Field Triage Decision Scheme: Field Triage Decision Scheme: The National Trauma The National Trauma

Triage ProtocolTriage Protocol

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionCenters for Disease Control and Prevention

National Center for Injury Prevention and ControlNational Center for Injury Prevention and ControlDivision of Injury ResponseDivision of Injury Response

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ObjectivesObjectives

Review the importance of accurate Review the importance of accurate Field Triage in Trauma CareField Triage in Trauma Care

Review the history of the American Review the history of the American College of Surgeons Field Triage College of Surgeons Field Triage Decision SchemeDecision Scheme

Discuss the changes in the 2006 Field Discuss the changes in the 2006 Field Triage Decision SchemeTriage Decision Scheme

Review CDC educational initiatives for Review CDC educational initiatives for the 2006 Field Triage Decision Scheme the 2006 Field Triage Decision Scheme

Source: National Center for Injury Prevention and Control, Centers for Disease Source: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Control and Prevention. Web-based Injury Statistics Query and Reporting System. Ten Leading Causes of Death, 1999-2004.Ten Leading Causes of Death, 1999-2004.

Source: MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect Source: MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. of trauma-center care on mortality. N Engl J MedN Engl J Med. 2006 Jan 26; 354(4):366-78.. 2006 Jan 26; 354(4):366-78.

History of the Decision SchemeHistory of the Decision Scheme

The American College of Surgeons-The American College of Surgeons-Committee on Trauma (ACS-COT) Committee on Trauma (ACS-COT) developed guidelines to designate developed guidelines to designate “trauma centers” in 1976 “trauma centers” in 1976 -- Set standards for personnel, facilities, and Set standards for personnel, facilities, and

processes necessary for the best care of processes necessary for the best care of injured personsinjured persons

Studies showed mortality reduction in Studies showed mortality reduction in regions with trauma centersregions with trauma centers

History of the Decision SchemeHistory of the Decision Scheme

National consensus conference in 1987 National consensus conference in 1987 resulted in first ACS field triage resulted in first ACS field triage protocol, the “Triage Decision Scheme”protocol, the “Triage Decision Scheme”

The Decision Scheme serves as the The Decision Scheme serves as the basis for field triage of trauma patients basis for field triage of trauma patients in most EMS systems in the U.S.in most EMS systems in the U.S.

History of the Decision SchemeHistory of the Decision Scheme

The Decision Scheme has been revised The Decision Scheme has been revised four times (1990, 1993, 1999, 2006)four times (1990, 1993, 1999, 2006)

In 2005-2006 the Centers for Disease In 2005-2006 the Centers for Disease Control and Prevention (CDC), with Control and Prevention (CDC), with support from the National Highway Traffic support from the National Highway Traffic Safety Administration (NHTSA), convened Safety Administration (NHTSA), convened the National Expert Panel on Field Triagethe National Expert Panel on Field Triage

National Expert Panel on Field TriageNational Expert Panel on Field Triage

Membership Membership – National leadership, expertise, and contributions National leadership, expertise, and contributions

in the realm of injury prevention and controlin the realm of injury prevention and control MembersMembers

– EMS Providers and Medical DirectorsEMS Providers and Medical Directors– Emergency Medicine Physicians and NursesEmergency Medicine Physicians and Nurses– Trauma SurgeonsTrauma Surgeons– Public HealthPublic Health– Federal AgenciesFederal Agencies– Automotive IndustryAutomotive Industry

National Expert Panel on Field TriageNational Expert Panel on Field Triage

The role of the Expert Panel is to:The role of the Expert Panel is to:– Periodically review the Decision Periodically review the Decision

SchemeScheme– Ensure criteria are consistent with Ensure criteria are consistent with

existing evidence existing evidence – Ensure criteria are compatible with Ensure criteria are compatible with

advances in technology advances in technology – Make necessary recommendations Make necessary recommendations

for revisionfor revision

2006 Decision Scheme2006 Decision Scheme

Why this Decision Scheme is UniqueWhy this Decision Scheme is Unique

Takes into account recent changes in Takes into account recent changes in assessment and care of the injured assessment and care of the injured patient in the U.S. patient in the U.S.

Adds views of a broader range of Adds views of a broader range of disciplines and expertise into the disciplines and expertise into the processprocess

PurposePurpose

This Decision Scheme was revised to This Decision Scheme was revised to facilitate more effective triage and facilitate more effective triage and better match trauma patients’ better match trauma patients’ conditions with the medical facility conditions with the medical facility best equipped to treat thembest equipped to treat them

Specific Changes to the Specific Changes to the Field Triage Decision SchemeField Triage Decision Scheme

Step 1: Physiologic CriteriaStep 1: Physiologic Criteria

Step 1: 2006 ChangesStep 1: 2006 Changes

AddedAdded– A threshold for respiratory rate (<20 bpm) in A threshold for respiratory rate (<20 bpm) in

infantsinfants

RemovedRemoved– Revised Trauma ScoreRevised Trauma Score

Step 2: Anatomic CriteriaStep 2: Anatomic Criteria

Step 2: 2006 ChangesStep 2: 2006 Changes

AddedAdded– Crushed, degloved, or mangled extremityCrushed, degloved, or mangled extremity

ModifiedModified– ““Open and depressed” changed to “open Open and depressed” changed to “open or or

depressed” skull fracturedepressed” skull fracture

RemovedRemoved– Burns moved to Step FourBurns moved to Step Four

Step 3: Mechanism of Injury CriteriaStep 3: Mechanism of Injury Criteria

Step 3: 2006 ChangesStep 3: 2006 Changes

AddedAdded– Vehicle telemetry data consistent with high Vehicle telemetry data consistent with high

risk of injuryrisk of injury ModifiedModified

– Falls:Falls: Adults: >20 feet (one story = 10 feet)Adults: >20 feet (one story = 10 feet) Children: > 10 feet, or 2–3 times the Children: > 10 feet, or 2–3 times the

child’s heightchild’s height– ““High speed auto crash” was changed to High speed auto crash” was changed to

“high-risk auto crash”“high-risk auto crash”

Time OutTime Out

What is vehicle telemetry?What is vehicle telemetry?– Combination of telematics and computingCombination of telematics and computing– Integration of vehicle’s electrical Integration of vehicle’s electrical

architecture, cellular communication, GPS architecture, cellular communication, GPS systems, and voice recognitionsystems, and voice recognition

Can notify of exact location of crashCan notify of exact location of crash Can enable communication with occupantsCan enable communication with occupants Can provide key injury information to providers Can provide key injury information to providers

regarding force, mechanics, and energy of a regarding force, mechanics, and energy of a crash that may help predict severity of injurycrash that may help predict severity of injury

ModifiedModified– Intrusion modified to >18 inches at any siteIntrusion modified to >18 inches at any site– Auto-pedestrian/struck/auto-bicycle injury Auto-pedestrian/struck/auto-bicycle injury

changed to “Auto v. pedestrian/bicyclist thrown, changed to “Auto v. pedestrian/bicyclist thrown, run over, or with significant (>20mph) impact” run over, or with significant (>20mph) impact”

– Motorcycle crash shortened to “Motorcycle crash Motorcycle crash shortened to “Motorcycle crash >20mph”>20mph”

Step 3: 2006 ChangesStep 3: 2006 Changes

RemovedRemoved– Rollover crash Rollover crash – Extrication time >20 minutesExtrication time >20 minutes– Crush depth Crush depth – Vehicle deformity >20 inches and vehicle Vehicle deformity >20 inches and vehicle

speed >40 mphspeed >40 mph

Step 3: 2006 ChangesStep 3: 2006 Changes

Step 4: Special ConsiderationsStep 4: Special Considerations

Step Four: 2006 ChangesStep Four: 2006 Changes

AddedAdded– Burns (moved from Step Two)Burns (moved from Step Two)– Time-sensitive extremity injuriesTime-sensitive extremity injuries– End stage renal disease requiring End stage renal disease requiring

hemodialysishemodialysis– EMS Provider judgmentEMS Provider judgment

ModifiedModified– AgeAge

Older adults: Risk of Older adults: Risk of injury/death increases after age injury/death increases after age 5555

Children: Should be triaged Children: Should be triaged preferentially to pediatric preferentially to pediatric capable trauma centerscapable trauma centers

Step Four: 2006 ChangesStep Four: 2006 Changes

– Pregnancy changed to read “Pregnancy greater Pregnancy changed to read “Pregnancy greater than 20 weeks”than 20 weeks”

Step Four: 2006 ChangesStep Four: 2006 Changes

Removed Removed – Cardiac and respiratory diseaseCardiac and respiratory disease– Diabetes MellitusDiabetes Mellitus– Morbid obesityMorbid obesity– ImmunosuppressionImmunosuppression– CirrhosisCirrhosis

Resources for EMS ProvidersResources for EMS Providers

Tool Kit for ImplementationTool Kit for Implementation

CDC Educational InitiativeCDC Educational Initiative

CDC, in collaboration with partners and CDC, in collaboration with partners and experts, has developed:experts, has developed:– EMS leader’s guide to the revised Decision EMS leader’s guide to the revised Decision

SchemeScheme– Decision Scheme poster and pocket-sized Decision Scheme poster and pocket-sized

reference cardreference card– Morbidity and Mortality Weekly ReportMorbidity and Mortality Weekly Report

(MMWR)(MMWR) article, “Guidelines for Field Triage article, “Guidelines for Field Triage of Injured Patients, Recommendations of the of Injured Patients, Recommendations of the National Expert Panel on Field Triage”National Expert Panel on Field Triage”

Contains continuing education creditsContains continuing education credits

Endorsing OrganizationsEndorsing Organizations

With concurrence from the National Highway Traffic Safety Administration

ReferencesReferences

1.1. National Center for Injury Prevention and Control, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Web-based Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Ten Injury Statistics Query and Reporting System. Ten Leading Causes of Death, 1999-2004.Leading Causes of Death, 1999-2004.

2.2. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nahens AB, Frey MacKenzie EJ, Rivara FP, Jurkovich GJ, Nahens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on evaluation of the effect of trauma-center care on mortality. mortality. N Engl J MedN Engl J Med. 2006 Jan 26; 354(4):366-78.. 2006 Jan 26; 354(4):366-78.

3. Centers for Disease Control and Prevention. Guidelines 3. Centers for Disease Control and Prevention. Guidelines for Field Triage of Injured Patients, Recommendations of for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage. MMWR 2009; the National Expert Panel on Field Triage. MMWR 2009; 58 (1): 1-35.58 (1): 1-35.

For more information or to order or For more information or to order or download materials, visit:download materials, visit:

www.cdc.gov/FieldTriagewww.cdc.gov/FieldTriage

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