Ohio Trauma Triage Update EMS Providers Session Fall 2002

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Ohio Trauma Triage UpdateEMS Providers
SessionFall 2002
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Objectives

• Describe Ohios legal definition of trauma
• List the anatomic and physiologic criteria to be
  used by when evaluating adult and pediatric
  trauma victims
• Discuss the role that mechanism of injury and
  special considerations play in trauma triage
• List and discuss the five exceptions to trauma
  triage
• Describe the process for development and approval
  of regional triage protocols
• Discuss how the trauma triage rules will be
  enforced, and the importance of documentation of
  the criteria.
• Review trauma scenarios and apply the trauma
  triage rules to determine transport to a trauma
  center

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EMS/Trauma Map Updated 11/14/02
LEGEND
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Ashtabula
H
Lake
Williams
Fulton
H
X
Lucas
H
Geauga
Ottawa
I
EMS Region
H
14
5
Wood
Henry
Trumbull
Sandusky
IX
Erie
Defiance
Cuyahoga
IV
Portage
H
Huron
County names underlined indicates a county with
only (1) hospital Counties in RED CAPITALS have
NO hospital
Summit
Medina
Paulding
Seneca
Lorain
VIII
Hancock
H
PUTNAM
Mahoning
Wyandot
Richland
Ashland
Van Wert
Wayne
Crawford
H
Columbiana
VII
Allen
III
H
Hardin
Stark
Marion
Morrow
CARROLL
Auglaize
Tuscarawas
Holmes
Helicopter
H
Jefferson
Logan
Mercer
No 9-1-1 service
Shelby
Coshocton
Union
Delaware
Knox
Harrison
H
Darke
Champaign
H
Guernsey
Licking
Miami
Muskingum
(Wheeling WV)
Belmont
4
Franklin
II
H
Clark
VI
The icon SHAPE indicates the trauma center level
Franklin
Fairfield
H
Madison
NOBLE
PREBLE
Greene
Pickaway
MONROE
PERRY
4
MORGAN
Level 3 Trauma Center
Fayette
Montgomery
Level 2 Trauma Center
Hocking
Butler
Clinton
WARREN
4
V
Washington
Level 1 Trauma Center
Athens
Ross
H
I
The icon COLOR indicates Status ACS or Ohio
Provisional Adult or Pediatric
Highland
VINTON
Hamilton
8
H
(Parkersburg WV)
Clermont
ACS Adult
MEIGS
Jackson
Pike
H
(Covington, KY)
ACS Pediatric
Brown
Adams
Non trauma center hospital
Scioto
Gallia
In counties with more than 3 non trauma center
hospitals, a bold number next to a hospital icon
indicates that number of non trauma center
hospitals in that county
ACS Adult Pediatric
Ohio Provisional Adult
Lawrence
(Huntington WV)
(Ashland, KY)
Ohio Provisional Pediatric
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Ohio Triage Protocol
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Physiologic Criteria

• Physiologic Criteria - Adult
• GCS lt 13
• Loss of Consciousness gt 5 minutes
• Deterioration in LOC at scene or in transport
• Failure to localize pain (GCS motor score lt 4)
• Respiratory rate lt 10 or gt 29
• Requires Endotracheal Intubation
• Requires relief of tension pneumothorax
• Pulse gt 120 with evidence of hemorrhagic shock
• Systolic BP lt 90 mmHg

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Definitions

• Evidence of Hemorrhagic Shock
• Any of the following
• Delayed capillary re-fill (gt 2 seconds)
• Cool, pale, diaphoretic skin
• Decreasing SBP with narrowing pulse pressure
• systolic and diastolic pressures narrowing
• Altered Level of Consciousness

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Physiologic Criteria

• Physiologic Criteria - Pediatric
• GCS lt 13
• Loss of Consciousness gt 5 minutes
• Deterioration in LOC at scene or in transport
• Failure to localize pain (GCS motor score lt 4)
• Evidence of Poor Perfusion
• Evidence of Respiratory Distress/Failure

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Definitions

• Evidence of Poor Perfusion
• Any of the following
• Weak Distal Pulses
• Pallor
• Cyanosis
• Delayed capillary re-fill (gt 2 seconds)
• Tachycardia
• age appropriate

• Evidence of Respiratory Distress
• Any of the following
• Stridor
• Grunting
• Retractions
• Cyanosis
• Hoarseness
• Difficulty Speaking

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Anatomic Criteria

• Anatomic Criteria - Adult Pediatric
• Penetrating injury head, neck or torso
  (chest/abdomen)
• Significant penetrating injury to extremities
  proximal knee/elbow with neurovascular compromise
• Injuries to head, neck or torso
• Visible Crush
• Abdominal tenderness, distention or seat belt
  sign
• Pelvic Fracture (not isolated hip fractures)
• Flail Chest

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Anatomic Criteria

• Anatomic Criteria - Adult Pediatric
• Injuries to extremities with
• Amputations proximal to wrist or ankle
• Visible crush
• Fracture of 2 or more long bones (femur or
  humerus)
• Evidence of neurovascular compromise
• Sign/Symptoms of Spinal Cord Injury
• Serious Burns
• 2 or 3 degree gt 10 TBSA
• Involve face, airway, hands, feet, genitalia

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Definitions

• Signs or Symptoms of Spinal Cord Injury
• Paralysis
• Weakness
• Numbness/Tingling

• Evidence of Neurovascular Compromise
• The 5 Ps
• Paresthesia (numb/tingling)
• Pain (severe)
• Pallor (pale)
• Paralysis
• Pulse (Loss of)

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Mechanism of InjurySpecial Consideration

• Mechanism of Injury and Special Considerations
  must be considered, but should not be used as
  absolute criteria.
• As taught in the state curriculums for EMT-B,
  EMT-I and EMT-P

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Mechanism of Injury

• Motor Vehicle Crash
• Ejected from vehicle
• Death in same passenger compartment
• Rollover
• Extrication gt 20 minutes
• Evidence of high speed crash
• Speed gt 40 mph
• Major Auto Deformity gt 20 inches
• Intrusion into Passenger Compartment gt 12 inches

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Mechanism of Injury

• Auto-pedestrian/auto -bicycle gt 5 mph
• Pedestrian thrown or run over
• Motorcycle crash gt 20 mph or rider separated from
  bike
• Falls gt 20 feet

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Special Considerations

• Special Considerations (Examples)
• Age
• lt 5 years or gt 55 years old
• Pregnancy
• Co-Morbid Conditions
• Cardiac or Respiratory Disease
• Cirrhosis (Liver failure)
• Insulin Dependant Diabetes (type I diabetes)
• Immunosupressed patients (Cancer, HIV)
• Bleeding disorders or on Anti-coagulants
• Morbidly Obese

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Triage Exceptions

• Exceptions for Trauma Triage Protocols
• 1. It is medically necessary to transport to
  another hospital for initial assessment and
  stabilization.
• 2. It is unsafe or medically inappropriate due to
  adverse weather conditions or excessive transport
  times.
• 3. Would cause a shortage of local EMS resources.
• 4. No trauma center is able to receive patient
  and provide care with out undue delay.
• 5. Before transport begins, if the patient or
  parent request transportation to a particular
  hospital.

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Triage Exceptions

• Exceptions for Trauma Triage Protocols
• It is medically necessary to transport to another
  hospital for initial assessment and
  stabilization.
• Cardiac arrest, blunt mechanism of injury
• Unstable airway, not controlled by conventional
  means
• Uncontrolled hemorrhage

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Triage Exceptions

• Exceptions for Trauma Triage Protocols
• It is unsafe or medically inappropriate due to
  adverse weather conditions or excessive transport
  times.
• Weatherits anyone's Guess
• Ground Transport Time
• gt 30 minutes?
• Air Transport Time
• Air response time gt ???

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Triage Exceptions

• Use of air medical services at the scene
• OAC 13017-1-03
• (I) FM-102.7 Authority at fires and emergencies
  The fire chief or his authorized representative
  shall be in charge at the scene of a fire or
  other emergency involving the protection of life
  and/or property, and shall remain in charge until
  authority is relinquished. This includes the
  authority to request additional resources, like a
  medical helicopter.
• AG opinion 2001-011 (March 26, 2001)
• www.ag.state.oh.us/opinions/agopinio.htm"
• click on "2001 opinions" and click on "2001-011".
  

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Triage Exceptions

• Exceptions for Trauma Triage Protocols
• Would cause a shortage of local EMS resources.
• Do you know your regions resources?
• What situations cause shortages of resources?
• Personnel ?
• Vehicles?
• Equipment?

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Triage Exceptions

• Exceptions for Trauma Triage Protocols
• No trauma center is able to receive patient and
  provide care with out undue delay.
• What causes a Trauma Center to go on EMS
  Diversion?
• No available trauma surgeon
• All Operating rooms full
• CT scanner is down
• ED is physically full
• No critical care beds available
• ???

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Triage Exceptions

• Exceptions for Trauma Triage Protocols
• Before transport begins, if the patient or parent
  request transportation to a particular hospital.
• You cant force a competent patient to be
  transported
• Quickly educate patient/parent on need for trauma
  care
• Document, Document, Document!

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Regional Triage Protocol Variations

• Must be approved by the EMS Board
• Are reviewed by the Trauma Committee
• Must provide care comparable to state minimum
• Must be submitted to the Board by the RPAB
• RPABs must consult with
• Neighboring RPABs
• Hospitals Trauma Centers
• Physician, Nursing EMS organizations
• EMS instructors

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Regional Triage Protocol Variations

• Must require transport to Trauma Centers.
• Must seek to minimize over and under triage.
• May discriminate only based upon patients medical
  needs.
• You must know what the capabilities are of the
  various trauma centers in your region
• May include any of of the exceptions.
• When approved, supercede state protocols.
• Must be reviewed at least every three years.

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Triage Enforcement

• Enforcement of Triage Protocols
• EMS Medical Directors
• Quality Improvement
• Peer Review
• Regional Physician Advisory Boards (RPAB)
• Assist and Advise Medical Directors
• Mediate and problem solve
• EMS Board
• Current investigations process

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Triage Documentation

• Documentation
• Ohio Trauma Registry
• Collect data on trauma triage criteria used in
  the field
• Each component of the state protocol
• Multiple criteria can be reported
• Hospitals will abstract info from the EMS Report
• Specific Section for triage criteria on local
  forms?
• Narrative Sections
• Vital Signs
• Critical to measuring the specificity and
  sensitivity of the triage criteria

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Triage Documentation

• Documentation
• Use the narrative sections of your report...
• Describe the physiologic criteria you used to
  triage
• ...triaged as trauma due to evidence of
  hemorrhagic shock
• ...triaged as trauma, GCS lt13
• triaged as trauma, required intubation
• Describe the anatomic criteria you used to triage
• ...triaged as trauma due to GSW to abdomen
• ...triaged as trauma, suspected flail chest
• triaged as trauma, suspected spinal cord
  injury

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Triage Documentation

• Documentation
• Use the narrative sections of your report...
• Describe the mechanism of injury criteria used to
  triage
• ...triaged as trauma due to evidence of high
  speed crash
• ...triaged as trauma, fall gt 20 feet
• triaged as trauma, death of passenger same
  car
• Describe the special considerations criteria used
  to triage
• ...triaged as trauma, injured patient with age
  lt5
• ...triaged as trauma, injuries with significant
  cardiac Hx
• triaged as trauma, injured patient pregnant

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Triage Documentation

• Documentation
• Use the narrative sections of your report...
• Describe the exceptions criteria you used
• triaged as trauma, signs of hemorrhagic shock,
  transport to XXX hospital due to weather
• triaged as a trauma, LOC gt 5min., transport to
  XXX medical center, due to ZZZ Trauma Center on
  EMS diversion
• triaged as trauma, GSW to head, transport to XXX
  hospital, medically necessary, unable to obtain
  airway

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Triage Documentation

• Documentation
• Use the narrative sections of your report...
• Describe the exceptions criteria you used
• triaged as trauma, 2 long bone fractures.
  Transport to XXX hospital, parents request
• Document your attempts to educate the
  parent/guardian on the potential seriousness of
  the injuries and the need for evaluation in a
  trauma center!

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Trauma Education

• The Board will require eight hours of trauma
  continuing education in each three year
  certification cycle.
• DOESNT increase the total number of CE hours
• EMT-B40 EMT-I60 EMT-P80
• Of these hours, eight (8) must be trauma
• Of the eight hours, two (2) must be on trauma
  triage
• What about taking the test in place of CE hours?
• Providers must still obtain 2 hours of trauma
  triage CE
• Can be on state protocol, OR approved regional
  triage protocol

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Triage Scenarios
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Case Scenario 1

• 27 y/o male, driver, single car MVC. 45 mph
  collision with tree. Front seat passenger dead
  at scene
• Vital Signs
• Pulse 108 BP 100/palp
  Respiration 26
• Neuro Assessment
• No documented loss of consciousness
• GCS 14 (E-4, V-4, M-6)
• Injuries
• Multiple facial lacerations
• Fracture left upper extremity
• Bilateral ankle fractures

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Case Scenario 2

• 42 y/o male, fall at construction site,
  approximately 15 ft.
• Vital Signs
• Pulse 130
• BP 98/ palp
• Respiration 24
• Neuro Assessment
• No documented loss of consciousness
• GCS 13 (E-3, V-5, M-5)
• Injuries
• Bleeding from left ear and nose
• Fracture right femur
• Decreased Breath sounds right chest

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Case Scenario 3

• 31 y/o female, stab wound to right upper
  extremity.
• Vital Signs
• Pulse - 112 BP - 114/90
  Respiration - 24
• Neuro Assessment
• No documented loss of consciousness
• GCS 15 (E-4, V-5, M-6)
• Injuries
• Two stab wounds right forearm
• Abrasions right hand and right knee

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Case Scenario 4

• 10 y/o female, fell off bike, no helmet.
• Vital Signs
• Pulse - 110 BP - 100/74
  Respiration - 20
• Neuro Assessment
• No documented loss of consciousness
• Pediatric GCS 15 (E-4, V-5, M-6)
• Injuries
• Bilateral forearm fractures
• Abrasions to face
• Abrasions lower extremities

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Case Scenario 5

• 4 y/o male, MVC, no CSS, in backseat with lap
  belt
• Vital Signs
• Pulse - 120 Respiration - 28
• Neuro Assessment
• No documented loss of consciousness
• Pediatric GCS 15 (E-4, V-5, M-6)
• Injuries
• Ecchymosis face
• Ecchymosis and abrasions left forearm
• Abrasions ecchymosis to abdomen

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Resources

• Resources for Optimal Care of the Injured
• Advanced Trauma Life Support-Provider Manual
• Trauma 4th Edition Mattox, et al
• Basic Trauma Life Support-Provider Manual
• Prehospital Trauma Life Support-Provider Manual
• Guidelines for the Prehospital Management of
  Traumatic Brain Injury

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Important Contacts

• Mark Resanovich, EMT-P - EMS Board Chair
• [phone] rose_at_cityofgreen.org
• William Cotton, MD - EMS Board Vice Chair
• [phone] cottonw_at_pediatrics.ohio-state.edu
  
• Joe Luria, MD - Trauma Committee Chair
• [phone] joe.luria_at_chmcc.org
• Jay Johannigman, MD - TC Vice Chair
• [phone] johannja_at_ucmail.uc.edu

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Important Dates

• Dates that Rules become effective
• EMS Medical Director Qualifications8/26/02
• Trauma Triage10/28/02
• Provisional Trauma Centers11/03/02

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For More Information

• Ohio Public Safety, Division of EMS
• Mike Glenn, RN
• State Trauma Coordinator
• Phone [phone]
• Fax [phone]
• E-mail mglenn_at_dps.state.oh.us