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Trauma TrIage

Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education prehospitalmd@gmail.com. Trauma TrIage. Objectives. Historical development of triage R elationship between triage & development of trauma systems H ow changes in triage affect resources

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Trauma TrIage

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  1. Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education prehospitalmd@gmail.com Trauma TrIage

  2. Objectives • Historical development of triage • Relationship between triage & development of trauma systems • How changes in triage affect resources • Review Region V Trauma Triage Guidelines “Those who cannot remember the past are condemned to repeat it.” ~George Santayana

  3. The “Disease” of Trauma • Leading killer in US of persons <44 yo, however: • Life or limb-threats in 10% of all trauma pts • 150,000 deaths annually • 44,000 MVC • 28,000 GSW • Most expensive “disease” in terms of lost wages, initial care, rehabilitation & lifelong maintenance

  4. Triage • French: “to sort, cull or select” • Evaluation & classification of casualties initially for evacuation & treatment of battlefield wounded • Greatest good for greatest number • Prior to 1700s rank trumped injury

  5. Napoleonic Wars • Baron Dominique–Jean Larrey was Napoleon’s Surgeon Major during Rhine Campaign (1792-1798) • Developed “Flying Ambulance” (1797) to transport wounded off battlefield • Goal was treatment within 24 hrs • Rescue casualties based on injury not rank • Immediate treatment • Transport to 1st line hospitals • Baron Pierre Percy developed alternative “Casualty Transport System” to transport surgeons & supplies to patient • 1st “Mobile Hospitals”

  6. American Civil War • 1847: Congress authorizes 1st commissions for medical officers • 1861: Battle of Bull Run • Medical corps dysfunction • Too few ambulances • Minimal organization • Casualties not evacuated for days • Prompted 1862 appointment of 1st Surgeon General Bill Hammond • 1862: 2nd Battle of Bull Run • Dr Letterman appointed Medical Director Army of Potomac • Revised ambulance core

  7. Jonathan Letterman MD • “ Napoleonic” casualty care • Transferred all medical care to Army Medical Corps • Reformed medical supply distribution • Triage by Medical Corps provided 1st prehospital standards of care • 3 Tiered Evacuation System • Field Dressing / Aid Station • Field Hospital / MASH Unit • Large Hospitals

  8. World War I • Collecting Zone • Advanced field aid stations • Evacuating Zone • Clearing Hospital • Distributing Zone • Rest Stations • Transport based upon “self-evacuation” ability • “Lyers” vs “Walkers” • “Casualty Clearing Hospitals” • MASH • “Specialty” Surgeons: Abdominal, Orthopedics, Plastics • Minimum10% operative rate

  9. World War II • Radio communications • Resuscitation • Antibiotics • 1st Air Transport • Development of Echelon System

  10. WWII Echelon System • 1st Echelon: • “Physician First” • Treat & Street after emergent procedures • No holding capacity but could treat 300-500 wounded simultaneously • 2nd Echelon: • Secondary triage • 72 hour holding • OR Capable • Supported 3-9 Aid Stations

  11. WWII Echelon System • 3rd Echelon • Combat Support Hospitals / MASH units • Advanced care capable of facility rapid evacuation • 4th Echelon • Full spectrum of hospitals with rehabilitation capabilities outside combat zone • Definitive care • Limited to no mobility

  12. Korean War • Increased use of aeromedical transport • Directly transported most seriously injured patients, bypassing “inappropriate” facilities

  13. Trauma-Related Deaths* *Includes environmental & post-operative complications

  14. Patient Outcomes & Time to Definitive Care

  15. Civilian Trauma System Evolution • 1966 NHTSA “White Paper” Highway Safety Act of 1966 • “Accidental Death and Disability: The Neglected Disease of Modern Society” detailed MVC pts dying from initial trauma & inadequate prehospital care • 1ststatewide prehospital system in 1969 in Maryland • 1971 Illinois Trauma Program • Trauma center categorization • Advanced communications • Safer ambulance designs • Improved prehospital training • Trauma Registry development / CQI • 1973-1976 • ACS publishes “Optimal Hospital Resources for Care of the Injured Patient” resulting in the Emergency Medical Services Act

  16. Civilian Trauma System Evolution • 1990: • ACS“Trauma Care Systems Planning & Development Act”established guidelines, funding & state-level leadership for trauma system development • 1992 • “Model Trauma Care System Plan” introduced concept of “Inclusive” vs “Exclusive” Systems • Assumes all acute care facilities are part of a larger integrated system • Tiered approach based on known quantity of available & invariable resources

  17. “Exclusive” Trauma Systems • Centralizes all injuries regardless of severity to tertiary centers • Excludes acute care facilities with variable capabilities • Over-triage to avoid under-triage • Problems • Payer mix • Triage based on likelihood of admission vs tiered resource utilization • Non-participation of uncategorized facilities • Lack of MCI training

  18. Trauma Triage Leads to Trauma Care Systems • CDC / ACS / NHTSA Trauma Triage Guidelines assist providers in triaging pts to the proper facility • Guidelines offer pt-specific destination criteria for definitive treatment • Development of a Trauma Care System integrates prehospital & hospital care to reduce cost, time to OR / ICU, & mortality

  19. Elements of a Functional Trauma System • Defined Need, Authority & Legislation • Standardized Care with Adaptive Changes Based Upon Resources • Tiered Triage Based on Injury Severity, With Mechanisms to Bypass Lower Echelons • Rapid Transport & Concurrent Treatment Utilizing Standardized Care • Integration of Advanced Technology • Commitment to Training • Outcomes Driven Model

  20. Triage Tools Problems • “One Size Fits All” • No, it doesn’t • Populations & resources vary & change • Mature & busy systems have better outcomes • Incident influences outcomes • Changes in triage absolutely affect system resources & patient outcomes

  21. Triage Tools • START • Trauma Index • Trauma Score / RTS • CRAMS Score • Circulation, Respiration, Abdomen, Motor, Speech • Prehospital Index • Trauma Triage Rule • Kampala Triage

  22. Abbreviated Injury Scale (AIS) Injury Severity Score (ISS) • Anatomically based global severity scoring system that classifies each injury in every body region according to its severity on a 6 point scale: • 1 = Minor • 2 = Moderate • 3 = Serious • 4 = Severe • 5 = Critical • 6 = Maximal (unsurvivable) • 9 body regions: • Head • Face • Neck • Thorax • Abdomen • Spine • Upper Extremity • Lower Extremity • External & other • Take highest AIS each of the 3 most severely injured body regions, square each AIS & add the 3 squared numbers together • ISS = A2 + B2 + C2 • ISS scores ranges from 1 to 75 • AIS 0-5 for each category • If any of the 3 scores is a 6, the score is automatically set at 75 • Since a score of 6 indicates futility of further medical care in preserving life, this generally means a cessation of further care A major trauma requiring a Trauma Center is defined as an ISS > 15

  23. ACS Field Triage Decision Scheme • Physiologic Criteria • Anatomic Criteria • Mechanism Criteria • Age & Co-morbidities • “When In Doubt Take To A Trauma Center” Criteria

  24. Physiologic Criteria (Vitals) • 1st triage step identifies pts at high risk of suffering from severe injuries: • Hypovolemic shock • Neurogenic shock • Cardiogenic shock • Traumatic brain injury • However, critical injuries resulting in “shock” may not be reflected early in vitals due to physiologic compensation • “Do not pass “GO”, Do not collect $100”

  25. Anatomic Criteria • 2nd step evaluates injuries related to anatomical location • Penetrating trauma may cause significant injury dependent on area • Proximal long bone fractures, pelvic fractures & amputations all cause major bleeding • Skull fractures place pt at risk due to bleeding & increased ICP • Paralysis indicative of spinal trauma

  26. Mechanism of Injury • Significant mechanism of injury often assoc with internal injuries masked by early physiologic compensation • Mechanism alone not enough to determine triage destination

  27. Special Considerations • Use of anticoagulants (clopidogrel, aspirin, warfarin, NSAIDs) • Bleeding disorder (i.e. hemophiliacs) • Special Popuations • Geriatrics (>70) • Pediatrics • Pregnancy • Physiologic changes: increased CO & TBV, hypercoagulability • High risk of abruption with “minor” trauma • Provider impression • Sick vs Not Sick? • Not Sick with high potential for Sick?

  28. Densmore. Outcomes and delivery of care in pediatric injury. J Ped Surg. 2006. • PURPOSE • Site of care must be correlated with outcomes to design effective pediatric trauma care systems • Results • 80,000 injury cases in 27 states • Grouped by age, ISS & site of care • 89% received care outside of children's hospitals • If 0-10 yrs with ISS >15, mortality, LOS & charges all significantly higher in adult hospitals • CONCLUSIONS • Younger & seriously injured children have improved outcomes in children's hospitals

  29. Caterino. Modification of Glasgow Coma Scale criteria for injured elders. AcadEmerg Med. 2011 • CONCLUSIONS • 52,412 pts • In elders, mortality & TBI increased with GCS decreasing from 15 to 14 & 14 to 13 • In adults, mortality did not increase with the GCS drop-offs

  30. Trauma & Co-Morbidities

  31. Trauma & Co-Morbidities

  32. Appendix J: Air Medical Transport Protocols • Does not require Med Control approval, but does require oversight • Nearest Appropriate Facility: • Uncontrolled airways unless ALS can intercept in a more timely fashion • Arrest due to blunt trauma • Air Medical Transport • If meets specific criteria & scene arrival time to arrival time at nearest appropriate hospital, including extrication time > 20 mins • Location, weather or road conditions preclude ground ambulance • Multiple casualties exceed capabilities of local agencies

  33. Appendix J: Air Medical Transport Protocols Patient Conditions • Physiologic Criteria • Unstable vitals (SBP <90, RR >30 or <10) • Anatomic Criteria • Spinal cord injury • Severe Blunt Trauma: • Head Injury (GCS <12) • Severe chest, abdominal or pelvic injuries excluding simple hip fractures • Burns: • >20% BSA 2nd or 3rd degree burns • Airway, facial or circumferential extremity • Associated with trauma • Penetrating injuries of head, neck, chest, abdomen or groin • Amputations of extremities, excluding digits

  34. Appendix J: Air Medical Transport Protocols Patient Conditions • Special Conditions considered in decision to request air medical transport, but not automatic or absolute • MVC • Ejected • Death in same compartment • Pedestrian struck & thrown >15 ft, or run over • Significant Medical History • Age >55 or <10 • Significant coexistent illness • Pregnancy

  35. Cudnik. Prehospital factors associated with mortality in injured air medical patients. PEC. 2012 • BACKGROUND: • Air medical transport provides rapid transport to definitive care. Overtriage & the expense & transportation risks may offset survival benefits • RESULTS: • 557 pts transported by air to a level 1 trauma center. Majority were male (67%), white (95%) with an injury rurally. Most injuries were blunt (97%), & pts had a median ISS of 9. Overall mortality 4% • Most common reasons for air transport were MVC with high-risk mechanism (18%), MVC speed >20 mph (18%), GCS <14 (15%), & LOC >5 mins (15%) • Factors with high mortality: age >44 yrs, GCS <14, SBP <90 mmHg & flail chest • Most common trauma indicators resulting in death, receipt of blood, surgery, ICU admission included EMS ETI, >2 fractures of humerus/femur, neurovascular injury, cranial crush or penetrating injury, failure to localize to pain on examination, GCS <14 • CONCLUSIONS • Few prehospital criteria assoc with clinically important outcomes in helicopter-transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated & developed

  36. Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation • 1,200 trauma admits/year • Pts w/ ISS >15 (240 total or 35 pts/surgeon) • Immediate surgical capability available • In-house trauma surgeon • General surgery residency program or trauma fellowship • Research • No minimum patient criteria • Surgical capability available in a “reasonably acceptable time” • General surgeon present at resuscitation • Desirable to have residents • No research minimum LEVEL I TRAUMA CENTER LEVEL II TRAUMA CENTER

  37. Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation • Level III • “Community” Trauma Center • Specialized ED with majority of subspecialties on-call • Level IV • Rural community hospitals • No immediate surgical interventions available • Stabilize & transfer • Uncategorized • Essentially aLevel IV not participating in ACS classification • “Free-standing” EDs

  38. Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation • Specialty Centers • Neurocenters • Burn Centers • Pediatric Trauma • Hyperbaric Medicine • Microsurgery • Most have “Medical Specialties” certified by Joint Commission • MICU • CICU / Cath Lab • Stroke Centers

  39. MA State Trauma Centers • Region I • Baystate (Level 1 Adult & Pediatric); Springfield • Berkshire Medical Center (Level 2 Adult & Pediatric); Pittsfield • Region II • UMass Memorial (Level 1 Adult Trauma & Pediatric); Worcester • Region III • Anna Jaques Hospital (Level 3 Adult); Newburyport • Beverly Hospital (Level 3 Adult); Beverly • Caritas (Level 3 Adult); Methuen • Salem Hospital (Level 3 Adult); Salem • Lawrence General Hospital (Level 3 Adult); Lawrence     • Lowell General Hospital (Level 3 Adult); Lowell) • Region IV • Beth Israel (Level 1 Adult); Boston • BMC(Level 1 Adult & Pediatric); Boston      • Brigham & Women’s (Level 1 Adult); Boston            • Boston Children’s (Level 1 Pediatric); Boston         • Lahey Clinic (Level 2 Adult); Burlington      • Massachusetts General (ACS Level 1 Adult & Pediatric); Boston           • Tufts / NEMC (Level 1 Adult & Pediatric); Boston • Region V • No verified ACS Trauma Centers • Rhode Island • Rhode Island Hospital (Level 1 Adult); Providence • Hasbro Hospital (Level 1 Pediatric); Providence

  40. Mass ACS Verified Trauma Centers

  41. Quality Improvement (CQI / QA) • Data & Trauma Registry • Data retrieval system for trauma patient information • Used to evaluate & improve the trauma system as well as provide individual feedback • CQI • Examine system performance to improve outcomes • Evaluate calls to determine if standard of care met • Relies upon accurate & complete documentation

  42. Transport Decisions • Should be based upon “evidence-based” criteria • Can critical problems be managed en-route • Use Medical Control early & often

  43. Summary • The lessons of battlefield medicine created civilian trauma systems • Triage tools best understood within the context of the type of system they serve • As field resources change so must trauma systems

  44. References • Bucher. Does Your Patient Need A Trauma Center? EMS World. 2011 • Loftus. Banner Good Samaritan Medical Center. Statewide Trauma Rounds, 2007. • Bledsoe. Essentials of Paramedic Care. 2006. • OEMS Prehospital provider Protocols. March 2012. • Mosby, Brady, Caroline. Prehospital Care Textbooks. “Trauma” • References cited throughout presentation.

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