FIELD TRIAGE

Field triage identifies severely injured trauma patients at the point of injury in the “field” and triggers a decision to transport severely injured patients to a hospital that has resources commensurate with patient needs. A common field triage decision scheme assesses the injured patient in four steps, each step linked to a determination about patient need for a level of care at a trauma center. The field triage decision scheme presented here (Figure 1), originally developed by the American College of Surgeons Committee on Trauma, was revised through an evidence-based review by an expert panel representing emergency medical services, emergency medicine, trauma surgery, and public health. The panel was convened by the Centers for Disease Control and Prevention (CDC), with support from the National Highway Traffic Safety Administration (NHTSA). Its contents are those of the expert panel and do not necessarily represent the official views of CDC and NHTSA.

Figure 1 Field triage decision scheme.

Step 1 assesses physiology; step 2, anatomy of the injury; step 3, mechanism of injury and high-energy impact; and step 4, special patient or system considerations. Effective implementation of a triage decision scheme is enhanced by simplicity within relevant steps. In other words, scheme complexity harms good triage.

Steps 1 and 2 are screens of the severity of physiologic and anatomic injury, respectively, and rapidly identify the most critically injured patients requiring transport to higher levels of care within the trauma system. The initial physiologic assessment of the patient measures vital signs (systolic blood pressure and respiratory rate) and level of consciousness (Glasgow Coma Scale). Anatomic assessment emphasizes readily visualized or identifiable anatomic injuries, to include centrally located penetrating injuries, severe musculoskeletal injuries, and consequent paralysis. Patients without apparent life-threatening physiologic or anatomic issues are then screened in step 3 for further evidence of high-energy mechanisms that increase the risk for significant injury. Certain characteristics of falls, automobile crashes, pedestrian/bicyclist crashes, and motorcycle crashes are associated with a higher risk of injury that is less obvious, and yet merits further evaluation at a facility within the trauma system. Step 4 looks for patient characteristics antecedent to the traumatic event that exacerbate the consequences of injury (extremes of age, bleeding diatheses, end-stage renal disease, and pregnancy), isolated limb or eyesight-threatening injuries, and burns. The presence of patient characteristics or characteristic injuries prompts consideration for patient transport to specific centers within a trauma system.

The field triage decision scheme emphasizes the importance of explicitly defining the capabilities of facilities within the system of care and matching the patient to the facility with the most appropriate level of care. An inclusive trauma system brings all local prehospital agencies and acute care facilities together as a network for the focused application of system capabilities to the care of each acutely injured patient. The idea is to get the right patient to the right place within the right time. Underestimation of patient injuries can lead to undertriage to facilities without adequate resources for patient needs, and overestimation of patient injuries can lead to overtriage to facilities with resources far greater than patient needs. Effective triage requires an integrated and defined shared mental model of triage across all settings of care.