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Patient Care

Does Your Patient Need A Trauma Center?

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The Centers for Disease Control and Prevention (CDC) Trauma Triage Guidelines, composed by the American College of Surgeons' Committee on Trauma and the National Highway Traffic Safety Administration, help EMS providers triage trauma patients to the proper facility. These guidelines offer patient-specific criteria used for determining which facility a patient sustaining traumatic injuries needs to provide the level of definitive treatment required.

   Two years ago, the CDC released a report on the updated triage guidelines. Unfortunately, they have not been actively circulated among all EMS providers, yet they are something all of us must understand and be able to apply. The following case highlights some of the new guidelines. The actual changes were made in 2006, but the CDC only published the report in 2009, highlighting the changes and the reasons behind them.

Scenario

   You are dispatched to a motor vehicle collision with unknown injuries. Upon arriving, you find a 67-year-old female standing outside of her car complaining of head pain. She is wearing a cervical collar that was applied by a first responder. Upon questioning, she reveals she was an unrestrained passenger in a head-on collision with a pole while traveling at an unknown velocity. Inspection of the vehicle reveals an 18-inch intrusion into the engine compartment. Her initial vitals are 220/130 BP, 22 RR, 98 bpm and 96 SpO2. Further assessment on scene revealed sluggish pupils bilaterally. She was slightly confused and lethargic with a GCS of 14. Prior to transport, the already-collared patient was immobilized on a longboard and received O2 at 12 lpm by a non-rebreather mask.

   You are unable to determine her medications while en route to the local community hospital because she did not bring her list with her, but she tells you she suffers from diabetes and hypertension, has had a past MI and had one kidney removed. You perform a complete trauma assessment and find that she has right upper quadrant abdominal tenderness upon palpation, which she rates at an 8/10 in severity. She complains of substernal abdominal pain, also rated as an 8/10. No abnormalities are noted on her head in association with her pain.

   At this point, would you transport her to the local community hospital? Does she meet the criteria to be transported to a trauma center? What are the criteria? Following is a discussion of the triage guidelines to determine what hospital she should be transported to.

   The first step of triage involves physiologic indications or vital signs. These criteria identify the patients who are at high risk of suffering from more severe injuries, such as shock due to a variety of causes (hypovolemic shock due to hemorrhage, neurogenic shock due to head or spinal injury, cardiogenic shock due to cardiac trauma) or traumatic brain injury (TBI). A positive result in the Step #1 criteria necessitates transport to a level 1 or 2 trauma center. She did not meet the criteria in Step #1, so we proceed to Step #2.

   Step #2 involves specific injuries related to their anatomical location. These anatomical injuries are important for many reasons. Penetrating trauma may cause significant injury like arterial bleeding, central vessel punctures (such as a large artery or vein like the inferior vena cava or subclavian artery) lacerations and hemorrhage of vital organs, cardiac injuries, tension pneumothorax and more. Proximal long bone fractures, pelvic fractures and amputations all can cause major bleeding, especially proximal femur fractures, from large arteries and veins that are close to these structures. Skull fractures are a serious injury due to the little space inside the skull to support bleeding and the risk of brain herniation through the fracture or the foramen magnum (the base of the skull) due to swelling or hemorrhage. Paralysis indicates spinal cord injury, which is indicative of severe spinal trauma. A positive result in Step #2 necessitates transport to a level 1 or 2 trauma center as well. The patient did not meet the criteria in Step #2, so we proceed to Step #3.

   Step #3 involves mechanism of injury (MOI). While not the most useful criteria due to a high amount of overtriage, a significant mechanism of injury can be associated with internal injuries that are otherwise masked by the patient's physiologic compensation. The criteria of Step #3 were determined based upon scientific evidence through studies and expert opinion/experience. These mechanisms have a higher rate of severe injury compared to less forceful mechanisms. A positive mechanism of injury would necessitate transport to a level 3 or 4 trauma center, not necessarily a level 1 or 2. It is unknown how fast she was going, so we could consider that she met this criteria. Also, an 18-inch intrusion is considered a significant MOI and would validate transport to a trauma center.

   The fourth and last step involves special considerations. Patients who are on anticoagulation drugs like clopidogrel (Plavix), aspirin, warfarin (Coumadin), chronic NSAIDs and many others will have increased risks of major hemorrhaging due to their inability to form blood clots. Patients with bleeding disorders such as hemophilia or von Willebrand disease also have problems clotting and bleed significantly. Any patient with atrial fibrillation should be suspected as being on anticoagulation medicine if they cannot provide you with a list of medications. Older patients have a high risk of severe injury or death due to trauma. Pregnancy causes many physiologic changes, such as increased cardiac output, increased blood volume and hypercoagulability. Pregnant patients need to be carefully evaluated by a trauma center since there are two potential lives at stake.

   If at any point during the assessment you think the patient does not look stable, use your judgment to determine where to transport him or her. Patients matching these criteria can be transported to a level 3 or 4 trauma center.

Guidelines Changes

   What is drastically different from the 1999 guidelines many of us were trained under? There are several major changes.

  • "Crushed, degloved or mangled extremity" has been added to the list of serious injuries under anatomic criteria in Step #2.
  • Under the mechanism of injury category in Step #3, vehicle telemetry data consistent with a high-speed auto crash was added. This may be important in the upcoming years as more and more vehicles are being installed with electronics that can output this data quickly and reliably.
  • Falls has been edited to include falls of children >10 ft or 2-3 times their height.
  • "High-risk" auto crash was changed from "high-speed" and now includes: intrusion >12 inches at occupant site, >18 inches at any site, partial or complete ejection or death of another passenger in same compartment.
  • Auto-pedestrian/auto-bicyclist injury was changed from 5 miles an hour to >20 miles an hour, thrown or run over. Motorcycle crashes were revised to only >20 mph.
  • Speed >40 mph, deformity >20 inches, rollovers, and prolonged extrication time were all removed because of a lack of evidence supporting the need to transport these patients to a trauma center.
  • The last step, special considerations, added time-sensitive extremity injury, end-stage renal disease requiring dialysis and EMS provider judgment.
  • Pregnancy was added at >20 weeks, and patients with cardiac disease, respiratory disease, diabetes, cirrhosis, obesity or immunosuppression were removed due to a lack of evidence.

Patient Transport and Outcome

   Looking at all of the factors, including the patient's age (67), the possibility of internal abdominal injuries due to blunt trauma, the fact that the vehicle was traveling at an unknown speed, the dangerously high blood pressure, the history of previous acute myocardial infarction and personal opinion, we diverted from a local hospital and transported to the closest level 1 trauma center.

   After trauma assessment at the hospital, CT scans were all negative. The patient had an extracranial hematoma and was admitted for observation for the night. Luckily, she did not have any serious consequences related to the motor vehicle accident and was discharged home the following day.

   While she had a good outcome and no serious injuries, according to the CDC guidelines, she qualified to be transported to a trauma center. While maintaining an acceptable level of overtriage, these guidelines should help prevent undertriage, a situation that can result in high morbidity and mortality for patients who are not transported to facilities capable of managing their serious injuries.

Step #1 Physiologic Criteria
Blood pressure Systolic BP <90 mmHg
Respiratory rate <10, >29, <20 in an infant <1 yr old
GCS <14
Step #2 Anatomic Criteria
Penetrating injuries to head, neck, torso, proximal extremities Flail chest
> or = to 2 proximal long bone fractures Crushed, degloved or mangled extremity
Amputation proximal to wrist or ankle Pelvic fracture
Open or depressed skull fracture Paralysis
Step #3 Mechanism of Injury
Falls Adults >20 feet; children >10 feet or 2-3x their height
High-risk motor vehicle collision Intrusion >12 inches into occupant site or >18 inches anywhere
Ejection from vehicle
Death in the same passenger compartment
Telemetry data consistent with high risk of injury
Auto vs. pedestrian/bicycle Patient was thrown, run over, or hit while vehicle traveling >20 mph
Motorcycle collision >20 mph
Step #4 Special Considerations
Age Greater than 55 y/o increases risk of injury or death
Children should be transported to pediatric-capable trauma centers
Hematologic criteria Patients who are anticoagulated or have bleeding disorders
Burns With trauma, go to trauma center
Without trauma, go to burn center
Renal disease End-stage renal disease requiring dialysis
Pregnancy >20 weeks
EMS provider judgment  
Time Time-sensitive extremity injury (such as amputation)

Bibliography

Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients-Recommendations of the National Expert Panel on Field Triage. MMWR 58:RR-1:1-35, 2009.

Joshua Bucher, BA, EMT-B, is a member of the Morganville First Aid & Rescue Squad in Marlboro, NJ, and a third-year medical student at Jefferson Medical College.

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