Trauma triage

Trauma triage is the use of trauma assessment for prioritising of patients for treatment
or transport according to their severity of injury. Primary triage is carried out at the
scene of an accident and secondary triage at the casualty clearing station at the site of
a major incident. Triage is repeated prior to transport away from the scene and again at
the receiving hospital.
The primary survey aims to identify and immediately treat life-threatening injuries and is
based on the 'ABCDE' resuscitation system:

Airway control with stabilisation of the cervical spine.

Breathing.

Circulation (including the control of external haemorrhage)

Disability or neurological status.

Exposure or undressing of the patient while also protecting the patient from
hypothermia.

Priority is then given to patients most likely to deteriorate clinically and triage takes
account of vital signs, pre-hospital clinical course, mechanism of injury and other
medical conditions.Triage is a dynamic process and patients should be reassessed
frequently, the following is one example of triage sieve which is used in the UK:

Priority 1 (P1) or Triage 1 (T1): immediate care needed - requires immediate

life-saving intervention. Colour code red.

P2 or T2: intermediate or urgent care needed - requires significant intervention

within two to four hours. Colour code yellow.

P3 or T3: delayed care - needs medical treatment, but this can safely be
delayed. Colour code green.

Dead is a fourth classification and is important to prevent the expenditure of

limited resources on those who are beyond help. Colour code black.

Triage systems are most often used following trauma incidents but may be required in
other situations, such as an influenza epidemic.[1] Once further resources are available
to hand, the patients will undergo a further, more detailed triage based on vital signs eg, respiratory rate. One such score is called the Revised Trauma Score (see below).

Additional patient triage

Following the initial triage, there is usually a further detailed pre-hospital triage of
patients. The following is one example:

Modified sieve systems are available for use in children.

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Trauma scoring
Trauma scores are often audit and research tools used to study the outcomes of trauma
and trauma care, rather than predicting the outcome for individual patients. Many
different scoring systems have been developed; some are based on physiological
scores (eg, Glasgow Coma Scale (GCS)) and other systems rely on anatomical
description (eg, Abbreviated Injury Scale (AIS)). There is, however, no universally
accepted scoring system and each system has its own limitations.

The triage sort or Revised Trauma Score (RTS)[2]

Used as a triage tool in a pre-hospital setting.

It is a common physiological scoring system based on the first data sets of three
specific physiological parameters obtained from the patient.

The three parameters are: the GCS, systemic blood pressure (SBP), and the
respiratory rate (RR).[3]

Limitations
These include the inability to accurately score patients who are intubated and
mechanically ventilated.

Physiological variable

Value

Score

Respiratory rate

10-29

Systolic blood pressure

>29

6-9

1-5

>90

76-89

50-75

1-49

Glasgow Coma Scale (GCS)

13-15

9-12

6-8

4-5

A total score of 1-10 indicates priority T1, 11 indicates T2, and 12 indicates T3. A score
of 0 means dead.

Anatomical scoring systems

Abbreviated Injury Scale (AIS)[3]

Since its introduction as an anatomical scoring system in 1969, the AIS has been
revised and updated many times.

The AIS scale is similar to the Organ Injury Scale (OIS) introduced by the Organ
Injury Scaling Committee of the American Association for the Surgery of Trauma;
however, AIS is designed to reflect the impact of a particular organ injury on patient
outcome.

The Association for the Advancement of Automotive Medicine monitors the scale.

Injury Threat

AIS Score

Minor

Moderate

Serious

Severe

Critical

Unsurvivable

Limitations

The AIS scale does not provide a comprehensive measure of severity.

The AIS scale does not represent a linear scale, ie the difference between AIS1
and AIS2 is not the same as the difference between AIS4 and AIS5.

When used alone, the current AIS version is not useful for predicting patient
outcomes or mortality; instead, it forms the basis of the Injury Severity Score (ISS)
and the Trauma and Injury Severity Score (TRISS).

Injury Severity Score (ISS) and New Injury Severity Score

(NISS)

The ISS was introduced in 1974 as a method for describing patients with multiple
injuries and evaluating emergency care. It has since been classed as the 'gold
standard' of severity scoring.[4]

Each injury is initially assigned an AIS score and one of six body regions (head,
face, chest, abdomen, extremities, external).

The highest three AIS scores (only one from each body region may be included)
are squared and the ISS is the sum of these scores.

Limitations

Inaccurate AIS scores are carried forward.

Many different injury patterns can yield similar ISS scores.

It is not useful as a triage tool.[5]

It only considers one injury per body region and therefore may underestimate the
severity in trauma victims with multiple injuries affecting one body part. [4]

The NISS is a modified version of the ISS developed in 1997. The NISS sums
the severity score for the top three AIS injuries regardless of the body region;
hence, NISS scores greater than ISS values indicate multiple injuries in at least one
body region.[4][6]

Organ Injury Scale (OIS)

This scale provides a classification of injury severity scores for individual organs.

The OIS is based on injury description scaled by values from 1 to 5, representing

the least to the most severe injury.

The Organ Injury Scaling Committee of the American Association for the Surgery
of Trauma (AAST) developed the OIS in 1987; the scoring system has been
updated and modified since that time.[3]

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Physiological scoring systems

Glasgow Coma Scale (GCS) and Glasgow Paediatric
Coma Scale (GPCS)

The GCS (see separate Glasgow Coma Scale (GCS) article) and the GPCS are
simple and common methods for quantifying the level of consciousness following
traumatic brain injury.

The scale is the sum of three parameters:

Best Eye Response

Best Verbal Response

Best Motor Response

Scales are based on values ranging between 3 (worst) to 15 (best). [3]

The Acute Physiology and Chronic Health Evaluation

(APACHE)

APACHE was first introduced in 1981. APACHE IV is an updated version

introduced in 2006.

This evaluation system is used widely for the assessment of illness severity in
intensive care units (ICUs).[7]

Combination scoring systems

Trauma and Injury Severity Score (TRISS)[3]
This score determines the probability of patient survival (Ps) from the combination of
both anatomical and physiological (Injury Severity Score (ISS) and Revised Trauma
Score (RTS), respectively) scores. A logarithmic regression equation is used:

Ps = 1/(1+e-b), where b = bo + b1 (RTS) + b2 (ISS) + b3 (Age Score)

RTS and ISS are calculated as above and Age Score is either 0 if the patient is <55
years old or 1 if aged 55 and over. The coefficients b0-b3 depend on the type of trauma
(NB: there is some variation in the published values for these). A TRISS calculator is
available on the trauma.org website.[8]

Coefficient

Blunt trauma or age <15 years

Penetrating trauma

b0

-0.4499

-2.5355

b1

0.8085

0.9934

b2

-0.0835

-0.0651

b3

-1.7430

-1.1360

Future directions

Trauma triage and scoring is an ongoing development in process and new

systems are being optimised on a daily basis.

Lactate measures may become more important in future. It is a better predictor of

blood transfusion need and mortality.[9]

Provide Feedback

Further reading & references

1.

Talmor D, Jones AE, Rubinson L, et al; Simple triage scoring system predicting
death and the need for critical care resources for use during epidemics. Crit Care
Med. 2007 May;35(5):1251-6.

2.

Kilner T; Triage decisions of prehospital emergency health care providers, using

a multiple casualty scenario paper exercise. Emerg Med J. 2002 Jul;19(4):348-53.

3.

Scoring Systems; Trauma.org

4.

Husum H, Strada G; Injury Severity Score versus New Injury Severity Score for
penetrating injuries. Prehosp Disaster Med. 2002 Jan-Mar;17(1):27-32.

5.

Paffrath T, Lefering R, Flohe S; How to define severely injured patients?-An Injury

Severity Score (ISS) based approach alone is not sufficient. Injury. 2014 Oct;45
Suppl 3:S64-9. doi: 10.1016/j.injury.2014.08.020.

6.

Eid HO, Abu-Zidan FM; New Injury Severity Score Is a Better Predictor of
Mortality for Blunt Trauma Patients Than the Injury Severity Score. World J Surg.
2014 Sep 5.

7.

Salluh JI, Soares M; ICU severity of illness scores: APACHE, SAPS and MPM.
Curr Opin Crit Care. 2014 Oct;20(5):557-65. doi:
10.1097/MCC.0000000000000135.

8.

Trauma - Injury Severity Score (TRISS) Calculator; Trauma.org

9.

Vandromme MJ, Griffin RL, Weinberg JA, et al; Lactate is a better predictor than
systolic blood pressure for determining blood J Am Coll Surg. 2010
May;210(5):861-7, 867-9.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.

The initial assessment and management of seriously injured patients is a challenging

task and requires a rapid and systematic approach.
This systematic approach can be practised to increase speed and accuracy of the
process but good clinical judgement is also required. [1][2] Although described in
sequence, some of the steps will be taken simultaneously.
The aim of good trauma care is to prevent early trauma mortality. Early trauma deaths
may occur because of failure of oxygenation of vital organs or central nervous system
injury, or both.
Injuries causing this mortality occur in predictable patterns and recognition of these
patterns led to the development of advanced trauma life support (ATLS) by the
American College of Surgeons. A standardised protocol for trauma patient evaluation
has been developed.[3][4] The protocol celebrated its 25th anniversary in 2005. [5] Good
teaching and application of this protocol are held to be important factors in improving
the survival of trauma victims worldwide.[6]
Different systems of trauma scoring have been developed.

Aims of the initial evaluation of trauma

patients

Stabilise the patient.

Identify life-threatening conditions in order of risk and initiate supportive

treatment.

Organise definitive treatments or organise transfer for definitive treatments.

Preparation and co-ordination of care

Assessment and management will begin out of hospital at the scene of injury and good
communication with the receiving hospital is important. The preparatory measures are
outlined below to 'set the scene'.
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The pre-hospital phase

Co-ordination and communication with the receiving hospital so that the trauma
team can be alerted and mobilised.

Airway maintenance.

Control of external bleeding shock.

Keeping the patient immobilised.

Information gathering: time of injury; related events; patient history. Key elements
are the mechanism of injury to alert the trauma team to the degree and type of
injury.

Keeping time at the scene to a minimum.

The hospital phase

Preparation of a resuscitation area.

Airway equipment - laryngoscopes, etc (accessible, tested).

Intravenous (IV) fluids (warming equipment, etc).

Immediately available monitoring equipment.

Methods of summoning extra medical help.

Prompt laboratory and radiology backup.

Transfer arrangements with trauma centre.

Guidelines on protection when dealing with body fluid should be followed throughout
this and subsequent procedures.

Triage and organisation of care

See separate related article Trauma Triage and Scoring.
This is the sorting of patients according to their need for treatment and the resources
available. It starts at the scene (see above) and continues at the receiving hospital.
[7]

Priority is given to patients most likely to deteriorate clinically and triage takes account

of vital signs, pre-hospital clinical course, mechanism of injury, age and other medical
conditions. In trauma centres, teamwork should ensure critically injured patients are
evaluated as diagnostic procedures are performed simultaneously, thus reducing the
time to treatment. A team approach is demanding of personnel and resources and, in
smaller institutions, non-hospital settings or with mass casualties, available personnel
and resources can rapidly be overwhelmed:

Triage: is done according to the 'ABCDE' principles (Airway maintenance with

cervical spine protection, Breathing and ventilation, Circulation with haemorrhage
control,Disability: neurological status, Exposure/environmental control).

Selection of hospital: is according to available services, so that trauma patients

should be taken to trauma centres.

Multiple casualties: where the number of patients and severity of injury do not
exceed the capacity of the treatment centre, life-threatening injuries and multiple
system injuries are treated first.

Mass casualties: when the the number of patients and severity of injury do
exceed capacity of the treatment centre, patients are selected for treatment
according to best chance of survival with least expenditure of resources (time,
personnel, equipment, supplies).

Initial assessment
This comprises:

Resuscitation and primary survey.

Secondary survey.

Definitive treatment or transfer for definitive care.

Resuscitation and primary survey

For speed and efficacy a logical sequence of assessment to establish treatment
priorities must be gone through sequentially although, with good teamwork, some things
will be done simultaneously (resuscitation procedures will begin simultaneously with the
assessment involved in the primary survey, ie lifesaving measures are initiated when
the problem is identified). Special account should be taken of children, pregnant women
and the elderly as their response to injury is modified. [8] The primary survey is according
to:
A = Airway maintenance cervical spine protection

Are there signs of airway obstruction, foreign bodies, facial, mandibular or

laryngeal fractures? Management may involve secretion control, intubation or
surgical airway (eg, cricothyroidotomy, emergency tracheostomy).

Establish a clear airway (chin lift or jaw thrust) but protect the cervical spine at all
times.[9] If the patient can talk, the airway is likely to be safe; however, remain

vigilant and recheck. A nasopharyngeal airway should be used in a conscious

patient; or, as a temporary measure, an oropharyngeal airway in an unconscious
patient with no gag reflex. Definitive airway should be established if the patient is
unable to maintain integrity of airway; mandatory if Glasgow Coma Scale (GCS) is
less than 8.

Cervical spine protection is critical throughout the airway management process.

Movement of the cervical spine could cause spinal injury so movement of the
cervical spine should be avoided unless absolutely necessary for maintaining an
airway.[9] The trauma mechanism or history may suggest the likelihood of a cervical
spine injury, but always assume there is a spinal injury until proven otherwise,
especially in any multisystem trauma or if there is an altered level of
consciousness. Inline immobilisation and protection of the spine should be
maintained and X-rays can be taken once immediately life-threatening conditions
have been dealt with.

B = Breathing and ventilation

Provide high-flow oxygen through a rebreather mask if not intubated and ventilated.
[10]

Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate

exposure: watch chest movement, auscultate, percuss to detect lesions acutely

impairing ventilation:

Tension pneumothorax - requires needle thoracostomy followed by drainage.

Flail chest - management involves ventilation.

Haemothorax - will usually require intercostal drain insertion.

Pneumothorax - may require intercostal drain insertion.

Note: it can be difficult to tell whether the problem is an airway or ventilation problem.
What appears to be an airway problem, leading to intubation and ventilation, may turn
out to be a pneumothorax or tension pneumothorax which will be exacerbated by
intubation and ventilation.

C = Circulation with haemorrhage control

Blood loss is the main preventable cause of death after trauma. To assess blood loss
rapidly observe:

Level of consciousness.

Skin colour.

Pulse.

Bleeding - this should be assessed and controlled:

IV access should be achieved with two large cannulae (size and length of
cannula is determinant of flow not vein size) in an upper limb. Access by cut
down or central venous catheterisation may be done according to skills
available. At cannula insertion, blood should be taken for crossmatch and
baseline investigations.

IV fluids will need to be given rapidly, usually as 250 ml to 500 ml warmed

boluses (10-20 ml/kg in children). Often a total of 2-3 L of IV fluids is
necessary (40 ml/kg in children), which will then need to be followed by blood
transfusion (O negative to begin with, if typed blood is not available). Ringer's
lactate is the preferred initial crystalloid solution. [11]

Direct manual pressure should be used to stem visible bleeding (not

tourniquets, except for traumatic amputation, as these cause distal ischaemia).

Transparent pneumatic splinting devices may control bleeding and allow

visual monitoring; surgery may be necessary if these measures fail to control
haemorrhage.

Occult bleeding into the abdominal cavity and around long-bone or pelvic
fractures is problematic but should be suspected in a patient not responding to
fluid resuscitation.

Note: response to blood loss differs in:

Elderly - limited ability to increase heart rate; poor correlation between blood loss
and blood pressure.

Children - tolerate proportionately large volume loss but then rapidly deteriorate.

Athletes - do not show the same heart rate response to blood loss.

Chronic conditions and medication may affect response and early on in trauma
management will not be known about.

D = Disability: neurological status

After A, B and C above, rapid neurological assessment is made to establish:

Level of consciousness, using GCS.

Pupils: size, symmetry and reaction.

Any lateralising signs.

Level of any spinal cord injury (limb movements, spontaneous respiratory effort).

Oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all

also affect the level of consciousness.

Patients should be re-evaluated frequently at regular intervals, as deterioration can

occur rapidly and often patients can be lucid following a significant head injury before
worsening. Signs such as pupil asymmetry or dilation, impaired or absent light reflexes,
and hemiplegia/weakness all suggest an expanding intracranial mass or diffuse
oedema. This requires IV mannitol, ventilation and urgent neurosurgical opinion.
Hypertonic saline can be used as an alternative to mannitol especially in hypovolaemic
patients.
E = Exposure/environmental control
Undress the patient, but prevent hypothermia. Clothes may need to be cut off but, after
examination, attend to prevention of heat loss with warming devices, warmed blankets,
etc. Also check blood glucose levels.

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Additional considerations to primary survey and

resuscitation
ECG monitoring: this can guide resuscitation by diagnosing dysrhythmias, ischaemia,
cardiac injury, pulseless electrical activity (PEA) - which may indicate cardiac
tamponade - hypovolaemia, tension pneumothorax, and extreme hypovolaemia.
Hypoxia or hypoperfusion should be suspected if there is bradycardia, aberrant
conduction, and premature beats. Hypothermia produces dysrhythmias.
Urinary/gastric catheters:

Output of urine can guide fluid replacement (reflects renal perfusion). Adequate
output is 0.5-1 ml/kg/hour. Note: prior to catheter insertion urethral injury should be
excluded - suspect if there is blood at meatus, pelvic fracture, scrotal blood,
perineal bruising. Per rectum and genital examination are mandatory prior to
catheter insertion.

Gastric catheters are inserted to reduce aspiration risk. Suction should be

applied.Note: care should be taken not to provoke aspiration by triggering gagging.

Other monitoring: monitoring of resuscitation by measuring various important

parameters measures adequacy of resuscitation efforts. Values for various parameters
should be obtained soon after the primary survey and reviewed regularly. Important
parameters are:

Pulse rate,[12] blood pressure, ventilatory rate, arterial blood gases, body
temperature and urinary output.

Carbon dioxide detectors may identify dislodged endotracheal tubes.

Pulse oximetry measures oxygenation of haemoglobin colorimetrically (sensor on

finger, ear lobe, etc.).

Remember: blood pressure is a poor measure of perfusion.

Diagnostic procedures: care should be taken that these do not hamper resuscitation.
They may be best deferred to the secondary survey. Modifications to the ATLS
guidelines have been suggested.[13][14] X-rays most likely to guide resuscitation early on,
especially in blunt trauma, include:

CXR.

Pelvic X-ray. It has been suggested that CT scans may be used in some stable
patients.[13]

Lateral cervical spine X-ray.

Other useful procedures include FAST (= focused assessment with sonography for
trauma), eFAST (= extended focused assessment with sonography for trauma) and/or
CT scanning to detect occult bleeding.

Secondary survey
This begins after the 'ABCDE' of the primary survey, once resuscitation is underway and
the patient is responding with normalisation of vital signs. The secondary survey is
essentially a head-to-toe examination with completion of the history and reassessment
of progress, vital signs, etc. It requires repeat physical examinations and may require
further X-ray and laboratory tests. It comprises:
History

A = Allergies.

M = Medication currently used.

P = Past illnesses/Pregnancy.

L = Last meal.

E = Events/Environment related to injury

Physical examination
This will repeat some examinations already undertaken in the primary survey and will be
further informed by the progress of the resuscitation. It aims to identify serious injuries,
occult bleeding, etc. A review of neurological status including GCS score is also
undertaken. Back and spinal injuries are commonly missed and pelvic fractures cause
large blood loss which is often underestimated.
Beware: burns (fluid requirements, inhalation injury); cold injury (continue resuscitation
until rewarmed); high-voltage electricity injuries (extensive muscle injury likely to be
concealed).

Additional considerations to secondary survey

A range of further diagnostic tests and procedures may be required after the secondary
survey. These include CT scans , ultrasound investigations, contrast X-rays,
angiography, bronchoscopy, oesophageal ultrasound, etc.

Definitive care
Choosing where care should continue most appropriately will depend on results of the
primary and secondary surveys and knowledge of the facilities available to receive the
patient. The closest appropriate facility should be chosen.

Records and legal considerations

Remember:

Keep meticulous records (times for all entries, etc). Teamwork with timekeeping
and recording of clinical measurements, and observations can be helpful. Some
units have a member of the nursing staff whose sole role is to record and collate
patient care information accurately.

Consent for treatment is not always possible with lifesaving treatment and
consent may have to be given later.

Forensic evidence may be required in injuries caused by criminal activity.

Practice tips
Regular training in resuscitation by the whole practice team is recommended. Attention
to a team approach is essential. Involvement in medical cover at schools, sports events,
and car accidents (British Association for Immediate Care (BASICS) requires higherlevel training and regular refresher courses.
Provide Feedback

Further reading & references

Davis M; Should there be a UK based advanced trauma course? Emerg Med J.

2005 Jan;22(1):5-6.

BASICS - British Association for Immediate Care

1.

Scherer LA, Chang MC, Meredith JW, et al; Videotape review leads to rapid and
sustained learning. Am J Surg. 2003 Jun;185(6):516-20.

2.

Mohammad A, Branicki F, Abu-Zidan FM; Educational and clinical impact of

Advanced Trauma Life Support (ATLS) courses: a systematic review. World J Surg.
2014 Feb;38(2):322-9. doi: 10.1007/s00268-013-2294-0.

3.

Bell RM, Krantz BE, Weigelt JA; ATLS: a foundation for trauma training. Ann
Emerg Med. 1999 Aug;34(2):233-7.

4.

Esposito TJ, Kuby A, Unfred C, et al; General surgeons and the Advanced
Trauma Life Support course: is it time to refocus? J Trauma. 1995 Nov;39(5):92933; discussion 933-4.

5.

Collicott PE; ATLS celebrates 25th anniversary. Bull Am Coll Surg. 2005
May;90(5):18-21.

6.

Hogan MP, Boone DC; Trauma education and assessment. Injury. 2008 May 24;.

7.

Santaniello JM, Esposito TJ, Luchette FA, et al; Mechanism of injury does not
predict acuity or level of service need: field triage criteria revisited. Surgery. 2003
Oct;134(4):698-703; discussion 703-4.

8.

Hayden B, Plaat F, Cox C; Managing trauma in the pregnant woman. Br J Hosp

Med (Lond). 2013 Jun;74(6):327-30.

9.

Austin N, Krishnamoorthy V, Dagal A; Airway management in cervical spine

injury. Int J Crit Illn Inj Sci. 2014 Jan;4(1):50-6. doi: 10.4103/2229-5151.128013.

10.

McCullough AL, Haycock JC, Forward DP, et al; Early management of the
severely injured major trauma patient. Br J Anaesth. 2014 Aug;113(2):234-41. doi:
10.1093/bja/aeu235.

11.

Harris T, Thomas GO, Brohi K; Early fluid resuscitation in severe trauma. BMJ.
2012 Sep 11;345:e5752. doi: 10.1136/bmj.e5752.

12.

Victorino GP, Battistella FD, Wisner DH; Does tachycardia correlate with
hypotension after trauma? J Am Coll Surg. 2003 May;196(5):679-84.

13.

Hilty MP, Behrendt I, Benneker LM, et al; Pelvic radiography in ATLS algorithms:
A diminishing role? World J Emerg Surg. 2008 Mar 4;3:11.

14.

Kool DR, Blickman JG; Advanced Trauma Life Support. ABCDE from a
radiological point of view. Emerg Radiol. 2007 Jul;14(3):135-41. Epub 2007 Jun 12.