This post will be sort of a reference for people to find trauma triage criteria I refer to in later posts. One problem with trauma triage criteria is that they are referred to as being promoted by the ACS (American College of Surgeons). If I go to their web site, I cannot find them, at least not using the kind of search terms I would expect to turn them up. Why does an organization work so hard at establishing standards for trauma triage, but then seem to make it difficult to find this authoritative information. Although, if you want their opinion on what laws we should pass, that is a significant portion of the information they make available to the public.
There is one reason to make it difficult to find the specific trauma triage criteria to refer to. A lot of these criteria do not work. The amount of damage to the exterior of a car may be meaningless in estimating whether the occupants are injured. The injuries to truck occupants may much more predictable from the exterior damage, since truck safety tends to follow the Mongo principle. Collision avoidance is ignored, while the vehicle is made as large as possible, assuming that there is no other Mongo out there.
As an introduction, below are the Pennsylvania Trauma Triage Criteria. I use these because I am familiar with them, they are available on line, and because Pennsylvania is one state that has been doing a lot to change its protocols to what can be supported by science.
These criteria appear to be mostly consistent with the rest of the country. The first category is Physiologic Criteria – the patients with mental status or vital signs changes that may indicate a serious injury.
The most notable differences from the rest of the country are the uses of mental status and respirations. Pennsylvania does not use respirations (less than 10 or greater than 29).
Another difference is that Pennsylvania only uses Patient does not follow commands for the mental status criterion. If the patient does not remember events, or does not know where he is, or does not know what day/month/year it is, there is no reason to rush the patient to a trauma center – and certainly no reason to fly the patient to a trauma center. Here are the Pennsylvania trauma protocols.[1]
Trauma Triage CriteriaAssess patient for any one of the following
Physiologic Criteria:
• Patient does not follow commands (GCS Motor ≤ 5)
• Hypotension, even a single episode (SBP adults or SBP
Physiologic criteria identify the patients generally considered to be the most seriously injured, but they often do not do a good job of predicting outcome or need for a trauma center, so Pennsylvania adds a twist to this. I left that for the end.
Anatomic Criteria:
• Penetrating injury to head, neck, torso and extremities proximal to elbow or knee (unless obviously superficial)
• Chest injuries with respiratory distress (for example, flail chest)
• Two or more proximal long-bone (humerus or femur) fractures
• Pelvic fractures
• Limb paralysis (spinal cord injury)
• Amputation proximal to wrist or ankle
Anatomic criteria are less serious and less likely to predict outcome.
CATEGORY I TRAUMA
Requires immediate transport to a trauma center (Level 1 or 2), if possible
Otherwise if possible, transport to a Level 3 trauma center if patient can arrive at the Level 3 center before an air ambulance can arrive to the patient’s location.
Notify Trauma Center ASAP (including category and ETA)
Mechanism of Injury:
• Falls
- Adult: > 20 feet (one story = 10 feet)
- Peds: > 10 feet or 2-3 x height of child
• High Risk Auto Crash
- Passenger compartment intrusion: > 12 in. occupant side or > 18 in. into compartment any side
- Ejection (partial or complete) from automobile
- Death in same passenger compartment
• Auto vs. Pedestrian/ Bicyclist: Thrown, run over, or >20 mph impact
• Motorcycle crash > 20 mph
Other factors combined with traumatic injuries:
• Age 55 years
• Combination of trauma with burns
• Crushed/ degloved/ mangled extremity or finger amputation
• Known bleeding disorder or taking coumadin/ heparin
• Pregnancy (>20 weeks)
Mechanism is the topic I will be addressing. These criteria are often useless. Pennsylvania has eliminated, or modified, many of bad ones and has created a Other factors combined with traumatic injuries category.
CATEGORY 2 TRAUMA
EITHER:
Contact medical command (if required in EMS region)
OR
Transport to Trauma Center (Level 1, 2, or 3) (if possible)
Everything that does not fall into the above –
CATEGORY 3 TRAUMA
TRANSPORT TO CLOSEST APPROPRIATE RECEIVING FACILITY:
Frequently reassess for Category 1 or 2 criteria
Contact medical command, if doubt about appropriate destination
Otherwise if possible, transport to a Level 3 trauma center if patient can arrive at the Level 3 center before an air ambulance can arrive to the patient’s location.
Pennsylvania is trying to find the right way to restrict the use of helicopters in EMS, but there are still some taking the Mongo approach. Assuming that EMS cannot assess patients, so we must fly everything that might be bad. They are essentially saying, What if . . .?
Rather than try to improve the ability of EMS to care for patients, they adopt the motto – When In Trouble Or In Doubt Run In Circles Scream And Shout. Calling for a helicopter may be part of the screaming and shouting.
These are the EMS leaders. Many have graduated from medical school. Many have decades of experience in the hospital. They have access to this information, but it is like changing the direction of a large ship with Larry, Moe, and Curly at the helm. Change is slow.
In contrast to trauma, where about 5% of the patients meeting trauma criteria end up in surgery soon after arrival, there is the opposite approach to cardiac care. There is tremendous resistance to having EMS call STEMI (ST segment Elevation Myocardial Infarction) alerts, even though the erroneous STEMI alerts may only be about 5% with competent EMS.
With trauma, there are many other reasons to go to a trauma center, besides immediate need for surgery, but that is the excuse given for flying patients with minor injuries – What if EMS misses a serious injury? These patients can often be transferred later on.
With heart attacks, the opposite approach is taken. What if you wake up a cardiologist and it is not a STEMI?
With one approach, we have specialized trauma centers to keep round-the-clock trauma surgery available, no matter how little it is used. While, with the other approach, we seem to go out of our way to delay care and to come up with idiotic excuses for those delays.
Is the sleep of a trauma surgeon less valuable that the sleep of a cardiologist?
Is the life of someone having a heart attack less valuable than the life of someone with minor injuries?
There is another category for Trauma in Pennsylvania. This is the group of patients too serious for the trauma triage criteria listed above. From page 20/97 on the PDF.
A. Extremely critical patients that are rapidly worsening:
1. Patients with the following conditions should be transported as rapidly as possible to the closest receiving hospital:
a. Patients without an adequate airway, including patients with obstructed or nearly obstructed airways and patients with inhalation injuries and signs of airway burns).
b. Patients that cannot be adequately ventilated.
c. Patients exsanguinating from uncontrollable external bleeding with rapidly worsening vital signs (for example, a patient with severe hypotension and rapid bleeding, from a neck or extremity laceration, that cannot be controlled.).
d. Other patients, as determined by a medical command physician, whose lives would be jeopardized by transportation to any but the closest receiving hospital.
2. The receiving facility should be contacted immediately to allow maximum time to prepare for the arrival of the patient.
Footnotes:
[1] Pennsylvania Statewide Basic Life Support Protocols
Effective November 1, 2008
Sections 180 and 181
Pages 20/97 to 25/97 on the PDF page counter.
Page with link to the full text PDF of the protocols.
.
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