inconsistent in
  its triage point relative to the other
  physiologic variables.
• Pediatric-specific vital signs are unnecessary
  except for respiratory rate. Heart rate is too
  variable to be reliable, a lower BP is only
  relevant for infants and over-triage would not be
  unacceptable, and RR will pick up those infants
  in respiratory distress and shock.

i.
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Step 2 Anatomic Criteria

• All penetrating injuries to head, neck torso and
  prox. extremities
• Flail chest
• Crush, degloved or mangled extremity
• Amputation prox. to wrist and ankle
• Pelvic fractures
• Open or depressed skull fracture
• Paralysis

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Step 2 Anatomic Criteria

• i. there is likely a difference in need for
  surgical response for gun shot and stab wound
  mechanisms, but not for pre hospital triage.
• ii. Flail chest, two or more proximal long-bone
  fractures, parlaysis, pelvic fractures and
  amputation proximal to wrist and ankle are
  unchanged criteria.
• iii. Open or depressed skull fracture, not open
  and depressed.
• iv.Crush, degloved or mangled extremity added.
• v. Burns are removed from this section and placed
  in Step Four, to emphasize the need to determine
  if the burn occurred with or without other
  injuries.

i.
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Transition Boxes

• Take to a trauma center. Step 1 and 2 attempt to
  identify the most seriously injured patients.
  These patients would be transported
  preferentially to the highest level of care
  within the trauma system.

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Transition Boxes

• These emphasize that the goal of triage is to
  identify the most seriously injured patient and
  to get them to the highest-level trauma center
  available in the system. This applies to both
  Step 1 and Step 2 patients. In most systems this
  will be a Level I or II trauma center. The level
  is specifically not stated to allow local system
  assessment and control.

i.
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Step 3 Mechanism of Injury Criteria

• Falls
• Adults gt 20 ft (one story is 10 ft)
• Children gt 10 ft or 2-3 times the height of the
  child
• High risk auto crash
• Intrusion gt 12 in occupant site gt 18 in any site
• Ejection (partial or complete)
• Death of an occupant
• Vehicle telemetry data consistent with high risk
  of injury
• Auto v. pedestrian/bicyclist thrown, run over, or
  with significant ( gt 20 mph) impact
• Motorcycle crash gt 20 mph

i.
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Crash Direction and Delta-V
Threshold
Higher Injury Risk at Low Delta-V for Nearside
Crashes!
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Evaluation of ACS criteria

• Esposito 1995 All patients who meet at least
  one of the criteria (identified prehospital or
  hospital) over a year statewide (n2,260)
• 24 of patients who meet any one of the criteria
  had severe trauma
• Resulting in 76 of patients being over triage

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Mechanism of Injury Criteria

• Knopp, R 1988
• Prospective 9 week study of all EMS calls in a
  single county and transfers from surrounding
  counties.
• Trauma defined ISSgt15

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Step 3 Mechanism of Injury Criteria

• Most changes to minimize over-triage.
• Falls specified, with adult and pediatric
  criteria.
• iii. High-risk auto crash data were established
  based on best data from the CIREN project, as
  well as literature searches and published
  information from hospitals or trauma systems.
  Three of the four criteria listed (intrusion,
  ejection, death) are retained from previous
  versions, and have evidence to support a 20
  positive predictive value (PPV) of candidate
  criteria to predict ISS 15, major OR, or ICU
  admission.

i.
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Step 3 Mechanism of Injury Criteria

• iv. Crash telemetry data may provide the best
  information on forces applied at the time of a
  MVC, and the group felt this document should
  encourage and support efforts to make this data
  available to pre-hospital personnel. Crash
  telemetry data is available from at least two
  vendors (e.g. OnStar) and becoming industry
  standard in new cars.
• v. Pedestrians or bicyclists struck by cars, or
  run over at a rather arbitrary, but higher than
  previous versions of this document, were
  retained.
• vi. Motorcycle crash was retained.

i.
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Step 3-4 Transition Box
Transport to closest appropriate trauma center,
which, depending on the trauma system, need not
be the highest level trauma center.
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Step 3-4 Transition Box
This box has different wording specifically to
emphasize the ability to make use of inclusive
trauma systems, and to not overly burden a single
trauma center. Best data supports the triage of
Step 3 patients to lower level trauma centers in
an inclusive system as being safe and effective.
Specific wording and arrow directions next
emphasize that there may be special patient or
system consideration at this point in
pre-hospital triage decisions that can and should
apply, and this is addressed in Step 4.
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Step 4 Special Circumstances

• Age
• Anticoagulation and bleeding disorders
• Burns
• Time senstive extremity injury
• End-stage renal disease requiring dialysis
• Pregnancy gt 20 weeks
• EMS provider judgement

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Step 4 Special Circumstances

• Age
• Risk of death increases after age 55
• Children should be triaged preferentially to
  pediatric-capable trauma centers
• Burns
• Without trauma -- take to a burn center
• With trauma -- take to trauma center

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Step 4 Special Circumstances- Paramedic judgement

• Data mixed
• Simmons 1995
• Advanced provider judgment combined with triage
  criteria improved prediction of need for trauma
  center evaluation
• Fries 1994
• Medic judgment had a 91 sensitivity and 60
  specificity
• When used with the Baxt criteria 100 sensitivity
  and 75 specificity
• May lead to abuses
• Other hospitals dont like HIV patients
• He didnt look like he had insurance
• You guys do a better job than other hospitals

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Final Words

• Contact medical control and consider transport to
  a trauma center or specific resource hospital
  (e.g dialysis, OB)
• When in doubt, transport to a trauma center