Systematic Trauma Triage

1. Systematic Trauma Triage Pret Bjorn, RN, etc Trauma Coordinator EMMC 45 minutes of review in less than 90 minutes!

2. Definitions & History

3. TRAUMA “The neglected disease of modern society.”

4. U.S. Trauma ONE DEATH EVERY SIX MINUTES (90,000 per year) ONE INJURY EVERY TWO SECONDS (18,200,000 per year) Source: National Safety Council Estimates

5. Injuries per 1,000 Persons per Year 900 Not Injured 90 Discharged with Minor Injury 8 2 Admitted with Minor Injury Admitted with Major Injury Source: Cales & Associates

6. Early Battlefield Triage:The 18th Century • Evacuation of major injuries typically waited until darkness. • Average time from injury to treatment was 24-36 hours • Many wounded soldiers remained on the battlefield for three to four days. • Mortality for major injury > 80%

7. Baron Dominique Jean Larrey (1766-1842) • Chief Surgeon of Napoleon’s Grand Army • First to use the term triage in medicine • Developed “Flying Ambulances” • Used rapid evacuation and early amputation to substantially reduce battlefield mortality

8. Modern Military Triage Korea • Rapid transfer without treatment (How? Why?) • Battalion aid stations • M*A*S*H Vietnam • Bleeding control • IV’s • Splinting • Bypass of aid stations in favor of hospitals 1.8% Mortality from major injuries

9. MODERN EMS • Leaders in organized civilian emergency care • Documentation • Education • Quality Improvement • EMS Triage: the starter’s pistol

10. Trauma is Tricky to Triage • Variable number of patients • Disease of the young • Potential injury to various & multiple systems • Most common symptom is subjective (pain) • Most common objective symptoms are respiratory failure & shock (“a momentary pause in the act of dying”)

11. Blunt trauma is trickier than penetrating - and more common EMMC TRAUMA REGISTRY JUNE ‘95 TO MAY ‘98

12. Systematizing Trauma Triage The ACS and Howard Champion

13. The Champion Trauma Triage Decision Scheme PART ONE

14. The Champion Trauma Triage Decision Scheme PART TWO

15. The Champion Trauma Triage Decision Scheme PART THREE

16. Does it need to be so hard?

17. METHODOLOGY of TRAUMA TRIAGE It’s easier than you might think

18. Three Components of Trauma Triage Assessment • Physiologic Stability • Anatomic Injury • Kinematic Factors

19. PHYSIOLOGIC markers of severity

20. Select Physiologic Indices GLASGOW COMA SCORE REVISED TRAUMA SCORE PEDIATRIC TRAUMA SCORE

21. GLASGOW COMA SCORE (GCS) Eye-opening, verbal, and motor responses 3-15 points Beware the “A-V-P-U” system

22. Calculating the GCS 3 +4 +5 = 12

23. REVISED TRAUMA SCORE (RTS) Overall severity assessment based on combined physiologic findings: • GCS • Systolic B/P • Respiratory Rate

24. Calculating the RTS 1 +4 +1 = 6

25. PEDIATRIC TRAUMA SCORE (PTS) • Developed to reflect differences between adult & child physiology • Diminished emphasis on blood pressure • Scores reflect size, airway patency, and severity & multiplicity of obvious wounds • Superiority over RTS is as yet unproven

26. Calculating the PTS 2 +2 +1 +1 -1 -1 = 4

27. ANATOMIC markers of severity

28. Destabilizing Injury Types • Multiple proximal long bone fractures • Pelvic fractures • Penetrating central injuries

29. Specialty Care Concerns • Burns • Spinal cord injuries • Frank brain injury (open/depressed skull fractures) • Proximal amputations (above wrist or ankle)

30. KINEMATIC markers of severity (AKA MOI)

31. Traditional Kinematic Markers

32. Expressions of Vehicle Deformation • Various vehicle intrusions • Axle displacement • Steering wheel collapse • Starred windshield

33. Estimates of “v” • Fall >x feet • MVC >x mph • Pedestrian/cyclist struck by auto

34. Other Kinematics • Ejection • Rollover • CO-OCCUPANT FATALITY

35. So mechanism of injury isn’t important?

36. Putting it all together

37. MAINE EMS TRAUMA TRIAGE PROTOCOL • Determine: • Glasgow Coma Scale • Systolic Blood Pressure • Respiratory Rate • I. OLMC confirms RTS/PTS • II. OLMC considers patient transport to Trauma Center, using following guidelines: • a) If transport time by ground or air to Trauma Center is less than 30 minutes, patient should go to Trauma Center directly; • b) If transport time to Trauma Center is greater than 30 minutes, determine the difference in transport time between the Trauma Center and the most accessible hospital: • 1) If difference is less than 10 minutes, consider transport to Trauma Center; • 2) If difference is greater than 10 minutes, consider transport to most accessible hospital; • III. If, upon arrival in the ED, • a) Facility is not a Trauma Center, and; • b) Patient continues to satisfy criteria of Assessments One and Two, and; • c) Patient can be stabilized for further transport, then receiving ED clinician should provide only life-saving procedures (avoiding unnecessary diagnostics) prior to transport to Trauma Center unless he/she judges clinical situation to not warrant such transfer. Calculate: Revised Trauma Score (RTS) or Pediatric Trauma Score (PTS) YES Is RTS <11 or PTS <8? NO • Determine: if any of the following exist: • Paralysis; • Amputation proximal to wrist or ankle; • Penetrating injury to chest, abdomen, head or neck; • Two or more proximal long bone fractures; • Unstable pelvic fracture; • Open or depressed skull fracture; • Burn associated with trauma YES NO Determine: if there is associated fatality in same vehicle compartment YES NO If pre-hospital providers are unable to definitively manage the airway, maintain breathing or support circulation, begin transport to most accessible hospital and simultaneously request ALS intercept and OLMC. TRANSPORT TO TRAUMA SYSTEM PARTICIPATING HOSPITAL

38. Green One, Part One:PHYSIOLOGIC INSTABILITY • Revised Trauma Score • Resp Rate • Systolic B/P • GCS • Pediatric Trauma Score • Weight • Airway • Distal Pulse • LOC • Open Wounds • Fractures

39. Green One, Part Two:ANATOMIC COMPROMISE • Paralysis • Amputation above wrist or ankle • Penetrating injury to head, neck or trunk • Two or more proximal long bone fractures • Unstable pelvic fracture • Open or depressed skull fracture • Burn associated with trauma

40. Green One, Part Three:KINEMATICS • Death of another occupant of same vehicle compartment

41. Green One, System LinkageON-LINE MEDICAL CONTROL • Patient destination directed locally • Field treatment guided by physicians • Hospital responses initiated by prehospital data • Special transport options now available (LifeFlight of Maine)

42. I. OLMC confirms RTS/PTS • II. OLMC considers patient transport to Trauma Center, using following guidelines: • a) If transport time by ground or air to Trauma Center is less than 30 minutes, patient should go to Trauma Center directly; • b) If transport time to Trauma Center is greater than 30 minutes, determine the difference in transport time between the Trauma Center and the most accessible hospital: • 1) If difference is less than 10 minutes, consider transport to Trauma Center; • 2) If difference is greater than 10 minutes, consider transport to most accessible hospital; • III. If, upon arrival in the ED, • a) Facility is not a Trauma Center, and; • b) Patient continues to satisfy criteria of Assessments One and Two, and; • c) Patient can be stabilized for further transport, then receiving ED clinician should provide only life-saving procedures (avoiding unnecessary diagnostics) prior to transport to Trauma Center unless he/she judges clinical situation to not warrant such transfer.

43. Hospital Trauma Alert Systems:Code-11 and Tiered Response

44. Patient Distribution

45. Emergency Department Deaths/DRA’s

46. Overall Mortality

47. ED Death or Admit to ICU 100% Mean ISS 27.90 Mean ISS 15.84 Mean ISS 23.3

48. ED Death or Admit via OR Mean ISS 27.60 Mean ISS 24.07 Mean ISS 6.99

49. Delivery of a Living Patient to ICU Mean ISS 15.79 Mean ISS 23.6 Mean ISS 28

50. Let’s Play...