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Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education

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Presentation on theme: "Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education"— Presentation transcript:

1 Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education

2 Objectives  Historical development of triage  Relationship between triage & development of trauma systems  How changes in triage affect resources  Review Region V Trauma Triage Guidelines “Those who cannot remember the past are condemned to repeat it.” ~ George Santayana

3 The “Disease” of Trauma  Leading killer in US of persons <44 yo, however: Life or limb-threats in 10% of all trauma pts 150,000 deaths annually 44,000 MVC 28,000 GSW  Most expensive “disease” in terms of lost wages, initial care, rehabilitation & lifelong maintenance

4 Triage  French: “to sort, cull or select”  Evaluation & classification of casualties initially for evacuation & treatment of battlefield wounded  Greatest good for greatest number  Prior to 1700s rank trumped injury

5 Napoleonic Wars  Baron Dominique–Jean Larrey was Napoleon’s Surgeon Major during Rhine Campaign (1792-1798)  Developed “Flying Ambulance” (1797) to transport wounded off battlefield  Goal was treatment within 24 hrs Rescue casualties based on injury not rank Immediate treatment Transport to 1 st line hospitals  Baron Pierre Percy developed alternative “Casualty Transport System” to transport surgeons & supplies to patient 1 st “Mobile Hospitals”

6 American Civil War  1847: Congress authorizes 1 st commissions for medical officers  1861: Battle of Bull Run Medical corps dysfunction ○ Too few ambulances ○ Minimal organization ○ Casualties not evacuated for days Prompted 1862 appointment of 1 st Surgeon General Bill Hammond  1862: 2nd Battle of Bull Run Dr Letterman appointed Medical Director Army of Potomac Revised ambulance core

7 Jonathan Letterman MD  “ Napoleonic” casualty care  Transferred all medical care to Army Medical Corps  Reformed medical supply distribution  Triage by Medical Corps provided 1 st prehospital standards of care  3 Tiered Evacuation System Field Dressing / Aid Station Field Hospital / MASH Unit Large Hospitals

8 World War I  Collecting Zone Advanced field aid stations  Evacuating Zone Clearing Hospital  Distributing Zone Rest Stations  Transport based upon “self- evacuation” ability ○ “Lyers” vs “Walkers”  “Casualty Clearing Hospitals” MASH “Specialty” Surgeons: Abdominal, Orthopedics, Plastics Minimum10% operative rate

9 World War II  Radio communications  Resuscitation  Antibiotics  1 st Air Transport  Development of Echelon System

10 WWII Echelon System  1 st Echelon: “Physician First” Treat & Street after emergent procedures No holding capacity but could treat 300-500 wounded simultaneously  2 nd Echelon: Secondary triage 72 hour holding OR Capable Supported 3-9 Aid Stations

11 WWII Echelon System  3 rd Echelon Combat Support Hospitals / MASH units Advanced care capable of facility rapid evacuation  4 th Echelon Full spectrum of hospitals with rehabilitation capabilities outside combat zone Definitive care Limited to no mobility

12 Korean War  Increased use of aeromedical transport  Directly transported most seriously injured patients, bypassing “inappropriate” facilities

13 Trauma-Related Deaths* *Includes environmental & post-operative complications War# / 1000 Mexican104 Civil71 Spanish-American34 WWI17 WWII0.6

14 Patient Outcomes & Time to Definitive Care WarTimeMortality WWI12-18 hrs8.5% WWII6-12 hrs5.8% Korea2-4 hrs2.4% Vietnam65 mins1.7%

15 Civilian Trauma System Evolution  1966 NHTSA “White Paper” Highway Safety Act of 1966 “Accidental Death and Disability: The Neglected Disease of Modern Society” detailed MVC pts dying from initial trauma & inadequate prehospital care 1 st statewide prehospital system in 1969 in Maryland  1971 Illinois Trauma Program Trauma center categorization Advanced communications Safer ambulance designs Improved prehospital training Trauma Registry development / CQI  1973-1976 ACS publishes “Optimal Hospital Resources for Care of the Injured Patient” resulting in the Emergency Medical Services Act

16 Civilian Trauma System Evolution  1990: ACS “ Trauma Care Systems Planning & Development Act” e stablished guidelines, funding & state-level leadership for trauma system development  1992 “Model Trauma Care System Plan” introduced concept of “Inclusive” vs “Exclusive” Systems Assumes all acute care facilities are part of a larger integrated system Tiered approach based on known quantity of available & invariable resources

17 “Exclusive” Trauma Systems  Centralizes all injuries regardless of severity to tertiary centers  Excludes acute care facilities with variable capabilities  Over-triage to avoid under-triage  Problems Payer mix Triage based on likelihood of admission vs tiered resource utilization Non-participation of uncategorized facilities Lack of MCI training

18 Trauma Triage Leads to Trauma Care Systems  CDC / ACS / NHTSA Trauma Triage Guidelines assist providers in triaging pts to the proper facility  Guidelines offer pt-specific destination criteria for definitive treatment  Development of a Trauma Care System integrates prehospital & hospital care to reduce cost, time to OR / ICU, & mortality

19 Elements of a Functional Trauma System  Defined Need, Authority & Legislation  Standardized Care with Adaptive Changes Based Upon Resources  Tiered Triage Based on Injury Severity, With Mechanisms to Bypass Lower Echelons  Rapid Transport & Concurrent Treatment Utilizing Standardized Care  Integration of Advanced Technology  Commitment to Training  Outcomes Driven Model

20 Triage Tools Problems  “One Size Fits All” No, it doesn’t Populations & resources vary & change  Mature & busy systems have better outcomes  Incident influences outcomes  Changes in triage absolutely affect system resources & patient outcomes

21 Triage Tools  START  Trauma Index  Trauma Score / RTS  CRAMS Score Circulation, Respiration, Abdomen, Motor, Speech  Prehospital Index  Trauma Triage Rule  Kampala Triage

22  Anatomically based global severity scoring system that classifies each injury in every body region according to its severity on a 6 point scale: 1 = Minor 2 = Moderate 3 = Serious 4 = Severe 5 = Critical 6 = Maximal (unsurvivable)  9 body regions: Head Face Neck Thorax Abdomen Spine Upper Extremity Lower Extremity External & other  Take highest AIS each of the 3 most severely injured body regions, square each AIS & add the 3 squared numbers together ISS = A 2 + B 2 + C 2  ISS scores ranges from 1 to 75 AIS 0-5 for each category  If any of the 3 scores is a 6, the score is automatically set at 75  Since a score of 6 indicates futility of further medical care in preserving life, this generally means a cessation of further care Abbreviated Injury Scale (AIS)Injury Severity Score (ISS) A major trauma requiring a Trauma Center is defined as an ISS > 15

23 ACS Field Triage Decision Scheme  Physiologic Criteria  Anatomic Criteria  Mechanism Criteria  Age & Co-morbidities  “When In Doubt Take To A Trauma Center” Criteria

24 Physiologic Criteria (Vitals)  1 st triage step identifies pts at high risk of suffering from severe injuries: Hypovolemic shock Neurogenic shock Cardiogenic shock Traumatic brain injury  However, critical injuries resulting in “shock” may not be reflected early in vitals due to physiologic compensation  “Do not pass “GO”, Do not collect $100”

25 Anatomic Criteria  2 nd step evaluates injuries related to anatomical location  Penetrating trauma may cause significant injury dependent on area Proximal long bone fractures, pelvic fractures & amputations all cause major bleeding Skull fractures place pt at risk due to bleeding & increased ICP Paralysis indicative of spinal trauma

26 Mechanism of Injury  Significant mechanism of injury often assoc with internal injuries masked by early physiologic compensation  Mechanism alone not enough to determine triage destination

27 Special Considerations  Use of anticoagulants (clopidogrel, aspirin, warfarin, NSAIDs)  Bleeding disorder (i.e. hemophiliacs)  Special Popuations Geriatrics (>70) Pediatrics Pregnancy ○ Physiologic changes: increased CO & TBV, hypercoagulability ○ High risk of abruption with “minor” trauma  Provider impression Sick vs Not Sick? Not Sick with high potential for Sick?

28 Densmore. Outcomes and delivery of care in pediatric injury. J Ped Surg. 2006.  PURPOSE Site of care must be correlated with outcomes to design effective pediatric trauma care systems  Results 80,000 injury cases in 27 states Grouped by age, ISS & site of care 89% received care outside of children's hospitals If 0-10 yrs with ISS >15, mortality, LOS & charges all significantly higher in adult hospitals  CONCLUSIONS Younger & seriously injured children have improved outcomes in children's hospitals

29 Caterino. Modification of Glasgow Coma Scale criteria for injured elders. Acad Emerg Med. 2011  CONCLUSIONS 52,412 pts In elders, mortality & TBI increased with GCS decreasing from 15 to 14 & 14 to 13 In adults, mortality did not increase with the GCS drop-offs

30 Trauma & Co-Morbidities


32 Appendix J: Air Medical Transport Protocols  Does not require Med Control approval, but does require oversight  Nearest Appropriate Facility: Uncontrolled airways unless ALS can intercept in a more timely fashion Arrest due to blunt trauma  Air Medical Transport If meets specific criteria & scene arrival time to arrival time at nearest appropriate hospital, including extrication time > 20 mins Location, weather or road conditions preclude ground ambulance Multiple casualties exceed capabilities of local agencies

33 Appendix J: Air Medical Transport Protocols Patient Conditions  Physiologic Criteria Unstable vitals (SBP 30 or <10)  Anatomic Criteria Spinal cord injury Severe Blunt Trauma: ○ Head Injury (GCS <12) ○ Severe chest, abdominal or pelvic injuries excluding simple hip fractures Burns: ○ >20% BSA 2 nd or 3 rd degree burns ○ Airway, facial or circumferential extremity ○ Associated with trauma Penetrating injuries of head, neck, chest, abdomen or groin Amputations of extremities, excluding digits

34 Appendix J: Air Medical Transport Protocols Patient Conditions  Special Conditions considered in decision to request air medical transport, but not automatic or absolute  MVC Ejected Death in same compartment Pedestrian struck & thrown >15 ft, or run over  Significant Medical History Age >55 or <10 Significant coexistent illness Pregnancy

35 Cudnik. Prehospital factors associated with mortality in injured air medical patients. PEC. 2012  BACKGROUND: Air medical transport provides rapid transport to definitive care. Overtriage & the expense & transportation risks may offset survival benefits  RESULTS: 557 pts transported by air to a level 1 trauma center. Majority were male (67%), white (95%) with an injury rurally. Most injuries were blunt (97%), & pts had a median ISS of 9. Overall mortality 4% Most common reasons for air transport were MVC with high-risk mechanism (18%), MVC speed >20 mph (18%), GCS 5 mins (15%) Factors with high mortality: age >44 yrs, GCS <14, SBP <90 mmHg & flail chest Most common trauma indicators resulting in death, receipt of blood, surgery, ICU admission included EMS ETI, >2 fractures of humerus/femur, neurovascular injury, cranial crush or penetrating injury, failure to localize to pain on examination, GCS <14  CONCLUSIONS Few prehospital criteria assoc with clinically important outcomes in helicopter- transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated & developed

36  1,200 trauma admits/year  Pts w/ ISS >15 (240 total or 35 pts/surgeon)  Immediate surgical capability available  In-house trauma surgeon  General surgery residency program or trauma fellowship  Research  No minimum patient criteria  Surgical capability available in a “reasonably acceptable time”  General surgeon present at resuscitation  Desirable to have residents  No research minimum LEVEL I TRAUMA CENTERLEVEL II TRAUMA CENTER Trauma Center Designations Trauma Center Designations ACS Committee on Trauma / State site verification & accreditation

37  Level III “Community” Trauma Center Specialized ED with majority of subspecialties on-call  Level IV Rural community hospitals No immediate surgical interventions available Stabilize & transfer  Uncategorized Essentially a Level IV not participating in ACS classification “Free-standing” EDs

38 Trauma Center Designations Trauma Center Designations ACS Committee on Trauma / State site verification & accreditation  Specialty Centers Neurocenters Burn Centers Pediatric Trauma Hyperbaric Medicine Microsurgery  Most have “Medical Specialties” certified by Joint Commission MICU CICU / Cath Lab Stroke Centers

39 MA State Trauma Centers  Region I Baystate (Level 1 Adult & Pediatric); Springfield Berkshire Medical Center (Level 2 Adult & Pediatric); Pittsfield  Region II UMass Memorial (Level 1 Adult Trauma & Pediatric); Worcester  Region III Anna Jaques Hospital (Level 3 Adult); Newburyport Beverly Hospital (Level 3 Adult); Beverly Caritas (Level 3 Adult); Methuen Salem Hospital (Level 3 Adult); Salem Lawrence General Hospital (Level 3 Adult); Lawrence Lowell General Hospital (Level 3 Adult); Lowell)  Region IV Beth Israel (Level 1 Adult); Boston BMC(Level 1 Adult & Pediatric); Boston Brigham & Women’s (Level 1 Adult); Boston Boston Children’s (Level 1 Pediatric); Boston Lahey Clinic (Level 2 Adult); Burlington Massachusetts General (ACS Level 1 Adult & Pediatric); Boston Tufts / NEMC (Level 1 Adult & Pediatric); Boston  Region V No verified ACS Trauma Centers  Rhode Island Rhode Island Hospital (Level 1 Adult); Providence Hasbro Hospital (Level 1 Pediatric); Providence

40 Mass ACS Verified Trauma Centers





45 Quality Improvement (CQI / QA)  Data & Trauma Registry Data retrieval system for trauma patient information Used to evaluate & improve the trauma system as well as provide individual feedback  CQI Examine system performance to improve outcomes Evaluate calls to determine if standard of care met Relies upon accurate & complete documentation

46 Transport Decisions  Should be based upon “evidence-based” criteria  Can critical problems be managed en- route  Use Medical Control early & often

47 Summary  The lessons of battlefield medicine created civilian trauma systems  Triage tools best understood within the context of the type of system they serve  As field resources change so must trauma systems

48 References  Bucher. Does Your Patient Need A Trauma Center? EMS World. 2011  Loftus. Banner Good Samaritan Medical Center. Statewide Trauma Rounds, 2007.  Bledsoe. Essentials of Paramedic Care. 2006.  OEMS Prehospital provider Protocols. March 2012.  Mosby, Brady, Caroline. Prehospital Care Textbooks. “Trauma”  References cited throughout presentation.

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