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TRAUMA TRIAGE GUIDELINES STEP #2 STEP #1 Blood pressure Respiratory rate GCS PHYSIOLOGIC CRITERIA Systolic BP <90 mmHg <10, >29, <20 in an infant <1 yr old <14 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 physi- ologic 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 Penetrating injuries to head, neck, torso, proximal extremities ANATOMIC CRITERIA Flail chest > or = to 2 proximal long bone fractures Crushed, degloved or mangled extremity Amputation proximal to wrist or ankle Open or depressed skull fracture Pelvic fracture Paralysis 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) lacera- tions 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 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 neces- sarily 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. For More Information Circle 34 on Reader Service Card See Us at Clincon International Booth #514 and Pinnacle Conference Booth #11 56 JULY 2011 | EMSWORLD.com 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 indica- tive 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 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 fibril- lation 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