CHAPTER 7 TRAUMA SYSTEMS AND TRAUMA TRIAGE ALGORITHMS

Antonio Pepe, Antonio Marttos, Mauricio Lynn, Jeffrey A. Augenstein

Trauma is a major national health care problem that affects one of four U.S. citizens annually. Traumatic injury, both accidental and intentional, is the leading cause of death in the United States for people aged 1 to 34 years. There are as many as 150,000 trauma deaths and approximately 80,000 others who sustain long-term disability each year with annual costs of more than $260 billion for trauma injury and treatment when loss of future productivity is considered. The most common fatal injuries in the country result form motor vehicle crashes, followed closely by gunshot wounds. Driving while impaired by alcohol is the most frequent cause of fatal motor vehicle crashes and accounts for 40% of traffic fatalities. The causes of traumatic death vary considerably depending on demographics. Urban and politically unstable areas typically have a higher incidence of penetrating trauma, whereas rural and stable communities have a predominance of blunt injuries, usually vehicular accidents. Nonetheless, causes of death after injury are remarkably similar. Central nervous system injury accounts for approximately half of all fatalities; hemorrhage for 35%; and sepsis, multiple organ failure, and pulmonary embolism combine for approximately 15%. With the introduction of trauma systems during the last three decades, the incidence of preventable death has dropped from approximately 25% to less than 5%. This is the result of improvements in care both for acute head injuries and for control of hemorrhage. In addition, the incidence of late death attributable to sepsis and multiple organ failure has diminished, possibly as a result of better and early resuscitation. The responsibility of the trauma surgeon encompasses the early recognition of injury, resuscitation, and then definitive care of the patient. As we improve the operative and intensive care rendered to trauma patients, we are beginning to reach the flat portion of the outcome curve. The area of injury prevention is still open to substantial improvement. To reduce the morbidity and mortality from trauma, surgeons must take a more active role in the prevention of trauma at the community level. Studies have shown the effect of these systems on the improvement of trauma care, with outcomes better than those predicted for some study populations. The necessary elements of a trauma system have been defined. These include four primary patient needs—access to care, prehospital care, hospital care, and rehabilitation. In addition, five issues require social and political solutions to supplement medical efforts: prevention, disaster medical planning, patient education, research, and rational financial planning. Recent federal legislation (The Trauma Care Systems Planning and Development Act) authorized planning, implementation, and development of statewide trauma care systems.

Data show, however, that only 23 states in the United States have functional, statewide trauma systems, and eight states have no trauma system at all. In the United States, as many as 35% of trauma patients who die do so because optimal acute care is not available. Despite the evidence that trauma care systems save lives, existing systems serve only one fourth of the U.S. population.

TRAUMA SYSTEMS

A trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients and is integrated with the local public health system. The true value of a trauma system is derived from the seamless transition between each phase of care, integrating existing resources to achieve improved patient outcomes. Success of a trauma system is largely determined by the degree to which it is supported by public policy. The development of civilian regional trauma systems has provided the single most significant improvement in the care of injured patients in the last three decades.

Numerous regional and statewide systems have been created to optimize quality of care and outcomes for severely injured patients. An essential component of a trauma system involves the evaluation of patients at the scene by emergency medical technicians to determine if their injuries meet specified trauma triage criteria that indicated they would be best served by being transported to a trauma center, thereby integrating the prehospital, transport, and trauma center settings. Triage is the process whereby the patient’s medical needs are matched with the available medical resources and can occur in the field and at the hospital. Field triage identifies those patients needing transport to the most appropriate trauma center rather than the nearest hospital and also identifies the type of transport needed. The trauma patient is an injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals. Supported by the appropriate resources, the goal is to diminish or eliminate the risk of death or permanent disability. Injuries occur across a broad spectrum and a trauma system must determine the appropriate level of care for each type of injury. The goal of triage criteria is to closely match patients’ needs to the appropriate resources.

With respect to hospital triage, both the available level of hospital resources and time/distance factors are considered in making triage and destination decisions. Level III/IV hospital triage should serve to identify those patients who require initial stabilization and rapid transfer to the next highest level of care, and those patients that can be safely held in a Level III/IV center for further evaluation and serial observations. Level I/II hospital triage identifies patients who require a full trauma team approach as well as those who can be initially evaluated by identified members of the trauma team with subsequent consultation by either a trauma surgeon or the appropriate subspecialist.

Many areas of the country already have resources in place to provide appropriate trauma care. To provide optimal care of the seriously injured with maximum efficiency and minimal cost in terms or lives, disability, and dollars, these resources must be organized using a systems approach to plan for the rapid decisions required for initial treatment or all injured patients—an inclusive system. A proper systems approach requires a regional triage system with identified trauma centers capable of providing trauma care to major trauma patients. Patients must be identified and delivered or transferred based on clinical need to the appropriate level of care in a timely fashion. An optimal trauma care system is designed to care for all injured patients with specific attention focused on major trauma patients.

Major trauma patients are those with either a severe injury or a risk for severe injury. A severe injury is one that could result in morbidity or mortality, and is classically defined as an injury with an Injury Severity Score (ISS) of 16 or higher. On initial evaluation, these patients typically have abnormal vital signs or a significant anatomical injury. However, triage is often inexact due to patients’ variable physiological responses to trauma. In some patients, minor injuries can result in morbidity or mortality due to the patient’s age and/or comorbid factors, and some patients may have a delayed physiological response to trauma. Patients involved in a high-energy event are at risk for severe injury. Five to 15% of these patients, despite normal vital signs and no apparent anatomical injury on initial evaluation, will have a severe injury discovered after full trauma evaluation with serial observations (Figure 1).

Figure 1 Triage in trauma care system.

Current systems (“exclusive systems”) often rely on overtriage to trauma centers, and often an exaggerated and unnecessary response from trauma professionals. Such systems may cause overtreatment of certain patients, unnecessary expenses, burnout of participants, and underutilization of certain health care resources, including personnel. In spite of these excesses, such systems may still run the risk of not treating all injured patients, including not appropriately treating all major trauma patients. Undertriage runs the obvious risk of excluding some major trauma patients from receiving appropriate care. An inclusive system uses a tiered response to provide appropriate delivery, evaluation, and care for all patients, including the major trauma patient, in a cost-effective manner. One example of an inclusive trauma system is patient triage designed to care for major trauma patients by matching patient severity to facility in a timely manner. Considerations in triage include injury severity, injury severity risk, time and distance from site of injury to definitive care, inter-hospital transfers considering guidelines for immediate versus postintervention transports, and factors that activate the regional system (Figure 2).

Figure 2 Components of an inclusive trauma care system. The components in this model are based on the components described in several trauma care resources.

(Adapted from Trauma Care Systems, a position paper from the Third National Injury Control Conference, “Setting the National Agenda for Injury Control in the 1990’s,” p. 388.)

TRAUMA SYSTEMS SUMMARY

A systems approach to the provision of trauma care, including appropriate guidelines for the triage of patients, is essential. The triage protocols should be reasonable and inclusive, considering such factors as time and distance to designated trauma centers and appropriate utilization or resources at these centers. In order for a systems approach to work, appropriate protocols that are well thought out and supported by all members of the trauma system should be in place and followed unless clinical judgment dictates a valid reason otherwise.

By combining triage algorithms with an appropriate quality improvement monitoring system, optimal and cost-effective care can be provided. Continuous quality improvement and research are essential to evaluate an algorithm’s applicability in a given trauma care system. The result should be protocols with the sensitivity to identify major injury, yet specific enough to not overburden the system, allowing for optimal and cost-effective care using existing resources. Identification of the major trauma patient is fundamental to trauma system design because it describes the patient who will benefit the most from regionalized care, and indirectly determines the level and intensity of resources needed to provide definitive care.

Triage criteria should provide a basis for the establishment of protocols for patient identification, delivery decisions, and appropriate response at acute care facilities for all trauma patients in an inclusive care system. They should recognize the requirements of individual trauma systems, as well as the importance of clinical judgment. Patients can then be delivered, depending on degree of injury in addition to time and distance from site of injury to definitive care.

SUPPORT FOR REGIONALIZED TRAUMA CARE

Although regionalization of trauma care has the inevitable consequence of increased prehospital transport times, particularly in rural areas removed from large trauma centers, some states have designed inclusive systems in which a large number of smaller centers have been designated as lower-level trauma centers. One of the primary functions of a statewide trauma system is to oversee the initiation of standardized protocols intended to ensure the timely triage and transfer of severely injured patients to facilities with appropriate therapeutic resources. Several studies document increased trauma center use and enhanced patient outcomes among metropolitan trauma centers after implementation of a regionalized trauma system.

In 1987, Shackford et al. examined the impact of a trauma system on the survival of patients and attributed the improved survival to the integration of prehospital and hospital care and subsequent expeditious surgery. In 1999, Mullins and Mann reviewed published studies that used population-based data in evaluating the effectiveness of trauma systems in North America. They found that data for eight of nine trauma systems evaluated demonstrated improve outcomes (15%–20%), principally measured as hospital survival, after the establishment of a trauma system or some component of a trauma system. In the National Study on the Costs and Outcomes of Trauma (2006), MacKenzie et al. examined the effect of care in a trauma center on the risk of death and costs associated with treatment at hospitals with a Level 1 trauma center and at hospital without a trauma team. They concluded that, with the 25% lower overall risk of death noted when care was provided at a trauma center versus a non-trauma center, efforts for continued regionalization should be supported.

INITIAL APPROACH TO THE CRITICALLY INJURED PATIENT

Salvage of the critically injured patient is optimized by a coordinated team effort in an organized trauma system. Management of life-threatening trauma must be prioritized according to physiologic necessity for survival—that is, active efforts to support airway, breathing, and circulation (the ABCs) are usually initiated before specific diagnoses are made. A systematic approach to the severely injured patient within the “golden hour” is critical. The initial approach to the critically injured patient can be divided into prehospital care and emergency department (ED) management; the ED component is further divided into (1) primary survey with initial resuscitation, (2) evaluation and continued resuscitation, and (3) secondary survey with definitive diagnosis and triage.

Prehospital Care: Intervention at Injury Site

Resuscitation and evaluation of the trauma patient begins at the injury site. The goal is to get the right patient to the right hospital at the right time for definitive care. First responders (typically, firefighters and police) provide rapid basic trauma life support (BTLS) and are followed by paramedics and fight nurses with advanced trauma life support (ATLS) skills. Medical control is ensured by pre-established field protocols, radio communication with a physician at the base hospital, and subsequent trip audits. Management priorities of BTLS on the scene are (1) to access and control the scene for the safety of the patient and the prehospital care providers, (2) to tamponade external hemorrhage with direct pressure, (3) to protect the spine after blunt trauma, (4) to clear the airway of obstruction and provide supplemental inspired oxygen, (5) to extricate the patient, and (6) to stabilize long-bone fractures. Whereas the benefits of BTLS are undisputed, the merits of the more advanced interventions remain controversial.^1,² Airway access, once considered a major asset of the care provided by paramedics and flight nurses, has now been questioned, not only because missed tracheal intubation is a concern but also because unintentional hyperventilation (hypocarbia) is detrimental in the setting of traumatic brain injury (TBI) and during cardiopulmonary resuscitation (CPR).³^–⁵ Moreover, the value of intravenous fluid administration remains controversial.^6,⁷

Field Triage

Prehospital trauma scores have been devised to identify critically injured trauma victims, who represent about 10%–15% of all injured patients. When it is geographically and logistically feasible, critically injured patients should be taken directly to a designated Level I trauma center or to a Level II trauma center if a Level I trauma center is more than 30 minutes away. The currently available field trauma scores, however, are not entirely reliable for identifying critically injured patients ⁸: to capture a sizable majority of patients with life-threatening injuries, a 50% overtriage is probably necessary. Advance transmission of key patient information to the receiving trauma center facilitates the organization of the trauma team and ensures the availability of ancillary services⁹ (Figures 3 and 4).

Figure 3 Trauma field triage criteria and point-of-entry plan for adult patients.

(From Commonwealth of Massachusetts, Department of Public Health.)

Figure 4 Adult triage, transport, and transfer guidelines: Oklahoma model trauma triage algorithms for (A) prehospital, (B) Level I/II trauma center, and (C) Level III/IV trauma center. For prepubescent patients, refer to the pediatric trauma algorithm (Figure 5). 1. In addition to hypotension, other early signs of hypovolemia may include pallor, tachycardia, or diaphoresis. 2. Tachypenia (hyperventilation) alone will not necessarily initiate this level of response. 3. Altered sensorium secondary to sedative-hypnotic will not necessarily initiate this level of response. 4. High-energy event signifies a large release of uncontrolled energy. Patient is assumed injured until proven otherwise, and multisystem injuries might exist. Determinants to be considered by medical professionals are direction and velocity of impact, patient kinematics and physical size, and the residual signature of energy release (e.g., major vehicle damage). 5. Clinical judgment must be exercised and may upgrade to a high level of response and activation. Age and comorbid conditions should be considered in the decision. 6. Isolated blunt or penetrating trauma not associated with a high-energy event with a potential for multisystem injury.

(Based on American College of Emergency Physicians Guidelines. Approved by the Triage, Transport, and Transfer Committee of the Oklahoma State Trauma Advisory Council, October 27, 1995, and the Oklahoma Emergency Medical Services Advisory Council on January 24, 1997.)

Declaration of Death at Scene

The determination that care is futile during prehospital evaluation is best made on the basis of the cardiac rhythm. Asystole justifies declaration of death at the scene, and recent profound bradycardia (heart rate <40 beats/min) has been shown to signal an unsalvageable situation.

GUIDELINES FOR WITHHOLDING OR TERMINATION OF RESUSCITATION IN PREHOSPITAL CARDIOPULMONARY ARREST

Injury is the leading cause of death for Americans between age 1 and 44 years. The EMS system is the portal into the medical system for many of the most seriously injured trauma victims. Some of these patients will be unsalvageable due to the extent of their injuries. In order to preserve dignity and conserve precious human and financial resources, as well as to minimize risks to the health care workers involved, patients who can be predicted to be unsalvageable should not be transported emergently to the emergency department (ED) or trauma center. The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (COT) support out-of-hospital withholding or termination of resuscitation for adult traumatic cardiopulmonary arrest (TCPA) patients who meet specific criteria. The literature review of prehospital TCPA is extrapolated from emergency thoracotomy research. This research is retrospective in nature, therefore limiting the validity of the conclusions. The guidelines appear in Table 1.

Table 1 Guidelines for Withholding or Termination of Resuscitation in Prehospital Cardiopulmonary Arrest

Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’stient assessment, is found apneic, pulseless, and without organized ECG activity upon the arrival of EMS at the scene.

Victims of penetrating trauma found apneic and pulseless by EMS, based on their patient assessment, should be rapidly assessed for the presence of other signs of life, such as papillary reflexes, spontaneous movement, or organized ECG activity. If any of these signs are present, resuscitation should be performed and the patient transported to the nearest emergency department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld.

Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life, such as decapitation or hemi-corpectomy.

Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with evidence of a significant time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition.

Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a nontraumatic cause of the arrest, should have standard resuscitation initiated.

Termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation (CPR).

Traumatic cardiopulmonary arrest patients with transport time to an emergency department or trauma center of more than 15 minutes after the arrest is identified may be considered nonsalvageable, and termination of resuscitation should be considered.

Guidelines and protocols for TCPA patients who should be transported must be individualized for each EMS system. Consideration should be given to factors such as the average transport time within the system, the scope of practice of the various EMS providers within the system, and the definitive care capabilities (trauma centers) within the system. Airway management and intravenous line placement should be accomplished during transport when possible.

Special consideration must be given to victims of drowning and lightning strike and in situations where significant hypothermia may alter prognosis.

EMS providers should be thoroughly familiar with the guidelines and protocols affecting the decision to withhold or terminate resuscitative efforts.

All termination protocols should be developed and implemented under the guidance of the system EMS medical director. On-line medical control may be necessary to determine the appropriateness of terminating resuscitation.

Policies and protocols for terminating resuscitation efforts must include notification of the appropriate law enforcement agencies and notification of the medical examiner or coroner for final disposition of the body.

Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, as needed. EMS providers should have access to resources for debriefing and counseling as needed.

Adherence to policies and protocols governing termination of resuscitation should be monitored through a quality review system.

Initial Electrocardiographic Rhythm

There is some evidence that the initial ECG rhythm obtained at the scene by EMS may be predictive of survival. All of the studies combined by Batistella et al.,¹⁰ Fulton et al., Esposito et al.,⁹ and Aprahamian suggest that the presence of an ECG rhythm such as asystole, idioventricular rhythm, or severe bradycardia is indicative of an unsalvageable patient. Patients with a sinus-based pulseless electrical activity may represent a potentially salvageable subset of TCPA patients. Given that the TCPA is a critical event, the presence of any abnormal ECG pattern as an indicator of survival has limited significance. Blunt and penetrating injury as the cause of the TCPA was not distinguished in these studies, and given that blunt injury causing TCPA is associated with a very poor survival rate, it may be that survivors of TCPA may have penetrating trauma as their inciting event.

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