Triage is important. Injuries are the leading cause of death for Americans up to age 44, and in 2008 EMS transported 5.4 million injured patients to emergency departments. With each one, a crew faced the weighty challenge of identifying their injury type(s) and severity in the field, delivering immediate care and determining where best to transport them.
That’s not a decision to make lightly. Research suggests the overall risk of death could be as much as 25% lower for patients treated at Level 1 trauma centers vs. non-trauma centers. But Level 1s aren’t appropriate for all patients, and distinguishing those needing such a high-level resource is integral not only to optimizing their care, but to ensuring an emergency medical system’s overall assets are used efficiently.
That’s why there’s been such a sustained effort at triage help. The American College of Surgeons Committee on Trauma first released its “Field Triage Decision Scheme” in 1986. That was updated three times before the committee joined with the CDC in 2005 to undertake a full revision. The National Expert Panel on Field Triage charged with that published its work in 2006, and then the CDC followed three years later with an explanation of the scientific rationales behind it. Finally, last year, the CDC reconvened the panel to review its 2006 work against recently published literature and the experiences of those implementing it.
The result of that—“Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage, 2011”—was published in the Morbidity and Mortality Weekly Report of Jan. 13. It has some changes. These are “made upon the best available evidence,” the CDC says, “and incorporate the experiential base that CDC has developed through its close work with states, national organizations, communities and individual professionals.”
Key differences in the updated guidelines include:
• Changed GCS threshold from <14 to 13 for clarity;
• Added need for ventilatory support to respiratory criteria.
• Added pulselessness to crushed, degloved or mangled extremities;
• Broadened flail chest to chest wall instability or deformity (e.g., flail chest);
• Changed a pair of ands to ors to recognize arm and leg injuries generally occur separately and can each be severe enough to merit highest-level care.
• Changed automobile intrusion criterion to include roof intrusion.
• Added to criteria for older adults that SBP <110 might represent shock after age 65, and low-impact mechanisms like ground-level falls can result in severe injury;
• Added under anticoagulation and bleeding disorders that head-injured patients are at high risk for rapid deterioration;
• Removed criteria for time-sensitive extremity injury and end-stage renal disease requiring dialysis.
For more, see www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm.