Prehospital Trauma Triage

1. Prehospital Trauma Triage Jim Holliman, M.D., F.A.C.E.P. President-Elect, International Federation for Emergency Medicine Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland, U.S.A. Adjunct Professor of Emergency Medicine Nanjing Medical University

2. Prehospital Trauma Triage : Lecture Objectives • Summarize techniques of effective communication between prehospital care providers and the Emergency Department (E.D.) to which they are bringing a trauma patient • Provide advice on communications for specific situations • Review different systems of field trauma triage

3. Goals of Prehospital Trauma Triage • Identify the trauma patients that will need a high level of trauma care • Bring the trauma patient to the particular hospital that will be the most capable of caring for the patient • Efficiently care for and distribute patients from multi-casualty events

4. Importance of Communication Between Prehospital Care Providers and the Emergency Department (E.D.) • Allows early warning of the E.D. to prepare for incoming trauma patients • Clear rooms or stretchers • Obtain equipment • Obtain extra personnel • Put other services "on hold“ or “on notice” • Operating room(s) • Radiology • Clinical laboratory • Blood bank • Chaplain / public relations • Specialty surgical services

5. Importance of Communication Between Prehospital Care Providers & the E.D. (continued) • Allows physician ("medical command") input into prehospital decision-making • Allows coordination between multiple receiving facilities • Allows acquisition of additional resources if needed for prehospital personnel : • helicopter • hospital-based personnel • Additional ambulances

6. Timing of Prehospital Radio or Cell Phone Reports for Trauma Patients • Should be given prior to leaving the scene, or at initiation of transport, especially if transport time is less than 5 to 10 minutes • However, should not delay or extend on-scene time • Should take < 45 seconds for complete report (especially if multi-victim incident) • Quality Assurance (Q/A) programs should monitor this

7. What Information Should be Relayed in the Prehospital Care Report ? • Number of victims, their ages & gender • Identity of units transporting • Mechanism of injury • Verified & suspected major injuries • Vital signs • Treatment measures started • Estimated Time of Arrival (E.T.A.) • Any special precautions for the E.D.: • Hazardous materials contamination • Combative patient or accompanying persons

8. Hospital Personnel to Consider Notifying About an Incoming Trauma Patient • Radiology technicians • Computed tomography technicians • Respiratory therapy • Blood bank • Security • Chaplain • Intensive care unit • Operating room • Public relations & administration

9. Specific Equipment to Consider Readying Upon Notification of Incoming Trauma Patients • Airways / Endotracheal tubes / laryngoscopes • Sedatives / paralytic agents • Intravenous bags / lines • Blood tubes / blood gas kits • Chest tubes / waterseal bottles or Pleurevacs • O negative blood units from blood bank • Universal precautions gowns, etc.

10. Criteria to Consider Dispatching a Physician to the Trauma Scene • Prolonged patient entrapment anticipated • Only central intravenous access possible • Limb amputation required for extrication • Chest tube required • Antibiotics or pain meds required • Multicasualty incident requiring field triage

11. Criteria for Consideration for Helicopter Dispatch for Trauma • The patient meets one or more of the criteria for referral to a trauma center, and : • Distance from trauma center > 16 km. • Snow or highway congestion will delay ground transport • Multiple on-scene victims • Medical skills beyond those of ground personnel required

12. American College of Surgeons (ACS) Prehospital Criteria for Referral to a Trauma Center • Vital signs and level of consciousness (any one or more of the following) : • Glasgow Coma Scale (GCS) < 14 • Respiratory rate < 10 or > 29 • Pediatric Trauma Score < 9 • Systolic BP < 90 • Revised Trauma Score < 11

13. ACS Prehospital Criteria for Referral to a Trauma Center (cont.) • Anatomy of Injury • Flail chest • Pelvic fractures • Two or more proximal long bone fractures • Burns > 10 % Total Body Surface Area (TBSA) with inhalation injuries or other trauma • Penetrating injuries to head, neck, torso, or proximal limbs • Limb paralysis • Proximal limb amputation

14. ACS Prehospital Criteria for Referral to a Trauma Center (cont.) • Mechanism of injury / high energy impact : • Ejection from vehicle • Death of another occupant of the vehicle • Pedestrian thrown or run over by vehicle • Displacement of front axle > 50 cm. • Intrusion into passenger compartment > 30 cm. • Falls > 6 meters height • Vehicle roll-over • Motorcycle crash > 32 km/hr with separation of rider and biike

15. ACS Prehospital Criteria for Referral to a Trauma Center (cont.) • Suspected major trauma & preexistent conditions : • Age < 5 or > 55 years • Cardiac disease • Respiratory disease • Insulin dependent diabetes • Cirrhosis • Malignancy • Obesity • Coagulopathy

16. Physician Medical Command Responsibilities for Multi-Casualty Incident • Determine how many patients his hospital can accept • E.D. capacity • Call Intensive Care Unit (ICU) to determine # of ICU beds available • Notify Operating rooms • Call other local hospital E.D.'s by phone to determine their capacity • Call on-scene personnel by radio or phone to inform them of hospital capacities • Consider activation of hospital disaster plan • Consider mobilization of other resources • Regional helicopters • Military units

17. Advice for Communication with Prehospital Personnel • Sometimes prehospital personnel need to be reminded of these principles of emergency trauma care : • If a patient has multiple injuries, treat first the one that is the greatest threat to life. • Indicated treatments should not be withheld or delayed simply because the diagnosis is not certain. • A detailed history is not essential to start evaluation & treatment.

18. Advice for Communication with Prehospital Personnel (cont.) • In multicasualty situations, sometimes prehospital personnel need to be reminded : • If adequate personnel / equipment available : • Treat first those with life-threatening or multiple injuries • If field personnel & equipment not adequate : • Treat patients first with greatest chances of survival • Treat first patients requiring least time, personnel, & equipment

19. Advice for Communication with Prehospital Personnel (cont.) • Don't expect personnel to enter an unsecure scene or put themselves at risk • May need to delay evaluation or treatment of a patient from an insecure scene till the patient is in the ambulance • The physician may need to talk directly to on-scene police by phone or radio to facilitate their cooperation

20. Advice for Communication with Prehospital Personnel (cont.) • Order adequate restraints for violent patients to protect the crew • May require police to accompany crew in vehicle • Don't expect blood draw or IV until patient restrained • Restraint IMPERATIVE for safe aeromedical transport • Usually need chemical restraint ( benzodiazepines, narcotics, +/- haloperidol) • Once patient restrained, evaluate for hypoxia, hypoglycemia, and hyperthermia

21. Advice for Communication with Prehospital Personnel (cont.) • If hospital-based physicians expect prehospital personnel to give brief & focused reports, then they should not ask for repeated or irrelevant information from the prehospital personnel : • Family history always irrelevant • If immobilization, O2, & IV fluids already started, then only a few limited additional interventions are possible: • Check for hypoglycemia, +/- give IV 50 % dextrose or glucagon • Naloxone for narcotic overdose • Cardiac or respiratory medications are almost never indicated for trauma patients prehospital

22. Advice for Communication with Prehospital Personnel (cont.) • Requirements to allow a valid refusal of transport by a trauma patient : • Patient has been completely examined by prehospital personnel • Patient is alert & oriented • No significant head injury • No alcohol / illicit drugs • Not a minor • No possible child abuse or neglect • All the above should be documented on trip sheet • If in doubt, ask to talk to the patient directly • Alternative is to have police arrest the patient & take him to the E.D.

23. Advice for Communication with Prehospital Personnel (cont.) • Criteria to allow an Advanced Care Prehospital Unit to release a trauma patient to a Basic Care transport unit : • The patient is awake, alert, oriented • Age < 55 years • Pulse 60 to 100 • Systolic BP 100 to 180 • Diastolic BP < 100 • No respiratory distress • Bleeding controlled • No past history of cardiac or respiratory disease • No ACS major trauma criteria (anatomy or MOI) • Private vehicle transport should be allowed only for no evident injuries or for isolated distal extremity trauma

24. Considerations for Pronunciations of Death in Prehospital Trauma Patients • If patient develops asystole or arrest prior to arrival of helicopter, usually air transport should then be denied • If penetrating trauma and some initial signs of life that are subsequently lost, rapid transport still indicated • If possible hypothermia, should transport with CPR even if in cardiac arrest

25. Criteria for Death Pronunciations in the Field by Prehospital Personnel • Decapitation • Rigor mortis (caution: possible hypothermia) • Dependent lividity • Major open brain injury or trunk dismemberment • Adult with blunt trauma mechanism and asystole (caution : possible high voltage electrical or lightning injury) • Some blunt trauma victims in cardiac arrest may be considered for resuscitation attempt & transport for possible organ donation • “Do Not Resuscitate” (DNR) status directly verified by patient's physician • Always notify police

26. Monitoring On-scene Time by Prehospital Personnel • For any unstable non-entrapped trauma victim : on-scene time should be < 10 minutes • Scene times should be monitored in a Quality Assurance Program • The only procedures which should be done on scene : • Airway management / intubation / ventilation • Control of external hemorrhage • Spine & neck immobilization • IV placement should be done in vehicle • For entrapped patient and non-professional rescue squad • crew should ensure patient extricated by fastest and simplest means

27. Special Types of Trauma That May Mandate Altering the Destination Hospital • Need for hyperbaric oxygen chamber • Carbon monoxide poisoning (this is debated) or diving injury • Major burns • Need for limb replantation • Hazardous materials or radiation contamination • Active duty military patient • Previous organ transplant patient

28. General Scheme of Prehospital Trauma Care • "Stay and Play" vs. "Scoop and Run" • a number of studies now have shown no survival benefit to on-scene Advanced Life Support care for trauma • so "Load and Go" or "Scoop and Run" is best approach • Third true alternative however: "Scoop and Treat" • care measures done enroute to hospital in vehicle • documented high IV success rates • saves time compared to IV placement in E.D.

29. Prehospital Trauma Scoring Systems and In-Field Triage • Goal of scoring systems is to identify patients who would benefit from transport to a trauma center • If calculated mortality > 10 %, should go to trauma center • Expected "undertriage" rate is 5 % • Expected "overtriage" rate is 30 to 50 % • AIS (Abbreviated Injury Scale) & ISS (Injury Severity Score) cannot be used prehospital because these require known definitive diagnosis

30. Required Criteria for Prehospital Trauma Scoring Systems • Simple • Based on easily accessible data • Have predictive validity • Correlate with outcome measures (death, disability) • Have face validity • Be intuitively reasonable to personnel • Have inter- & intra- observer reliability

31. Prehospital Trauma Scoring Systems (and year of introduction) • Trauma Index (1971) • Glasgow Coma Scale (1974) • Triage Index (1980) • Trauma Score (1981) • CRAMS Scale (1982) • Prehospital Index (1986) • Revised Trauma Score (1989) • Trauma Triage Rule (1990) • Pediatric Trauma Score (1987)

32. Glasgow Coma Scale (GCS) Points • Eye Opening ( E score ) • Spontaneous 4 • To speech 3 • To pain 2 • None (closed) 1 • Best motor response ( M score ) • Obeys commands 6 • Moves toward stimulus 5 • Withdraws to pain 4 • Flexion response to pain ** 3 • Extensor response to pain* 2 • None 1 • Best Verbal Response (V score) • Oriented 5 • Confused 4 • Inappropriate (garbled) 3 • Incomprehensible (grunts) 2 • None 1 • Sum of the E, M, & V scores then is the GCS score # ** (decorticate posturing) * (decerebrate posturing)

33. Use of GCS to Categorize Head Trauma Severity • Older Categorization Scheme : • Severe : GCS < or = 8 • Moderate : GCS 9 to 12 • Minor : GCS 13 to 15 • Modern Categorization Scheme : • Severe : GCS < or = 12 • Moderate : GCS 13 to 14 • Minor : GCS 15

34. The Four Most Popular Prehospital Trauma Scoring Systems • Revised Trauma Index (Smith, 1990) • Score > 15 : 95 % sensitive, 37 % overtriage • Trauma Score (Champion, 1981, 1986) • Score < 14 : 66 % sensitive, 25 % overtriage • CRAMS (Gormican, 1982, 1988) • Score < 6 : 95 % sensitive, 48 % overtriage • Trauma Triage Rule (Baxt, 1990, 1995) • If positive : 92 % sensitive, 8 % overtriage

35. Revised Trauma Index Scores 1 3 5 6 Region Limbs Skin Back only Chest only Head, Abd., Multiple Type Minor open wound Single blunt, 2nd deg burn Major wound, 3rd deg burn GSW, Multi blunt Cardiovasc. SBP > 100 Pulse < 100 SBP 80 to 100 P 100 to 140 SBP < 80 Pulse > 140 No pulse Respiratory Chest pain 10< RR < 25 25 < RR < 35 RR >35, <10 Retractions Apnea CNS Drowsy, Confused Responds to verbal Responds to pain Unresponsive Add highest in each category for total score : 3 to 9 is minor, 10 to 14 is moderate, 15 to 19 is severe, and > 20 is critical. If Trauma Index is 15 or more, then transfer to trauma center.

36. The Trauma Score Points Respiratory Rate 10 to 24 25 to 35 > 35 < 10 0 4 3 2 1 0 The Trauma Score is the Sum of the 5 Category Points (range 1 to 16) Respiratory Effort Normal Shallow or retractive 1 0 Systolic Blood Pressure > 90 70 to 90 50 to 69 < 50 0 4 3 2 1 0 Capillary Refill Normal Delayed None 2 1 0 Glasgow Coma Scale 14 to 15 11 to 13 8 to 10 5 to 7 3 to 4 5 4 3 2 1

37. Correlation of Trauma Score (TS) & Percent Survival • TS 16 : 99 % • TS 15 : 98 % • TS 14 : 95 % • TS 13 : 91 % • TS 12 : 83 % • TS 11 : 71 % • TS 10 : 55 % • TS 9 : 37 % • TS 8 : 22 % • TS 7 : 12 % • TS 6 : 7 % • TS 5 : 4 % • TS 4 : 2 % • TS 3 : 1 % • TS 2 : 0 • TS 1 : 0

38. Revised Trauma Score Score : Respiratory rate (breaths/min.) 10 to 24 25 to 35 > 36 1 to 9 0 4 3 2 1 0 RTS then is the sum of the three scores (range 0 to 12) Systolic blood pressure (mm Hg) > 89 70 to 89 50 to 69 1 to 49 0 4 3 2 1 0 Glasgow Coma Scale 13 to 15 9 to 12 6 to 8 4 to 5 < 4 4 3 2 1 0

39. CRAMS Scoring System (score < 8 is major trauma, score > 8 is minor trauma) Score : Circulation Normal cap refill & BP > 100 Delay cap refill, 85<BP<100 No cap refill or BP < 85 2 1 0 Respirations Normal Abnormal (labored) Absent 2 1 0 Abdomen Abdomen & chest nontender Abdomen or chest tender Abd rigid, flail chest, or stab 2 1 0 Motor Normal Responds only to pain No response or decerebrate 2 1 0 Speech Normal Confused No intelligible words 2 1 0 CRAMS Score = C + R + A + M + S Scores

40. The Trauma Triage Rule • Major trauma defined as any patient with one or more of these 3 parameters : • Systolic blood pressure < 85 mm Hg • Motor component of Glasgow Coma Scale < 5 • Penetrating trauma of head, neck, or trunk

41. Pediatric Trauma Score (PTS) Score : +2 +1 Minus 1 Weight > 20 kg 10 to 20 kg < 10 kg Airway Normal Oral or nasal airway Intubated Systolic Blood Pressure (mm Hg) > 90 50 to 90 < 50 Level of Consciousness Completely awake Obtunded or loss of consciousness Comatose Open Wound None Minor Major or penetrating Fractures None Minor Open or multiple Total score < 8 implies need to refer patient to pediatric trauma center

42. Studies of Paramedic Subjective Judgement as a Prehospital Trauma Triage Method • Fries et al. (1994) • 91.4 % sensitive, 60 % specific • Emerman (1991) • Judgement more sensitive than Trauma Score • Ornato (1985) • 93 % sensitive, 91 % specific • Hedges (1982) • Less sensitivity, but different major trauma definition used, & medics less experienced

43. Prehospital Trauma Triage : Summary • Focused communications are important for E.D. preparation to receive a trauma patient, & for guidance in prehospital decision-making • The Trauma Triage Rule or experienced prehospital personnel subjective judgment are the best & simplest prehospital trauma triage methods • Ask the prehospital personnel directly if they think the trauma patient warrants referral to a trauma center and if the patient will need a maximum trauma response from the E.D.