Injury, Int. J.

Care Injured 43 (2012) 13811385

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Injury
journal homepage: www.elsevier.com/locate/injury

Do pre-hospital trauma alert criteria predict the severity of injury and a need for an emergent surgical intervention?
Guy Lin a,*, Alexander Becker b, Mauricio Lynn c
a

The Trauma Unit, Western Galilee Hospital, Naharia, Israel Department of Surgery A, Haemek Medical Center, Afula, Israel c The Dewitt-Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, University of Miami School of Medicine, Miami, FL, United States
b

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 10 November 2010 Keywords: Triage Trauma alert criteria Emergent surgical intervention Evacuation priority

Objective: Efcient triage may have a major inuence on mortality and morbidity as well as nancial consequences. A continuous effort to improve this decision making process and update the trauma alert criteria is being made. However, criteria for determining the evacuation priority are not well developed. We performed a prospective study to evaluate which pre-hospital parameters identify major trauma victims with an emphasis on a need for emergent surgical procedures. Methods: A prospective cohort included 601 patients admitted to a level one trauma centre over a three months period. The pre-hospital trauma alert criteria were recorded and set as independent variables. All major surgical procedures were graded in real time as: emergent, urgent, or not urgent. The ISS was calculated after completion of all the diagnostic workup. Patients were classied as major trauma victims if their calculated ISS was 16 or greater, and those needed an urgent intervention or intensive care. The relative risks (RR) for major trauma and a need for an emergent operation were calculated. Results: 243 (40%) patients were classied as having a major trauma. 39 (6.5%) patients required an emergent operative intervention: 24 for an active bleeding, 5 for a pericardial tamponade and 10 for an imminent cerebral herniation. Paramedic judgement and a penetrating injury to the trunk were the most common causes for over triage. However, a penetrating injury to the trunk had been the only clue that the victim needed an emergent operation in ve cases. 128 patients had a pre-hospital Glasgow coma score (GCS) 12. Altered mental status was the most common and a signicant predictor of both major trauma (RR of 3.00 with a 95% condence interval (CI) of 1.984.53) and a need for an emergent operation (RR, 95% CI: 4.43, 2.288.58). Also, a systolic blood pressure 90 mmHg was highly associated with an emergent operation (RR, 95% CI: 11.69, 5.8523.36). Conclusion: For determining the evacuation priority, we suggest a triage system based on three major criteria: mental status, hypotension and a penetrating injury to the trunk. Overall, the set of trauma alert criteria system can be further simplied and enable better utilisation of resources. 2010 Elsevier Ltd. All rights reserved.

Introduction Trauma centre triage criteria are designed to ensure the evacuation of wounded to the correct destination. These criteria do not deal with the question of priority in the evacuation, that is, of the injured who is the most urgent. It has been claimed that outcome is adversely affected if the initial assessment of severely injured patients is done in a non-trauma hospital.21 Conversely, the resources of a trauma centre must not be overwhelmed by assessment and treatment of minor trauma patients who could

From the Dewitt-Daughtry Family Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami School of Medicine, Miami, FL. * Corresponding author. Tel.: +972 50 2061927. E-mail address: ofralin@gmail.com (G. Lin).

reasonably expected to do well with care in their local area. Hence, there are attempts at reducing overtriage without compromising outcomes in trauma patients.5 For optimal allocation of resources in the treatment of trauma, it would be useful to decide as early as possible which patients would benet most from transport to a dedicated trauma centre.9,13 Overtriage occurs when a false assumption that the patient is seriously injured is made based on prehospital criteria. Undertriage involves an assumption that serious injuries are not present when, in fact, they are. The American College of Surgeons (ACS) suggests the need for a 50% overtriage rate to maintain a 10% under triage rate.22 Kane et al.12 demonstrated that to obtain a 15% under triage rate, a 60% over triage rate was necessary, with 12% of patients triaged to trauma centres actually suffering serious injury. In a multi casualty situation, when shortage of transport means is anticipated, the triage system must include effective tools to

00201383/$ see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.11.014

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decide which patients should be transported rst.7 Obviously, injuries that require emergent surgical intervention are a priority. Therefore, there is a special importance to dene the indices that indicate the highest probability of such injuries.3 Patients who appear initially stable but are later determined to have potentially fatal injuries presents a major challenge. The best method to identify those patients is yet to be established.1 For triage considerations, most studies done so far were retrospective in nature. We believe that there is a need for prospective study to assess correctly the need for an emergent surgical intervention. The purpose of this prospective study is to evaluate the ability of our trauma centre triage criteria to identify major trauma victims with an emphasis on a need for an emergent surgical procedure. Materials and methods This study was approved by the University of Miami institutional review board. From July 1st to September 30th 2007, Ryder Trauma Centre patients were prospectively entered into the study if they met the Miami-Dade County trauma centre triage criteria. Patients were excluded from the study for: age less than 15, thermal, chemical and electrical injuries, patients experiencing a cardiac arrest before any surgical procedure, those transferred from another hospital and when adequate prehospital data could not be obtained. Demographic data collected were: age, sex, mechanism of injury, injury time (as estimated by the 911 call), hospital arriving time and the trauma alert criteria as determined by the paramedics. Miami-Dade County pre-hospital trauma alert criteria set forth in Table 1 are based on a modication of the recommendations of the ACS. There are eight criteria named: age, airway (AW), consciousness, circulation, fracture, cutaneous, mechanism of injury and high index of suspicion (paramedics gut feeling). The criteria are divided into two categories named category 1 and category 2 (as detailed in Table 1, there is no category 1 for age and mechanism of injury and no category 2 for high index of suspicion). The trauma centre was activated for any patient presenting any category 1 criterion or at least two category 2 criteria. In order to double-check the triage criteria, the Glasgow coma score (GCS), heart rate (HR), systolic blood pressure (SBP), respiratory rate and pulse oximetery values (SaO2) were measured and recorded during pre-hospital transport. All major surgical procedures were graded by the team as: emergent (a lifesaving operation is needed within minutes), urgent (a lifesaving operation is needed within hours) and not urgent. To note, open fractures were referred as not urgent in this study. In
Table 1 Miami-Dade County adult trauma alert criteria. Category 1 Age Airway Consciousness Circulation Fracture Cutaneous Mechanism of injury Other High index of suspicion

order to reduce bias, the classication of the surgical procedure was approved by one of the investigators. For all the patients, the ISS was calculated after completion of all diagnostic workup. The length of ICU stay was added latter to the data collection sheet. Patients were classied as major trauma victims when their calculated ISS was 16 or greater, when they needed an emergent surgery and when they needed ICU care. A further subdivision to a very severe trauma for patients with an ISS  25 was performed. All other patients were categorised as over triaged with a further subdivision to an obvious over triaged for patients who stayed in the hospital less than 24 h. Variables are expressed as number of cases and percentage for categorical data, and as means and standard deviations for numerical data. The triage criteria were set as independent variables. Dependent variables were the classication into the groups of major trauma or over triage, and the need for an emergent operation. Associations were analysed using [x]2 test. The results are given as relative risks (RR) with the 95% condence intervals (95% CI). The statistical signicance level was set at 5% (a = 0.05). Results Demographics (Table 2) A cohort of 601 patients who met inclusion criteria represents the study population. This group includes 490 men and 111 women. The mean age was 38.25 18.43 years (range 15100) whilst 103 of the patients were more than 55 years old. Injury mechanisms were blunt in 417 cases: motor vehicle collisions (MVC) 192, pedestrian hit by car (PHBC) 52, motorcycle (including ATV) collisions (MCC) 58, falls 65, water sports 7, industrial accidents 14 and assaults 29. 184 (30.6%) patients suffered a penetrating mechanism: gun shot wounds (GSW) 104 and stab wounds (SW) 80. The mean time from injury to hospital arrival was 44.8 17.63 min (range 10144 min). The Mean time from injury to hospital arrival was not different for the wounded who needed emergent surgical treatment (43.4 11.7). High index of suspicion was the most common triage criterion, being applied to 222 (36.9%) patients. The next most common triage criterion was cutaneous category 1 mainly a penetrating injury to the trunk being applied to 139 (23.1%) patients. An altered level of consciousness was the third common reason for trauma alert (128 patients). 243 patients were dened as major trauma (40%). 126 (21% of the cohort) major trauma patients had an ISS of 25 or more. The mean ISS of the cohort was 14.32 13.71 (range 175). 39 patients required an emergent operative intervention: 24 for active bleeding (liver 7, spleen 3, other abdominal 4, neck 2,

Category 2 >55 years old Respiratory rate  30 BMR = 5 (BMR = best motor response of the GCS) Sustained heart rate = 120 bpm Any long bone fracture sustained in a MVC or fall  10 feet Major degloving injury, or major ap avulsion >5 inches, or GSW to the extremities Ejection from a closed motor vehicle, or steering wheel deformity

Active airway assistance beyond supplemental O2 BMR <5, or paralysis, or suspicion of spinal cord injury, or loss of sensation, or GCS  12 No radial pulse and sustained heart rate  120, or SBP  90 mmHg 2 or more long bone fractures (humerus, radius, ulna, femur, tibia, bula) Deep penetrating injury to head, neck & torso, Amputation at or proximal to wrist or ankle

G. Lin et al. / Injury, Int. J. Care Injured 43 (2012) 13811385 Table 2 Patients/injuries/interventions demographics. Characteristics Age Age >55 Men Women Time from injury to hospital ISS Overtriage Obvious overtriage (hospital stay <24 h) ISS  25 Injury mechanisms blunt MVC PHBC MCC Fall Water sports Industrial/crush Assault Injury mechanisms penetrating GSW SW Emergent operations Bleeding control Pericardial tamponade Neurosurgical emergency Urgent operations Value 38.25 18.43 years (range 15100) 103 (17.14%) 490 (81.26%) 111 (18.74%) 44.8 17.63 min (range 10144) 14.32 13.71 (range 175) 358 (60%) 168 (28%) 126 (21%) 417 (69.38%) 192 52 58 65 7 14 29 184 (30.62%) 104 80 39 24 5 10 42

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Trauma alert criteria and over triage (Table 3) 358 (60%) patients matched the over triage denition, 168 (28% of the cohort) of them were discharged within 24 h. High rates of over triage were caused by the high index of suspicion criterion (175/222 = 78.8%) and the cutaneous category 1 (mainly a penetrating injury to the trunk) criterion (73/ 139 = 52.5%). Trauma alert criteria and major trauma (Table 3) 40 patients matched the AW category 1 triage criterion. 34 patients were dened as sustaining major trauma (RR 9.54, 95% CI 3.9423.12), in 28 of them the ISS was 25 or more (RR 11.02, 95% CI 5.4222.43). 128 patients matched the consciousness category 1 triage criterion (all with a GCS  12). 90 patients were dened as sustaining major trauma, in 65 of them the ISS was 25 or more (RR, 95% CI: 3.00, 1.984.53; 6.97, 4.4910.81, respectively). 63 patients matched the circulation category 1 triage criterion (all with a SBP  90 mmHg). 52 patients were dened as sustaining major trauma, in 37 of them the ISS was 25 or more (RR, 95% CI: 4.60, 2.677.94; 5.23, 3.128.75, respectively). 37 patients matched the fracture category 1 triage criterion. 27 patients were dened as sustaining major trauma, in 14 of them the ISS was 25 or more (RR, 95% CI: 3.94, 1.928.11; 2.35, 1.18 4.69, respectively). 139 patients matched the cutaneous category 1 triage criterion. 66 patients were dened as sustaining major trauma, 29 of them with an ISS of 25 or more (not signicant). 222 patients matched the high index of suspicion triage criterion. 47 patients were dened as sustaining major trauma, 18 of them with an ISS of 25 or more (not signicant). Trauma alert criteria and emergent surgical procedures (Table 3) AW category 1 triage criterion An orotracheal intubation or an attempted intubation had been performed at the scene on 40 patients. 10 of the 40 patients needed an emergent (within minutes) surgical procedure (RR 6.11, 95% CI 2.7313.71), but all had at least one more category-1 criterion. 82

femoral vessels 2 and massive haemothorax 2), 5 patients sustained a pericardial tamponade whereas 10 patients required an immediate neurosurgical intervention for imminent cerebral herniation (5 had an epidural haematoma and 5 had a subdural haematoma). Another 42 patients underwent urgent operations (which could have been delayed for several hours). Disposition of patients was as follows: ICU 148 patients, regular oors 262 patients, discharged from the ER 168 patients, expired in the OR 17 patients. The mean ICU stay was 17.84 22.03 days (range 1120). The median ICU stay was 6 days. Overall, the cohort experienced a 38/601 (6.3%) incidence of mortality (17 patients expired in the operating room (OR) and 21 succumbed to their illness in the ICU).
Table 3 Triage criteria analysis. Parameter AW category 1 RR 95% CI Consciousness category 1 RR 95% CI Circulation category 1 RR 95% CI Fractures category 1 RR 95% CI Cutaneous category 1 RR 95% CI Suspicion category 1 RR 95% CI Two or more category 1 criteria RR 95% C Two or more category 2 criteria RR 95% CI No. 40 Hospital stay <24 h 0

Overtriage 6 (15%)

Major trauma 34 9.54 3.9423.12 90 3.00 1.984.53 52 4.60 2.677.94 27 3.94 1.928.11 66 Not signicant 48 Not signicant 68 10.31 5.5419.18 10 Not signicant

ISS  25 28 11.02 5.4222.43 65 6.97 4.4910.81 37 5.23 3.128.75 14 2.35 1.184.69 29 Not signicant 18 Not signicant 52 13.81 7.9823.91 2 Not signicant

Emergent operation 10 6.11 2.7313.71 20 4.43 2.288.58 21 11.69 5.8523.36 6 3.01 1.187.71 20 3.92 2.037.58 0

128

16 (12.5%)

38 (29.7%)

63

13 (20.6%)

20 (31.7%)

37

3 (8.1%)

11 (29.7%)

139

26 (18.7%)

73 (52.5%)

222

96 (43.2%)

175 (78.8%)

81

2 (2.5%)

13 (16%)

44

21 (47.7%)

32 (72.7%)

23 12.49 6.2424.99 0

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additional intubations were performed by anaesthetists on admission for various indications (not primary AW problems). Consciousness category 1 triage criterion 20 of the 128 patients needed an emergent surgical procedure (RR, 95% CI: 4.43, 2.288.58), 5 of them had consciousness category 1 triage criterion as the sole category 1 criterion, all having neurosurgical emergencies. To note, no one from the 483 patients with a GCS  14 on admission needed a neurosurgical procedure. Circulation category 1 triage criterion 21 of the 63 patients needed an emergent surgical procedure (RR, 95% CI: 11.69, 5.8523.36). To note, only 2/542 (0.4%) patients with a SBP > 90 on admission needed an emergent bleeding control. Fracture category 1 triage criterion 4 of the 37 patients needed an emergent surgical procedure for concomitant severe injuries (not signicant). Cutaneous category 1 triage criterion 20 of the 139 patients needed an emergent surgical procedure for concomitant severe injuries (RR, 95% CI: 3.92, 2.037.58). 15 patients were hypotensive on admission (BP < 90 mmHg), and 5 patients had cutaneous-1 triage criterion as the sole class-1 criterion (3 sustaining GSW and 2 sustaining SW). High index of suspicion Triage criterion: none of the 222 patients needed an emergent surgical procedure. One patient with a pseudo-aneurism of the aorta underwent surgery the next day. Combined trauma alert criteria 81 patients had two or more category-1 triage criteria. When combining two or more category-1 triage criteria, the ability to identify major trauma, very severe trauma and a need for immediate surgery is highly signicant (RR, 95% CI: 10.31, 5.54 19.18; 13.81, 7.9823.91; 12.49, 6.2424.99, respectively). 44 patients were transferred to the trauma centre for a combination of two or more category 2 triage criteria category. 32 (72.7%) patients were dened as over triaged, 10 were dened as a major trauma, 2 of them had an ISS  25 and no one needed an emergent surgery. As can be seen, a combination of two category 2 criteria was not associated with a major trauma or a need for an emergent surgery. Discussion The strength of this study lies in this prospective design with no sample bias and a complete data base, as retrospective analysis cannot set a reliable evaluation of the urgency of treatment and probably tends to overestimate it. Limitations of this study are related to the lack of attention to under triage rates and a relatively low number of patients requiring emergent operations; this could limit the power of the statistical analysis despite the large sample size. The Miami-Dade County triage criteria (Table 1) led to an over triage in 60% of cases. This rate is higher than the 46.1% overtriage rate reported by our institution 19 years ago.14 It is higher than the 50% rate recommended by the ACS22 and similar to the 60% rate recommended by Kane et al.12 Trauma team activation patients receive the highest priority with regard to investigations and are being continuously monitored in the ER and the radiology department. Hence, such a high rate of overtriage is probably delaying the care of other patients. Still, there is some advantage to over triage as the experience gathered in trauma centres may allow less workup for clearance of mildly injured patient.18

The high index of suspicion (paramedic judgement) criterion led to an over triage in 78.8% of cases. No patient transferred by this criterion needed an emergent surgical procedure. Provider gut feeling alone was found to be a low-yield triage criterion in previous studies.9,18 In contrast, Emerman et al.8 found that the prehospital provider judgement triage criterion was equal or superior to other less subjective tools in its ability to identify severe injury. When it comes to a single victim, over triage should be encouraged. However, in a multi casualty situation, when paramedic judgement is a major triage tool, over triage should be reduced.7,10 According to current criteria, any patient with a penetrating injury to the trunk/head/neck is transferred to a trauma centre. Although the criterion states deep penetrating injury, there is no practical way to evaluate the depth of the wound in the eld. The high over triage rate is the result of wounds that are found to be supercial, tangential or just missing vital structures. However, this criterion was signicantly associated with a need for an emergent lifesaving surgery. Hence, we agree with Sava et al.19 that all patients with truncal gunshot wounds deserve trauma team activation. GCS has been previously considered as the most reliable triage criterion.20 It is well accepted that a low GCS is highly predictive of the need for emergent interventions but the exact break point in the GCS score at which it becomes predictive has not been identied. GCS as high as 1415 and as low as 84,23 has been proposed to mandate full trauma team activation. Although others have found a GCS of 12 as a cause for a high rate of overtriage16 our results support our policy of referring a GCS of 12 as the threshold for trauma team activation. Vital signs are not sensitive neither specic indicators of the haemodynamic status.17 Brown et al.2 stated that following a penetrating abdominal trauma, haemodynamic stability does not reliably exclude signicant haemorrhage. In contrast, we found that when the SBP had been more than 90 mmHg on admission, an emergent operation was rarely needed. A SBP  90 mmHg was highly associated with a major trauma and an emergent surgery. Category 2 criteria have not found to be contributors to triage. Although passengers that are thrown out of a vehicle tend to be more severely injured,11 the ejection criterion was not a contributor to triage, perhaps because passengers who are lying out of the car are often been mistaken for being ejected. Sustained heart rate 120 beats per minute and respiratory rate 30 are category 2 triage criteria. Like previously noted,14 these parameters are not good indicators to the haemodynamic status and also can be altered by substance abuse. Heart rate variability may be a better triage parameter than the traditional vital signs.6 Meanwhile, it seems that our triage system can be simplied by omitting category 2 criteria. A modied triage system is needed for situations that require setting priorities for evacuation of wounded. In these situations, the injured requiring emergent surgical interventions should be evacuated rst. To achieve this goal, based on our results, we suggest three major criteria: altered mental status, hypotension and a penetrating truncal injury. It seems that patients presenting two or more major criteria should be triaged as the most urgent patients. Conict of interest statement We hereby declare that we have no nancial and personal relationships with other people, or organisations, that could inappropriately inuence the study: Do pre-hospital trauma alert criteria predict the severity of injury and a need for an emergent surgical intervention?. References
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