Medical Triage of Traumatic victims

นพ.เพชรพงษ์� กำ��จรกำ�จกำ�รภ�ควิ�ช�เวิชศ�สตร�ฉุ�กำเฉุ�น

วิ�ทย�ลั�ยแพทยศ�สตร�กำร�งเทพมห�นครแลัะวิช�รพย�บ�ลั

• PREVENTION

• TRAINING

• EVALUATION

AllInjuredPatients

MajorTraumaPatients

PREHOSPITAL• Communication• Medical Direction• Triage• Transport

ACUTE CARE FACILITY WITHIN A TRAUMA

SYSTEM other injured patients

TRAUMA CENTER most severity injured or

SPECIALTY CARE FACILITY peds, burns,

and so on

INTERFACILITYTRANSFER

REHABILITATION

Triage

• Dispatch criteria (triage)

• Field triage– Triage of the single victim– Multiple- and mass-casualty triage

• Emergency department triage

No. ofPatients

INCLUSIVE SYSTEM

FIELD TRIAGE

EXCLUSIVESYSTEM

MINOR MODERATE SEVERE

Injury Severity Risk*

Dispatch Criteria - Triage

• - Individual Chief Complaints

• - Traumatic Incidents

• - Time/Life-Critical Events

Type of Response

• - RED: response time within 8 minutes

• - YELLOW: response time within 15 minute

• - GREEN:

• - WHITE

• - BLACK

Traumatic Incident Types

• ปั�จจ�ยที่��ใช้�ในการตั�ดสิ�นใจสิ�งที่�มปัฏิ�บั�ตั�การช้�วยเหลื�อ– กลืไกการบัาดเจ บั– อว�ยวะหร�อสิ�วนของร�างกายที่��ได�ร�บัการบัาดเจ บั– อาการ/อาการแสิดงที่��สิ$าคั�ญ

• ช้ อก• บัาดเจ บัศี�รษะ• การตักเลื�อดมาก• การหายใจม�ปั�ญหา• Specific injury

Prehospital Care Process

ม เหต�ฉุ�กำเฉุ�นเกำ�ดขึ้#$น

แจ%งเหต�(วิ�ธี กำ�รแจ%ง?)

ร�บแจ%งเหต�

ประเม�น/ต�ดส�นใจในกำ�รออกำปฏิ�บ�ต�กำ�ร

แจ%งหน+วิยปฏิ�บ�ต�กำ�รฉุ�กำเฉุ�น(รถ/เร-อ/ฯลัฯ)ออกำปฏิ�บ�ต�กำ�ร

เด�นท�งถ#งท /เกำ�ดเหต�

ประเม�นสถ�นกำ�รณ์�แลัะต�ดส�นใจเพ-/อให%กำ�รร�กำษ์�พย�บ�ลั

เบ-$องต%นในท /เกำ�ดเหต�

ต�ดส�นใจส+งสถ�นพย�บ�ลั

ท /เหม�ะสมถ#งสถ�นพย�บ�ลั

ร�ยง�นเหต�กำ�รณ์�แกำ+ผู้2%เกำ /ยวิขึ้%อง

ให%กำ�รร�กำษ์�พย�บ�ลัณ์ ท /เกำ�ดเหต�

พบเหต�

จบกำ�รปฏิ�บ�ต�กำ�ร

Emergency Medical Dispatcher (EMD)

Medical Instruction– คัวามเปั)นไปัได�

• ผู้+�แจ�งไม�ได�อย+�ก�บัผู้+�เจ บัปั,วย• โที่รศี�พที่/ไม�ได�อย+�ใกลื�ก�บัผู้+�เจ บัปั,วย• สิ��อสิารก�นไม�เข�าใจ

– คัวามเหมาะสิม• ผู้+�แจ�งได�ให�การช้�วยเหลื�อในสิ��งที่�� EMD จะให�คั$าแนะน$า

ไปัแลื�ว• สิถานการณ์//สิถานที่��ไม�เหมาะสิมที่��จะที่$า

ถ2กำท��ร%�ย/บ�ดเจ3บ




BURN

BURN

พลั�ดตกำหกำลั%ม/อ�บ�ต�เหต�/เจ3บปวิด



อ�บ�ต�เหต�จร�จร



Field TriageField Triage

Single victim triage

• Single victim triage– aim– Scoring system (GCS, trauma score, etc.)– Triage decision scheme

• Antomical criteria• Mechanism of injury• Medical criteria

Triage Decision Scheme

Measure vital signs and level of consciousness

Glasgow Coma Scale < 14 orSystolic blood pressure < 90 orRespiratory rate < 10 or > 29 orRevised Trauma Score < 11 Pediatric Trauma Score < 9

YES NO

Take to trauma center; alert trauma team

Assess anatomy of injury

Step 2

Step 1


All penetrating injured to head, neck, torso, and extremities proximal to elbow and knee Flail chest Combination trauma with burn Two or more proximal long bone fracture Pelvic fracture Limb paralysis Amputation proximal to wrist and ankle

YES NO

Take to trauma center; alert trauma team

Evaluate for evidence of mechanism of injury and high-energy impact

Step 3

Step 2

Triage Decision Scheme Ejection from automobile Death in same passenger compartment Extrication time > 20 minutes Falls > 20 feet Rollover High-speed auto crash:

initial speed > 60 mphmajor auto deformity > 20 inchesintrusion into passenger compartment > 12 inches

Auto-pedestrian/auto-bicycle injury with significant (> 5 mph) impact Pedestrian thrown or run over Motorcycle crash > 20 mph or with separation of rider from bike

YES NO

Step 4

Step 3

Contact medical control and consider transport to a trauma centerConsider trauma team alert


Age < 5 or > 55 Cardiac disease, respiratory disease Insulin-dependent diabetes, cirrhosis, or morbid obesity Pregnancy Immunosuppressed patients Patient with bleeding disorder or patient on anticoagulants

YES NO

Reevaluate with medical control

Step 4

Contact medical control and consider transport to a trauma centerConsider trauma team alert

Multiple- or mass-casualty triage

Hot zone

Warm zone

Cold zoneDecontamination area

Wind direction

Command Center / supporting unit

Predicted ED casualties

• With in 90 minutes following an event, 50-80% of the acute casualties will likely arrive at the closest medical facilities.

• The less-injured casualties often leave the scene under their own power and go to the nearest hospital.

Total Expected Casualties = (Number of casualties arriving in one hour window) x 2


• Multiple- or mass-casualty triage– Aim – categorize– How

• Ability to walk• Mental status• +/– of ventilation or capillary perfusion

– Tagging– Secondary and tertiary triage – every 15 min.– Shifting from the immediate-care to dead-and-

dying category


• Timing for triage : Dynamic Triage

• First look

• Clearing station

• Prior to evacuation

• Hospital ER


INCIDENT SITE

TRIAGE SIEVE TRIAGE SORT

ALP

RECEIVING HOSPITAL

RECEIVING HOSPITAL

RECEIVING HOSPITAL

1 - Immediate 1 - Immediate

2 - Urgent 2 - Urgent

3 - Delayed

4 - Expectant

Dead

4 - Expectant

Body Holding Area

TEMPORARY MORTUARY

CCS


• Common locations for triage– Primary triage ( Triage sieve )

• At the scene

• Ambulance personnel

– Secondary triage ( Triage sort )

• At CCS

• Medical personnel


• Triage Priority 1 (Immediate) • Casualties who require immediate life-

saving interventions

• Triage Priority 2 (Urgent)– Casualties who require surgical or other

interventions within 2 - 4 hours


• Triage Priority 3 (Delayed)– Casualties whose treatment may be

safely delayed for >4 hours

• Triage Priority 4 (Expectant) – Injuries are

1. So severe that they cannot survive, or

2. So severe that their treatment would compromise the care of others


• Triage decisions need to be made

quickly, safely

• If adequate resources become

available T3 T1

WALKING

BREATHING

RESPIRATORY

RATE

CAPILLARY

REFILL

PRIORITY 3 (delayed)

DEAD

PRIORITY 1 (immediate)

PRIORITY 2 (urgent)

Yes

Yes

No

No

When airway

opened

10 - 29Ove

r 2 se

c

2 seconds or under

Triage Sieve Diagram

9 or less 30 or more


• Triage Sort

– More data needed

– Triage revised trauma score (TRTS)

• Respiratory rate

• Systolic BP

• Glascow Coma Scale

Revised trauma score

GCS SBP RR Coded Value

13 – 15 > 89 10 – 29 4 9 – 12 76 – 89 > 29 3 6 – 8 50 – 75 6 – 9 2 4 – 5 1 – 49 1 – 5 1 3 0 0 0

TRTS = GCS + SBP + RR

• T1 Immediate1 – 10

• T2 Urgent 11

• T3 Delayed 12

• T4 Expectant 0

Triage revised trauma score (TRTS)


INCIDENT SITE

TRIAGE SIEVE TRIAGE SORT

ALP

RECEIVING HOSPITAL

RECEIVING HOSPITAL

RECEIVING HOSPITAL

1 - Immediate 1 - Immediate

2 - Urgent 2 - Urgent

3 - Delayed

4 - Expectant

Dead

4 - Expectant

Body Holding Area

TEMPORARY MORTUARY

CCS


• Triage Labelling

– Essential, should be prepared

– Indicates that triage has been done

– Indicates the current triage priority

– Changes with patient’s condition


Single card system


Folding/Cruciform Card System


Emergency Department Triage

Emergency Department Triage

The Canadain E.D. Triage and Acuity Scale

Level Iresuscitation

Nurse – immediatePhysician - immediate

Usual Presentation

ArrestMajor traumaShock statusNear death asthmaSevere respiratory distressAltered mental state (unconscious, delerious)seizures

Sentinel Diagnosis

Traumatic shockPneumothorax - traumatic / tensionFacial burns with airway compromiseSevere burn > 30% TBSOverdose with hypotension/unconsciousAAAAMI with complications / CHF / low BPStatus asthmaticusHead injury – major / unconsciuosStatus epilepticus


Level IIemergency

Nurse – immediatePhysician – 15 min

Usual Presentation

Head injury (risk features – altered mental state)Severe trauma

Sentinel Diagnosis

Head injury

Trauma:- multiple sites, multiple rib fracture, neck injury / spinal cord


Level IIemergency

(con’t)


Usual Presentation

Altered mental state (lethargic, drawsy, agitated)Chemical exposure – eyesAllergic reaction (severe)Chest pain : visceral, non-traumatic : + associated symptomsOverdose (conscious), Drug withdrawal

Sentinel Diagnosis

Alkaline / caustic occular burnsAnaphylaxisAMI, unstable angina, CHF, chest pain NOSGastrointestinal refluxUnspecified drug / medicinal overdose


Level IIemergency

(con’t)


Usual Presentation

Abd pain (age > 50) with visceral symptomBack pain (nontrauma, not musculoskeletal)GI bleed with abnormal vital signsCVA with major deficitAsthma severe (PEFR < 40%)Moderate/severe dyspnea/ difficulty breathing

Sentinel Diagnosis

AAA, appendicitis, cholecystitis

Gastrointestinal bleed, hypotension

CVASevere asthmaCOPD, Croup


Level IIemergency

(con’t)


Usual Presentation

Vaginal bleeding: acute, pain scale > 5 + abnormal vital signsVomiting and/or diarrhea (with suspicious of dehydration)Signs of serious infection (purpuric rash, toxic)Chemotherapy or immunocompromisedFever (age < 3 mo.) temp > 38.0 (rectal)

Sentinel Diagnosis

Spontaneous abortionEctopic pregnancy/Rupture

Epiglottitis, meningitis, sepsis


Level IIemergency

(con’t)


Usual Presentation

Acute psychotic episode/ extreme agitationDiabetes: hypoglycemia, hyperglycemiaHeadache (pain scale 8 – 10/10)Pain scale 8 – 10 (CVA, back, eye)Sexual assaultNeonate (< 7 days old)

Sentinel Diagnosis

Acute phychotic episode / agitation

Hypoglycemia, DKA, hyperglycemia

Migraine

Renal colic, LBP / stain (disc), keratitis, Iriitis


Level IIIurgent

Nurse – 30 minPhysician – 30 min

Usual Presentation

Head injury, alert, vomitingModerate trauma

Abuse / neglect / assualtVomiting and/or diarrhea (< 2 yrs)Dialysis problemSigns of infectionMild / moderate asthma

Sentinel Diagnosis

Head injuryAnterior dislocated shoulder, tibia/fibular fracture, bimalleolar or trimalleolar ankle fracture

PyelonephritisAsthma without status / COPD


Level IIIurgent(con’t)


Usual Presentation

Mild / moderate dyspneaChest pain no viscal symptom (sharp) no previous heart diseaseGI bleed with normal vital signsSeizue, alert on arrivalAcute psychosis + suicidal ideaPain scale 8-10/10 with minor injuryPain scale 4-7/10 (headache, CVA, back)

Sentinel Diagnosis

Bronchiolitis / croup, pneumonisChest pain NOS (musculoskeletal, GI, respitatory)

GI bleed, no complicationSeizure Acute psychosis + suicidal idea

Migraine, renal colic, LBP/strain (disc)


Level IVLess urgent


Usual Presentation

Head injury, alert, no vomitingMinor traumaAbd pain (acute)EaracheChest pain, minor trauma or musculoskeleton, no distress

Vomiting and diarrhea (> 2 yrs./no dehydration)Suicidal ideation / depression

Sentinel Diagnosis

Head injury, alert, no vomitingColles fracture, ankle sprainAppendicitis, chelecystitisOtitis media / otitis externaChest pain NOS (musculoskeletal, GI, respitatory) gastroesophageal reflux

Suicidal ideation / depression


Level IVLess urgent

(con’t)


Usual Presentation

Allergic reaction (minor)Corneal foreign bodyBack pain (chronic)URI symptomsPain scale 4-7Headache (non-migraine / not sudden)

Sentinel Diagnosis

UrticariaCorneal foreign bodyLBP painURI


Level Vnon urgent


Usual Presentation

Minor trauma, not necessarity acuteSore throat, no respiratory symptomsDiarrhea alone (no dehydration)Vomiting alone, normal mental status (no dehydration)MensesMinor symptoms

Sentinel Diagnosis

LBP / strain

URI

GastroenteritisVomiting

Disorder of menstruationDressing changes, cast changes


Level Vnon urgent

(con’t)


Usual Presentation

Abd pain (chronic)Psychiatric complaints

Pain scale < 4

Sentinel Diagnosis

ConstipationSymptoms / neurotic, personality and nonpsychotic mental disordersUnspecified superficial laceration

Patient should have an initial triage assessment within 10 minutes

of arrival

ผู้+�ปั,วยช้ายไที่ยอาย3 18 ปั4 เก�ดอ3บั�ตั�เหตั3ข��จ�กรยานยนตั/ช้นก�บัรถจ�กรยานยนตั/ปัระมาณ์ 20 นาที่� ก�อนมาถ5งโรงพยาบัาลื เพ��อนที่��ข��จ�กรยานยนตั/ไปัด�วยก�นน$าสิ�งโรงพยาบัาลื

1 hr later good consciuos, pale, BP 80/40 mmHg,groos hematuria

แรกร�บั triage

BP 110/70 mmHg RR 20/minLacerated wound above left eye brew 3 cm.

Intraoperative finding: intraperitoneal blood 2,000 cc.ruptered speen, retroperitoneal hematoma, not expansion, zone 2

Retriage

In 15 min.

ATLS

Trauma victim

ED Triage

Evaluate in ED and Discharge

Evaluate in EDand observe

Resuscitate in EDand admit

Resuscitate in EDand transport to OR

Transport directly toOR for resuscitation

Pronounce DOA

Mass casualty in ED ?

Thank you

Economy & Finance

Medical Triage of Traumatic victims