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North Central Texas Trauma Regional Advisory Council

Trauma Triage Protocol

INTRODUCTION that is designated by the Texas Department


A systems approach requires a of Health. A facility that is actively
regional triage system with identified pursuing designation can receive trauma
Trauma Centers capable of providing patients appropriate to the level of
trauma care to major trauma patients. designation to which the facility is
Patients must be identified and transported pursuing until December 1, 1999 if they
to the appropriate level of care in a timely demonstrate their commitment to trauma
fashion based on clinical need. by informing the Department of Health or
the NCTTRAC of their intentions or by
Triage is the classification of having applied for designation or
patients according to medical need. Since consultation to either the Department of
the majority of trauma deaths occur either Health or the American College of
before reaching the hospital or within four Surgeons.
hours of arrival, prehospital and
emergency department personnel must The North Central Texas Regional
make rapid triage decisions based on pre- Advisory Council has developed these
established system standards. triage guidelines to provide prehospital,
hospital, and trauma facilities with
Trauma Service Area-E (TSA-E) is assistance in triaging injured patients to
diverse with urban, suburban, and rural appropriate levels of care. These guidelines
areas. Persons injured in each of these may need to be modified to accommodate
areas may need to be triaged differently local conditions and will be continuously
but with the intention of providing optimal monitored by the NCTTRAC Quality
care in spite of the area where the injury Improvement Program.
occurred. TSA-E has many different
prehospital providers ranging from
volunteer units to advanced aircraft
agencies. Similarly, the hospitals in the
region are variable in their ability and
desire to care for injured patients.

Some hospitals in TSA-E are


designated as trauma facilities. Other
hospitals are actively working towards
achieving designation. Other hospitals are
not pursuing any level of designation. For
the purposes of this document, a trauma
facility is defined as a health care facility

Approved NCTTRAC: 4/14/98; Amended: 7/14/98


Approved TDH: 5/4/98
INCLUSIVE SYSTEM to provide appropriate delivery,
evaluation, and care for all patients,
Major trauma patients are those including the major trauma patient, in a
with either a severe injury or a risk for cost-effective manner.
severe injury. A severe injury is one that
could result in morbidity or mortality and
is classically defined as an injury with an PATIENT IDENTIFICATION
Injury Severity Score (ISS) of 16 or One characteristic of an inclusive
greater. On initial evaluation, these trauma system is patient triage designed to
patients typically have abnormal vital signs care for major trauma patients by matching
or a significant anatomical injury. patient severity to facility in a timely
However, triage is often inexact due to manner. A systems approach will consider
patients’ variable physiological responses injury severity, injury severity risk, time
to trauma. In some patients, minor injuries and distance from site of injury to
can result in morbidity or mortality due to definitive care, interhospital transfers
the patient’s age and/or co-morbid factors, considering guidelines for immediate
and some patients may have a delayed versus post-intervention transports, and
physiological response to trauma. factors that activate the regional system
(see Table 1).
Patients involved in a high-energy
event are at risk for severe injury. Five to Table 1
fifteen percent of these patients, despite Definition of Major Trauma-Adult

normal vital signs and no apparent ! Multisystem Blunt or Penetrating Trauma


anatomical injury on initial evaluation, will With Unstable Vital Signs (BP<90, HR>120,
RTS<11, GCS<14)
have a severe injury discovered after full ! Penetrating Injury of head, neck, torso, groin
trauma evaluation with serial observations. ! Burns > 20% TBSA (2nd or 3rd degree) or
involving face, airway, hands, feet, or genitalia
! Amputation (with reimplantation potential)
A continuum of services must be ! Paralysis or other signs of spinal cord injury
developed to provide preventive programs, ! Flail chest
prehospital care, acute care, and ! Open or suspected depressed skull fracture
! Unstable pelvis or suspected pelvic fracture
rehabilitation to all injured patients and to !Two or more long bone fractures
match resources with individual patient ! High energy event, such as
needs. ! Ejection from vehicle
! Significant fall (> 20 feet)
! Rollover mechanism
Current systems often rely on over-triage ! Bent steering wheel
to Trauma Centers and often an ! Auto-pedestrian impact
! Motorcycle or bicycle involvement
exaggerated and unnecessary response ! Significant assault
from trauma professionals. Such systems
may cause over-treatment of certain
patients, unnecessary expenses, burnout of Major trauma patient triage criteria
participants, and under-utilization of should consider categories such as:
certain health resources, including
personnel. In spite of these excesses, such - Patients with multisystem blunt or
systems may still run the risk of not penetrating trauma and unstable vital
treating all injured patients, including not signs.
appropriately treating all major trauma - Patients with known or suspected
patients. Under-triage runs the obvious anatomical injuries and stable or
risk of excluding some major trauma normal vital signs.
patients from receiving appropriate care. - Patients who are involved in a “high-
An inclusive system uses a tiered response energy” event with a risk for severe
North Central Texas Trauma Regional Advisory Council
Trauma Triage Protocol

injury despite stable or normal vital PREHOSPITAL TRAUMA TRIAGE


signs.
Prehospital triage should consider
time and distance and identify patients
Once identified, these patients should needing transport to the most appropriate
activate an appropriate systems response. designated Trauma Center rather than the
Triage occurs at both the prehospital and nearest acute care facility. In addition,
hospital level. prehospital triage criteria should allow for
the activation of the trauma system from
the field including an appropriate response
Pediatric patients (<13 years old) require a from the designated Trauma Center.
separate definition of major trauma due to (NOTE: Field personnel should always
their different physiologic response to seek guidance from physicians providing
injury: on-line medical direction if there is any
doubt regarding destination decisions or
Table 2
Definition of Major Trauma- Pediatric system activation.) Figure 1 is the model
prehospital algorithm for TSA-E.
! Multisystem Blunt or Penetrating Trauma After the trauma patient is
With Unstable Vital Signs:
BP: identified, the first priority of management
Neonate: <60 mmHg is the recognition of possible serious
Infant (<2yr): <65 mmHg airway compromise. If this potential is
Child (2-5 yr): <70 mmHg
Child (6-12 yr): <80 mmHg identified, control of the airway is
Respiratory rate: <10 or >60 essential. If the field personnel are not
PTS<9 capable of controlling the airway, then the
GCS<14
! Penetrating Injury of head, neck, torso, groin patient should be transported to the
! Burns > 20% TBSA (2nd or 3rd degree) or nearest facility capable of managing airway
involving face, airway, hands, feet, or genitalia
or respiratory compromise. The
! Amputation (with reimplantation potential)
! Paralysis or other signs of spinal cord injury prehospital providers should be familiar
! Flail chest with the facilities in their area that are
! Open or suspected depressed skull fracture
! Unstable pelvis or suspected pelvic fracture
capable of managing airway problems
!Two or more long bone fractures rapidly.
! High energy event, such as
! Ejection from vehicle
! Significant fall (> 20 feet)
If no airway problems are present
! Rollover mechanism or the airway has been controlled, the next
! Auto-pedestrian impact determination is the presence of
! Motorcycle or bicycle involvement
! Significant assault
hypotension that indicates the possibility of
active hemorrhage. These patients may
need blood transfusions rapidly to prevent
irreversible shock and death and should be
transported to the nearest facility that can

Approved NCTTRAC: 4/14/98; Amended: 7/14/98


Approved TDH: 5/4/98
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North Central Texas Trauma Regional Advisory Council
Trauma Triage Protocol

initiate rapid stabilization and transfusions. and rapid transfer to a more


In rural areas, this “facility” may include a comprehensive Trauma Center) and those
higher level EMS agency or an air patients that could be safely managed in
evacuation site. Air evacuation services the Level III/IV facility for further
can initiate transfusions during transport to evaluation and serial observations. Level
a Level I or II Trauma Center. For ground III facilities are expected to have the
transport, the patient should be capability to manage most injuries and
transported to the highest level facility transfer those injuries that they do not
within 15 minutes. Prehospital providers have the capability to manage to the
should not wait longer than 15 minutes nearest Level I or II facility. Level IV
after the patient is ready for transport for facilities are expected to be stabilization
aircraft evacuation; the patient should and transfer facilities and are expected to
either be directed to a landing site closer to transfer most patients to higher level
the Level I/II Trauma Center or to a local facilities. Both Level III and Level IV
facility for stabilization. facilities should develop protocols
If no hypotension is present, the identifying which patients should be
patient should be taken to the most transferred, and these protocols should be
appropriate level Trauma Center within 15 widely disseminated throughout the
minutes. Since Level I and Level II Emergency Department. All Emergency
Trauma Centers are capable of providing Department personnel should be familiar
the same level of care, they should be with these protocols. Each Level III/IV
considered equal for triage purposes. If no Trauma Center should have a three-tiered
Trauma Center is present within 15 response. The Level 1 Response identifies
minutes, the patient should be transported those patients that require a Trauma Team
to the nearest Trauma Center, regardless Activation. In many of these cases, the
of level of designation. Stabilization and treatment requirements are not available at
transport can then be initiated at that the Level III/IV facility and stabilization
facility prior to transport to a higher level and transport to a Level I/II Trauma
facility. Center is necessary. The Level 2
For pediatric patients, the priorities Response identifies those patients that can
are the same, but the definition of major initially be evaluated by a designated
trauma is different. Figure 2 is the model member of the trauma team with
pediatric prehospital algorithm for TSA-E. subsequent evaluation by a trauma
surgeon. The Level III Response identifies
LEVEL III/IV TRAUMA CENTER those patients that can initially be
evaluated by the Emergency Department
Level III/IV Trauma Center triage Team with subsequent evaluation by a
criteria should identify those patients trauma surgeon or appropriate
needing immediate post-intervention subspecialist, if necessary. Figure 3 is the
transport (i.e., requiring initial stabilization model Level III/IV algorithm for TSA-E.

Approved NCTTRAC: 4/14/98; Amended: 7/14/98


Approved TDH: 5/4/98
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North Central Texas Trauma Regional Advisory Council
Trauma Triage Protocol

LEVEL I/II TRAUMA CENTER

Level I/II Trauma Center triage


criteria should provide for the
comprehensive evaluation and treatment of
major trauma patients. The Level I
Response identifies those patients that
require a Trauma Team Activation. The
Level 2 Response identifies those patients
that can initially be evaluated by a
designated member of the trauma team
with subsequent evaluation by a trauma
surgeon. The Level 3 Response identifies
those patients that can initially be
evaluated by the Emergency Department
Team with subsequent evaluation by a
trauma surgeon or appropriate
subspecialist, if necessary. (NOTE: The
Trauma Center triage criteria should also
consider changes that might occur during
evaluation and observation.) Figure 4 is
the model Level I/II algorithm for TSA-E.

Approved NCTTRAC: 4/14/98; Amended: 7/14/98


Approved TDH: 5/4/98
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North Central Texas Trauma Advisory Council
Trauma Triage Algorithm
Prehospital - Adult

Major Trauma No → Transport to


appropriate facility

Yes

Serious Airway
Compromise Yes → Transport to closest
facility capable of
managing airway
No

BP less than 90mmHg
Or Yes → Continue to transport to Highest
Level Trauma Center ¹. If
Pulse>120/min
transport is greater than 15
Or
minutes - Transport to nearest
Other signs of shock
facility to provide stabilization
refractory to fluids
& transfer

No

Transport to
appropriate Level 1 or
Level 2 Trauma
Center

¹Level 1 and Level 2 facilities should be treated as having equal capabilities.

Figure 1
North Central Texas Trauma Advisory Council
Trauma Triage Algorithm
Prehospital - Pediatric

Major Trauma No → Transport to


appropriate facility

Yes

Serious airway or
respiratory compromise Yes → Transport to nearest
facility capable of
that cannot be managed?
managing
No airway/respiratory
compromise

Hypotension present?
Neonate: <60 Yes → Transport to nearest facility¹
that can rapidly initiate blood
Infant (<2yr): <65
and provide initial
Child (2-5yr): <70
stabilization² and transfer out
Child (6-12yr): <80
to higher level of care.

No

Transport to Pediatric
Trauma Center, if
within 15 minutes²

¹Nearest facility might include higher level of EMS agency or air evacuation landing site.
²If multiple levels of designation present within 15 minutes of each other, go to highest level facility. Level
I and II Trauma Centers should be considered equal.

Figure 2
North Central Texas Trauma Advisory Council
Trauma Triage Algorithm
Level III/IV Trauma Center

Level 1 Response
CMultisystem Blunt Trauma with Unstable Vital
Signs (BP<90, RTS<11, GSC<14)
CPenetrating Injury of head, neck, chest, abdomen
CBurns >20% TBSA (2nd or 3rd degree) or CInitiate Trauma Team Activation
involving face, airway, hands, feet, or genitalia CConsider early transport to Level I/II
CAmputations (with reimplantation potential) Trauma Center
CParalysis or other signs of spinal cord injury CCoordinate transport with Level I/II
CFlail chest Trauma Center
COpen or suspected depressed skull fracture
CUnstable pelvis or open pelvic fracture

Level 2 Response
CTwo or more longbone fractures
CSuspected pelvis fracture
CSignificant spinal column injury CInitiate Trauma Treatment Protocol
CInitiate Transfer Protocol to Level I/II
Center, if appropriate

Level 3 Response
High Energy Event, such as
CFall >20 ft
CEjection from vehicle
CDeath of occupant in same vehicle CPerform complete trauma evaluation
CRollover mechanism and appropriate serial examinations
CBent steering wheel
CAuto-pedestrian impact
CMotorcycle or bicycle involvement
CSignificant assault

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CDeterioration in patient condition with
decrease in GCS, vital signs, or other
significant findings then initiate either
Trauma Team Activation or Trauma
Treatment Protocol

Figure 3
North Central Texas Trauma Advisory Council
Trauma Triage Algorithm
Level I/II Trauma Center

Level 1 Response
CMultisystem Blunt Trauma with Unstable Vital
Signs (BP<90, RTS<11, GSC<14)
CPenetrating Injury of head, neck, chest, abdomen
CBurns >20% TBSA (2nd or 3rd degree) or CInitiate Trauma Team Activation
involving face, airway, hands, feet, or genitalia
CAmputations (with reimplantation potential)
CParalysis or other signs of spinal cord injury
CFlail chest
COpen or suspected depressed skull fracture
CUnstable pelvis or open pelvic fracture

Level 2 Response
CTwo or more longbone fractures
CSuspected pelvis fracture
CSignificant spinal column injury CInitiate Trauma Treatment Protocol

Level 3 Response
High Energy Event, such as
CFall >20 ft
CEjection from vehicle
CDeath of occupant in same vehicle CPerform complete trauma evaluation
CRollover mechanism and appropriate serial examinations
CBent steering wheel
CAuto-pedestrian impact
CMotorcycle or bicycle involvement
CSignificant assault

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CDeterioration in patient condition with
decrease in GCS, vital signs, or other
significant findings then initiate either
Trauma Team Activation or Trauma
Treatment Protocol

Figure 4