Trauma Triage Education
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Trauma Triage Education Trauma Triage Education Presentation Transcript

  • Ohio Department of Public Safety Division of Emergency Medical Services Ohio Prehospital Trauma Triage Rules Revised January 2009
  • In accordance with ORC §4765.16, this presentation on trauma was developed under the direction of Carol A. Cunningham, MD, FACEP, FAAEM State Medical Director Ohio Department of Public Safety, Division of EMS and John Crow, MD, FACS Chair of the Trauma Committee of the State EMS Board
  • The standards and criteria in this presentation were developed for Emergency Medical Technicians operating in the prehospital setting to determine if a person has suffered injuries severe enough to require treatment at a trauma center.
  • Ohio Trauma Triage Rules LEARNING OBJECTIVES
        • Describe Ohio’s legal definition of trauma
        • Discuss the definition of a trauma center and what the different levels of trauma center designation mean
        • List the anatomic and physiologic criteria to be used when evaluating pediatric, adult, and geriatric trauma victims
        • Discuss the role that mechanism of injury and special considerations play in trauma patient destination
        • State the five exceptions to transporting trauma patients directly to trauma centers
        • Describe the key aspects of regional trauma triage protocols
        • Discuss the importance of EMS documentation of trauma triage criteria
  • Ohio Prehospital Trauma Triage Rules Legal Definitions
    • The Ohio General Assembly establishes laws in the Ohio Revised Code (ORC).
    • Laws are amplified by State Boards and agencies through rules established in the Ohio Administrative Code (OAC).
    • The General Assembly established laws in ORC sections 4765.01 and 4765.40 which define:
      • Traumatic injury
      • Trauma patient / trauma victim
      • Trauma care
      • Trauma center
      • Trauma triage
    • These definitions are expanded and clarified for EMS providers by the State Board of Emergency Medical Services in OAC chapters 4765-1 and 4765-14
    • ‘ Trauma patients’ or ‘trauma victims’ are legally defined as those who have sustained a traumatic injury. ‘Traumatic injury’ is legally defined as “damage to or destruction of tissue that satisfies both of the following conditions:
      • Poses a significant risk of
        • Loss of life
        • Loss of limb
        • Permanent disfigurement
        • Permanent disability
      • Is caused by
        • Blunt or penetrating injury
        • Exposure to electromagnetic, chemical or radioactive energy
        • Drowning, suffocation or strangulation
        • A deficit or excess of heat”
    • ‘ Trauma care’ is legally defined as “assessment, diagnosis, transportation, treatment, or rehabilitation of a trauma victim by emergency medical service personnel or by a physician, nurse, physician assistant, respiratory therapist, physical therapist…licensed to practice as such in this state...”
    • The qualifications for a hospital to become a trauma center are also defined in law.
    • A hospital is designated as a trauma center by the State of Ohio when it:
      • Receives verification from the American College of Surgeons as an adult or pediatric trauma center
      • or
      • Operates under Ohio’s Provisional Trauma Center laws
      • or
      • Is located in another state and is licensed or designated as a trauma center by that state
  • Ohio Prehospital Trauma Triage Rules Trauma Centers
    • What makes a hospital a trauma center?
    • A trauma center is a hospital which has the immediate availability of specialized surgeons, physician specialists, anesthesiologists, nurses, resuscitation and life support equipment, and operating rooms on a 24-hour basis to care for severely injured patients.
    • Why take seriously injured patients directly to a trauma center?
    • The definitive care of internal bleeding or traumatic brain injury cannot occur in the prehospital setting or in a routine and timely manner at a non-trauma center hospital
    • Trauma centers have 24-hour availability of emergency medicine and surgical services which allow the patient to be taken directly to the operating room, if needed
    • Studies of over 250,000 Ohio trauma patient records have shown that trauma patients taken to a non-trauma center hospital spend, on average, over four hours at that hospital before transfer to a trauma center is initiated.
    • Trauma centers are designated as Level 1 through Level 4
    • The differences in levels are based on the depth of the resources available to treat the trauma victim
    • The differences in the levels are not based on quality of care – all trauma centers are required to have a commitment to high quality of care
    What are the levels of trauma centers and how are they different?
    • Level I – A regional resource trauma center that must have the capability of providing total care for every aspect of injury, from prevention through rehabilitation. Level I trauma centers also have responsibility of providing leadership in education, research, and system planning.
    What are the levels of trauma centers and how are they different?
    • Level II – A trauma center that provides initial definitive trauma care, regardless of the severity of the injury. Depending on location and available resources, Level II trauma centers may not be able to provide the same comprehensive care as a Level I trauma center. The Level II trauma center assumes responsibility for education and system leadership in areas where a Level I trauma center does not exist.
    What are the levels of trauma centers and how are they different?
    • Level III – Level III trauma centers are meant to serve communities that do not have immediate access to a Level I or II trauma center. Level III trauma centers can provide prompt assessment, resuscitation, emergency operations and stabilization of the trauma patient, as well as arrange for possible transfer to a facility that can provide a higher level of definitive trauma care.
    What are the levels of trauma centers and how are they different?
    • Level IV – Level IV trauma facilities provide advanced trauma life support prior to patient transfer in remote areas where a higher level of care is not available.
    What are the levels of trauma centers and how are they different?
  • Key Concept
    • The law requires that all trauma victims be transported directly to a trauma center.
    • There are five exceptions to this mandatory
    • transport law. These will be discussed later.
  • 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 1 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 1 2 2 2 2 2 2 3 Ft. Wayne, IN Huntington, WV Wheeling, WV Pittsburgh, PA Erie, PA Parkersburg, WV 4 Weirton, WV 4 New Martinsville, WV 4 Point Pleasant, WV 4 Ohio Designated Trauma Centers Locations within each county not exact
  • Ohio Prehospital Trauma Triage Rules Trauma Patient / Trauma Victim Definitions
    • There are three age groups for trauma patients:
    • Pediatric
      • Age 0 – 15 years
    • Adult
      • Age 16 – 69 years
    • Geriatric
      • Age 70 years and older
    • A trauma patient or trauma victim is a person who has suffered an injury that:
    • 1) Poses a significant risk of loss of life; loss of limb; permanent disfigurement; or permanent disability
    • and
    • 2) Is caused by blunt or penetrating injury; exposure to electromagnetic, chemical or radioactive energy; drowning, suffocation or strangulation; or a deficit or excess of heat
    • “ Body region” means a portion of the trauma victim’s body divided into the following areas:
      • Brain
      • Head, face and neck
      • Chest
      • Abdomen and pelvis
      • Extremities
      • Spine
    • “ Evidence of hemorrhagic shock” includes any of the following
      • Delayed capillary refill (greater than 2 seconds)
      • Cool, pale, diaphoretic skin
      • Decreasing systolic blood pressure with narrowing pulse pressure (the difference between the systolic and diastolic pressures becoming smaller)
      • Altered level of consciousness
    • “ Evidence of neurovascular compromise” includes one or more of the following (“The 5 Ps”)
      • Paresthesia (numbness/tingling)
      • Pain (severe)
      • Paralysis
      • Pallor / pale
      • Pulselessness
    • “ Evidence of poor perfusion” means one or more of the following:
      • Weak distal pulses
      • Pallor / paleness
      • Cyanosis
      • Delayed capillary refill (greater than 2 seconds)
      • Tachycardia (appropriate for the patient’s age)
    • “ Evidence of respiratory distress” includes one or more of the following
      • Stridor
      • Grunting
      • Retractions
      • Cyanosis
      • Hoarseness
      • Difficulty speaking
    • “ Evidence of traumatic brain injury” means signs of external trauma and physiologic indicators that the brain has suffered an injury caused by external force including, but not limited to
      • Decrease in level of consciousness from the victim’s baseline
      • Unequal pupils
      • Blurred vision
      • Severe or persistent headache
      • Nausea or vomiting
      • Change in neurological status
    • “ Proximal long bone” is the humerus or femur
    • “ Seat belt sign” is bruises or abrasions on the chest and/or abdomen resulting from the use of a seat belt during a motor vehicle crash
    • “ Signs and symptoms of spinal cord injury” include
      • Paralysis
      • Weakness
      • Numbness / tingling
    • When evaluating an injured person for triage to a trauma center, EMS providers must look for certain indicators of serious injury. These indicators will be either:
    • - Anatomic – the injuries suffered
    • - Physiologic – the body’s response to the injury, or
    • - Mechanistic – cause of injury (geriatrics only).
    • If the patient is found to have any of these indicators, they are required to be transported directly to a trauma center, unless one of the five exceptions apply.
    • There are also special circumstances surrounding the injury that should be considered by EMS providers when deciding the injured patient’s destination.
    • There are differences in the indicators for pediatric, adult and geriatric trauma patients.
    • If an injured person has any of the following indicators, they should be transported directly to a trauma center.
    • Pediatric Anatomic Indicators
    • Penetrating injury to the head, neck or torso
    • Significant penetrating injury to the extremities, proximal to the knee or elbow, with neurovascular compromise
    • Visible crush of head, neck or torso
    • Abdominal tenderness, distention or seat belt sign
    • Flail chest
    • Pelvic fracture
    • Pediatric Anatomic Indicators
    • Injuries to the extremities with
      • Visible crush
      • or
      • Evidence of neurovascular compromise
    • Amputations proximal to the wrist or ankle
    • Fracture of 2 or more proximal long bones (humerus or femur)
    • Signs and symptoms of spinal cord injury
    • Serious burns
      • 2 nd or 3 rd degree burns over more than 10% of total body surface area
      • or
      • Involving face, airway, hands, feet, genitalia
    • Pediatric Physiologic Indicators
    • Glasgow Coma Score of 13 or less
    • Loss of consciousness for greater than 5 minutes
    • Failure to localize pain (GCS motor score 4 or less)
    • Evidence of poor perfusion
      • Weak distal pulse, pallor, cyanosis, delayed cap refill, or tachycardia
    • Evidence of respiratory distress or failure
      • Stridor, grunting, retractions, cyanosis, hoarseness, difficulty speaking
    • Adult Anatomic Indicators
    • Penetrating injury to the head, neck or torso
    • Significant penetrating injury to the extremities, proximal to the knee or elbow, with neurovascular compromise
    • Visible crush of head, neck or torso
    • Abdominal tenderness, distention or seat belt sign
    • Flail chest
    • Pelvic fracture (this does not include isolated hip fractures)
    • Adult Anatomic Indicators
    • Injuries to the extremities with
      • Visible crush
      • or
      • Evidence of neurovascular compromise
    • Amputations proximal to the wrist or ankle
    • Fracture of 2 or more proximal long bones (humerus or femur)
    • Signs and symptoms of spinal cord injury
    • Serious burns
      • 2 nd or 3 rd degree burns over more than 10% of total body surface area
      • or
      • Involving face, airway, hands, feet, genitalia
    • Adult Physiologic Indicators
    • Glasgow Coma Score of 13 or less
    • Loss of consciousness for greater than 5 minutes
    • Failure to localize pain (GCS motor score 4 or less)
    • Respiratory rate less than 10 or greater than 29
    • Requires endotracheal intubation
    • Requires relief of tension pneumothorax
    • Pulse rate greater than 120 with evidence of hemorrhagic shock
    • Systolic blood pressure less than 90 mm Hg
    • Geriatric Indicators
    • Geriatric trauma indicators are similar to adult.
    • Differences are marked with an asterisk *
    • Geriatric Anatomic Indicators
    • Penetrating injury to the head, neck or torso
    • Significant penetrating injury to the extremities, proximal to the knee or elbow, with neurovascular compromise
    • Visible crush of head, neck or torso
    • Abdominal tenderness, distention or seat belt sign
    • Flail chest
    • Pelvic fracture (this does not include isolated hip fractures)
    • Injury sustained in two or more body regions*
    • Geriatric Anatomic Indicators
    • Injuries to the extremities with
      • Visible crush
      • or
      • Evidence of neurovascular compromise
    • Amputations proximal to the wrist or ankle
    • Fracture of 2 or more proximal long bones (humerus or femur)
    • Signs and symptoms of spinal cord injury
    • Serious burns
      • 2 nd or 3 rd degree burns over more than 10% of total body surface area
      • or
      • Involving face, airway, hands, feet, genitalia
    • Geriatric Physiologic Indicators
    • Glasgow Coma Score of 13 or less
    • Glasgow Coma Score less than 15 with a known or suspected traumatic brain injury*
    • Loss of consciousness for greater than 5 minutes
    • Failure to localize pain (GCS motor score 4 or less)
    • Respiratory rate less than 10 or greater than 29
    • Requires endotracheal intubation
    • Requires relief of tension pneumothorax
    • Pulse rate greater than 120 with evidence of hemorrhagic shock
    • Systolic blood pressure less than 100 mm Hg*
    • Geriatric Mechanism Indicators
    • Fracture of 1 or more proximal long bones (humerus or femur) sustained in a motor vehicle crash*
    • Pedestrian struck*
    • Falls from any height – including standing – with evidence of a traumatic brain injury *
    • Remember, if an injured person has any of the indicators just listed, they must be transported directly to a trauma center.
    • As taught in your EMT-B, EMT-I and EMT-P courses, EMS personnel also must be concerned about mechanism of injury & special considerations when determining whether or not to transport to a trauma center.
    • These should be used as additional factors in decision making, not as stand-alone conditions that will triage a patient to a trauma center.
    • Mechanism of injury
    • Motor vehicle crashes with
      • Ejection
      • Rollover
      • Extrication greater than 20 minutes
      • Death in same passenger compartment
      • Evidence of high speed crash
        • Speed greater than 40 miles per hour
        • Major auto deformity (greater than 20 inches)
        • Intrusion into passenger compartment greater than 12 inches
    • Mechanism of injury
    • Auto vs. pedestrian, greater than 5 mph.
    • Auto vs. bicycle, greater than 5 mph.
    • Motorcycle crash greater than 20 mph.
    • Motorcycle crash with rider separated from bike
    • Falls greater than 20 feet
    • Special Considerations
    • Pregnancy
    • Co-morbid conditions
      • Cardiac or respiratory disease
      • Liver failure or cirrhosis
      • Insulin-dependant diabetes (Type 1)
      • Compromised immune system
        • Cancer, HIV, Transplant
      • Bleeding disorders or on anti-coagulants
      • Morbidly obese
    • Remember, mechanism of injury and special considerations should not be the only reason to decide whether or not to transport to a trauma center.
  • Ohio Prehospital Trauma Triage Rules Five Exceptions
    • The law requires that trauma patients be transported directly to a trauma center.
    • There are five exceptions to this requirement
    • Medical necessity for initial assessment and stabilization
    • Unsafe or medically inappropriate due to adverse weather conditions or excessive transport time
    • It would cause a shortage of local EMS resources
    • No trauma center is able to receive and provide care to the patient without undue delay
    • Before transport begins, the patient (or parent/guardian) requests transportation to a hospital that is not a trauma center
    Five Exceptions to Mandatory Transport
    • It is medically necessary to transport the patient to a hospital without a trauma center for initial assessment and stabilization before transfer.
    • These must be legitimate, immediately life-threatening medical reasons.
      • Unable to open or maintain airway
      • Traumatic arrest
      • Uncontrollable external bleeding
    • EMS agency protocols should provide guidance on when this is appropriate
    Five Exceptions to Mandatory Transport
    • Unsafe or medically inappropriate due to adverse weather conditions or excessive transport time.
    • In cases of bad weather or when transport time to the nearest trauma center is excessive, a patient may be better served by stopping at the nearest hospital for stabilization and transfer.
      • Consider other methods of transport, such as air medical
      • Local and regional protocols should provide guidance on when this is appropriate
      • Use your best professional judgment
    Five Exceptions to Mandatory Transport
    • It would cause a shortage of local resources.
    • Many EMS jurisdictions have limited resources – equipment and/or personnel – to provide for the emergency medical needs of their community. If transporting to a trauma center causes a shortage of these resources, it may be better to transport to the closest hospital where transfer can be arranged.
    • Each community must assess its available resources, including air medical services and mutual aid, to understand when this exception applies.
    Five Exceptions to Mandatory Transport
    • No trauma center is able to receive and provide care to the patient without undue delay.
    • This exception was originally intended to address situations where trauma centers were diverting trauma patients. However, with today’s mature state and regional trauma systems, this is mostly a thing of the past. Trauma centers avoid trauma patient diversion.
    • If, for some unusual reason, a trauma center diverts your patient, you must use your best judgment, along with guidance from medical control, to determine the next best destination for your trauma patient.
    Five Exceptions to Mandatory Transport
    • Before transport of a trauma patient begins, the patient requests to be transported to a hospital that is not a trauma center. This request may also be made by the parents / legal guardian of a trauma patient who is a minor, or by a legal representative of the patient.
    • Competent patients have the right to have input into where they will receive treatment. EMS personnel should attempt to convince the patient of the need for treatment at a trauma center but should respect the competent patient’s wishes.
    Five Exceptions to Mandatory Transport
  • Ohio Prehospital Trauma Triage Rules Overtriage and Undertriage
    • Undertriage
    • Transporting a severely injured patient to a hospital that is not a trauma center.
      • Worst case scenario? The patient dies or suffers complications or disabilities that are avoidable.
    • Trauma systems aim for 0% undertriage
    • Overtriage
    • Transporting a minimally injured patient to a trauma center.
      • Worst case scenario? Trauma center overload; unnecessary, expensive transfers of the patient; inconvenience for the patient and their family.
    • Trauma systems accept a certain amount of overtriage in order to keep life-threatening undertriage low.
  • Ohio Prehospital Trauma Triage Rules Regional Variations
  • Delaware Madison Union Licking Fairfield Pickaway Fayette Clark Champaign Logan Hardin Allen Hancock Wyandot Marion Crawford Huron Richland Ashland Morrow Knox Coshocton Tuscarawas Carroll Harrison Belmont Guernsey Muskingum Monroe Noble Perry Morgan Washington Athens Hocking Meigs Gallia Vinton Jackson Lawrence Scioto Adams Pike Ross Highland Shelby Miami Montgomery Greene Darke Preble Mercer Auglaize Van Wert Paulding Defiance Williams Putnam Henry Fulton Wood Lucas Ottawa Sandusky Seneca Erie Lorain Cuyahoga Medina Wayne Holmes Lake Geauga Ashtabula Trumbull Portage Summit Stark Mahoning Columbiana Jefferson Clinton Brown Clermont Warren Butler Hamilton Franklin Franklin Ohio’s EMS Regions 1 10 9 4 8 7 3 2 5 6
    • The law allows for regional variations to Ohio’s trauma triage protocols as long as the following criteria are met:
      • Ohio’s minimum triage criteria are met
      • The appropriate Regional Physician Advisory Board (RPAB) submits the variation to the EMS Board
      • The EMS Board’s Trauma Committee has the opportunity to review and comment
      • They are approved by the EMS Board
    • Prior to submission of a regional variation to the EMS Board, the RPAB must consult with:
      • Neighboring RPABs
      • Hospitals and trauma centers in their region
      • State-level EMS, physician and nursing organizations
      • EMS instructors in their region
    • Regional trauma triage protocol variations:
      • Must require that EMS transport trauma victims to trauma centers
      • May include any of the 5 exceptions to mandatory transport but cannot create additional exceptions
      • Must seek to minimize overtriage and undertriage
      • Supersede Ohio’s protocols once approved by the EMS Board
      • Are automatically amended to meet the state triage protocol if the EMS Board updates the state protocol.
  • Ohio Prehospital Trauma Triage Rules Periodic Review
  • The law requires that Ohio’s trauma triage protocols be reviewed and updated every three years by the State EMS Board in order to minimize overtriage and undertriage. These reviews are done through public hearings, public comment periods and examination of the data in the EMS Incident Reporting System (EMSIRS) and the Ohio Trauma Registry (OTR).
  • EMS documentation is very important to effectively perform these reviews. Each EMS run report should record what, if any, trauma triage criteria were met by the injured patient, as well as their vital signs and the Glasgow Coma Score. This information is submitted to EMSIRS and used by the EMS Board to study how the EMS portion of the trauma system is functioning. This means y our run data is being used to improve the care given to all injured patients.
  • Ohio Prehospital Trauma Triage Rules Summary
    • Questions every EMS provider should consider when evaluating an injured patient and making the decision on where to transport:
    • Is this patient at risk of losing life or limb?
    • Is this patient at risk for disability or disfigurement?
    Ohio Prehospital Trauma Triage Rules Summary
    • Questions every EMS provider should consider when evaluating an injured patient and making the decision on where to transport:
    • Is there evidence of respiratory distress or failure?
    • Is there evidence of poor perfusion or hemorrhagic shock?
    • Are there significant neurological symptoms?
    • Are there signs/symptoms of spinal cord injury?
    • Is there neurovascular compromise in an extremity?
    Ohio Prehospital Trauma Triage Rules Summary
    • Questions every EMS provider should consider when evaluating an injured patient and making the decision on where to transport:
    • Are there penetrating wounds to the head, neck or torso?
    • Are there visible crush injuries?
    • Is there abdominal distention, tenderness or seat belt sign?
    • Are there signs of a pelvic fracture or flail chest?
    • Are there amputations above the wrist or ankle?
    • Are there significant, serious burns?
    Ohio Prehospital Trauma Triage Rules Summary
    • If the answer is yes to any of those questions, the patient must be transported to a trauma center.
    Ohio Prehospital Trauma Triage Rules Summary Prehospital assessment is key to rapid transport to the appropriate medical facility
  • Ohio Prehospital Trauma Triage Rules Summary Trauma centers are capable of providing 24-hour surgical care to allow the trauma patient to be taken directly to the operating room, if needed. Transporting a trauma patient to a non-trauma center hospital can result in significant delay in the patient’s arrival at a trauma center for definitive care.
  • Ohio Prehospital Trauma Triage Rules Summary Undertriage – - Transporting a severely injured patient to a hospital that is not a trauma center. - Can result in death or disability of the trauma patient. - Every trauma system’s goal is to have NO undertriaged trauma patients. Overtriage – - Transporting a minimally injured patient to a trauma center. - Can create a burden on system resources. - Most trauma systems need 25% - 30% overtriage to ensure ALL severely injured patients get to a trauma center.
  • Ohio Prehospital Trauma Triage Rules Summary Your documentation is very important to improving Ohio’s trauma system. Accurate documentation of the trauma triage criteria an injured person meets (if any), along with all vital signs, allows the EMS Board to improve the efficiency of the system.
    • ATLS: Advanced Trauma Life Support, 7 th Edition. 2004. American College of Surgeons; Chicago, IL.
    • Basic Trauma Life Support for the EMT-B and First Responder, 4th Edition. 2003. Campbell JE and Alabama Chapter of Emergency Physicians. Dothan, AL.
    • Basic Trauma Life Support for Advanced Providers, 5 th Edition. 2003. Campbell JE and Alabama Chapter of Emergency Physicians. Dothan, AL.
    • PHTLS: Basic and Advanced Prehospital Trauma Life Support, 4 th Edition. 1999. Eds. Paturas JL, Wertz EM and McSwain NE, Jr. Mosby, St. Louis, MO.
    • Ohio Revised Code, §4765.01, §4765.06, §4765.16, §4765.40, §4765.41
    • Ohio Administrative Code, §4765-14-01, §4765-14-02, §4765-14-03, §4765-14-04, §4765-14-05, §4765-14-06, §4765-15-01, §4765-16-01, §4765-17-01
    Ohio Prehospital Trauma Triage Rules References and Resources