You are on page 1of 5

Injury, Int. J.

Care Injured 43 (2012) 1381–1385

Contents lists available at ScienceDirect

journal homepage:

Do pre-hospital trauma alert criteria predict the severity of injury and a need for an emergent surgical intervention?§
Guy Lin a,*, Alexander Becker b, Mauricio Lynn c

The Trauma Unit, Western Galilee Hospital, Naharia, Israel Department of Surgery A, Haemek Medical Center, Afula, Israel c The Dewitt-Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, University of Miami School of Medicine, Miami, FL, United States



Article history: Accepted 10 November 2010 Keywords: Triage Trauma alert criteria Emergent surgical intervention Evacuation priority

Objective: Efficient triage may have a major influence on mortality and morbidity as well as financial consequences. A continuous effort to improve this decision making process and update the trauma alert criteria is being made. However, criteria for determining the evacuation priority are not well developed. We performed a prospective study to evaluate which pre-hospital parameters identify major trauma victims with an emphasis on a need for emergent surgical procedures. Methods: A prospective cohort included 601 patients admitted to a level one trauma centre over a three months period. The pre-hospital trauma alert criteria were recorded and set as independent variables. All major surgical procedures were graded in real time as: emergent, urgent, or not urgent. The ISS was calculated after completion of all the diagnostic workup. Patients were classified as major trauma victims if their calculated ISS was 16 or greater, and those needed an urgent intervention or intensive care. The relative risks (RR) for major trauma and a need for an emergent operation were calculated. Results: 243 (40%) patients were classified as having a major trauma. 39 (6.5%) patients required an emergent operative intervention: 24 for an active bleeding, 5 for a pericardial tamponade and 10 for an imminent cerebral herniation. Paramedic judgement and a penetrating injury to the trunk were the most common causes for over triage. However, a penetrating injury to the trunk had been the only clue that the victim needed an emergent operation in five cases. 128 patients had a pre-hospital Glasgow coma score (GCS) 12. Altered mental status was the most common and a significant predictor of both major trauma (RR of 3.00 with a 95% confidence interval (CI) of 1.98–4.53) and a need for an emergent operation (RR, 95% CI: 4.43, 2.28–8.58). Also, a systolic blood pressure 90 mmHg was highly associated with an emergent operation (RR, 95% CI: 11.69, 5.85–23.36). Conclusion: For determining the evacuation priority, we suggest a triage system based on three major criteria: mental status, hypotension and a penetrating injury to the trunk. Overall, the set of trauma alert criteria system can be further simplified and enable better utilisation of resources. ß 2010 Elsevier Ltd. All rights reserved.

Introduction Trauma centre triage criteria are designed to ensure the evacuation of wounded to the correct destination. These criteria do not deal with the question of priority in the evacuation, that is, of the injured – who is the most urgent. It has been claimed that outcome is adversely affected if the initial assessment of severely injured patients is done in a non-trauma hospital.21 Conversely, the resources of a trauma centre must not be overwhelmed by assessment and treatment of minor trauma patients who could


From the Dewitt-Daughtry Family Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami School of Medicine, Miami, FL. * Corresponding author. Tel.: +972 50 2061927. E-mail address: (G. Lin).

reasonably expected to do well with care in their local area. Hence, there are attempts at reducing overtriage without compromising outcomes in trauma patients.5 For optimal allocation of resources in the treatment of trauma, it would be useful to decide as early as possible which patients would benefit most from transport to a dedicated trauma centre.9,13 Overtriage occurs when a false assumption that the patient is seriously injured is made based on prehospital criteria. Undertriage involves an assumption that serious injuries are not present when, in fact, they are. The American College of Surgeons (ACS) suggests the need for a 50% overtriage rate to maintain a 10% under triage rate.22 Kane et al.12 demonstrated that to obtain a 15% under triage rate, a 60% over triage rate was necessary, with 12% of patients triaged to trauma centres actually suffering serious injury. In a multi casualty situation, when shortage of transport means is anticipated, the triage system must include effective tools to

0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.11.014

Amputation at or proximal to wrist or ankle . Therefore. consciousness. Injury mechanisms were blunt in 417 cases: motor vehicle collisions (MVC) – 192.1382 G. The mean time from injury to hospital arrival was 44. In order to double-check the triage criteria. A further subdivision to a ‘‘very severe trauma’’ for patients with an ISS  25 was performed. mechanism of injury. Associations were analysed using [x]2 test. respiratory rate and pulse oximetery values (SaO2) were measured and recorded during pre-hospital transport. mechanism of injury and high index of suspicion (paramedics’ ‘‘gut feeling’’). The purpose of this prospective study is to evaluate the ability of our trauma centre triage criteria to identify major trauma victims with an emphasis on a need for an emergent surgical procedure.32 Æ 13. patients experiencing a cardiac arrest before any surgical procedure. femur.6%) patients suffered a penetrating mechanism: gun shot wounds (GSW) – 104 and stab wounds (SW) – 80. Dependent variables were the classification into the groups of major trauma or over triage. neck & torso. water sports – 7.43 years (range 15–100) whilst 103 of the patients were more than 55 years old. The next most common triage criterion was ‘‘cutaneous category 1’’ mainly a penetrating injury to the trunk being applied to 139 (23. Category 2 >55 years old Respiratory rate  30 BMR = 5 (BMR = best motor response of the GCS) Sustained heart rate = 120 bpm Any long bone fracture sustained in a MVC or fall  10 feet Major degloving injury. Care Injured 43 (2012) 1381–1385 decide which patients should be transported first. or paralysis. In Table 1 Miami-Dade County adult trauma alert criteria. The best method to identify those patients is yet to be established. 184 (30. / Injury. 39 patients required an emergent operative intervention: 24 for active bleeding (liver – 7. airway (AW). systolic blood pressure (SBP). Category 1 Age Airway Consciousness Circulation Fracture Cutaneous Mechanism of injury Other High index of suspicion order to reduce bias. Patients were classified as major trauma victims when their calculated ISS was 16 or greater. This group includes 490 men and 111 women. circulation. Materials and methods This study was approved by the University of Miami institutional review board. and the need for an emergent operation. 243 patients were defined as major trauma (40%). The mean ISS of the cohort was 14. The trauma centre was activated for any patient presenting any ‘‘category 1’’ criterion or at least two ‘‘category 2’’ criteria. other abdominal – 4. Ryder Trauma Centre patients were prospectively entered into the study if they met the Miami-Dade County trauma centre triage criteria.4 Æ 11. hospital arriving time and the trauma alert criteria as determined by the paramedics. there is a special importance to define the indices that indicate the highest probability of such injuries. Miami-Dade County pre-hospital trauma alert criteria set forth in Table 1 are based on a modification of the recommendations of the ACS. when they needed an emergent surgery and when they needed ICU care. motorcycle (including ATV) collisions (MCC) – 58. Results Demographics (Table 2) A cohort of 601 patients who met inclusion criteria represents the study population. or GCS  12 No radial pulse and sustained heart rate  120. For all the patients. All other patients were categorised as ‘‘over triaged’’ with a further subdivision to an ‘‘obvious over triaged’’ for patients who stayed in the hospital less than 24 h. heart rate (HR).05). sex. neck – 2. cutaneous. The length of ICU stay was added latter to the data collection sheet. or loss of sensation. the classification of the surgical procedure was approved by one of the investigators. All major surgical procedures were graded by the team as: emergent (a lifesaving operation is needed within minutes). spleen – 3. being applied to 222 (36. most studies done so far were retrospective in nature. Demographic data collected were: age. those transferred from another hospital and when adequate prehospital data could not be obtained. open fractures were referred as not urgent in this study. the Glasgow coma score (GCS). The results are given as relative risks (RR) with the 95% confidence intervals (95% CI).8 Æ 17. An altered level of consciousness was the third common reason for trauma alert (128 patients). The criteria are divided into two categories named category 1 and category 2 (as detailed in Table 1. chemical and electrical injuries.3 Patients who appear initially stable but are later determined to have potentially fatal injuries presents a major challenge. fracture. injuries that require emergent surgical intervention are a priority. There are eight criteria named: age. Variables are expressed as number of cases and percentage for categorical data. 126 (21% of the cohort) major trauma patients had an ISS of 25 or more. or major flap avulsion >5 inches. or SBP  90 mmHg 2 or more long bone fractures (humerus. ulna. or GSW to the extremities Ejection from a closed motor vehicle. ‘‘High index of suspicion’’ was the most common triage criterion. there is no category 1 for age and mechanism of injury and no category 2 for high index of suspicion). Patients were excluded from the study for: age less than 15. industrial accidents – 14 and assaults – 29. fibula) Deep penetrating injury to head. We believe that there is a need for prospective study to assess correctly the need for an emergent surgical intervention.1 For triage considerations. the ISS was calculated after completion of all diagnostic workup. falls – 65.9%) patients. pedestrian hit by car (PHBC) – 52. thermal. To note. tibia.7). Lin et al.1%) patients. and as means and standard deviations for numerical data. Int. From July 1st to September 30th 2007. injury time (as estimated by the 911 call). The statistical significance level was set at 5% (a = 0. The mean age was 38. or steering wheel deformity Active airway assistance beyond supplemental O2 BMR <5.63 min (range 10–144 min).71 (range 1–75). J. radius. The Mean time from injury to hospital arrival was not different for the wounded who needed emergent surgical treatment (43. or suspicion of spinal cord injury. urgent (a lifesaving operation is needed within hours) and not urgent. The triage criteria were set as independent variables.7 Obviously.25 Æ 18.

8 Æ 17. Int. 40 Hospital stay <24 h 0 Overtriage 6 (15%) Major trauma 34 9.81 37 5.00 1. 95% CI 3.69 5.94 1.43).54.99 0 .5%).18– 4. respectively).98–4.75 14 2.35 1.67–7.54 3. 5. / Injury.3%) incidence of mortality (17 patients expired in the operating room (OR) and 21 succumbed to their illness in the ICU).54–19.81 7.58 21 11.7%) 63 13 (20. the cohort experienced a 38/601 (6. 139 patients matched the cutaneous category 1 triage criterion.02 5. The mean ICU stay was 17. 82 femoral vessels – 2 and massive haemothorax – 2).5%) 13 (16%) 44 21 (47.92–8. 63 patients matched the circulation category 1 triage criterion (all with a SBP  90 mmHg).G. 18 of them with an ISS of 25 or more (not significant). Disposition of patients was as follows: ICU – 148 patients. in 28 of them the ISS was 25 or more (RR 11.11 2. Trauma alert criteria and major trauma (Table 3) 40 patients matched the AW category 1 triage criterion. 95% CI: 4. 34 patients were defined as sustaining major trauma (RR 9. 95% CI 2. 2.28–8.7%) 73 (52. 222 patients matched the ‘‘high index of suspicion’’ triage criterion.60 2.18 10 Not significant ISS  25 28 11.81.43 years (range 15–100) 103 (17. 3. Parameter AW category 1 RR 95% CI Consciousness category 1 RR 95% CI Circulation category 1 RR 95% CI Fractures category 1 RR 95% CI Cutaneous category 1 RR 95% CI Suspicion category 1 RR 95% CI Two or more category 1 criteria RR 95% C Two or more category 2 criteria RR 95% CI No.43 65 6. 5 patients sustained a pericardial tamponade whereas 10 patients required an immediate neurosurgical intervention for imminent cerebral herniation (5 had an epidural haematoma and 5 had a subdural haematoma).94–23.91 2 Not significant Emergent operation 10 6.69 29 Not significant 18 Not significant 52 13.8%) and the ‘‘cutaneous category 1’’ (mainly a penetrating injury to the trunk) criterion (73/ 139 = 52.60. 29 of them with an ISS of 25 or more (not significant).2%) 175 (78.42–22. but all had at least one more category-1 criterion.92 2.03 days (range 1–120).94 27 3. Characteristics Age Age >55 Men Women Time from injury to hospital ISS Overtriage Obvious overtriage (hospital stay <24 h) ISS  25 Injury mechanisms – blunt MVC PHBC MCC Fall Water sports Industrial/crush Assault Injury mechanisms – penetrating GSW SW Emergent operations Bleeding control Pericardial tamponade Neurosurgical emergency Urgent operations Value 38. 52 patients were defined as sustaining major trauma.18–7. Table 3 Triage criteria analysis. Care Injured 43 (2012) 1381–1385 Table 2 Patients/injuries/interventions demographics.49 6.14%) 490 (81. 47 patients were defined as sustaining major trauma.62%) 104 80 39 24 5 10 42 1383 Trauma alert criteria and over triage (Table 3) 358 (60%) patients matched the over triage definition.5%) 222 96 (43. High rates of over triage were caused by the ‘‘high index of suspicion’’ criterion (175/222 = 78.71).63 min (range 10–144) 14.53 52 4. in 14 of them the ISS was 25 or more (RR. 95% CI: 3. 1.03–7.92–8. Overall.97 4. Another 42 patients underwent urgent operations (which could have been delayed for several hours).25 Æ 18.12 90 3.71 20 4.18–4.01 1.35.5%) 38 (29. discharged from the ER – 168 patients.73–13. 1.12–8.11. 128 patients matched the consciousness category 1 triage criterion (all with a GCS  12). 27 patients were defined as sustaining major trauma.7%) 32 (72.1%) 11 (29.98–4. J.94–23.32 Æ 13.71 20 3.97.7%) 139 26 (18.43 2.58 0 128 16 (12. The median ICU stay was 6 days.23.11 66 Not significant 48 Not significant 68 10.02.42–22.11.7%) 37 3 (8. 2.94.98–23.23 3.26%) 111 (18.8%) 81 2 (2.12–8.38%) 192 52 58 65 7 14 29 184 (30.31 5. 90 patients were defined as sustaining major trauma.53.84 Æ 22. 6.69.7%) 23 12. expired in the OR – 17 patients. in 65 of them the ISS was 25 or more (RR.75.49–10.67–7. 95% CI 5. Trauma alert criteria and emergent surgical procedures (Table 3) AW category 1 triage criterion An orotracheal intubation or an attempted intubation had been performed at the scene on 40 patients.73–13.71 (range 1–75) 358 (60%) 168 (28%) 126 (21%) 417 (69.74%) 44.36 6 3.85–23. 4.24–24. regular floors – 262 patients.6%) 20 (31. 95% CI: 3.94. 168 (28% of the cohort) of them were discharged within 24 h. respectively). 1. in 37 of them the ISS was 25 or more (RR. respectively). Lin et al.00. 66 patients were defined as sustaining major trauma.12). 37 patients matched the fracture category 1 triage criterion.49–10. 10 of the 40 patients needed an emergent (within minutes) surgical procedure (RR 6.

In these situations. that could inappropriately influence the study: ‘‘Do pre-hospital trauma alert criteria predict the severity of injury and a need for an emergent surgical intervention?’’.81. and 5 patients had cutaneous-1 triage criterion as the sole class-1 criterion (3 sustaining GSW and 2 sustaining SW).19 that all patients with truncal gunshot wounds deserve trauma team activation. 5.98–23.8 found that the prehospital provider judgement triage criterion was equal or superior to other less subjective tools in its ability to identify severe injury. in a multi casualty situation.9. 13.6 Meanwhile. To note. Discussion The strength of this study lies in this prospective design with no sample bias and a complete data base. Circulation category 1 triage criterion 21 of the 63 patients needed an emergent surgical procedure (RR. 95% CI: 4. 2. Although passengers that are thrown out of a vehicle tend to be more severely injured. Hence. When combining two or more category-1 triage criteria. such a high rate of overtriage is probably delaying the care of other patients. no one from the 483 patients with a GCS  14 on admission needed a neurosurgical procedure. 95% CI: 10. Limitations of this study are related to the lack of attention to under triage rates and a relatively low number of patients requiring emergent operations. perhaps because passengers who are lying out of the car are often been mistaken for being ejected.10 According to current criteria. The high over triage rate is the result of wounds that are found to be superficial. Int.8% of cases. there is some advantage to over triage as the experience gathered in trauma centres may allow less workup for clearance of mildly injured patient.20 It is well accepted that a low GCS is highly predictive of the need for emergent interventions but the exact break point in the GCS score at which it becomes predictive has not been identified. Combined trauma alert criteria 81 patients had two or more category-1 triage criteria. there is no practical way to evaluate the depth of the wound in the field.03–7.36). all having neurosurgical emergencies.54– 19. we suggest three major criteria: altered mental status.7%) patients were defined as over triaged. Provider gut feeling alone was found to be a low-yield triage criterion in previous studies. GCS has been previously considered as the most reliable triage criterion. / Injury.31.91.85–23. 5.4%) patients with a SBP > 90 on admission needed an emergent bleeding control. the ability to identify major trauma. One patient with a pseudo-aneurism of the aorta underwent surgery the next day. only 2/542 (0. The Miami-Dade County triage criteria (Table 1) led to an over triage in 60% of cases.49. based on our results. over triage should be reduced. Still. 95% CI: 11. ‘‘High index of suspicion’’ Triage criterion: none of the 222 patients needed an emergent surgical procedure. an emergent operation was rarely needed. Field trauma triage: combining mechanism of injury with the prehospital index for an improved trauma triage tool. In contrast.18 In contrast.28–8. hypotension and a penetrating truncal injury. Vital signs are not sensitive neither specific indicators of the haemodynamic status. Emerman et al. this criterion was significantly associated with a need for an emergent lifesaving surgery. Lin et al. Although others have found a GCS of 12 as a cause for a high rate of overtriage16 our results support our policy of referring a GCS of 12 as the threshold for trauma team activation. Cutaneous category 1 triage criterion 20 of the 139 patients needed an emergent surgical procedure for concomitant severe injuries (RR.11 the ‘‘ejection’’ criterion was not a contributor to triage. To note. respectively). 32 (72. we found that when the SBP had been more than 90 mmHg on admission. J Trauma 1997.14 It is higher than the 50% rate recommended by the ACS22 and similar to the 60% rate recommended by Kane et al.18 The ‘‘high index of suspicion’’ (paramedic judgement) criterion led to an over triage in 78. Sustained heart rate 120 beats per minute and respiratory rate 30 are category 2 triage criteria. 6.14 these parameters are not good indicators to the haemodynamic status and also can be altered by substance abuse. Conflict of interest statement We hereby declare that we have no financial and personal relationships with other people. This rate is higher than the 46. However.43:283–7. However.7. Bond RJ.23 has been proposed to mandate full trauma team activation. Care Injured 43 (2012) 1381–1385 additional intubations were performed by anaesthetists on admission for various indications (not primary AW problems). very severe trauma and a need for immediate surgery is highly significant (RR. 10 were defined as a major trauma.24–24. or organisations. Heart rate variability may be a better triage parameter than the traditional vital signs. Like previously noted. As can be seen.18. .1% overtriage rate reported by our institution 19 years ago. over triage should be encouraged. a combination of two category 2 criteria was not associated with a major trauma or a need for an emergent surgery.69. any patient with a penetrating injury to the trunk/head/neck is transferred to a trauma centre. 2. References 1. this could limit the power of the statistical analysis despite the large sample size. A modified triage system is needed for situations that require setting priorities for evacuation of wounded. It seems that patients presenting two or more major criteria should be triaged as the most urgent patients.58). Hence. as retrospective analysis cannot set a reliable evaluation of the urgency of treatment and probably tends to overestimate it. when paramedic judgement is a major triage tool. we agree with Sava et al.58). Preshaw RM. No patient transferred by this criterion needed an emergent surgical procedure. haemodynamic stability does not reliably exclude significant haemorrhage. the injured requiring emergent surgical interventions should be evacuated first.99. Category 2 criteria have not found to be contributors to triage. When it comes to a single victim. 2 of them had an ISS  25 and no one needed an emergent surgery. To achieve this goal. A SBP  90 mmHg was highly associated with a major trauma and an emergent surgery. 44 patients were transferred to the trauma centre for a combination of two or more category 2 triage criteria category. J. 95% CI: 3.92.2 stated that following a penetrating abdominal trauma. it seems that our triage system can be simplified by omitting category 2 criteria.12 ‘‘Trauma team activation patients’’ receive the highest priority with regard to investigations and are being continuously monitored in the ER and the radiology department. Kortbeek JB. Fracture category 1 triage criterion 4 of the 37 patients needed an emergent surgical procedure for concomitant severe injuries (not significant). 12.43. Although the criterion states ‘‘deep penetrating injury’’. 7. GCS as high as 1415 and as low as 84.1384 G.17 Brown et al. 15 patients were hypotensive on admission (BP < 90 mmHg). tangential or just missing vital structures. Consciousness category 1 triage criterion 20 of the 128 patients needed an emergent surgical procedure (RR. 5 of them had consciousness category 1 triage criterion as the sole category 1 criterion.

Arch Surg 2001. O’Connor RE. Do prehospital trauma center triage criteria identify major trauma victims? Arch Surg 1995. Convertino VA. Trauma team activation: simplified criteria safely reduces overtriage. 1385 14. et al. The evaluation of a two-tier trauma response system at a major trauma center: is it cost effective and safe? J Trauma 1995. 13. Offner PJ. et al. J Trauma 2007. 5. Shoemaker W. A prospective evaluation of field categorization of trauma patients. J Trauma 1988. Neville AL. Carney DE. 7. Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories.53: 503–7. J Trauma 1991. et al. Acosta JA. Englehardt R. A comparison of EMT judgement and prehospital triage instruments. et al. Analysis of motor vehicle ejection victims 11.39:971–7.81:1217–62. 4. Cuadrado DG. 17. 1998. Gomez GA. J. J Trauma 2002. 8. King TS. et al. et al. Tinkoff GH. J Trauma 2001. 3. Reis ED. Surg Clin North Am 2001. Chicago. 15. Rozycki G. Kries DJ.51:854–9. 16. et al. Fine EG. Smith JS. Reducing overtriage without compromising outcomes in trauma patients. Int.G.60:363–70. et al. Lehmann RK. Emerg Med Serv 2002. ‘‘All-out response’’. Trauma scoring systems: a review. Salinas J. J Trauma 1985. et al. Velmahos GC. Muscarella P. Macioce D. Jurkovich GJ.31:55–61. Young WW. 19. 21. A prehospital Glasgow coma scale score 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions. Velmahos GC. Resources for optimal care of the injured patient. Norwood SH. Martin LF. Brown CV. Shade B.52: 1153–9. Cook CH. Care Injured 43 (2012) 1381–1385 2.136:752–6. J Trauma 2002.52:276–9. 18. 10. Senkowski CK. Empirical development and evaluation of prehospital trauma triage instruments. ´ ngora E.193:630–5. Esposito TJ. Acad Emerg Med 2004. Trauma team activation and the impact on mortality.30:1533–8. / Injury.239:304–10.140:767–72. Butler FK. . et al. Go admitted to a level I trauma center. et al. Celentano J. Cherry RA. 23.63:326–30.166:625–31. 20. Surgeons committee on trauma – American college of surgeons. Berne JD. Current controversies in shock and resuscitation. McKenney MG.189:491–503. Hammel JM. et al. 12. et al. Einav S. Tactical medicine training for SEAL mission commanders. Alo K. Kane G. Heart rate variability and its association with mortality in prehospital trauma patients. J Trauma 2002. Ann Surg 2004. Bretz SW. Milit Med 2001. Lin et al. 22. Praba AC. Arthurs ZM. Sava J. IL: American College of Surgeons. 9.130:171–6. Kubincanek J. Ochsne MG.11:1–9. J Trauma 1990. Hemodynamically ‘‘stable’’ patients with peritonitis after penetrating abdominal trauma: identifying those who are bleeding. Kohn MA. Arch Surg 2005. Trauma team activation criteria as predictors of patient disposition from the emergency department. Cooke WH. Validation of new trauma triage rules for trauma attending response to the emergency department. Weissman C. 6. All patients with truncal gunshot wounds deserve trauma team activation. EMS in Israel. Orlinsky M. Schmidt J. McAuley CE. Taigman M.28:995–1000.25:482–4.31:1369–75. et al. Evacuation priorities in mass casualty terror-related events: implications for contingency planning. Emerman CL. Am J Surg 2007. Forster J. J Trauma 2006. Wang DS. Feigenberg Z. Ryan K. J Am Coll Surg 1999.