TRAUMA TRIAGE: CONCEPTS IN PREHOSPITALTRAUMA CARE Robert E. O'Connor, MD, MPH, FACEP ABSTRACT is immense, with 1.6 million emergency department visits for assault in 2002. While there were more than This report examines the efficacy of current trauma triage 42,000 automotive deaths in the United States in 2002, roles to determine the exigency of field care and transport there were more than 17,000 homicides, with a death of severely injured patients from a variety of medical pop- ulations. Key words: emergency medical services; trauma; rate of 6.1 per 100,000. The vast majority of homicides, triage. nearly 12,000, are caused by firearms, with a death rate PREHOSPITALEMERGENCYCARE2006;10:307-310 of 6.1 per 100,000.6The health care burden of caring for the injured is vast and requires that the regional health INTRODUCTION care system share this burden with minimal overtriage and undertriage. A regional trauma plan is an inclu- Effectivefield triage of trauma victims requires iden- sive model tha t integra tes the resources of hospitaIs and tification of patients at risk of dying and their rapid communities throughout the region in providing care transport to hospitaIs capable of treating severe injuries. to the severely injured trauma patient. ldentification of these patients at the scene can be diffi- When the trauma triage rule works well, emergency cultbecause prehospital personnel must rapidly apply medical technicians (EMTs) and paramedics get to the structured triage decision making. Precise application scene and apply judgment with explicit triage criteria oíprehospital trauma triage criteria is critical for ensur- to determine quickly which hospital to transport pa- ing that the maximum number of patients with severe tients to and which life-saving interventions to admin- injuries is transported to trauma centers. The tradeoff ister at the scene and during transport. Most prehospital in the prehospital management of trauma balances a trauma triage criteria adopt a combination of physio- perceived need to "stay and play" tempered by the re- logic, anatomic, and mechanism of injury components, ality of having to "load and go." While the prehospital but this approach still fails to identify a number of pa- trauma triage instrument may be helpful in determin- tients with severe injuries and often burdens trauma ing the exigency of field care and initiation of trans- centers with patients with minor injuries.7,8 port, the real utility lies in identifying patients war- ranting transport to the regional trauma center, even ifnon-trauma centers are bypassed on the way.l-13 On- Physiologic Criteria line medical direction may be used to enhance triage decisions.4 Various types of diagnostic and monitoring techniques The annual automotive crash distribution in the are available in the prehospital environment, but it is United States is shown in Table 1. Less than one half of unclear how increasing complexity of diagnostic equip- all tow-away crashes involve personal injury. Of those ment improves the ability to predict the need for a life- injured, fewer than 9% have serious injury and fewer saving intervention. One recent study suggested that a than 3% have time-critical injury. Rapid identification weak radial pulse may be used to triage trauma patients of patients with serious injury, especially if time crit- in field conditions with limited instrumentation.9 An- ical, is the goal of any prehospital triage scheme. To other study showed that when an abnormal radial pulse appropriately conserve resources, such a scheme must character (weak or absent) and abnormal Glasgow have sufficient specificity and not result in excessive Coma Scale (GCS) verbal and motor components were overtriage.5 present, the probability of needing a life-saving inter- While automotive trauma accounts for the larger pro- vention was >88%. These data show that simple and portion of patients likely to benefit from treatment at a rapidly acquired manual measurements could be used trauma center, interpersonal violence places substantial to effectively triage non-head-injured trauma patients demands on trauma systems. The scope of the problem and may provide a more rapid and accurate assessment than more sophisticated techniques.lO If blood pressure (BP) is to be used as a triage in- strument, a manual BP should be obtained. Automated From the Department of Emergency Medicine, Christiana Care BP determinations are consistent1y higher than manual Health System, Newark, DE. BP, particularly in hypotensive patients. Some recom- mend that automated BP devices should not be used for Address correspondence to: Robert E. O'Connor, MO, MPH, FACEP, Christiana Care Health System, 4755 Ogletown-Stanton Road, PO Box field or hospital triage decisions. Manual BP determi- 6001, Newark, DE 19718. e-mail: <[email protected]>. nations should be used until systolic BP is consistent1y doi: 10.1080 /10903120600723947 >110 mm Hg.n 307 308 PREHOSPITALEMERGENCYCARE jULY / SEPTEMBER2006 VOLUME 10/ NUMBER 3 TABLE1. Annual Automotive Crash Distribution in the (side vs. front vs. rear), rollover, restraint use, and bag United States29 deployment. In the future, information from car sen- Motor vehicle crashes 11.4 million sors to public safety answering point, crash location, Vehicle towed 3.0 million and even voice communication with occupant may be Treated and released from hospital 1.2 million used to predict injury severity. Vehides equipped with Treated at the scene 300,000 "smart" sensors will be able to relay information to Hospitalized 230,000 Vehicles involved in fatalities 47,000 EMTs on change in velocity, vector of impact, and res- cue strategies before they arrive at the crash site. Safety measures could indude instructions on extrication and Another predictor of serious trauma is a respiratory disabling of airbags to reduce the chance of inadvertent rate >25 breaths/min. Respiratory rate may be a useful deployment.17 triage tool for trauma care providers where the scene is Substantial undertriage of serious trauma patients to chaotic and evacuations 10ng.12 trauma centers appears to be occurring, especially in The prehospital GCS score is a reliable physiologic older persons and in persons with brain injuries. Ef- parameter for predicting hospital admission after a mo- forts to understand why undertriage is occurring so fre- tor vehide crash. When obvious indicators (hypoxemia, quently are hampered by fragmentation of the systems multiple long bone fractures, focal neurologic deficits) of care, inadequate data management systems, and lack for trauma team activation are lacking, the prehospi- of trauma care performance reporting by non-trauma tal GCS score may be used to reduce overtriage and center hospitals.18 undertriage rates.n Undertriage of older trauma victims has been a persistent and serious problem. Because of physio- logic changes and preexisting disease, blunt trauma in Mechanism Cri teria older persons is often covert. Prehospital trauma triage guidelines developed for use with a general adult pop- Investigators from the Royal Melbourne Hospital con- ulation may not be sensitive enough to detect covert ducted a study to assess whether prehospital triage injuries in elder1y trauma patients. In one study, under- guidelines, based on mechanistic criteria alone, accu- triage was 8% for young and middle-aged men, 12% rately identified victims of motor vehide crashes with for young and middle-aged women, 18% for older men, major injury. Multivariate logistic regression indicated and 15% for older women. Overtriage was also present that prolonged extrication time, passenger compart- in alI age groups, indicating that many motor vehide ment intrusion, high speed, and ejection from vehide crash victims who were admitted to trauma centers were statistically associated with major injury. Vehide could have been admitted to non-trauma center hos- rollover and fatality in the same vehide were not statis- pitaIs. Low sensitivity and specificity of trauma triage tically associated with major injury. These data suggest guidelines result in undertriage and overtriage. Some that existing guidelines for the prehospital triage of mo- argue that prehospital triage guidelines should indude tor vehide crash victims, based on mechanistic criteria age as a decision point to avoid placing older persons alone, may need revision.14 at risk for undertriage.19 Paramedic judgment has been identified as an alter- Conversely, overtriage of younger trauma patients native method for the triage of trauma patients but is appears to be prevalent. Helicopter transport of pedi- as of yet unverified.15 Although there is little evidence atric trauma patients in an urban emergency medical to strictly support the rule, scene time should generally services (EMS) system was assessed to identify the ap- be limited to ten minutes unless factors such as delayed propriateness of using this modality for the young. The extrication supervene. majority of pediatric trauma patients transported by he- Are some criteria more sensitive than others? In one licopter were found to have sustained minor injuries.20 study, mechanism of injury was the only reason for Trauma triage scores, severity of illness measures, trauma center transport in 29 of 112 patients. Neither and mortality prediction models quantify severity of intubation nor emergent surgery was required in any injury and stratify patients according to a specified out- of these patients, and alI survived. Only two had an In- come. Triage scoring