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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:
Breathing.
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:
P3 or T3: delayed care - needs medical treatment, but this can safely be
delayed. Colour code green.
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).
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.
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
>29
6-9
1-5
>90
76-89
50-75
1-49
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.
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 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).
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
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]
This scale provides a classification of injury severity scores for individual organs.
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]
PatientPlus
Trauma Assessment
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.
This evaluation system is used widely for the assessment of illness severity in
intensive care units (ICUs).[7]
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
Penetrating trauma
b0
-0.4499
-2.5355
b1
0.8085
0.9934
b2
-0.0835
-0.0651
b3
-1.7430
-1.1360
Future directions
Provide Feedback
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.
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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.
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.
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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.
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'.
NEW - log your activity
Co-ordination and communication with the receiving hospital so that the trauma
team can be alerted and mobilised.
Airway maintenance.
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.
Guidelines on protection when dealing with body fluid should be followed throughout
this and subsequent procedures.
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:
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:
Secondary survey.
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
Evaluate breathing: lungs, chest wall, diaphragm. Chest examination with adequate
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.
Level of consciousness.
Skin colour.
Pulse.
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.
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.
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.
Level of any spinal cord injury (limb movements, spontaneous respiratory effort).
PatientPlus
Blast Injury
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.
Pulse rate,[12] blood pressure, ventilatory rate, arterial blood gases, body
temperature and urinary output.
CXR.
Pelvic X-ray. It has been suggested that CT scans may be used in some stable
patients.[13]
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.
P = Past illnesses/Pregnancy.
L = Last meal.
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).
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.
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.
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
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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.
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.
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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.