Triage of the Trauma Patient

Authors

The EAST Practice Management Guidelines Work Group:

Robert D. Barraco, MD, MPH, Chair
William C. Chiu, MD, Vice Chair

Michael R. Bard, MD
Faran Bokhari, MD
Anthony Borzotta, MD
Osbert Blow, MD, PhD
Jeannette Capella, MD
Marie Dieter, RN
Thomas Z. Hayward III, MD
William S. Hoff, MD
Col. John C. Holcomb, MD
John F. McCarthy, DO
Michael Moncure, MD
Donna A. Nayduch, RN, MS

Consultants

Barbara Gaines, MD
Mark C. Henry, MD
Stanley Kurek, DO
Ellen J. MacKenzie, PhD

Statement of the Problem

The optimal triage of trauma patients has been the source of vigorous debate over the years. Clearly, as from the French, an efficient “sorting” of potentially injured patients translates into decreased transport times to definitive care, better outcomes as well as improved resource utilization. As a result, a trauma field triage decision scheme has been established by the American College of Surgeons Committee on Trauma (ACS­COT) and adapted by trauma systems across the nation (Figure 1). This scheme is based on a 5-10% under-triage rate and a 30–50% over-triage rate. It is this very issue which seems to be the most vexing: How do we ensure the minimum over-triage necessary without missing significant numbers of injuries? Furthermore, what is defined as a significant missed injury? Without accurate evidence based definitions and criteria it will be increasingly difficulty to optimize resource utilization and maximize patient safety. 

General criteria for patients who require trauma center care is outlined in Chapter 6 of the Textbook of Trauma. It is these criteria that determine the under- and over-triage rates. The reason previous evidence-based efforts have failed and the literature found difficult to evaluate is because no one definition has been agreed upon. Initial reports, including many of those reviewed here, used a plethora of variables, including the Injury Severity Score (ISS) >15, death rate in Emergency Department (ED), death rate in the Operating Room (OR), either immediately or within 24 hours, and ICU admission rate.  

Complicating matters further is that there have been profound changes in trauma care since the mid-1980s, such as employment of 23-hour or less observation, the advent of non-operative management and angiographic interventions as well as improved surgical techniques and resuscitative methods. How do these issues alter the definition of major trauma? Do billing and ED disposition concerns affect which patients are seen by the trauma team or the level of response? Does the burden of finding physicians to care for such patients force “minor trauma” patients to be transferred to trauma centers? The literature to date offers little insight. Much of the literature is based on those initial definitions. We decided to proceed with the guidelines and report the literature as it exists presently. We also intend to develop a definition of “major” trauma to be utilized in future studies.

Questions to Be Addressed by the Trauma Triage Guideline Subcommittee

The following issues all have some relation to trauma triage and, as such, we felt should be addressed by our group.  However, this task will take more than 1 year.

1. What factors should determine who goes to the trauma center? (Year 1)

a. Physiology
b. Anatomy
c. Mechanism
d. Co-morbidities/modifying factors
e. Field triage scores

2. How should they get there? (Year 2)

Process (Year 1)

An initial computerized search was undertaken using OVID Medline with citations published between the years 1966 and 2005. Search words included “trauma triage criteria” as keywords as well as combinations of the headings “Trauma Center,” “Emergency Medical Services,” and “Triage.” References were limited to human studies in the English language. These citations were supplemented by a list from another national workgroup, bibliographic references, and team recommendations. One hundred and thirty-two references were reviewed by a trauma surgeon, trauma nurse, or emergency medicine physician and classified according to the following standards. Data from each article was extracted using a data extraction form and arranged in a table format (Table 1). Conclusions of each article were critiqued and a determination made regarding consistency of the conclusion and data. Case reports and reviews of the literature were excluded save for examining the bibliography for further references. Six articles which addressed next year’s questions were removed.

Criteria for achieving a specific classification and the number of articles for each class are shown below:

Class I: Prospective randomized controlled trials.  (0 studies)

Class II: Clinical studies in which data was collected prospectively and retrospective analyses that were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies and case control studies (36 studies).

Class III: Studies based on retrospectively collected data, i.e. clinical series, database or registry review, large series of case reviews, and expert opinion (52 studies, 1 expert opinions/position statements).

Recommendations

Adult Prehospital Triage

Level 1 Standards

There are no Level 1 standards.

Level 2 Guidelines

• A combination of physiologic and anatomic parameters along with mechanism of injury (MOI), comorbidities, and demographics provides better triage than any smaller combination or any alone.
• If one considers single criteria, then physiologic parameters give the most accurate triage followed by anatomic parameters. Certain mechanisms are better indicators than others. Comorbidities and field personnel judgment have the lowest yields.

Level 3 Recommendations 

• Field personnel judgment should still be a factor in prehospital trauma triage but is more effective when there is physician medical control.
• Extrication time over 20 minutes and death of occupant in same vehicle may be considered as stand alone triage criteria.
• All other mechanisms may not be useful in and of themselves as triage criteria.
• The Revised Trauma Score (rTS), Prehospital Index (PHI), Trauma Score (TS), CRAMS (Circulation, Respiration, Abdomen, Motor GCS, and Speech GCS), Baxt Trauma Triage Rule (TTR), and Triage Index are not to be used as standalone criteria to triage patients.
• There should be increased weight given to advanced age (≥65) during triage.
• GCS Motor Score is valid for blunt trauma triage.

Adult In-hospital Triage

Level 1 Standards

There are no Level 1 standards.

Level 2 Guidelines

• Secondary triage with a tiered response is safe, accurate, and useful in optimizing team and resource utilization.
  Note: If not done appropriately, workup time and ED length of stay may increase.
• A combination of physiologic and anatomic parameters with mechanism provides better triage than any single factor.
• Mechanism alone may not be useful and should not be used as stand alone criteria for highest level trauma team response.
• GCS Motor Score is valid for blunt trauma triage.

Level 3 Recommendations

There are no Level 3 recommendations.

Pediatric Triage

Level 1 Standards

There are no Level 1 standards.

Level 2 Guidelines

There are no Level 2 guidelines.

Level 3 Recommendations 

• A two-tiered triage system in the ED by physicians can effectively reduce unnecessary resource utilization.
• Mechanism of injury alone may not be useful in triaging pediatric patients.
• A combination of physiologic and anatomic parameters with mechanism provides better triage utilizing age-appropriate vital signs.

Scientific Foundation

Prehospital Triage

Seventy-seven articles were examined with reference to prehospital triage. Twenty-six were rejected for use due to lack of relevancy or inaccurate conclusions. Class II data^[1­6] and Class III data^[7]&nbsp[8] all support the assertion that a combination of anatomic, physiologic, mechanistic, and/or demographic factors provide better triage than any one factor alone. In the study of the 1993 ACS criteria by Wuerz and co-workers^[8], physiology by itself was only 50% reliable in identifying patients with major injuries. In a 1995 study by Esposito et al.^[1], it was suggested that physiologic factors had higher yield than anatomic factors which had a higher yield than provider judgment. Knudson’s^[3] Class II data supported the claim that combination field triage criteria achieve the best sensitivity and specificity.

Trauma scores incorporating physiologic factors seemed to perform better than those that did not. Reviewing the individual scores, PHI had two Class II data articles in favor of its use alone^[9][10], one Class II in favor of its uses in combination with MOI^[11], and two articles, Class II^[12] and Class III^[13] data, respectively, citing poor triage performance.   Three studies referred to the Trauma Index. Two were rejected for inaccurate conclusions. The third was a validation study.  

Baxt TTR was the topic of two Class II articles^[14][15] and two Class III articles^[16][17]. Both Class II articles support its use, Emerman et al.^[14] as a stand alone and Fries and colleagues^[15] as an adjunct to paramedic judgment. Some limitations of the data in the Emerman paper may limit the strength of the conclusions. These limitations include lack of follow-up on 414 patients not taken to trauma centers, no mention of overall mortality in the group and a definition of major trauma that only includes requiring operation within two hours of admission or death.  The Class III articles were rejected based on unjustified conclusions.

There were seven articles that referred to CRAMS Scale. Two Class II articles propose CRAMS as a stand alone critieria^[18][19]. However, the definition of major trauma in the latter reference was based on need for surgery. In this era of non-operative management, that may not be appropriate. Another Class II data article by Knudson^[3] recommended CRAMS’ use alone or the Trauma Score in conjunction with mechanistic and anatomic critieria. CRAMS score <7 was only 33% sensitive and 96% specific in this reference. The threshold was therefore increased to <9 resulting in 93% sensitivity and 30% specificity. Class II data from Kane^[20] contradicted these findings, with CRAMS not performing well. Two Class III articles^[21][22] did not support the use of CRAMS as a stand-alone critieria. A third Class III article^[23] rejected the use of CRAMS completely.  

The Trauma Score was used in 17 articles. Three were rejected for use due to inaccurate conclusions or lack of applicability. Of the 14 remaining, 6 were based on Class II data, and 8 were based on Class III data. All of these articles are discussed in the paragraph which follows. Prehospital TS <15 identified 92% of deaths, but did not adequately identify major thoracic injury^[24]. Knopp et al.  ^[2] with Class II data showed that a combination of TS <13 along with MOI or anatomic injuries had the highest predictive values and best under- and over-triage rates. Class II data of Kreis et al.^[25] supported use of a Trauma Score <12 as the most accurate single predictor of severe injury, but the definition of severe injury was death in the emergency department, requiring emergent surgery or immediate admission to the ICU. The Class II data of Kane and co-workers^[20] contradicted this; compared to five other triage tools, TS did not perform well. The remaining Class II data showed the Trauma Score to be comparable or inferior to the Revised Trauma Score or other measures^[26][27]. In Class III data, TS predicted mortality as well as injury severity^[6][16][28]. However, Long^[6] indicated superiority of combined criteria over TS alone. The conclusions in the paper by Deane et al.^[28] were weakened by poor compliance with data collection. The use of the Trauma Score is supported by Sacco and others^[29], but only as a part of the triage scheme. Trauma Score was deemed not helpful^[23] or inferior to TRISS^[30] in the remaining Class III articles. The Revised Trauma Score (rTS) was used as the triage criteria in five papers, three Class II and two Class III. The Class II data was mixed on the use of the rTS. Champion et al.^[26] cite improved reliability compared to TS. Guzzo et al.^[27] list the RTS and TS as comparable. The data of Gilpin et al.^[31] indicates that RTS is inaccurate for blunt trauma. As for the Class III data, Baxt and co-workers^[21] show of the Trauma Score, CRAMS, PHI and RTS in mortality prediction. Additional Class III data^[22] show that RTS is not sufficiently sensitive to be used alone.

ACS COT criteria (Figure 1) were the focus of four articles. Three were Class III data (see below). The only Class II article by Henry and colleagues^[4] showed in a large state database study that anatomic and physiologic criteria performed well in predicting severe injury but some mechanisms only worsened specificity without increasing sensitivity. Scheetz^[32] showed a significant increase in under-triage in the elderly (>64). Sensitivity was 83% in the younger age group and 91% in the older age group. Norcross et al.^[33] indicated that the criteria were accurate. Wuerz and colleagues^[8] referred to the 1993 version of the ACS COT criteria. Physiologic criteria were only 50% reliable. Mechanism of injury was more sensitive but less specific and accounted for much of the over-triage, which agreed with the Henry et al.^[4] article.  

Isolated physiologic parameters were examined in four Class III data references (see below). One paper examined cardiac electrical activity, asystole, and severe bradycardia (HR <40)^[34]. No patient with asystole or severe bradycardia in the field requiring CPR survived. Only 2 of 455 with an emergency department heart rate of < 40 survived. They suggest not transporting patients in asystole or severe bradycardia requiring CPR in the field. However, the paper is prone to type II error, as small numbers may miss a small survival rate. McManus et al.^[35] looked at radial pulse character as a method of evaluation where instrumentation is not available. This seems quite subjective. The last two papers looked at loss of consciousness (LOC)^[36][37]. The results were contradictory. The first^[36] showed that isolated transient LOC was a significant risk factor for critical neurosurgical injuries. The second from Horowitz and Earle quoted a 97% over-triage rate^[37].  

Many papers included anatomic considerations but only one considered anatomic factors as the sole triage criteria. None supported the use of anatomic criteria alone. 

Four papers examined Glasgow Coma Score  (GCS) or its components alone as triage criteria^[36–39]. Class II data from Norwood et al.^[38] showed that GCS ≤14 was the only physiologic parameter after motor vehicle crash with an identifiable difference between those patients admitted to the hospital and those sent home. However, the reason for the altered mental status was not delineated. Healey and colleagues^[39] found a logarithmic format of the motor portion of the GCS (GCSM) was useful in predicting survival, but the data was Class III. Ross^[40] also used Class III data to show that the GCSM <6 and the full GCS <14 were equally effective in field identification of serious brain injury. However, 32% of patients needing craniotomy were not predicted by field triage criteria. Meredith^[41] showed the GCSM was as accurate as TS in field triage. However, this study suffered from its retrospective nature and incomplete data. Only 52% of patients had complete datasets and only 30% had the TS on their prehospital record. An additional paper by Holcomb et al.^[42] added radial pulse character to GCSM and GCSV (verbal) and was able to predict the need for lifesaving interventions (LSIs) in 88% of cases. However, radial pulse character is subjective and major trauma does not only involve lifesaving interventions.  

Provider judgment was examined in combination with other criteria. Esposito et al.  ^[1] determined that the field provider’s gut feeling resulted in a relatively low yield compared to other criteria. Only 15% of those triaged on provider “gut feeling” alone were considered major trauma victims. The yield was higher with rural providers. On the other hand, Fries et al.^[15] showed paramedic judgment to have a sensitivity of 91% and a specificity of 60%. Physician involvement raised the average severity of patients taken to a trauma center according to Champion^[30]. One Class III showed that EMT judgment was as good as the TS, CRAMS, and PHI was disregarded due to poor study design^[43].

Mechanism of injury criteria appear to be a major cause of overtriage, as reported by West et al.^[44]. However, few agree on which ones are most accurate. There were seven other Class II papers addressing this issue^{[1–3][11][25][45][46]}. Esposito et al.  ^[1] showed that prolonged prehospital time, pedestrian struck by a motor vehicle, and death of occupant in the same compartment had high yields. Patient ejection and vehicle intrusion had intermediate yields. And fall >20 feet and motor vehicle rollover had low yields. Only 13% of those falling over 20 feet and 12% involved in a vehicle rollover were considered major trauma victims. Knopp and co-workers  ^[2] determined the positive predictive values for ISS >15 for certain mechanisms. Values are prolonged extrication 40%, ejection 22.4%, fatality same vehicle 21.4%, intrusion 19%, pedestrian struck 19.9%, and fall > 15feet 14.3%. Knudson et al.^[3] reported 10% sensitivity and 90% specificity for mechanism of injury criteria alone. Kreis et al.^[25] and Cooper et al.^[45] concluded that mechanism of injury was not a good indicator of severe injury or eventual outcome. Henry and colleagues^[46] concluded that some mechanism criteria such as speed of motor vehicle crash and vehicle deformity worsen specificity and do not increase sensitivity. There was no increase in length of stay, intensive care unit services, or major non-orthopedic operative intervention. Counter to these, Bond et al.^[11] suggested that mechanism of injury criteria performed better than PHI alone, but a combination of the two is better. One Class III paper showed overtriage rates of 43%^[47]. Long et al.^[6], using a definition of major trauma as ISS ≥16, cited only prolonged extrication and death of occupant in the same passenger compartment as stand alone triage criteria. Norcross^[33] and Henry and co-workers^[46] seemed to agree with these conclusions, but had severe data limitations. Barnoski et al.^[48] showed falls did not accurately predict ISS >14 or mortality of 20% or greater. Santaniello et al.^[49] contradicted this data, stating that patients who sustained a significant mechanism of injury were likely to have serious injury requiring surgical intervention and/or ICU observation.

Age and comorbidities as criteria were examined in several articles. As mentioned previously, Scheetz^[32] cited a 15-18% undertriage rate in those >64 years old screened with the ACS-COT criteria. Demetriades’ paper^[50] discussing those over age 70 also supported this finding. However, this group was not compared to other age groups. Phillips et al.^[51] found the undertriage rate with the Florida trauma triage criteria to be doubled in the elderly (Table 2). These studies suggest lower physiologic reserves in the elderly may result in minimal detectable physiologic changes allowing for a similar degree of injury. Co-morbidities were low yield according to Esposito et al.^[1].

In-hospital Triage

In-hospital triage was specifically addressed in 10 of the papers. Six consisted of Class II data and four were Class III^{[52–60, 61]}. One was removed from consideration because it was not clinically applicable^[52]. Four of the papers looked at two-tier triage systems; all considered such systems safe and even reduced overtriage^[53–56]. One of these papers suggested that emergency department time increased^[55]. A three-tier system was studied by Kaplan et al.^[57]. This system increased early involvement of the trauma service while decreasing emergency department time and minimizing overtriage. Kohn and co-workers^[58] identified four mechanisms of injury that did not need trauma team activation, including motorcycle crash with separation of rider, pedestrian struck by motor vehicle, motor vehicle crash with rollover, and motor vehicle crash with death of occupant. However, the last was based on only two patients. Simon et al.^[59] and Terregino et al.^[54] only used physiologic and anatomic criteria for secondary in-hospital triage. About one-quarter of the patients not undergoing trauma team activation required admission while 100% of those undergoing team activation required admission^[54]. Mechanisms of injury did not require highest level (major trauma) response in the Class II study by Ryan et al.^[53]. The only Class III paper looking at anatomic criteria supported the use of gunshot wound to the torso warranting trauma team activation regardless of physiologic parameters^[60].

Pediatric Triage

Pediatric triage issues were examined in nine articles^[62–70]. Four of the papers could not support their conclusions due to poor study design or lack of generalizability^{[65–67][69]}. A tenth^[71] looked at care of pediatric patients in an adult ICU and is not within the scope of this guideline. In the studies looking at prehospital triage, mechanism of injury did not perform well alone. Qazi and co-workers^[70] showed that mechanism alone was a poor predictor of injury severity in stable blunt trauma patients. In patients who sustained falls, Wang et al.^[64] found that clinical and physiologic signs were more reliable indicators of injury. Contact surface seemed more important than height. Engum et al.^[68] supported the use of combination criteria again in the pediatric population. As far as in-hospital triage, use of a modified pediatric trauma score reduced the trauma team usage by 58% with a negative predictive value of 99% and a positive predictive value of 32%^[62]. This score is similar to the Pediatric Trauma Score, but simpler to use. Mechanism of injury alone did not predict risk for significant injury by statistical analysis. Of the five patients not identified by the modified Pediatric Trauma Score, three would have been triaged differently if loss of consciousness in the field was considered.  The fourth suffered only a skull fracture with no intracranial injury and the fifth had abdominal symptoms. Sola and co-workers^[63] supported a two-tier system to reduce unnecessary resource utilization.

Summary

The literature is of poor quality and does not answer definitively such important questions regarding trauma triage and system utilization. In addition, the lack of a consistent definition of the trauma patient with “major” injuries requiring care at a trauma center prohibits comparisons of existing studies. The primary message from the existing literature is that a combination of physiologic, anatomic, and select mechanistic criteria provides the best performance for pre-hospital and in-hospital triage of the trauma patient. Physiologic criterion gives the highest yield followed by anatomic criteria. Certain mechanisms of injury perform better than others and comorbidities and field personnel judgment have the lowest yields. Extremes of age should be given more importance in the triage of the trauma patient. None of these should be used as the sole criteria for triage decisions. Triaging patients into a tiered trauma response in-hospital can be very effective and reduce unnecessary resource utilization while maintaining quality of care.

Future Investigations

Clearly, a more comprehensive definition of the trauma patient requiring trauma center care needs to be developed. A subcommittee is working to accomplish this. Major trauma, complex care, resource availability and regionalization of care need to be considered. This definition must be developed prior to any further research in order for these studies to be meaningful. We need to be certain we are making valid comparisons of similar patients. The National Trauma Data Bank could then be examined for criteria effectiveness. Pediatric trauma centers and adult trauma centers with added pediatric qualifications should pool their data to address the paucity of literature on pediatric trauma triage.  

References

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