TRAUMA SYSTEMS AND TRAUMA TRIAGE ALGORITHMS

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CHAPTER 7 TRAUMA SYSTEMS AND TRAUMA TRIAGE ALGORITHMS

Antonio Pepe, Antonio Marttos, Mauricio Lynn, Jeffrey A. Augenstein

Trauma is a major national health care problem that affects one of four U.S. citizens annually. Traumatic injury, both accidental and intentional, is the leading cause of death in the United States for people aged 1 to 34 years. There are as many as 150,000 trauma deaths and approximately 80,000 others who sustain long-term disability each year with annual costs of more than $260 billion for trauma injury and treatment when loss of future productivity is considered. The most common fatal injuries in the country result form motor vehicle crashes, followed closely by gunshot wounds. Driving while impaired by alcohol is the most frequent cause of fatal motor vehicle crashes and accounts for 40% of traffic fatalities. The causes of traumatic death vary considerably depending on demographics. Urban and politically unstable areas typically have a higher incidence of penetrating trauma, whereas rural and stable communities have a predominance of blunt injuries, usually vehicular accidents. Nonetheless, causes of death after injury are remarkably similar. Central nervous system injury accounts for approximately half of all fatalities; hemorrhage for 35%; and sepsis, multiple organ failure, and pulmonary embolism combine for approximately 15%. With the introduction of trauma systems during the last three decades, the incidence of preventable death has dropped from approximately 25% to less than 5%. This is the result of improvements in care both for acute head injuries and for control of hemorrhage. In addition, the incidence of late death attributable to sepsis and multiple organ failure has diminished, possibly as a result of better and early resuscitation. The responsibility of the trauma surgeon encompasses the early recognition of injury, resuscitation, and then definitive care of the patient. As we improve the operative and intensive care rendered to trauma patients, we are beginning to reach the flat portion of the outcome curve. The area of injury prevention is still open to substantial improvement. To reduce the morbidity and mortality from trauma, surgeons must take a more active role in the prevention of trauma at the community level. Studies have shown the effect of these systems on the improvement of trauma care, with outcomes better than those predicted for some study populations. The necessary elements of a trauma system have been defined. These include four primary patient needs—access to care, prehospital care, hospital care, and rehabilitation. In addition, five issues require social and political solutions to supplement medical efforts: prevention, disaster medical planning, patient education, research, and rational financial planning. Recent federal legislation (The Trauma Care Systems Planning and Development Act) authorized planning, implementation, and development of statewide trauma care systems.

Data show, however, that only 23 states in the United States have functional, statewide trauma systems, and eight states have no trauma system at all. In the United States, as many as 35% of trauma patients who die do so because optimal acute care is not available. Despite the evidence that trauma care systems save lives, existing systems serve only one fourth of the U.S. population.

TRAUMA SYSTEMS

A trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of care to all injured patients and is integrated with the local public health system. The true value of a trauma system is derived from the seamless transition between each phase of care, integrating existing resources to achieve improved patient outcomes. Success of a trauma system is largely determined by the degree to which it is supported by public policy. The development of civilian regional trauma systems has provided the single most significant improvement in the care of injured patients in the last three decades.

Numerous regional and statewide systems have been created to optimize quality of care and outcomes for severely injured patients. An essential component of a trauma system involves the evaluation of patients at the scene by emergency medical technicians to determine if their injuries meet specified trauma triage criteria that indicated they would be best served by being transported to a trauma center, thereby integrating the prehospital, transport, and trauma center settings. Triage is the process whereby the patient’s medical needs are matched with the available medical resources and can occur in the field and at the hospital. Field triage identifies those patients needing transport to the most appropriate trauma center rather than the nearest hospital and also identifies the type of transport needed. The trauma patient is an injured person who requires timely diagnosis and treatment of actual or potential injuries by a multidisciplinary team of health care professionals. Supported by the appropriate resources, the goal is to diminish or eliminate the risk of death or permanent disability. Injuries occur across a broad spectrum and a trauma system must determine the appropriate level of care for each type of injury. The goal of triage criteria is to closely match patients’ needs to the appropriate resources.

With respect to hospital triage, both the available level of hospital resources and time/distance factors are considered in making triage and destination decisions. Level III/IV hospital triage should serve to identify those patients who require initial stabilization and rapid transfer to the next highest level of care, and those patients that can be safely held in a Level III/IV center for further evaluation and serial observations. Level I/II hospital triage identifies patients who require a full trauma team approach as well as those who can be initially evaluated by identified members of the trauma team with subsequent consultation by either a trauma surgeon or the appropriate subspecialist.

Many areas of the country already have resources in place to provide appropriate trauma care. To provide optimal care of the seriously injured with maximum efficiency and minimal cost in terms or lives, disability, and dollars, these resources must be organized using a systems approach to plan for the rapid decisions required for initial treatment or all injured patients—an inclusive system. A proper systems approach requires a regional triage system with identified trauma centers capable of providing trauma care to major trauma patients. Patients must be identified and delivered or transferred based on clinical need to the appropriate level of care in a timely fashion. An optimal trauma care system is designed to care for all injured patients with specific attention focused on major trauma patients.

Major trauma patients are those with either a severe injury or a risk for severe injury. A severe injury is one that could result in morbidity or mortality, and is classically defined as an injury with an Injury Severity Score (ISS) of 16 or higher. On initial evaluation, these patients typically have abnormal vital signs or a significant anatomical injury. However, triage is often inexact due to patients’ variable physiological responses to trauma. In some patients, minor injuries can result in morbidity or mortality due to the patient’s age and/or comorbid factors, and some patients may have a delayed physiological response to trauma. Patients involved in a high-energy event are at risk for severe injury. Five to 15% of these patients, despite normal vital signs and no apparent anatomical injury on initial evaluation, will have a severe injury discovered after full trauma evaluation with serial observations (Figure 1).

Figure 1 Triage in trauma care system.

Current systems (“exclusive systems”) often rely on overtriage to trauma centers, and often an exaggerated and unnecessary response from trauma professionals. Such systems may cause overtreatment of certain patients, unnecessary expenses, burnout of participants, and underutilization of certain health care resources, including personnel. In spite of these excesses, such systems may still run the risk of not treating all injured patients, including not appropriately treating all major trauma patients. Undertriage runs the obvious risk of excluding some major trauma patients from receiving appropriate care. An inclusive system uses a tiered response to provide appropriate delivery, evaluation, and care for all patients, including the major trauma patient, in a cost-effective manner. One example of an inclusive trauma system is patient triage designed to care for major trauma patients by matching patient severity to facility in a timely manner. Considerations in triage include injury severity, injury severity risk, time and distance from site of injury to definitive care, inter-hospital transfers considering guidelines for immediate versus postintervention transports, and factors that activate the regional system (Figure 2).

Figure 2 Components of an inclusive trauma care system. The components in this model are based on the components described in several trauma care resources.

(Adapted from Trauma Care Systems, a position paper from the Third National Injury Control Conference, “Setting the National Agenda for Injury Control in the 1990’s,” p. 388.)

TRAUMA SYSTEMS SUMMARY

A systems approach to the provision of trauma care, including appropriate guidelines for the triage of patients, is essential. The triage protocols should be reasonable and inclusive, considering such factors as time and distance to designated trauma centers and appropriate utilization or resources at these centers. In order for a systems approach to work, appropriate protocols that are well thought out and supported by all members of the trauma system should be in place and followed unless clinical judgment dictates a valid reason otherwise.

By combining triage algorithms with an appropriate quality improvement monitoring system, optimal and cost-effective care can be provided. Continuous quality improvement and research are essential to evaluate an algorithm’s applicability in a given trauma care system. The result should be protocols with the sensitivity to identify major injury, yet specific enough to not overburden the system, allowing for optimal and cost-effective care using existing resources. Identification of the major trauma patient is fundamental to trauma system design because it describes the patient who will benefit the most from regionalized care, and indirectly determines the level and intensity of resources needed to provide definitive care.

Triage criteria should provide a basis for the establishment of protocols for patient identification, delivery decisions, and appropriate response at acute care facilities for all trauma patients in an inclusive care system. They should recognize the requirements of individual trauma systems, as well as the importance of clinical judgment. Patients can then be delivered, depending on degree of injury in addition to time and distance from site of injury to definitive care.

SUPPORT FOR REGIONALIZED TRAUMA CARE

Although regionalization of trauma care has the inevitable consequence of increased prehospital transport times, particularly in rural areas removed from large trauma centers, some states have designed inclusive systems in which a large number of smaller centers have been designated as lower-level trauma centers. One of the primary functions of a statewide trauma system is to oversee the initiation of standardized protocols intended to ensure the timely triage and transfer of severely injured patients to facilities with appropriate therapeutic resources. Several studies document increased trauma center use and enhanced patient outcomes among metropolitan trauma centers after implementation of a regionalized trauma system.

In 1987, Shackford et al. examined the impact of a trauma system on the survival of patients and attributed the improved survival to the integration of prehospital and hospital care and subsequent expeditious surgery. In 1999, Mullins and Mann reviewed published studies that used population-based data in evaluating the effectiveness of trauma systems in North America. They found that data for eight of nine trauma systems evaluated demonstrated improve outcomes (15%–20%), principally measured as hospital survival, after the establishment of a trauma system or some component of a trauma system. In the National Study on the Costs and Outcomes of Trauma (2006), MacKenzie et al. examined the effect of care in a trauma center on the risk of death and costs associated with treatment at hospitals with a Level 1 trauma center and at hospital without a trauma team. They concluded that, with the 25% lower overall risk of death noted when care was provided at a trauma center versus a non-trauma center, efforts for continued regionalization should be supported.

INITIAL APPROACH TO THE CRITICALLY INJURED PATIENT

Salvage of the critically injured patient is optimized by a coordinated team effort in an organized trauma system. Management of life-threatening trauma must be prioritized according to physiologic necessity for survival—that is, active efforts to support airway, breathing, and circulation (the ABCs) are usually initiated before specific diagnoses are made. A systematic approach to the severely injured patient within the “golden hour” is critical. The initial approach to the critically injured patient can be divided into prehospital care and emergency department (ED) management; the ED component is further divided into (1) primary survey with initial resuscitation, (2) evaluation and continued resuscitation, and (3) secondary survey with definitive diagnosis and triage.

Prehospital Care: Intervention at Injury Site

Resuscitation and evaluation of the trauma patient begins at the injury site. The goal is to get the right patient to the right hospital at the right time for definitive care. First responders (typically, firefighters and police) provide rapid basic trauma life support (BTLS) and are followed by paramedics and fight nurses with advanced trauma life support (ATLS) skills. Medical control is ensured by pre-established field protocols, radio communication with a physician at the base hospital, and subsequent trip audits. Management priorities of BTLS on the scene are (1) to access and control the scene for the safety of the patient and the prehospital care providers, (2) to tamponade external hemorrhage with direct pressure, (3) to protect the spine after blunt trauma, (4) to clear the airway of obstruction and provide supplemental inspired oxygen, (5) to extricate the patient, and (6) to stabilize long-bone fractures. Whereas the benefits of BTLS are undisputed, the merits of the more advanced interventions remain controversial.^1,² Airway access, once considered a major asset of the care provided by paramedics and flight nurses, has now been questioned, not only because missed tracheal intubation is a concern but also because unintentional hyperventilation (hypocarbia) is detrimental in the setting of traumatic brain injury (TBI) and during cardiopulmonary resuscitation (CPR).³^–⁵ Moreover, the value of intravenous fluid administration remains controversial.^6,⁷

Field Triage

Prehospital trauma scores have been devised to identify critically injured trauma victims, who represent about 10%–15% of all injured patients. When it is geographically and logistically feasible, critically injured patients should be taken directly to a designated Level I trauma center or to a Level II trauma center if a Level I trauma center is more than 30 minutes away. The currently available field trauma scores, however, are not entirely reliable for identifying critically injured patients ⁸: to capture a sizable majority of patients with life-threatening injuries, a 50% overtriage is probably necessary. Advance transmission of key patient information to the receiving trauma center facilitates the organization of the trauma team and ensures the availability of ancillary services⁹ (Figures 3 and 4).

Figure 3 Trauma field triage criteria and point-of-entry plan for adult patients.

(From Commonwealth of Massachusetts, Department of Public Health.)

Figure 4 Adult triage, transport, and transfer guidelines: Oklahoma model trauma triage algorithms for (A) prehospital, (B) Level I/II trauma center, and (C) Level III/IV trauma center. For prepubescent patients, refer to the pediatric trauma algorithm (Figure 5). 1. In addition to hypotension, other early signs of hypovolemia may include pallor, tachycardia, or diaphoresis. 2. Tachypenia (hyperventilation) alone will not necessarily initiate this level of response. 3. Altered sensorium secondary to sedative-hypnotic will not necessarily initiate this level of response. 4. High-energy event signifies a large release of uncontrolled energy. Patient is assumed injured until proven otherwise, and multisystem injuries might exist. Determinants to be considered by medical professionals are direction and velocity of impact, patient kinematics and physical size, and the residual signature of energy release (e.g., major vehicle damage). 5. Clinical judgment must be exercised and may upgrade to a high level of response and activation. Age and comorbid conditions should be considered in the decision. 6. Isolated blunt or penetrating trauma not associated with a high-energy event with a potential for multisystem injury.

(Based on American College of Emergency Physicians Guidelines. Approved by the Triage, Transport, and Transfer Committee of the Oklahoma State Trauma Advisory Council, October 27, 1995, and the Oklahoma Emergency Medical Services Advisory Council on January 24, 1997.)

Declaration of Death at Scene

The determination that care is futile during prehospital evaluation is best made on the basis of the cardiac rhythm. Asystole justifies declaration of death at the scene, and recent profound bradycardia (heart rate <40 beats/min) has been shown to signal an unsalvageable situation.

GUIDELINES FOR WITHHOLDING OR TERMINATION OF RESUSCITATION IN PREHOSPITAL CARDIOPULMONARY ARREST

Injury is the leading cause of death for Americans between age 1 and 44 years. The EMS system is the portal into the medical system for many of the most seriously injured trauma victims. Some of these patients will be unsalvageable due to the extent of their injuries. In order to preserve dignity and conserve precious human and financial resources, as well as to minimize risks to the health care workers involved, patients who can be predicted to be unsalvageable should not be transported emergently to the emergency department (ED) or trauma center. The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (COT) support out-of-hospital withholding or termination of resuscitation for adult traumatic cardiopulmonary arrest (TCPA) patients who meet specific criteria. The literature review of prehospital TCPA is extrapolated from emergency thoracotomy research. This research is retrospective in nature, therefore limiting the validity of the conclusions. The guidelines appear in Table 1.

Table 1 Guidelines for Withholding or Termination of Resuscitation in Prehospital Cardiopulmonary Arrest

Resuscitation efforts may be withheld in any blunt trauma patient who, based on out-of-hospital personnel’stient assessment, is found apneic, pulseless, and without organized ECG activity upon the arrival of EMS at the scene.

Victims of penetrating trauma found apneic and pulseless by EMS, based on their patient assessment, should be rapidly assessed for the presence of other signs of life, such as papillary reflexes, spontaneous movement, or organized ECG activity. If any of these signs are present, resuscitation should be performed and the patient transported to the nearest emergency department or trauma center. If these signs of life are absent, resuscitation efforts may be withheld.

Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with injuries obviously incompatible with life, such as decapitation or hemi-corpectomy.

Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with evidence of a significant time lapse since pulselessness, including dependent lividity, rigor mortis, and decomposition.

Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with clinical condition, suggesting a nontraumatic cause of the arrest, should have standard resuscitation initiated.

Termination of resuscitation efforts should be considered in trauma patients with EMS-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation (CPR).

Traumatic cardiopulmonary arrest patients with transport time to an emergency department or trauma center of more than 15 minutes after the arrest is identified may be considered nonsalvageable, and termination of resuscitation should be considered.

Guidelines and protocols for TCPA patients who should be transported must be individualized for each EMS system. Consideration should be given to factors such as the average transport time within the system, the scope of practice of the various EMS providers within the system, and the definitive care capabilities (trauma centers) within the system. Airway management and intravenous line placement should be accomplished during transport when possible.

Special consideration must be given to victims of drowning and lightning strike and in situations where significant hypothermia may alter prognosis.

EMS providers should be thoroughly familiar with the guidelines and protocols affecting the decision to withhold or terminate resuscitative efforts.

All termination protocols should be developed and implemented under the guidance of the system EMS medical director. On-line medical control may be necessary to determine the appropriateness of terminating resuscitation.

Policies and protocols for terminating resuscitation efforts must include notification of the appropriate law enforcement agencies and notification of the medical examiner or coroner for final disposition of the body.

Families of the deceased should have access to resources, including clergy, social workers, and other counseling personnel, as needed. EMS providers should have access to resources for debriefing and counseling as needed.

Adherence to policies and protocols governing termination of resuscitation should be monitored through a quality review system.

Initial Electrocardiographic Rhythm

There is some evidence that the initial ECG rhythm obtained at the scene by EMS may be predictive of survival. All of the studies combined by Batistella et al.,¹⁰ Fulton et al., Esposito et al.,⁹ and Aprahamian suggest that the presence of an ECG rhythm such as asystole, idioventricular rhythm, or severe bradycardia is indicative of an unsalvageable patient. Patients with a sinus-based pulseless electrical activity may represent a potentially salvageable subset of TCPA patients. Given that the TCPA is a critical event, the presence of any abnormal ECG pattern as an indicator of survival has limited significance. Blunt and penetrating injury as the cause of the TCPA was not distinguished in these studies, and given that blunt injury causing TCPA is associated with a very poor survival rate, it may be that survivors of TCPA may have penetrating trauma as their inciting event.

Resuscitation Duration

The data collectively suggest that a patient with TCPA and more than a 15-minute transport time while in arrest will not survive, regardless of the aggressiveness of the care delivered.

Emergency Department Thoracotomy

The prehospital implications of these studies are significant. At the scene of blunt injury, patients without vital signs (reported survival rates less than 2%) or in the case of penetrating trauma, patients without vital signs or other significant signs of life will not survive even with the most aggressive of therapies. Therefore, resuscitation and emergent transport of these TCPA victims are not warranted. Of patients who sustain TCPA, data suggest that penetrating trauma isolated to the thorax is the most salvageable subset of patients and any signs of life at the time of EMS arrival may reflect a potential survivor.

Rapid Transport versus Field Stabilization

The question of which patients with severe traumatic injuries should be transported without delay, and which patients might benefit from on-scene stabilization has spurred debate for many years. Despite conflicting reports and recommendations, some generalizations can be made based on the available evidence. Consistent with data from the ET literature, in the case of TCPA, expeditious transportation of a patient deemed to be potentially salvageable to a trauma center for definitive treatment is crucial. In addition to the need for expedient transport, TCPA patients appear to benefit from interventions such as intubation and IV line insertion. Time is critical, and TCPA lasting more than 10–15 minutes in the field is a lethal event. It appears that, at least in urban settings with short EMS transport times, ATLS interventions may be lifesaving if they can be performed in a timely fashion.

Air Medical Transport

Studies by Wright et al. and Margolin et al. have specifically addressed the transport of TCPA patients in their respective studies. Although retrospective and influenced by selection bias, the results from theses studies may indicate that for a select group of patients who are resuscitated successfully, prompt transfer to a trauma center may confer a survival benefit.

Exceptions

Situations in which trauma is complicated by significant hypothermia should not be included in these recommendations. Profound hypothermia below 32° C will cause progressive bradycardia, decreased cardiac output, loss of consciousness, and, ultimately, loss of brainstem reflexes—effectively mimicking death, but with the potential for successful resuscitation with appropriate medical treatment and rewarming. Examples of hypothermia complicating trauma may include cold-water submersion (particularly in children), avalanche burial, and minor trauma with subsequent environmental exposures. In these situations, patients should be aggressively resuscitated and transported to a center capable of aggressively rewarming the victims.

PREHOSPITAL CARE CONTROVERSIES

Advanced Trauma Life Support

The growing sophistication of emergency medical services has expanded the scope of prehospital care, but the extent of prehospital interventions remains a highly controversial issue. In trauma, advocates of the so-called scoop-and-run philosophy argue that resuscitative efforts in the field unnecessarily delay provision of definitive care and have detrimental effects on physiology and survival when overzealously applied. At present, there is little evidence to support the use of ATLS in prehospital management of urban trauma patients. ATLS skills may be of value in rural areas where transport time exceeds 30 minutes, but unfortunately, the limited volume of serious trauma in such areas makes it difficult to gain the experience necessary to maintain this expertise.

Airway Management

The current recommendation—orotracheal intubation with in-line manual stabilization of the head and neck—has proved safe in clinical series to date. When orotracheal intubation fails, the laryngeal mask airway (LMA) is a rapid, safe, and effective technique for maintaining temporary airway control until definitive medical care becomes available. For patients with extensive maxillofacial trauma that precludes oral intubation, cricothyroidotomy has been the traditional alternative, but this procedure has some risks, particularly in children.

Prehospital Intubation of Patients with Traumatic Brain Injury

Because hypoxia has been associated with increased mortality in patients with TBI, aggressive prehospital airway protocols that include rapid sequence intubation have been instituted. This practice may, however, be associated with worse outcomes.³

Prehospital Volume Resuscitation

Hypotensive patients with penetrating torso injuries, survival improved when fluid resuscitation was delayed until surgical intervention had controlled the source of hemorrhage. Although this clinical trial had some methodologic flaws, it is important because it emphasizes that source control of hemorrhage is an overriding priority in hemodynamically unstable patients. At present, the rational compromise between these two approaches is hypotensive resuscitation with moderate volume loading. Whereas this approach is becoming the standard of care for penetrating trauma, its application to blunt trauma is not as clear. Some 20% of patients with major torso trauma have a serious concomitant TBI; if they are inadequately resuscitated, reduced cerebral perfusion pressure may lead to devastating secondary brain injury.

Resuscitation with Hypertonic Saline

Small-volume hypertonic saline (HS) has been shown to be as effective as large volume crystalloid in expanding plasma volume and enhancing cardiac output. HS increases perfusion of the microcirculation by inducing selective arteriolar vasodilation and by reducing the swelling of red blood cells and endothelium, at the expense of possibly increasing bleeding. HS combined with HS dextran (HSD) may have improved resuscitative effects. Trials comparing HS to HSD have shown inconsistent results with respect to improved survival, yet confirming that a bolus of either fluid was safe. Subgroup analysis of these studies showed that patients who presented with shock and concomitant severe TBI benefited the most from HSD. In comparison to isotonic saline, both HS and HSD raised cerebral perfusion pressure, lowered intracranial pressure, and reduced brain edema.

PEDIATRIC TRAUMA SYSTEM

Injury is the leading cause of death in children older than 1 year. In 2001, more than 5500 children younger than 15 years died as a result of injuries. Another 1000 died because of violent deaths, the result of homicide or suicide. With respect to nonfatal injuries, in 2002, more than 100,000 children were hospitalized, and more than 6 million children were evaluated in emergency departments after sustaining an injury. Falls are the most common mechanism of injury and motor vehicle crashes are the most deadly, accounting for 30%–60% of traumatic pediatric deaths. Trauma systems, pediatric trauma centers (PTCs), and caregivers who are specifically trained to treat children are all components of a system of care designed to provide better outcomes for patients. Regional PTCs were established to optimize the care of injured children. However, because of the relative shortage of PTCs, many injured children continue to be treated in adult trauma centers (ATCs). It is well known that the geographic distribution of trauma centers results in a significant number of children being treated in adult centers with various ACS designations.¹⁵ As a result, growing controversy has evolved regarding the impact of PTCs and ATCs on outcome for injured children. Many medical facilities are not adequately staffed or equipped with the necessary resources to optimally care for severely injured pediatric trauma victims.

An EMSC sponsored APSA study published in 2005 demonstrated that injured children have better outcomes when trauma care is received at a designated children’s hospital. Densmore et al.¹⁷ used the 2000 Kid’s Inpatient Database (part of the Health Care Cost and Utilization Project sponsored by the Agency for Health Care Research and Quality) to describe pediatric trauma patient allocation to hospitals and associated injury outcomes. Approximately 80,000 pediatric trauma cases from 27 states were analyzed. The authors concluded that younger and more severely injured children have improved outcomes in children’s hospitals.

Potoka et al.¹² analyzed 13,351 injured children from the Pennsylvania Trauma Outcome Study between 1993 and 1997. With mortality as the major outcome variable, cases were evaluated and compared based on type of trauma center: PTC, Level I ATC (ATC I), Level II ATC, or an ATC with added qualification to treat children (ATC AQ). They reported that most injured children were treated at a PTC or an ATC AQ and that most children younger than 10 years were admitted to a PTC. Overall survival was significantly better at a PTC and an ATC AQ compared with an ATC I and a Level II ATC. Survival for head, spleen, and liver injuries was significantly better at a PTC compared with all other destinations combined. Children who sustained moderate or severe head injuries were most likely to undergo neurosurgical intervention and have a better outcome when treated at a PTC. Despite similar mean AISs for spleen and liver trauma, significantly more children underwent surgical exploration (especially splenectomy) for spleen and liver injuries at an ATC compared with a PTC. Nonoperative management of splenic and hepatic injuries decreases the potential morbidities of surgical therapy and postsplenectomy sepsis. They concluded that pediatric commitment in a Level I trauma center results in nonoperative treatment of injured children commensurate with that established in regional PTCs. The authors concluded that children treated at a PTC or ATC-AQ have significantly better outcomes compared to those treated at an ATC. In addition, ACS-verified centers had significantly higher survival rates compared with unverified centers. Severely injured children (ISS >15) with head, spleen, or liver injuries had the best overall outcome when treated at a PTC. This difference in outcome may be attributable to the approach to operative and nonoperative management of head, liver, and spleen injuries at PTCs.

Three studies, two retrospective and one prospective, provided evidence (class 3) of the influence of trauma systems and pediatric trauma centers on mortality rates for children who sustain moderate to severe TBI as well as evaluating the influence of a PTC on the number of neurosurgical procedures. Conclusions from the studies follow:

Pediatric patients with severe TBI are more likely to survive if treated in PTCs or ATC AQs, rather than in Level I or Level II ATCs.

The pediatric patient with severe TBI who requires neurosurgical procedures has a lower chance of survival in Level II ATCs versus the other centers.

In 2001, Osler et al.¹⁹ reviewed 53,113 pediatric trauma cases from 22 PTCs and 31 ATCs included in the National Pediatric Trauma Registry to evaluate survival rates. They reported the overall mortality rate to be lower at PTCs (1.81% of 32,554 children) than at ATCs (3.88% of 18,368 children). The authors concluded that although PTCs have higher overall survival rates compared with ATCs, the difference disappears when the analysis controls for ISS, Pediatric Trauma Score, age, mechanism, and ACS verification status.

In 1994, Bensard et al.¹⁸ sought to critically evaluate the outcome of injured children treated in an ATC I by adult trauma surgeons. The probability of survival was calculated using TRISS methodology. They found that the observed survival (98.0%) in children compared favorably with the TRISS-predicted survival (97.7%), and showed no difference in relative risk for acutely injured children (+0.47) compared with young adults (+0.45) or national norms such as the Major Trauma Outcomes Study (MTOS) reference set. They concluded that the triage of injured children to an ATC I does not adversely affect outcome. However, there are limitations when applying the TRISS methodology to children which include very few pediatric patients in the original data set, elements of the physiological data which use adult norms and not pediatric norms, and finally, the MTOS-derived data from 1982 to 1989 may be questionable, as injury rates declined from 1990 to 2005. These data support the continued triage of acutely injured children to regional trauma centers regardless of pediatric or adult designation.

Conclusions

Over the past decade, there has been much debate regarding to pediatric trauma outcomes and their association with different types of trauma centers. There appears to be sufficient data, however, to support continued development of formalized pediatric systems despite the lack of definitive evidence on the effectiveness of PTCs and pediatric trauma systems. Several recent studies have concluded that injured children treated at PTCs have better outcomes and are more likely to survive compared with those treated at ATCs. Other studies concluded that children treated at a PTC or an ATC AQ have significantly better outcomes compared with those treated at ATCs. Studies on the management of blunt pediatric trauma suggest that trauma centers have lower rates of pediatric splenectomy after blunt trauma compared with nontrauma centers. Designated PTCs should spearhead the development of an effective field triage system that would guarantee that the most severely injured children undergo treatment at a trauma center with commitment to the care of the injured child.

With the regionalization of designated pediatric subspecialty and trauma care centers and the triaging of injured children to appropriate designations, pediatric trauma systems in the United States are becoming valuable tools in the optimum care of injured children. However, with the specialization of pediatric trauma care systems still in its infancy, the triage of all injured children to regional PTCs may be impractical and may unnecessarily exclude Level I ATCs from the care of acutely injured children. Ongoing studies on pediatric trauma, including measures of morbidity and functional outcomes, are needed to further define the optimal models and systems for trauma care. PTCs are the only institutions with the pediatric trauma volumes necessary for the study of outcome measures, and with the capabilities to take the initiative in the study injury prevention (Figure 5 and Table 2).

Figure 5 Pediatric trauma algorithm. This protocol refers to all pediatric major trauma victims. One of the greatest causes of death and permanent morbidity in children is hypoxia secondary to central nervous system or airway injury. Any child with neurologic compromise (Glasgow Coma Scale [GCS]≤10 or spinal deficit) should have a secure airway, adequate ventilation, and spinal immobilization, and then immediate transport to an accredited pediatric trauma center. As a goal, time on scene must not exceed 10 minutes for patients meeting physiologic (vital signs, GCS) or anatomy-of-injury trauma-triage criteria. Life-threatening injuries occur less frequently in patients who meet mechanism-of-injury criteria only. Therefore, if it is necessary to complete patient immobilization and packaging, prehospital providers may extend on-scene time to 20 minutes. Circumstances such as prolonged extrication, which result in on-scene time intervals exceeding those stated above, must be documented. 1. Confirm and document endotracheal tube placement with ETCO₂ detector. Listen for and document equal bilateral breath sounds in the chest and an absence of sounds over the epigastrium. 2. Clinical signs of hypoperfusion: (i) tachycardia, thready pulse; (ii) diaphoresis, peripherally cold and clammy; (iii) decreased capillary nail bed filling; (iv) lightheadedness, vertigo; (v) altered mental state; (vi) pallor, mottled, cyanotic; (vii) weakness, fatigue. 3. Organized ECG activity without vital signs (pulseless electrical activity [PEA]) indicates the need for immediate transport to a receiving facility that is determined appropriate by medical command authority. Ventricular fibrillation should be treated in accordance with the pediatric ventricular fibrillation protocol while en route. 4. For hypotensive trauma patients, an intravenous line of normal saline or lactated Ringer’s, as per trauma center protocols, may be started while en route to an accredited trauma center. If unable to obtain IV access, place an intraosseous (IO) line. Once established, the IO line replaces the IV line as the primary route of administration for fluid and medications. 5. Notify medical command.

(From Delaware County EMS Medical Intervention Procedures: Pediatric Protocols 2002.)

Table 2 Average Pediatric Vital Signs

PRACTICE MANAGEMENT GUIDELINES FOR GERIATRIC TRAUMA

Advanced age is a well-recognized risk factor for adverse outcomes following trauma. A substantial body of literature demonstrates increased morbidity and mortality in geriatric trauma patients compared to their younger counterparts. Whether this outcome difference is due to the deceased physiologic reserve that accompanies aging, a higher incidence of pre-existing medical conditions in the geriatric patient, or to other factors yet to be identified, remains unclear. It is clear, however, that good outcomes can be achieved in this patient with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible following injury, patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable, but are compatible with an acceptable quality of life.

Triage Issues in Geriatric Trauma

Statement of the Problem

The process of triage, as it relates to the geriatric trauma patient, is an attempt to provide the patient with the appropriate intensity of medical resources, taking into account the severity of illness, the cost and availability of medical resources, the prognosis for functional survival and, if known, the expressed desires of the patient. For the geriatric trauma patient this process begins in the prehospital phase of care where decisions must be made regarding the appropriate patient destination, trauma center versus non-trauma center. Throughout the hospital phase of care, the patients must be “triaged” toward or away from operative procedures, invasive and expensive critical care therapies, and powerful, yet potentially dangerous pharmacologic treatment options, decisions which, again, must be based upon the likelihood of achieving a good, long-term outcome for the patient.

Issues to define include the following:

1. Appropriate criteria for triage of geriatric trauma patients to trauma centers

2. Clinical variables that would be useful in predicting the need for intensive care resources for geriatric trauma patients

3. Clinical circumstances in which a nonaggressive approach from the outset could be justified (Table 3)

Table 3 Triage Recommendations for the Geriatric Patient

Level I	There are insufficient class I and class II data to support any standards regarding triage of geriatric trauma patients.
Level II	Advanced patient age should lower the threshold for field triage directly to a trauma center.
Level III	Advanced patient age is not predictive of poor outcomes following trauma, and therefore should not be used as the sole criterion for denying or limiting care in this patient population.
	The presence of pre-existing medical conditions in elderly trauma patients adversely affects outcome.
	In patients 65 years of age and older, a Glasgow Coma Scale (GCS) 8 is associated with a dismal prognosis. If substantial improvement in GCS is not realized within 72 hours of injury, consideration should be given to limiting further aggressive therapeutic interventions.
	Postinjury complications in the elderly trauma patient negatively impact survival and contribute to longer lengths of stay in survivors and nonsurvivors compared to younger trauma patients.
	With the exception of patients who are moribund on arrival, an initial aggressive approach should be pursued with the elderly trauma patient, as the majority will return home, and up to 85% will return to independent function.
	In patients 55 years of age and older, an admission base deficit 6 is associated with a 66% mortality. Patients in this category may benefit from inpatient triage to a high-acuity nursing unit.
	In patients 65 years of age and older, a Trauma Score 7 is associated with a 100% mortality. Consideration should be given to limiting aggressive therapeutic interventions.
	In patients 65 years of age and older, an admission respiratory rate 10 is associated with a 100% mortality. Consideration should be given to limiting aggressive therapeutic interventions.
	Compared to younger trauma patients, patients 55 years of age and older are at considerably increased risk for undertriage to trauma centers even when these older patients satisfy appropriate triage criteria. The factors responsible for this phenomenon must be identified and strategies developed to counteract it.

Scientific Foundation

For the geriatric trauma patient, the process begins in the prehospital arena, where prehospital providers must decide on the basis of relatively scant clinical information whether a patient should bypass the local hospital in favor of a trauma center. The American College of Surgeons Committee on Trauma (ACS-COT), among other medical organizations, in its manual “Optimal Resources for the Care of the Trauma Patient,” has published a set of triage criteria to aid prehospital providers in identifying appropriate patients for direct transport to trauma centers.¹ Within this document, it is suggested that patients aged over 55 should be “considered” for direct transport to a trauma center, apparently without regard to the severity of injury. This recommendation is based on a substantial medical literature that demonstrates significantly worse outcomes for geriatric trauma patients compared to their nongeriatric counterparts.

The MTOS, sponsored by the ACS-COT. Data from 3833 patients 65 years and older were compared with data from of 42,944 patients aged under 65. Mortality rose sharply between age 45 and 55 and doubled at 75. This age-dependent survival decrement occurred at all ISS values, for all mechanisms of injury, and for all body regions. Numerous other studies have supported the findings that the effect of trauma on the elderly is more serious than on younger patients.

Predictors of Mortality in Geriatric Population

Complications and Outcome

It is generally acknowledged that when the geriatric trauma patient sustains complications during the initial hospitalization that overall outcome is adversely affected. Comparing elderly survivors with nonsurvivors, a statistically higher incidence of cardiac and septic complications and respiratory complications occurs in nonsurvivors. Other authors, employing logistic regression statistical methodology, have identified cardiac, infectious, and pulmonary complications as independent predictors of poor outcome following geriatric trauma. The number of complications sustained by a given geriatric trauma patient has been identified as a risk factor for poor outcomes. Smith, in a study of 456 trauma patients aged 65 and over, reported 5.4% mortality for patients with no complications, 8.6% for those with one complication, and 30% for those with more than one complication. Similar results have been noted for geriatric patients sustaining TBIs.

Outcome from Geriatric Head Injury

The topic of geriatric head injury has received more attention in the literature than has any other aspect of geriatric trauma. Unfortunately, all of it is retrospective in nature and, therefore, suffers from many of the same methodological shortcomings. “Low” admission GCS is clearly associated with poor outcomes in elderly head-injured patients. The available scientific literature, however, does not support the use of a specific GCS that will reliably identify patients destined for poor outcomes. Thus, it seems that, while “low” GCS scores are indeed associated with poor outcomes, it does not seem possible, or advisable, based on the existing literature, to make triage decisions in head-injured geriatric patients based solely upon the admission GCS. It does seem reasonable to conclude that head-injured patients aged 65 years and older have very poor outcomes when the admission GCS is less than 7 or 8.

Parameters for Resuscitation of the Geriatric Trauma Patient

In the United States, the elderly, defined as individuals aged 65 years and older, are the fastest-growing segment of the population. Trauma is the seventh leading cause of death in the elderly with a death rate significantly higher compared to younger cohorts. Several studies have indicated that shock, respiratory failure, decreasing trauma score (TS), increasing injury severity score (ISS), increasing base deficit, and infectious complications portend a poor outcome. The multiply injured geriatric patient may appear stable, yet may have a significant perfusion deficit due to low cardiac output. The early use of invasive monitoring may improve survival. Although mortality may be increased compared to younger patients, an aggressive treatment program will allow many geriatric patients to regain function at or near their preinjury independence.

The evidence-based recommendations in Table 4 will provide the trauma practitioner a guide to decision making in the resuscitation phase of care of the geriatric patient.

Table 4 Evidence-Based Recommendations for Decision Making in Resuscitation Phase of Care of the Geriatric Patient

Level I recommendations:	There are insufficient data to support a Level I recommendation for endpoints of resuscitation in the elderly patient as a standard of care.
Level II recommendations:	Any geriatric patient with physiologic compromise, significant injury (Abbreviated Injury Scale [AIS] >3), high-risk mechanism of injury, uncertain cardiovascular status, or chronic cardiovascular or renal disease, should undergo invasive hemodynamic monitoring using a pulmonary artery catheter.
Level II recommendations:	There are insufficient data to support a Level I recommendation for endpoints of resuscitation in the elderly patient as a standard of care.
Level III recommendations:	Attempts should be made to optimize to a cardiac index 4 l/min/m² and/or an oxygen consumption index of 170 cc/min/m².
Level III recommendations:	Base deficit measurements may provide useful information in determining status of resuscitation and risk of mortality.