This week I decided to do a little bit on trauma assessments. It seems to be a tendency of pre-hospital providers to over triage trauma patients. This stems from an education system that teaches trauma from the over emphasis of the mechanism of injury. However recent studies have shown the mechanism to be an unreliable indicator of injury, and should be used as a guide or assessment tool rather than a rule. This is based on hard evidence from several retrospective studies (Rogue Medic
always has good stuff on this topic). Anecdotal evidence (stories you heard from a buddy who knows a friend that knew a guy’s cousin that had it happen to them) are unreliable and merely prove that no case is typical, and every situation requires careful and thorough assessment.
As with Rogue’s post, Tennessee’s trauma triage guidelines are very similar to Pennsylvania’s, with a few differences. Ours are exactly like the CDC’s document produced in 2009, however there is very little taught on this subject and very little done to follow up and keep information current. I tend to disagree with this, especially when it is said that we need to not burden Level I trauma centers with non-critical trauma, but we turn right around and add a “catch all” statement that causes us to feel the need to transport a non-critical patient to that facility. I think we should remove mechanism of injury as a triage guideline and make it an assessment tool only worthy of brief mention in a text book. I definitely believe that we can accurately triage trauma patients to appropriate facilities based on physiologic and anatomic criteria alone. Even the CDC in the training guidelines they put out state that not every patient requires a Level I trauma center.
So we will talk about physiologic criteria first. According to the chart you should first assess vital signs and determine the level of consciousness. The box after that describes the criteria that require transport to a Level I trauma center, and for those unfamiliar, it is the highest level in the system. The criteria state that the patient’s GCS (Glasgow Coma Scale) is less than 14, or the patient’s blood pressure less than 90 mmHg, and a respiratory rate less than 10 or greater than 29. This falls in with the RED category of the START triage system, if you were wondering.
If the patient does not meet those criteria, you move on to the anatomic criteria. This includes penetrating injuries to anywhere on the body including the extremities proximal to the elbows and knees, crushed or degloved extremities, two or more proximal long bone fractures, amputations proximal to wrists or elbows, pelvic fractures, paralysis, or open or depressed skull fractures. Honestly, these patients will probably fall into the first category before this one, but there are those rare times where you will have a stable patient but will meet these criteria. They should go to Level I center. The reasoning behind these criteria, I can only assume, is that since they are not immediately life threatening, you are now concerned about quality of life which the loss of a limb can certainly interfere with.
The next block is the mechanism of injury (MOI) box. This describes certain events that have been known to cause injury. It covers falls greater than 20 feet, car crashes with 12 inches of intrusion on that particular occupant’s side or 18 inches in any vehicle location, a death in the same compartment, car vs pedestrian where they were struck or thrown at greater than 20 mph, or motorcycle crashes at greater than 20 mph. The affirmative answer box states that patients not meeting the criteria above it BUT having been in one of these particular situations may require a trauma center, but it doesn’t need to be the highest level of care. This was designed to keep patients who don’t require the services of a Level I or II center but may still need a trauma service from tying up resources that would otherwise be utilized for more critical patients.
This is the most controversial section of the guidelines because they have a wide array of interpretation and are subsequently misinterpreted. There is also an extreme lack of education regarding how to use MOI, and some even consider it a cardinal rule forsaking all others. This is WRONG. The prerequisite to even get this far is an assessment, so you should be performing one. Indeed the whole purpose of a flow chart is that you assess then apply the finding to the criteria. I have seen Paramedics and EMT’s alike misapply the criteria based on MOI and transport to a Level I center or call a flight service, only for the patient to be discharged hours later with some NSAID’s for pain. We need to stop this and educate our colleagues about how to do this properly.
The final block is the “Special Considerations” block. These are a short list of medical conditions that may predispose the patient to an injury. It includes age, bleeding disorders or patients on anticoagulant therapy, burns with or without trauma mechanism, time sensitive extremity injuries (I think of these as injuries without a distal pulse), ESRD (end stage renal disease), pregnancy greater than 20 weeks, or provider judgement. These you have to contact medical control or consider a trauma center or a specialty resource.
I tend to think of these as more like things to consider when I’m making a decision on the 3 blocks above it. I don’t consider them stand alone criteria and I hardly consider the third block at all. I don’t believe we should be tying up Level I centers with patients because we think they may be injured. Just because we think they may be injured doesn’t mean we should wisk them away to the highest level of care, we should reserve that for patients that are actually seriously injured. The system is designed so that the lower levels can take patients that show no signs initially BUT can be transferred up if something arises. The diversion tactic used by hospitals based on mechanism usually stems from ignorance on the part of the facility. I typically generalize or avoid the MOI to avoid these problems.
Now that you have the tools to triage trauma patients, next week we will talk about the assessment itself as well as special considerations for patients with those special conditions.
The CDC trauma triage guidelines can be found here : http://www.cdc.gov/fieldtriage/index.html