North Central Texas Trauma Regional Advisory Council

Trauma Triage Protocol

INTRODUCTION that is designated by the Texas Department A systems approach requires a of Health. A facility that is actively regional triage system with identified pursuing designation can receive trauma Trauma Centers capable of providing patients appropriate to the level of trauma care to major trauma patients. designation to which the facility is Patients must be identified and transported pursuing until December 1, 1999 if they to the appropriate level of care in a timely demonstrate their commitment to trauma fashion based on clinical need. by informing the Department of Health or the NCTTRAC of their intentions or by Triage is the classification of having applied for designation or patients according to medical need. Since consultation to either the Department of the majority of trauma deaths occur either Health or the American College of before reaching the hospital or within four Surgeons. hours of arrival, prehospital and emergency department personnel must The North Central Texas Regional make rapid triage decisions based on pre- Advisory Council has developed these established system standards. triage guidelines to provide prehospital, hospital, and trauma facilities with Trauma Service Area-E (TSA-E) is assistance in triaging injured patients to diverse with urban, suburban, and rural appropriate levels of care. These guidelines areas. Persons injured in each of these may need to be modified to accommodate areas may need to be triaged differently local conditions and will be continuously but with the intention of providing optimal monitored by the NCTTRAC Quality care in spite of the area where the injury Improvement Program. occurred. TSA-E has many different prehospital providers ranging from volunteer units to advanced aircraft agencies. Similarly, the hospitals in the region are variable in their ability and desire to care for injured patients.

Some hospitals in TSA-E are designated as trauma facilities. Other hospitals are actively working towards achieving designation. Other hospitals are not pursuing any level of designation. For the purposes of this document, a trauma facility is defined as a health care facility

Approved NCTTRAC: 4/14/98; Amended: 7/14/98 Approved TDH: 5/4/98 INCLUSIVE SYSTEM to provide appropriate delivery, evaluation, and care for all patients, Major trauma patients are those including the major trauma patient, in a with either a severe injury or a risk for cost-effective manner. severe injury. A severe injury is one that could result in morbidity or mortality and is classically defined as an injury with an PATIENT IDENTIFICATION Injury Severity Score (ISS) of 16 or One characteristic of an inclusive greater. On initial evaluation, these trauma system is patient triage designed to patients typically have abnormal vital signs care for major trauma patients by matching or a significant anatomical injury. patient severity to facility in a timely However, triage is often inexact due to manner. A systems approach will consider patients’ variable physiological responses injury severity, injury severity risk, time to trauma. In some patients, minor injuries and distance from site of injury to can result in morbidity or mortality due to definitive care, interhospital transfers the patient’s age and/or co-morbid factors, considering guidelines for immediate and some patients may have a delayed versus post-intervention transports, and physiological response to trauma. factors that activate the regional system (see Table 1). Patients involved in a high-energy event are at risk for severe injury. Five to Table 1 fifteen percent of these patients, despite Definition of Major Trauma-Adult normal vital signs and no apparent ! Multisystem Blunt or Penetrating Trauma anatomical injury on initial evaluation, will With Unstable Vital Signs (BP<90, HR>120, have a severe injury discovered after full RTS<11, GCS<14) ! Penetrating Injury of head, neck, torso, groin trauma evaluation with serial observations. ! Burns > 20% TBSA (2nd or 3rd degree) or involving face, airway, hands, feet, or genitalia A continuum of services must be ! Amputation (with reimplantation potential) ! Paralysis or other signs of spinal cord injury developed to provide preventive programs, ! Flail chest prehospital care, acute care, and ! Open or suspected depressed skull fracture rehabilitation to all injured patients and to ! Unstable pelvis or suspected pelvic fracture !Two or more long bone fractures match resources with individual patient ! High energy event, such as needs. ! Ejection from vehicle ! Significant fall (> 20 feet) ! Rollover mechanism Current systems often rely on over-triage ! Bent steering wheel to Trauma Centers and often an ! Auto-pedestrian impact ! Motorcycle or bicycle involvement exaggerated and unnecessary response ! Significant assault from trauma professionals. Such systems may cause over-treatment of certain patients, unnecessary expenses, burnout of Major trauma patient triage criteria participants, and under-utilization of should consider categories such as: certain health resources, including personnel. In spite of these excesses, such - Patients with multisystem blunt or systems may still run the risk of not penetrating trauma and unstable vital treating all injured patients, including not signs. appropriately treating all major trauma - Patients with known or suspected patients. Under-triage runs the obvious anatomical injuries and stable or risk of excluding some major trauma normal vital signs. patients from receiving appropriate care. - Patients who are involved in a “high- An inclusive system uses a tiered response energy” event with a risk for severe North Central Texas Trauma Regional Advisory Council Trauma Triage Protocol

injury despite stable or normal vital PREHOSPITAL TRAUMA TRIAGE signs. Prehospital triage should consider time and distance and identify patients Once identified, these patients should needing transport to the most appropriate activate an appropriate systems response. designated Trauma Center rather than the Triage occurs at both the prehospital and nearest acute care facility. In addition, hospital level. prehospital triage criteria should allow for the activation of the trauma system from the field including an appropriate response Pediatric patients (<13 years old) require a from the designated Trauma Center. separate definition of major trauma due to (NOTE: Field personnel should always their different physiologic response to seek guidance from physicians providing injury: on-line medical direction if there is any doubt regarding destination decisions or Table 2 Definition of Major Trauma- Pediatric system activation.) Figure 1 is the model prehospital algorithm for TSA-E. ! Multisystem Blunt or Penetrating Trauma After the trauma patient is With Unstable Vital Signs: BP: identified, the first priority of management Neonate: <60 mmHg is the recognition of possible serious Infant (<2yr): <65 mmHg airway compromise. If this potential is Child (2-5 yr): <70 mmHg Child (6-12 yr): <80 mmHg identified, control of the airway is Respiratory rate: <10 or >60 essential. If the field personnel are not PTS<9 capable of controlling the airway, then the GCS<14 ! Penetrating Injury of head, neck, torso, groin patient should be transported to the ! Burns > 20% TBSA (2nd or 3rd degree) or nearest facility capable of managing airway involving face, airway, hands, feet, or genitalia or respiratory compromise. The ! Amputation (with reimplantation potential) ! Paralysis or other signs of spinal cord injury prehospital providers should be familiar ! Flail chest with the facilities in their area that are ! Open or suspected depressed skull fracture capable of managing airway problems ! Unstable pelvis or suspected pelvic fracture !Two or more long bone fractures rapidly. ! High energy event, such as ! Ejection from vehicle If no airway problems are present ! Significant fall (> 20 feet) ! Rollover mechanism or the airway has been controlled, the next ! Auto-pedestrian impact determination is the presence of ! Motorcycle or bicycle involvement hypotension that indicates the possibility of ! Significant assault active hemorrhage. These patients may need blood transfusions rapidly to prevent irreversible shock and death and should be transported to the nearest facility that can

Approved NCTTRAC: 4/14/98; Amended: 7/14/98 Approved TDH: 5/4/98 Page 3 North Central Texas Trauma Regional Advisory Council Trauma Triage Protocol

initiate rapid stabilization and transfusions. and rapid transfer to a more In rural areas, this “facility” may include a comprehensive Trauma Center) and those higher level EMS agency or an air patients that could be safely managed in evacuation site. Air evacuation services the Level III/IV facility for further can initiate transfusions during transport to evaluation and serial observations. Level a Level I or II Trauma Center. For ground III facilities are expected to have the transport, the patient should be capability to manage most injuries and transported to the highest level facility transfer those injuries that they do not within 15 minutes. Prehospital providers have the capability to manage to the should not wait longer than 15 minutes nearest Level I or II facility. Level IV after the patient is ready for transport for facilities are expected to be stabilization aircraft evacuation; the patient should and transfer facilities and are expected to either be directed to a landing site closer to transfer most patients to higher level the Level I/II Trauma Center or to a local facilities. Both Level III and Level IV facility for stabilization. facilities should develop protocols If no hypotension is present, the identifying which patients should be patient should be taken to the most transferred, and these protocols should be appropriate level Trauma Center within 15 widely disseminated throughout the minutes. Since Level I and Level II Emergency Department. All Emergency Trauma Centers are capable of providing Department personnel should be familiar the same level of care, they should be with these protocols. Each Level III/IV considered equal for triage purposes. If no Trauma Center should have a three-tiered Trauma Center is present within 15 response. The Level 1 Response identifies minutes, the patient should be transported those patients that require a Trauma Team to the nearest Trauma Center, regardless Activation. In many of these cases, the of level of designation. Stabilization and treatment requirements are not available at transport can then be initiated at that the Level III/IV facility and stabilization facility prior to transport to a higher level and transport to a Level I/II Trauma facility. Center is necessary. The Level 2 For pediatric patients, the priorities Response identifies those patients that can are the same, but the definition of major initially be evaluated by a designated trauma is different. Figure 2 is the model member of the trauma team with pediatric prehospital algorithm for TSA-E. subsequent evaluation by a trauma surgeon. The Level III Response identifies LEVEL III/IV TRAUMA CENTER those patients that can initially be evaluated by the Emergency Department Level III/IV Trauma Center triage Team with subsequent evaluation by a criteria should identify those patients trauma surgeon or appropriate needing immediate post-intervention subspecialist, if necessary. Figure 3 is the transport (i.e., requiring initial stabilization model Level III/IV algorithm for TSA-E.

Approved NCTTRAC: 4/14/98; Amended: 7/14/98 Approved TDH: 5/4/98 Page 4 North Central Texas Trauma Regional Advisory Council Trauma Triage Protocol

LEVEL I/II TRAUMA CENTER

Level I/II Trauma Center triage criteria should provide for the comprehensive evaluation and treatment of major trauma patients. The Level I Response identifies those patients that require a Trauma Team Activation. The Level 2 Response identifies those patients that can initially be evaluated by a designated member of the trauma team with subsequent evaluation by a trauma surgeon. The Level 3 Response identifies those patients that can initially be evaluated by the Emergency Department Team with subsequent evaluation by a trauma surgeon or appropriate subspecialist, if necessary. (NOTE: The Trauma Center triage criteria should also consider changes that might occur during evaluation and observation.) Figure 4 is the model Level I/II algorithm for TSA-E.

Approved NCTTRAC: 4/14/98; Amended: 7/14/98 Approved TDH: 5/4/98 Page 5 North Central Texas Trauma Advisory Council Trauma Triage Algorithm Prehospital - Adult

Major Trauma No® Transport to appropriate facility Yes ¯

Serious Airway Transport to closest Compromise Yes ® facility capable of managing airway No ¯

BP less than 90mmHg Continue to transport to Highest Or Yes® Level Trauma Center ¹. If Pulse>120/min transport is greater than 15 Or minutes - Transport to nearest Other signs of shock facility to provide stabilization refractory to fluids & transfer

No ¯

Transport to appropriate Level 1 or Level 2 Trauma Center

¹Level 1 and Level 2 facilities should be treated as having equal capabilities.

Figure 1 North Central Texas Trauma Advisory Council Trauma Triage Algorithm Prehospital - Pediatric

Major Trauma No® Transport to appropriate facility Yes ¯

Serious airway or Transport to nearest respiratory compromise Yes ® facility capable of that cannot be managed? managing No airway/respiratory compromise ¯

Hypotension present? Transport to nearest facility¹ Neonate: <60 Yes® that can rapidly initiate blood Infant (<2yr): <65 and provide initial Child (2-5yr): <70 stabilization² and transfer out Child (6-12yr): <80 to higher level of care.

No ¯

Transport to Pediatric Trauma Center, if within 15 minutes²

¹Nearest facility might include higher level of EMS agency or air evacuation landing site. ²If multiple levels of designation present within 15 minutes of each other, go to highest level facility. Level I and II Trauma Centers should be considered equal.

Figure 2 North Central Texas Trauma Advisory Council Trauma Triage Algorithm Level III/IV Trauma Center

Level 1 Response C Multisystem Blunt Trauma with Unstable Vital Signs (BP<90, RTS<11, GSC<14) C Penetrating Injury of head, neck, chest, abdomen C Burns >20% TBSA (2nd or 3rd degree) or C Initiate Trauma Team Activation involving face, airway, hands, feet, or genitalia C Consider early transport to Level I/II C Amputations (with reimplantation potential) Trauma Center CParalysis or other signs of spinal cord injury C Coordinate transport with Level I/II C Flail chest Trauma Center C Open or suspected depressed skull fracture C Unstable pelvis or open pelvic fracture

Level 2 Response C Two or more longbone fractures C Suspected pelvis fracture C Significant spinal column injury C Initiate Trauma Treatment Protocol C Initiate Transfer Protocol to Level I/II Center, if appropriate

Level 3 Response High Energy Event, such as C Fall >20 ft C Ejection from vehicle C Death of occupant in same vehicle C Perform complete trauma evaluation C Rollover mechanism and appropriate serial examinations C Bent steering wheel C Auto-pedestrian impact C Motorcycle or bicycle involvement C Significant assault 9

C Deterioration in patient condition with decrease in GCS, vital signs, or other significant findings then initiate either Trauma Team Activation or Trauma Treatment Protocol

Figure 3 North Central Texas Trauma Advisory Council Trauma Triage Algorithm Level I/II Trauma Center

Level 1 Response C Multisystem Blunt Trauma with Unstable Vital Signs (BP<90, RTS<11, GSC<14) C Penetrating Injury of head, neck, chest, abdomen C Burns >20% TBSA (2nd or 3rd degree) or C Initiate Trauma Team Activation involving face, airway, hands, feet, or genitalia C Amputations (with reimplantation potential) CParalysis or other signs of spinal cord injury C Flail chest C Open or suspected depressed skull fracture C Unstable pelvis or open pelvic fracture

Level 2 Response C Two or more longbone fractures C Suspected pelvis fracture C Significant spinal column injury C Initiate Trauma Treatment Protocol

Level 3 Response High Energy Event, such as C Fall >20 ft C Ejection from vehicle C Death of occupant in same vehicle C Perform complete trauma evaluation C Rollover mechanism and appropriate serial examinations C Bent steering wheel C Auto-pedestrian impact C Motorcycle or bicycle involvement C Significant assault 9

C Deterioration in patient condition with decrease in GCS, vital signs, or other significant findings then initiate either Trauma Team Activation or Trauma Treatment Protocol

Figure 4