TRAUMA TRIAGE: CONCEPTS IN PREHOSPITALTRAUMA CARE

Robert E. O'Connor, MD, MPH, FACEP

ABSTRACT

This report examines the efficacy of current trauma triageroles to determine the exigency of field care and transportof severely injured patients from a variety of medical pop-ulations. Key words: emergency medical services; trauma;triage.

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INTRODUCTION

Effective field triage of trauma victims requires iden-tification of patients at risk of dying and their rapidtransport to hospitaIs capable of treating severe injuries.ldentification of these patients at the scene can be diffi-cultbecause prehospital personnel must rapidly applystructured triage decision making. Precise applicationoíprehospital trauma triage cri teria is critical for ensur-ing that the maximum number of patients with severeinjuries is transported to trauma centers. The tradeoffin the prehospital management of trauma balances aperceived need to "stay and play" tempered by the re-ality of having to "load and go." While the prehospitaltrauma triage instrument may be helpful in determin-ing the exigency of field care and initiation of trans-port, the real utility lies in identifying patients war-ranting transport to the regional trauma center, evenifnon-trauma centers are bypassed on the way.l-13 On-line medical direction may be used to enhance triagedecisions.4

The annual automotive crash distribution in theUnited States is shown in Table 1. Less than one half of

all tow-away crashes involve personal injury. Of thoseinjured, fewer than 9% have serious injury and fewerthan 3% have time-critical injury. Rapid identificationof patients with serious injury, especially if time crit-ical, is the goal of any prehospital triage scheme. Toappropriately conserve resources, such a scheme musthave sufficient specificity and not result in excessiveovertriage.5

While automotive trauma accounts for the larger pro-portion of patients likely to benefit from treatment at atrauma center, interpersonal violence places substantialdemands on trauma systems. The scope of the problem

From the Department of Emergency Medicine, Christiana Care

Health System, Newark, DE.

Address correspondence to: Robert E. O'Connor, MO, MPH, FACEP,

Christiana Care Health System, 4755 Ogletown-Stanton Road, PO Box6001, Newark, DE 19718. e-mail: <roconnor@christianacare.org>.

doi: 10.1080 /10903120600723947

is immense, with 1.6 million emergency departmentvisits for assault in 2002. While there were more than42,000 automotive deaths in the United States in 2002,there were more than 17,000 homicides, with a deathrate of 6.1 per 100,000. The vast majority of homicides,nearly 12,000, are caused by firearms, with a death rateof 6.1 per 100,000.6The health care burden of caring forthe injured is vast and requires that the regional healthcare system share this burden with minimal overtriageand undertriage. A regional trauma plan is an inclu-sive model tha t integra tes the resources of hospitaIs andcommunities throughout the region in providing careto the severely injured trauma patient.

When the trauma triage rule works well, emergencymedical technicians (EMTs) and paramedics get to thescene and apply judgment with explicit triage criteriato determine quickly which hospital to transport pa-tients to and which life-saving interventions to admin-ister at the scene and during transport. Most prehospitaltrauma triage criteria adopt a combination of physio-logic, anatomic, and mechanism of injury components,but this approach still fails to identify a number of pa-tients with severe injuries and often burdens traumacenters with patients with minor injuries.7,8

Physiologic Criteria

Various types of diagnostic and monitoring techniquesare available in the prehospital environment, but it isunclear how increasing complexity of diagnostic equip-ment improves the ability to predict the need for a life-saving intervention. One recent study suggested that aweak radial pulse may be used to triage trauma patientsin field conditions with limited instrumentation.9 An-

other study showed that when an abnormal radial pulsecharacter (weak or absent) and abnormal GlasgowComa Scale (GCS) verbal and motor components werepresent, the probability of needing a life-saving inter-vention was >88%. These data show that simple andrapidly acquired manual measurements could be usedto effectively triage non-head-injured trauma patientsand may provide a more rapid and accurate assessmentthan more sophisticated techniques.lO

If blood pressure (BP) is to be used as a triage in-strument, a manual BP should be obtained. AutomatedBP determinations are consistent1y higher than manualBP, particularly in hypotensive patients. Some recom-mend that automated BP devices should not be used for

field or hospital triage decisions. Manual BP determi-nations should be used until systolic BP is consistent1y>110 mm Hg.n

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TABLE1. Annual Automotive Crash Distribution in theUnited States29

Motor vehicle crashesVehicle towed

Treated and released from hospitalTreated at the scene

HospitalizedVehicles involved in fatalities

11.4 million3.0 million1.2 million300,000230,00047,000

Another predictor of serious trauma is a respiratoryrate >25 breaths/min. Respiratory rate may be a usefultriage tool for trauma care providers where the scene ischaotic and evacuations 10ng.12

The prehospital GCS score is a reliable physiologicparameter for predicting hospital admission after a mo-tor vehide crash. When obvious indicators (hypoxemia,multiple long bone fractures, focal neurologic deficits)for trauma team activation are lacking, the prehospi-tal GCS score may be used to reduce overtriage andundertriage rates.n

Mechanism Cri teria

Investigators from the Royal Melbourne Hospital con-ducted a study to assess whether prehospital triageguidelines, based on mechanistic cri teria alone, accu-rately identified victims of motor vehide crashes withmajor injury. Multivariate logistic regression indicatedthat prolonged extrication time, passenger compart-ment intrusion, high speed, and ejection from vehidewere statistically associated with major injury. Vehiderollover and fatality in the same vehide were not statis-tically associated with major injury. These data suggestthat existing guidelines for the prehospital triage of mo-tor vehide crash victims, based on mechanistic criteriaalone, may need revision.14

Paramedic judgment has been identified as an alter-native method for the triage of trauma patients but isas of yet unverified.15 Although there is little evidenceto strictly support the rule, scene time should generallybe limited to ten minutes unless factors such as delayedextrication supervene.

Are some criteria more sensitive than others? In one

study, mechanism of injury was the only reason fortrauma center transport in 29 of 112 patients. Neitherintubation nor emergent surgery was required in anyof these patients, and alI survived. Only two had an In-jury Severity Score > 15. The remaining 83 had an 11%mortality rate. Fourteen (16.9%) had an Injury SeverityScore > 15. Defining an Injury Severity Score of 16 orgreater as severe injury, mechanism of injury alone hada positive predictive value of 7%.16

For blunt trauma as a result of a motor vehide crash,select mechanism of injury data such as skid marks,passenger compartment intrusion, and interior defor-mity willlikely be less reliable than location of impact

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(side vs. front vs. rear), rollover, restraint use, and bagdeployment. In the future, information from car sen-sors to public safety answering point, crash location,and even voice communication with occupant may beused to predict injury severity. Vehides equipped with"smart" sensors will be able to relay information toEMTs on change in velocity, vector of impact, and res-cue strategies before they arrive at the crash site. Safetymeasures could indude instructions on extrication and

disabling of airbags to reduce the chance of inadvertentdeployment.17

Substantial undertriage of serious trauma patients totrauma centers appears to be occurring, especially inolder persons and in persons with brain injuries. Ef-forts to understand why undertriage is occurring so fre-quently are hampered by fragmentation of the systemsof care, inadequate data management systems, and lackof trauma care performance reporting by non-traumacenter hospitals.18

Undertriage of older trauma victims has been apersistent and serious problem. Because of physio-logic changes and preexisting disease, blunt trauma inolder persons is often covert. Prehospital trauma triageguidelines developed for use with a general adult pop-ulation may not be sensitive enough to detect covertinjuries in elder1y trauma patients. In one study, under-triage was 8% for young and middle-aged men, 12%for young and middle-aged women, 18% for older men,and 15% for older women. Overtriage was also presentin alI age groups, indicating that many motor vehidecrash victims who were admitted to trauma centerscould have been admitted to non-trauma center hos-

pitaIs. Low sensitivity and specificity of trauma triageguidelines result in undertriage and overtriage. Someargue that prehospital triage guidelines should indudeage as a decision point to avoid placing older personsat risk for undertriage.19

Conversely, overtriage of younger trauma patientsappears to be prevalent. Helicopter transport of pedi-atric trauma patients in an urban emergency medicalservices (EMS) system was assessed to identify the ap-propriateness of using this modality for the young. Themajority of pediatric trauma patients transported by he-licopter were found to have sustained minor injuries.20

Trauma triage scores, severity of illness measures,and mortality prediction models quantify severity ofinjury and stratify patients according to a specified out-come. Triage scoring systems are typically used to assistprehospital personnel in determining which patientsrequire trauma center care, but they are not recom-mended as the sole determinant of triage. To optimizeoutcome, seriously injured trauma patients should betransported to the nearest trauma center. A recent land-mark report showed that the in-hospital mortality ratewas significant1y lower at trauma centers than at non-trauma centers (7.6% vs. 9.5%), as was the one-year mor-tality rate (10.4% vs. 13.8%).The effects of treatment at a

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O'Connor PREHOSPITALTRAUMA CARE

trauma center varied according to the severity of injury,with evidence to suggest that differences in mortalityrates were primarily confined to patients with more se-vere injuries.21

Trauma Centers

The extent to which severely injured patients receivedefinitive care at trauma centers is determined by theaccuracy of prehospital major trauma criteria in predict-ing severe injuries and by the leveI of compliance withthese triage instructions by prehospital providers. Themajority of patients meeting prehospital major traumacriteria are transported to designated trauma centers.Patients meeting only physiologic cri teria, however,are much less likely to be transported to trauma cen-ters, and there was a differentially low compliance forelderly trauma patients meeting physiologic criteriaalone.22

A trauma center is a hospital with a current Ameri-can College of Surgeons verification certificate, but thisvaries across states. The attending surgeon is expectedto be present in the emergency department upon arrivalof all patients to assure that hospital-specific guidelinesare met and to define major resuscitation when givensufficient advance notification from the field, within15 minutes of trauma team activation when the ad-

vance notification is short. Documentation of compli-ance with this expectation must be 80% or greater tobe verified. Online medical direction is encouraged fordifficult cases. Prearrival notification of the receivingfacility is essentia1.23 .

Only 56% of seriously injured patients in Califomiawere treated at trauma centers, despite most of the in-juries occurring in the catchment areas of designatedtrauma care systems. There are severa Ibarriers to an op-timal emergency medical system: 1) 75% of the UnitedStates is not covered by a trauma system; 2) region-alization of care, which would provide services with-out duplicating resources, is not common; and 3) somemechanisms criteria are not useful and those that are

useful should be used in the emergency departmentand in patient care as needed. Additionally, there is afailure to document elements and a failure to act onthose elements.18

Do EMS charts selectively report trauma triage crite-ria? Most mechanism of injury criteria noted on the datainstrument were infrequently documented on the stan-dard EMS reporto Patients who had mechanism criterianoted on the EMS report were more likely to be admit-ted to the hospital, to require major opera tive proce-dures, and to have prolonged lengths of stay than werepatients who had mechanism criteria documented onlyon the structured data instrument.24

Trauma triage scores, severity of illness measures,and mortality prediction models quantitate severity ofinjury and stratify patients according to a specified out-

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come. Triage scoring systems are typically used to as-sist prehospital personnel determine which patients re-quire trauma center care, but they are not recommendedas the sole determinant of triage.25

In the simplest of all triage schemes, investigatorssought to determine whether EMT judgment is ade-quate in identifying patients at high risk for death or theneed for immediate opera tive intervention. The EMTsrated the patient's overall severity on a four-point scaleand estimated the probability of patient mortality. Theinvestigators found that the EMT prediction of mortal-ity was as accurate as the various scores. The investi-gators concluded that EMT judgment is as accurate asthese three scoring systems in identifying patients whowere seriously injured.26

A rapid surgical response is predicated on adequatecommunication from prehospital providers. While on-line medical direction is encouraged to assist in themanagement of difficult cases, prearrival notificationof the receiving facility allows for the trauma center toamass the resources necessary to expedite the accuratemanagement of the trauma patient. Radio contact has anumber of additionaI benefits. For exampIe, ambulancecall report documentation is better with onIine medicaloversight. In addition, medical oversight helps reducethe number of refusals by incompetent patients, mayhelp convince patients who are competent but appearil1 to accept transport, and overall assists paramedicswith other difficult or unusual circumstancesP

What happens after EMS arrives at the hospital withthe injured patient? ln one study, the verbal communi-cation between EMT-paramedics and physicians in anemergency department trauma room was measured be-fore and after an educational intervention. Physiciansappear to recall paramedic verbal reports about traumapatients poorly. Recall is better with less injured pa-tients. Failed recall may have a nega tive impact on pa-tient care.28

CONCLUSIONS

The success of a trauma system relies on transfer of pa-tients from the field to the most appropriate hospital fordefinitive care. Effective field triage of trauma victimsrequires early identification of patients to hospitaIs ca-pable of treating their leveI of injury. Identification ofthese patients at the scene requires that prehospital per-sonnel rapidly apply structured triage decision making.Precise application of prehospital trauma triage crite-ria is critical but not uniform. Excessive overtriage andundertriage pIace significant burdens on the systemand require that prehospitaI triage criteria maximizesensitivity baIanced with optimal specificity. While avariety of triage criteria have been tested, most pre-hospital trauma triage cri teria adopt a combination ofphysioIogic, anatomic, and mechanism of injury com-ponents. It is recommended that EMS systems develop,

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apply, and validate a system for the triage of prehospitaltrauma patients.

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Reprinted with permission from Prehospital Emergency Care 2006; 1O(3):307-10.0'Connor RE. Trauma triage: concepts in prehospitaltrauma care. Copyright 2006 ~ National Joumal ofEMS Physicians, Informa Healthcare.

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