The Big Baby Blue Southeast Region 1 st Regional Trauma

The Big Baby BlueSoutheast Region

1st Regional Trauma

Care Conference

January 9, 2009Temecula, CA

WELCOME

TO

Anatomical

PhysiologicalTBI

SCI

Skeletal

Internal

GCSSBPRR

Mechanism

TRAUMA

TREE-ÁGE

CRITERIA

PRESENTED BY:

CINDI STOLL, RN

TRAUMA & AIR MEDICAL SYSTEM MANAGER

Riverside County EMS

CAN WE SEE THE FOREST THROUGH THE TREE-ÁGES

Trauma TriageThe Tale of Humpty Dumpty

Origins• 1793 In battlefield care & transport• 1871 Through the Looking Glass is published• 1896 First recorded Auto v Ped fatality. A 44 y/o

mother stepped off the curb and went into history as the first person to be killed by an auto in Britain. The British Coroner warned,

“This must never happen again!”• 1913 ACS is founded• 1966-1st trauma unit in Cook County Chicago &

the White Paper• 2009-Trauma Systems moving forward

Humpty Dumpty growled out. `… Why, if ever I did fall off -- which there's no chance of -- but if I did --' Here he pursed up his lips, and looked so solemn and grand that Alice could hardly help laughing. `If I did fall,' he went on, `the King has promised me -- ah, you may turn pale, if you like! You didn't think I was going to say that, did you? The King has promised me -- with his very own

mouth -- to -- to --'

`To send all his horses and all his men,' Alice interrupted, rather unwisely.

•American College of Surgeons-Committee on Trauma,

•The Great State of California

•each local EMS agency

has promised…

The Promise

TIMEaka

The Golden Hour

• Development of triage criteria

• Development of regulations

• Development of EMS, trauma systems, trauma centers

• Today we are here to review the criteria

ACS & PHTLS

Criteria The Gold Standar

d

Measure vital signs and level of consciousness

Glasgow Coma Scale <14Systolic Blood pressure <90Respiratory rate <10 or >29 (<20 in infant < one year)

YES NO

Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injuredpatients. These patients would be transported preferentially to the highest level ofcare within the trauma system.

Assess anatomy of injury

All penetrating injuries to head, neck, torso, and extremities proximal to elbow and kneeFlail chestTwo or more proximal long bone fracturesCrush, degloved or mangledAmputation proximal to wrist and anklePelvic fracturesOpen or depressed skull fracturesParalysis

YES NO

Assess mechanism of injuryand evidence of high-

energy impact.

FallsAdults: > 20 ft (one story is equal to 10 feet)Children: > 10 ft or 2-3 times the height of the child

High-risk auto crashIntrusion: >12 in occupant site;>18 in any siteEjection (partial or complete) from automobileDeath in same passenger compartmentVehicle telemetry data consistent with high-risk injury

Auto vs.. pedestrian /bicyclist thrown, run over or with significant (>20 mph) impactMotorcycle crash>20 mph

YES NO

Transport to closest appropriate trauma center which,depending on the trauma system, need not be thehighest level trauma center

Assess special patient orsystem considerations

Ageolder adults: Risk fo injury increases after age 55Children: Should be triaged preferentially to pediatric-cabable trauma centers

Anticoagulants and bleeding disordersBurns

Without other trauma mechanism: Triage to burn centerWith trauma mechanism: Triage to burn center

Time-sensitive extremity injuryEnd-stage renal disease requiring dialysisPregnancy > 20 weeksEMS provider judgment

YES NO

Contact medical control and consider transport totrauma center or a special resource hospital

Transport according toprotocol

WHEN IN DOUBT, TRANSPORT TO TRAUMA CENTER

Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously injuredpatients. These patients would be transported preferentially to the highest level ofcare within the trauma system.

Step One

Step Two

Step Three

Step Four

ICEMA Criteri

a

A patient shall be transported to the most appropriate trauma hospital when anyone of the following physiologicand/or anatomical criteria is present following a traumatic event (trauma base hospital contact shall be made)

Neurologic Glasgow Coma Scale <13, ped < 13LOC > 3 minutes, peds any LOC

Respiratory requiring assistance with ventilationHypoxia= O2 saturation that is consistently <90% AND Respiratory rate <10 or >29 <10: RR <12 or >40

< 1 year: RR <20 or >60Hypotension Exhibits inadequate tissue perfusion

Systolic Blood pressure <90 and abnormal vital signs according to ageTachycardia

Penetrating Injuries to: head, neck, torso, groin, and extremities proximal to elbow and kneeBlunt Chest trauma resulting in: Flail chest, unstable chest wall, ecchymosisSevere tenderness to: Head, neck, torso, abdomen, pelvisParalysis Traumatic, loss of sensation, suspected spinal cord injuryAbdomen Tenderness with firm and rigid abdomen on examinationAmputation proximal to wrist and ankleFractures Two or more proximal long bone fractures, PEDS: open fx, 2 or more long boneSkull deformityMajor tissue disruptionSuspected Pelvic fractures

If a patient has one or more of thefollowing mecahinism of injury with

any of the above physiologic oranatomic criteria transport to the most

appropriarte trauma hospital

High-Speed auto crash Initial speed > 40 mph (ACS:Vehicle telemetry data consistent w/ high risk of injury)major auto deformity > 18 inchesIntrusion into passenger space > 12 inUnrestrained passengerFront axle reward displacedBent steering wheelStarred windshield

Vehicle Rollover Complete roll overRollover multiple timesunrestrainedrestrained with significant injuries or high rate of speed

Motorcycle crash >20 mphSeparation of rider from the bike with significant injury

Pedestrian Auto-ped with significant impact >10 mphAuto-bicyclist with significant impact > 10 mphPedestrian thrown > 15 ft run over

Significant blunt trauma Head, neck, torsoExtrication >20 min with associated injuriesDeath of occupant In same passenger spaceEjection partial or complete ejection of patient from vehicleFalls Adults: > 15' Children: > 10 ft or 3 times the height of the child

Pediatric < 9 Adult > 65 Have known underlying respiratory, cardiac, liver disease or diabetes (ACS-anticoagulation/bleeding disorders, dialysis) Have know underlying hematologic or immunosuppressive conditions Isolated extremity injury with neurovascular compromise (time sensitive injury) pregnant (greater than 20 weeks in gestation) inability to communicate, e.g., language, psychological and or substance impairment

Unmanageable airway, severe blunt force trauma arrest, penetrating trauma arrest: transport to closesttrauma center if indicated- refer to Determination of death on scene protocol

Burn patients that meet CTP transport to nearest trauma hospital, Burn patients not meeting CTP transport toreceiving or Burn center

Remote location may be exempt from specific criteria upon written permission from the EMS Medical Director

CTP: adults will be transported to the most appropriate trauma hospital.Pediatrics patients will be transported to to pediatric trauma hospitalwhen there is less than a 20 min difference in transport time to the pedcenter.

3. Mechanism of Injury

4. Age and Co-Morbid

factors

ICEMA

1. Physiologic

2. Anatomic

REMSA Criteri

a

TRAUMA CENTER TRIAGE CRITERIA

Respiratory/Airway compromise Hypotension: Adults < 90 Peds-according to age or exhibits poor perfusion Loss of Conscioiusness Adults > 3 min Peds any LOC Glasgow Coma Scale <13 Revised Trauma Score <11

Adult patients identified as CTP will be transported to the closest most appropriatetrauma center. Pediatric patients identified as CTP will be transported to a Pediatrictrauma center when it is less than a 10 minute difference between a General traumacenter and the pediatric trauma center.

Severe tenderness to the head, neck, torso, abdomen or pelvis Penetrating injury of the head, neck torso, abdomen, pelvis or groin Firm or rigid abdomen Suspected pelvic fracture Open or depressed skull fracture Traumatic paralysis A femur fracture or two (any other) long bone fractures Amputations above the wrist or ankle Isolated extremity injury with suspected neurovascular compromise

Ejection from automobile Death in same passenger compartment Falls > 10 ft Extrication time > 20 min Rollover High-speed crash Initial speed >40 mph Major auto deformity > 20 in Intrusion into passenger compartment > 12 in Auto-pedestrian/auto bicycle with significant (>5 mph) impact Pedestrian thrown or run over Motorcycle crash > 20 mph or with separation of rider from bike

Even if the patient does not meet any of the abovecriteria, make Base Hospital contact on thosepatients who:

Are pediatric < 5 years of age adults > 65 years of age have know underlying respiratory, cardiac, or liver disease have know underlying hematologic or immunosuppressive conditions are pregnant

PHYSIOLOGIC

ANATOMIC

Mechanismof Injury

Special considerations

Imperial

County Criteria

CRITIAL TRAUMA PATIENT CRITERIAIF ANY OF THE FOLLOWING APPLY, TAKE TO THE HIGHEST LEVEL TRAUMA CENTER AVAILABLE,

AS PER TRAUMA PATIENT DESTINATION

Glasgow Coma Scale Adults <11, children <10Systolic Blood pressure <90, 80 age 7-14, 70 age<7Respiratory rate <10 or > 29

NON CRITICAL TRAUMA PATIENTPARAMEDICS JUDGMENT SHOULD ALWAYS BE CONSIDERED IN IDENTIFYING THE TRAUMATICALLYINJURED PATIENT. UTILIZE BASE MEDICAL DIRECTION WHEREVER NECESSARY. IF ANY OF THEFOLLOWING MECHANISMS OR CO-MORBID FACTORS EXIST CONSIDER TRANSPORT TO THE NEARESTAVAILABLE TRAUMA CENTER OR HOSPITAL IF NO TRAUMA CENTER WITHIN 30 MINUTES.

Fall > 20 feet Pedestrian hit at 20 mph or thrown 15 ft Death of same car occupant Unrestrained roll over Heavy extrication MC, ATV, Bicycle crash Passenger compartment intrusion Patient ejected from enclosed vehicle

Age <5 or > 60 Medical Illness: Cardiac or Respiratory disease, Morbid obesity, diabetic, cirrhosis,

immunosupressed, anticoagulants Hostile environment (heat or cold) Pregnancy Presence of intoxicants

Penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Amputation proximal to wrist or ankle Spinal injury with limb paralysis Flail chest Two or more obvious proximal fractures of femur or humerous

ANATOMIC

PHYSIOLOGIC

MECHANISMOF

INJURY

CO-MORBIDFACTORS

San Diego

County Criteria

Assess vital signs and LOC

Glasgow Coma Scale <14Systolic Blood pressure <90, peds < 60Respiratory rate <10 or >29 (<20 in infant < one year)

Peds: Abnormal appearance &/or abnormal work of breathing &/or abnormal circulation

YES NO

Call trauma base, transport to appropriate trauma center Assess anatomy of injury

Flail chest Combination trauma with burns Two or more proximal long bone fractures Child abuse-known or suspected with significant injury All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Amputation proximal to wrist and ankle Suspected Pelvic fractures Limb Paralysis Crush, degloved or mangled Neuro/vascular deficit of extremities

YES NO

EVALUATE FOR EVIDENCE OFMECHANISM OF INJURY &/OR

HIGH ENERGY IMPACT

Ejection from/off vehicle Vehicle rollover with unrestrained patient Death in same passenger compartment Auto vs. bicyclist/pedistrian thrown, run over or with significant (>20 mph) impact Fall >3 times patient’s height or >15 feet Exposure to blast or explosion Motorcycle crash > 20 mph

YES NO

CALL TRAUMA BASE, TRANPORT TO APPROPRIATE TRAUMA CENTER EVALUATE FOR CO-MORBID &OTHER MECHANISM FACTORS

Age<5 Or >55Pregnancy > 20 weeksBleeding disordersAnticoagulants or antiplatelets (i.e. coumadin or plavix, except ASA)LOC reportedSevere cardiac and or respiratory diseaseEMS provider judgmentEnd-stage renal disease requiring dialysisExtrication time > 20 minutesIntrusion into occupied passenger space > 12 inch frontalIntrusion into occupied passenger space > 8 inches side

YES NO

CONTACT TRAUMA BASE STATION; CONSIDERTRASPORT TO APPROPRIATE TRAUMA CENTER TO

A SPECIFIC RESOURCE HOSPITAL, (I.E., BURNS)

RE-EVALUATE WITH MEDICALDIRECTION AND TRANSPORT TO

THE APPROPRIATE FACILITY

WHEN IN DOUBT, TAKE PATIENT TO APPROPRIATE TRAUMA CENTER

CALL TRAUMA BASE, TRANSPORT TO APPROPRIATE TRAUMA CENTER

County pop increase % State % sq miles stateSD 2,900,000 4.5 7.6 4200 156,000IC 160,000 12.6 4100RC 2,030,000 31 7200SB 2,100,000 17 20,000Mono 12,800 -1 3000Inyo 18,000 2 10,200

48700 156,000 31% sq mi

7,220,800 36,500,000 20% pop

11.016667 11% increase

INTERESTING FACTS

Of the Big Baby Blue

US Dept of Census web site, 2000-2006

THE FALLTHINGS TO CONSIDER

• Are we setting ourselves up?

• Differences by design?

• Each LEMSA’s population

• Each LEMSA’s recreation

• Each LEMSA’s resources

AFTER THE FALLOver and under triage

• Impact towards sending

• Increased Air utilization for long transports

• Impact towards receiving

• Pt records

• EMTLA

• Continuation of Care

THE WALLBarriers to Regionalization

• Same language, is it needed?• Increase or decrease in volume?• Data consistency?• Registries?• Crossing county lines…(omg!)• Providers out of service time?• Funding?• Repatriation?• QI?

Moral of the Story…

The End

Acknowledgements to

• Patrice Shepherd for graphic design

• Bruce Barton for discussion points

• My husband for his tolerance

while using our holiday time

to prepare.

Anatomical

PhysiologicalTBI

SCI

Skeletal

Internal

GCSSBPRR

Mechanism