Dr. James Winslow
The American College of Surgeons has published the 2021 National Guidelines for the Field Triage of Injured patients. This document is the basis for the Trauma Triage Destination Guidelines that all EMS systems in North Carolina are required to utilize. The purpose of the guidelines is to ensure that severely injured patients are transported to the most appropriate trauma center. Severely injured adult patients have a 20% lower hospital mortality and a 25% lower one-year mortality when initially taken to a level 1 trauma center. There are similar benefits with severely injured children.
The guidelines are meant to make sure that patients are taken to an appropriate trauma center with a minimum of under or over triage. Over triage is when patients with only minor to moderate injuries are taken to a high-level trauma center when they do not need that level of care. Under triage is when severely injured patients are not taken to a high-level trauma center. The goal of the trauma system is to keep the amount of undertriage to less than 5% and to keep overtriage to less than 35%. Using the trauma triage guidelines helps reduce the level of over and undertriage.
The American College of Surgeons has a list of High-Risk Criteria for Serious Injury and a list for Moderate Risk of Serious Injury. The high-risk criteria are divided into injury patterns and mental status / vital signs. Any patient with high-risk criteria will likely need the care offered at a Level 1 trauma center. Patients who only meet the moderate risk criteria should be transported to any trauma center available to the EMS system. The moderate risk criteria are divided into Mechanism of Injury and EMS judgment.
The Trauma Triage Guidelines have a list of injury patterns that it classifies as high-risk injury patterns. These injury patterns are very specific for needing to go to a high-level trauma center. Changes have been made to the injury pattern criteria which predict severe injury and the need for a level 1 trauma center. Many of these changes were based on EMS feedback. One new high-risk criterion is active bleeding requiring a tourniquet or use of wound packing. The old criteria of “Penetrating injuries to the head, neck, torso, or other extremities” was changed to “proximal injuries.” Another old criterion of “paralysis” was changed to “suspected spinal injury with new motor or sensory loss.” The old criterion for chest wall injury were also changed. The guidelines used to state “Chest wall instability or deformity (e.g., flail chest).” The new criterion for chest injury simply say, “Chest wall instability, deformity, or suspected flail chest.” There were also other changes made to the injury criteria for two or more long bone fractures and pelvic injuries.
Mental status changes and vital signs also make up a list of high-risk criteria indicating the need for high-level trauma center care. These criteria like the injury pattern criteria are highly specific but not very sensitive for identifying patients who need a higher-level trauma center. A big change with this criterion is how the Glasgow Motor Score is used. In the past a GCS of less than or equal to 13 was used. Now it only matters if the patient has an abnormal motor exam. This means that a patient who cannot follow commands (GCS motor < 6) meets a high-risk criterion. A full GCS score does not need to be calculated to decide on where the patient should be taken. Another big change is the use of the shock index in adults. This means that if a patient’s heart rate is greater than their systolic blood pressure then they meet criteria for needing transport to a higher-level trauma center. A new criterion in the new document includes “Respiratory distress or need for respiratory support.” An additional new criterion is a room air pulse ox of less than 90%. This is for all ages.
Moderate risk criteria are divided into mechanism of injury and EMS Judgment. Patients meeting the moderate risk criteria should be taken to a trauma center, but not necessarily the highest-level trauma center. One new mechanism criterion is a child (0-9 years of age) unrestrained or in unsecured safety seat. The modified mechanism criteria include compartment intrusion, rider separated from vehicle (includes horse), fall from greater than ten feet, and pedestrian/ bicycle injuries. No changes were made to the criteria dealing with ejection, death in passenger compartment, and vehicle telemetry data.
EMS Judgment includes a list of criteria which should prompt EMS personnel to consider transport to a trauma center. These include suspected child abuse, high-resource care needs like chronic ventilator dependence or ventricular assist devices, and ground level falls in the elderly.
The NC College of Emergency Physicians has slightly modified the American College of Surgeons National Guidelines document to better match the needs of NC. The biggest change was that if a level 1 trauma center is not reasonably close then EMS can then take the patient to a level 2 or 3 center. Each EMS system can make changes to the NC College of Emergency Physicians Trauma Triage Guideline as they see fit.
Here is the link for more information on the American College of Surgeons National Guidelines for the Field Triage of Injured Patients: https://www.facs.org/quality-programs/trauma/systems/field-triage-guidelines/
The article from where much of this column was written can be found at this link: https://journals.lww.com/jtrauma/Fulltext/2022/08000/National_guideline_for_the_field_triage_of_injured.19.aspx
Dr. Winslow has worked at Baptist Hospital in Winston-Salem for the past 11 years. He was appointed as the Medical Director of the North Carolina Office of EMS in 2011. This document contains all protocol, procedures and policies for all EMS agencies in North Carolina.