1. Trauma Triage Diana Jones Paramedic

2. What is Trauma?  How do we define trauma?  How do we identify the need for trauma triage?  How do we select the appropriate receiving facility?  When should air medical service be requested?  How do we handle a situation with multiple patients?

3. What is Trauma?  As defined by Merriam- Webster, the medical definition of trauma is  An injury to living tissue caused by an extrinsic agent  Trauma is broadly classified into two types  Penetrating  Blunt

4. Trauma Triage  The purpose of trauma triage is to quickly and accurately identify the need for transport to a trauma center  When the mechanism of injury involves high energy, the need for trauma facility services greatly increases. Situations include:  Ejection from automobile  Death in the same passenger compartment  Auto/pedestrian or auto/bicycle >5mph  Auto crash >40mph  Passenger compartment intrusion >12”  Vehicle deformity >20”  Rollover with unrestrained passenger  Extrication time >20 min  Falls >20’  Motorcycle crash >20 mph or separation of rider and bike

5. Trauma Triage  In addition to mechanism of injury, patient status is also used for determination of transport to trauma facility  Kentucky State Protocols provide the algorithm set forth by American College of Surgeons to aid in identifying patients in need of trauma facility  Objective information that warrants a trauma facility  GCS <14  SBP <90  RR 29

6. Trauma Triage  Certain injuries, independent of all other factors indicate transport to trauma facility  Penetrating injuries to head, neck, torso, or extremities proximal to elbow or knee  Flail chest  Combination of trauma and burns  Two or more proximal long bone fractures  Pelvic fx  Open or depressed skull fx  Paralysis  Amputation proximal to wrist or ankle  Major burns  Patient age should also be used to guide: 55

7. Trauma Facilities  American College of Surgeons does not designate trauma levels  Designation is provided by government entities at both local and state levels  American College of Surgeons does verify the presence of resources  Participation by a facility is voluntary  There are 5 designated levels

8. Level I Trauma Facility  Highest level possible  Can provide total care for all aspects of injury  Resources include  24 hour coverage by general surgeons and availability of specialists in orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, internal medicine, radiology, plastic surgery, oral/maxillofacial, pediatric, and critical care  Referral resource for communities  Leadership in prevention and public education  Continuing education for trauma team members  Comprehensive quality assessment program  Organized teaching and research  Substance abuse screening and patient intervention  Minimum requirement for annual volume of severely injured patients

9. Level II Trauma Facility  The standards for clinical care of injured patients are identical to Level I facilities  Difference between Level I and Level II are distinguished by Level I requiring  Meeting minimum admission requirements (1200 trauma patients yearly or 240 admissions with Injury Severity Score >15)  Surgically directed critical care service  Training of residents, leader in education and outreach  Conduct trauma research

10. Level III Trauma Facility  To qualify as Level III designation, the following resources must be present  24 hour coverage by emergency medicine physician  Prompt availability of general surgeon and anesthesiologist  Quality assessment program  Transfer agreements for patient requiring care at Level I or II  Back-up care for rural and community hospitals  Continuing education of nursing and allied health personnel or trauma team  Involved with prevention efforts and active outreach program for referring communities

11. Level IV Trauma Facility  To qualify as Level IV designation, the following resources must be present  Emergency department facilities to implement ATLS protocols  24 hour laboratory coverage  Trauma nurse and physician available upon patient arrival  May provide surgery and critical care services  Developed transfer agreements for patient requiring care at Level I or II  Quality assessment program  Involved with prevention efforts and active outreach program for the community

12. Level V Trauma Facility  To qualify as Level V designation, the following resources must be present  Emergency department facilities to implement ATLS protocols  Trauma nurse and physician available upon patient arrival  After hours activation protocol if facility is not open 24 hours  May provide surgery and critical care services  Developed transfer agreements for patients requiring care at Level I, II, or III

13. Local Facilities  University of Kentucky- Level I  University of Cincinnati- Level II  Cincinnati Children’s Hospital Medical Center- Level I  University of Louisville- Level I  Meadowview Regional Medical Center- no designation  Harrison Memorial Hospital- Level IV in progress  St. Elizabeth, Ft. Thomas- Level III  St. Elizabeth, Edgewood-  St. Elizabeth, Florence

14. Air Medical Service  Should be utilized in life or limb situations  When transport by air improves transport time  When specialized care is required  When trauma algorithm indicates major trauma  Critically ill medical patients- CVA, MI  Do NOT request air medical for cardiac arrest, UNLESS hypothermia has been induced  Clinical Judgement

15. Multiple Patients  Mass casualty incident is defined as any event which overwhelms available resources due to number of patients or severity  During these times, it is of critical importance to utilize a triage system  START Triage is one of the most effective methods  Know your area and how to access additional resources

16. START Triage  Acronym that stands for Simple Triage and Rapid Treatment  Categorizes patients in one of 4 ways  Morgue  Immediate  Delayed  Minor

17. START Triage  Begins upon arrival at scene  1 st step is identifying minor illness/injury  “If you can hear me and are able to walk…..(direct to designated area)  Identifies “walking wounded”  2 nd step is identifying and categorizing non-ambulatory patients  Utilizes respiratory status, hemodynamic status, and neurological status

18. START Triage  Respiratory status  Not breathing- open airway with manual maneuver  If spontaneous respirations continue to be absent, tag as morgue  If spontaneous respirations resume, tag as immediate  Breathing patients  RR 30, tag as immediate  Move on to hemodynamic status  Hemodynamic status  Absent radial, tag as immediate  Profuse bleeding, implement simplest method to control and tag as immediate  Neurological status  Unconscious or cannot follow simple commands, tag as immediate  Can follow simple commands, tag as delayed

19. START Triage  Triage officer prioritizes patients and does not participate in patient care until conclusion of triage  If enough personnel are available designate a treatment and transport officer  General guideline is “First In, Last Out”  This means the first unit to arrive on scene assumes responsibility of triage and directs activities of others. This unit does not leave the scene until conclusion of the incident  Exception could be made if a higher level of care arrives on scene and assumes responsibility  Example: ALS unit assumes command from BLS

20. Additional Resources  All providers should anticipate the event in which additional resources will be required  Neighboring services include  Pendleton, Northern Pendleton, Campbell County, Mason County, Harrison County, and Nicholas County  Always err on the side of caution. If the dispatch information indicates the need for additional resources, request and mobilize them, you can always cancel.

21. Works Cited  http://www.merriam-webster.com/dictionary/trauma http://www.merriam-webster.com/dictionary/trauma  http://www.amtrauma.org/?page=traumalevels http://www.amtrauma.org/?page=traumalevels  https://www.facs.org/quality%20programs/trauma/vrc/resour ces https://www.facs.org/quality%20programs/trauma/vrc/resour ces  https://www.facs.org/~/media/files/quality%20programs/tra uma/vrc%20resources/resources%20for%20optimal%20care% 202014%20v11.ashx https://www.facs.org/~/media/files/quality%20programs/tra uma/vrc%20resources/resources%20for%20optimal%20care% 202014%20v11.ashx  file:///Users/hopkinsal14/Downloads/Kentucky%20State%2 0Protocols%2004-09-2014.pdf file:///Users/hopkinsal14/Downloads/Kentucky%20State%2 0Protocols%2004-09-2014.pdf