Amy Gutman MD
EMS Medical Director
ALS / BLS Continuing Education
prehospitalmd@gmail.com
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
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
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
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”
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
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
World War I

Collecting Zone
 Advanced field aid stations

Evacuating Zone
 Clearing Hospital

Distributing Zone
 Rest Stations

Transport based upon “selfevacuation” ability
○ “Lyers” vs “Walkers”

“Casualty Clearing Hospitals”
 MASH
 “Specialty” Surgeons: Abdominal,
Orthopedics, Plastics
 Minimum10% operative rate
World War II

Radio communications

Resuscitation

Antibiotics

1st Air Transport

Development of Echelon System
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
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
Korean War

Increased use of aeromedical
transport

Directly transported most seriously
injured patients, bypassing
“inappropriate” facilities
Trauma-Related Deaths*
War
# / 1000
Mexican
104
Civil
71
Spanish-American
34
WWI
17
WWII
0.6
*Includes environmental & post-operative complications
Patient Outcomes & Time to
Definitive Care
War
Time
Mortality
WWI
12-18 hrs
8.5%
WWII
6-12 hrs
5.8%
Korea
2-4 hrs
2.4%
Vietnam
65 mins
1.7%
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
 1st statewide 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
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
“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
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
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
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
Triage Tools

START

Trauma Index

Trauma Score / RTS

CRAMS Score
 Circulation, Respiration, Abdomen,
Motor, Speech

Prehospital Index

Trauma Triage Rule

Kampala Triage
Abbreviated Injury Scale (AIS)

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
Injury Severity Score (ISS)

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
ACS Field Triage Decision Scheme

Physiologic Criteria

Anatomic Criteria

Mechanism Criteria

Age & Co-morbidities

“When In Doubt Take To A
Trauma Center” Criteria
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”
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
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
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?
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
Caterino. Modification of Glasgow Coma
Scale criteria for injured elders. Acad Emerg 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
Trauma & Co-Morbidities
60
60
50
50
40
40
30
Avg. Age vs. #
Medical Problems
20
10
0
30
ICU Admit % vs. #
Medical Problems
20
10
None
One
Two
Three
or More
0
None One
Two Three
or
More
Trauma & Co-Morbidities
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Mortality % vs. #
Medical Problems
None
One
Two
Three
or More
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
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
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
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
Trauma Center Designations
ACS Committee on Trauma / State site verification & accreditation
LEVEL I TRAUMA CENTER
LEVEL II TRAUMA CENTER

1,200 trauma admits/year

No minimum patient criteria

Pts w/ ISS >15 (240 total or 35
pts/surgeon)

Surgical capability available in
a “reasonably acceptable time”

Immediate surgical capability
available

General surgeon present at
resuscitation

In-house trauma surgeon

Desirable to have residents

General surgery residency
program or trauma fellowship

No research minimum

Research
Trauma Center Designations
ACS 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 a Level IV not
participating in ACS classification
 “Free-standing” EDs
Trauma Center Designations
ACS 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
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
Mass ACS Verified
Trauma Centers
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
Transport Decisions

Should be based upon “evidence-based”
criteria

Can critical problems be managed enroute

Use Medical Control early & often
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
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.