Trauma Triage Criteria Inservice 1998 This presentation was created by Laurie Romig and approved by Dr. Rick Slevinski, State EMS Medical Director for use in inservicing EMS personnel on the 1998 Adult and Pediatric Trauma Scorecard Methodologies. The related rule language can be found in 64E-2.017 and 64E-2.0175. Composed by: Laurie A. Romig, MD, FACEP Bayflite/Bayfront Medical Center

Development Adult and Pediatric Trauma Triage TAPs Trauma study by FSU Prospective pilot program of peds criteria Paper comparison of old and new adult criteria by state EMS medical director 1. Technical Advisory Panels established by State EMS Office, with representation from all concerned constituency groups in the early to mid 1990’s. TAP’s utilized the Trauma Study referenced below to make final recommendations. 2. FSU Trauma Triage Study results reported in March 1994. Study utilized numbers from 9 counties with trauma centers during six months of 1991. 3. Peds pilot done in south Florida. 4. Paper comparison done by Dr. Rick Slevinski in 1997.

Development (continued) Comparative prospective trial of adult criteria currently ongoing Pediatric and adult criteria established by rule in 64E in August 1998 Adult criteria optional at local level until November 1999 1. Pediatric Trauma Triage Criteria should be incorporated into local Trauma Transport Protocols by mid-November 1998. 2. Local medical directors have a grace period until November 1999 to incorporate adult criteria, partially because of ongoing studies and potential need to modify rule prior to final implementation.

Common Features Color coded One RED criteria = Trauma Alert Two BLUE criteria = Trauma Alert Age or size now included Fewer mechanism of injury criteria Local criteria allowed EMS practitioner judgement allowed 1. This slide is intended to establish common ground between adult and pediatric criteria, for easier memorization and understanding. 2. Color notations (Red, Blue) are mentioned in rule, and are available as a color coded grid of criteria components. 3. Age included in adult, size (weight/length) in peds. 4. Mechanism of injury criteria included are now stratified into Blue and Red criteria, thus making these considerations more objective. 5. Local criteria beyond those specified in rule may be established by the medical director. 6. If no other criteria are met, paramedic judgement calls have been found to be statistically reliable (sensitive) and are allowable by rule.

Notes on Adult Criteria GCS < 12 = Trauma Alert independent of other criteria RED airway is defined as any airway support needed beyond oxygen Any BMR less than localizing pain is RED 1. These are major “hang your hat on” cut points, mostly new to the criteria. 2. Airway support is defined as intubation, BVM ventilation, use of oral or nasal airways, and repeated or continued manual airway maneuvers or suctioning. An isolated episode of suctioning does not meet these requirements. 3. BMR = Best Motor Response portion of GCS. Highest score possible is 6 for following commands. 5 = ability to localize and attempt to avoid pain. BMR of < 4 = Red. 4. Paralysis/loss of sensation/suspicion of spinal cord injury also included in Red.

Notes on Adult Criteria (cont.) > 15% BSA 2nd and 3rd degree burn is RED The only fractures included are longbone fractures: humerus, radius, ulna, femur, tibia, and fibula. Single long bone fracture is classified according to mechanism of injury Age > 55 is automatic BLUE criteria Ejection MOI excludes ejection from open motor vehicles 1. Burn percentage is emphasized here because the number is lower (10%) in peds. Also, emphasize that Body Surface Area burned (via Rule of 9’s or Patient Palm rule) includes only second and third degree burns. 2. Because both bones forearm or tib-fib fractures can be difficult to define in the field, the forearm and the lower leg are considered a single site. Even with an obvious tibia and fibula fracture, this would count as a single site, not multiple closed longbone fractures. 3. Obvious or suspected pelvic fracture is not specifically referenced in the criteria. These patients will often meet other criteria. If other criteria are not met, obvious pelvis fracture may be written into local policy or used as a provider judgement call. The EMS Medical Directors and the State EMS Medical Director agree that it would be reasonable to include pelvis fractures in the longbone category because of the potential for significant blood loss.(Rule may later be amended to reflect this.) 4. FSU trauma study found no scientific evidence to support changing 55 to a higher number. This may eventually be modified via prospective research. 5. Other Blue MOI (mechanism of injury) criteria include driver with steering wheel deformity and ejection BUT ejection excludes open vehicles such as motorcycles, bicycles, ATV’s, bed of pick up truck, open boat, etc.

Detailed Adult Criteria GCS < 12 = RED AIRWAY  ACTIVE airway assistance required (i.e., more than supplemental O2 without airway adjunct)  Sustained respiratory rate > 30 See previous note regarding suctioning.

Detailed Adult Criteria CIRCULATION No radial pulse AND heart rate > 120 OR BP < 90 systolic Sustained heart rate > 120 with radial pulse and BP > 90 systolic No specific additional comments

Detailed Adult Criteria BEST MOTOR RESPONSE BMR < 4 OR Paralysis, loss of sensation, suspicion of spinal cord injury BMR = 5 1. Loss of sensation does not mean a numb toe or finger. This should be considered positive when an entire extremity/extremities and/or the trunk has altered sensation. Diffuse altered sensation distal to an obvious extremity injury such as a knee or elbow dislocation may constitute an emergent condition if proper positioning does not remedy the complaint. This situation is not specifically addressed in rule. A reasonable approach would be to consider this as a Blue factor in local criteria.

Detailed Adult Criteria CUTANEOUS Amputation proximal to wrist or ankle OR > 15 % BSA 2nd and 3rd degree burns Penetrating injury to head, neck, torso, excluding superficial wounds Degloving injury or flap avulsion > 5 inches 1. See previous note regarding burn area calculations

Detailed Adult Criteria LONGBONE FRACTURE Multiple longbone fracture sites Single longbone fracture site due to MVC OR Single longbone fracture site due to fall from > 10 feet 1. See previous note regarding long bone definitions and multiple fracture sites. 2. Note that special consideration is given to two mechanisms of injury resulting in single longbone fractures. MVC’s and long falls are included because of the degree of kinetic force involved; these mechanisms may result in a higher incidence of occult injuries.

Detailed Adult Criteria AGE Age > 55 MECHANISM OF INJURY Ejection from vehicle (excludes open vehicles) OR Driver with deformed steering wheel See previous note regarding ejection exclusions.

Notes on Peds Criteria Applicable to age 15 or less Size component is based on Broslow color zone or weight Any airway maintenance beyond supplemental O2 and one-time need for suctioning = RED Any altered mental status other than amnesia = RED criteria Paralysis, loss of sensation, or suspicion of spinal cord injury = RED criteria under “Consciousness” category 1. Various trauma studies use different age cutoffs for pediatrics (i.e., 16, 14). FSU study showed no compelling evidence to change from 15. 2. Emphasize any traumatized child who is not alert and acting appropriately at the time of EMS exam = Red. 3. See previous comments regarding airway interventions and suctioning. 3. Paralysis, loss of sensation or suspicion of spinal cord injury also = Red level of consciousness (different from adult category).See also the previous note regarding loss of sensation.

Notes on Peds Criteria (cont.) Any reliable hx of LOC = BLUE Fracture criteria are also based on longbones (same as adults). Open long bone or multiple longbone fx/dislocations = RED > 10 % BSA 2nd and 3rd degree burn = RED 1. Any patient with amnesia or a reliable hx of LOC = Blue. 2. Long bones are defined the same as for adults: radius, ulna, humerus, femur, tibia, fibula. 3. Isolated wrist or ankle fractures or dislocations are excluded.

Detailed Peds Criteria SIZE Weight < 10 Kg (< 22 lbs..) or RED or PURPLE Broslow Tape Zone AIRWAY ACTIVE airway assistance required (i.e., more than supplemental O2/one-time suctioning without airway adjunct) 1. The Pediatric Criteria rule actually states that one-time suctioning qualifies as Red, but the State EMS Medical Director and the Florida Association of EMS Medical Directors have ruled against this. The rule will eventually be changed to reflect this. 2. Note that there are NO Blue criteria for Airway.

Detailed Peds Criteria CONSCIOUSNESS Patient not awake and appropriate OR Paralysis, loss of sensation, or suspected spinal cord injury Amnesia Reliable history of loss of consciousness 1. See previous note regarding loss of sensation.

Detailed Peds Criteria CIRCULATION No palpable pulses OR Weak carotid or femoral pulse Systolic BP < 50 Good carotid or femoral pulse with absent distal pulses Systolic BP 50-90 1. NOTE: The actual rule language is very confusing and somewhat contradictory. This breakdown has been approved by the State EMS Medical Director.

Detailed Peds Criteria LONGBONE FRACTURE Any open longbone fracture OR Multiple closed longbone fracture sites or dislocations Single closed long bone fracture site 1. Longbones include radius, ulna, humerus, femur, tibia, and fibula. 2. Because both bones forearm or tib-fib fractures can be difficult to define in the field, the forearm and the lower leg are considered a single site. Even with an obvious tibia and fibula fracture, this would count as a single site, not multiple closed longbone fractures. 3. Isolated ankle or wrist fractures or dislocations do not fall into these criteria. 4. See previous notes regarding pelvic fractures.

Detailed Peds Criteria CUTANEOUS Degloving injury, major flap avulsion OR Amputation proximal to wrist or ankle > 10% BSA 2nd and 3rd degree burns Penetrating injury to head, neck or torso 1. See previous note regarding determination of Body Surface Area burned. 2. There are NO Blue Cutaneous criteria for Pediatrics.

Practice Case #1 POSITIVE TRAUMA ALERT 68 yo female pedestrian struck GCS 14, BMR 5 Patent airway HR 100, BP 120/94, RR 20 Abrasions Unstable pelvis BLUE  POSITIVE TRAUMA ALERT 1. In all practice cases, there are no unstated positive trauma criteria, so all the information needed to make the trauma alert decision is found on the slide. 2. It is recommended, because of the mechanics of this presentation program, that all data be revealed without discussion. Then discuss each data point and touch enter or the “next” arrow only for a positive Blue or Red point. This will cause an arrowed “Blue” or “Red” to appear next to the data point. When finished with these, advance again to make the Positive or Negative Trauma Alert Box to appear. 3. Discussion points for this case include the age factor for this patient, use of the BMR, and the pelvic fracture issue. This patient meets alert criteria without consideration for the pelvic fracture, as will many such patients. If other criteria are not met, obvious pelvis fracture may be written into local policy or used as a provider judgement call. The EMS Medical Directors and the State EMS Medical Director agree that it would be reasonable to include pelvis fractures in the longbone category because of the potential for significant blood loss.

Practice Case #2 POSITIVE TRAUMA ALERT 21 yo male Stab wound to left chest Airway patent GCS 15 BS  on left BP 90/P, HR 130 RED POSITIVE TRAUMA ALERT 1. This is a clear-cut example based on both mechanism of injury and Circulation. May use this opportunity to revisit the issue of obviously superficial penetrating wounds.

Drowning is not considered trauma unless injury accompanies it! Practice Case #3 4 year old near- drowning in pool No signs of trauma Intubated Normal skin signs Normal brachial pulse Responsive to deep pain Drowning is not considered trauma unless injury accompanies it! 1. This is a somewhat tricky case because of fact that many people consider near-drowning to automatically qualify as trauma. However, the state does NOT count isolated near-drowning as trauma and it has never been included in previous trauma triage criteria. Isolated near-drowning tends to happen most frequently with young children and with adults with a primary medical problem. 2. It may be useful to approach this case the same way as other cases, asking whether each element hits triage criteria. This will still help in familiarization with the triage criteria. Also use this as a springboard to discuss that apparent near-drownings accompanied by another mechanism or signs of injury may possibly qualify as trauma patients. As examples, an older child or adult who dives into a body of water or a near-drowning associated with a vehicle into a body of water may be reasonably assumed to have a significant additional mechanism of injury.

Practice Case #4 POSITIVE TRAUMA ALERT 6 yo female fell 10 ft. from tree 22 kg weight amnestic for event, o/w alert airway patent obvious closed forearm fx nl vital signs BLUE POSITIVE TRAUMA ALERT 1. This case emphasizes the new Consciousness criteria for peds and the longbone fracture issue. This forearm fracture is counted as a single site, thus meeting Blue criteria rather than Red. 2. o/w means “otherwise”

Practice Case # 5 POSITIVE TRAUMA ALERT 6 month old male (purple) child abuse multiple cigarette burns & contusions abdomen rigid strong palpable carotid pulse only does not cry with exam BLUE RED POSITIVE TRAUMA ALERT 1. This case emphasizes the weight factor/Broslow zone classification and the new Circulation and Consciousness criteria. A child of this age, with these injuries, should normally cry during examination.

Implementation 1. Use this slide to insert your own service’s or facility’s implementation plan.