Category Archives: General

EMS: Do We Actually Follow the CDC Triage Guidelines?

One of the major components of any trauma system is the prehospital piece. These providers extricate, begin medical treatment, and decide where to take the patient. The choice of hospital can make a big difference, and the number of deaths can potentially be reduced by up to 25% by making the right decision. Where to take the patient is not necessarily clear cut, even though CDC guidelines exist to help. Geographic and weather factors can be a factor, as well as patient choice at times (unfortunately), local medical control, or even time of day (traffic).

Harborview and the University of Washington conducted a large retrospective review of the transport patterns for nearly 12,000 injured patients over a 5 year period. They specifically looked at whether CDC guidelines for field triage were being followed. About half were transported to Harborview, the only Level I center in the state. The remainder were transported to the 7 remaining trauma centers, levels III to V. There were a number of interesting findings:

  • Patients transported directly to the Level I center were more likely to be young, male, injured by a penetrating mechanism, have worse vital signs and GCS and higher injury severity
  • Older patients were less likely to be transported from scene to a Level I center
  • The oldest patients were 89% less likely to be transported to the Level I center, either directly or after initial management at a lower level center

Bottom line: For reasons that are not clear, elderly patients were far less likely to be transported to a Level I trauma center by prehospital providers in Washington state. In fact, the guidelines were obeyed only about 50% of the time! Does this happen in other states or countries? We don’t know. Is this a problem? Unfortunately, we also don’t know how much lower the mortality in these patients is when treated at higher level centers. It seems to be, especially in the more severely injured patients. What we do know is that if the guidelines exist, adhere to them unless you have good reason not to. Their life may depend on it!

Related posts:

Reference: Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Amer Col Surg 215(1):148-156, 2012.

Print Friendly, PDF & Email

Pop Quiz! The Answer!

Time for the answer! There were lots of well thought out guesses, and a few correct answers. 

Here’s the story. This is a young male who presented in the trauma room with a small penetrating injury on the lateral aspect of his right arm, and another one just medial to the top of the scapula. If you look at first image last Wednesday, you can see an obvious humeral fracture, a not so obvious lack of lung markings, and a few tiny metallic foreign bodies (bullet fragments picked up by Canuck ER MD, injuries surmised by Kurt Rubach, paramedic). I provided a zoomed in view on Thursday to make them a little more obvious.

What I didn’t tell you (besides the fact that there were bullet holes) was that there were no pulses in the arm. The patient was hemodynamically stable, so after evaluation in the ED and insertion of a chest tube, he was taken to angio to evaluate the injury location. Unlike many penetrating injuries where the location is obvious, this was a deep mediastinal hit possibly involving Zone I of the neck (thanks Traumahst). Angio was selected because this was in the days before chest CT.

This shows a cutoff of the right subclavian artery. The patient was taken to the OR for sternotomy with a right neck extension and resection of the medial third of the clavicle (see Friday’s xray). The injury was successfully repaired with good return of function, and some residual hemothorax. He was discharged home in a week.

Bottom line: This one was tough because I didn’t give you much of what trauma professionals really need: clinical context. An isolated xray without a clinical history is not enough. It’s very easy to see things that really aren’t there and end up on a wild goose chase. Keep that in mind the next time you expect your radiology colleagues to come up with miracle diagnoses while sitting in a darkened room. Give them the whole story, or have them pop over to the ED to see for themselves.

Print Friendly, PDF & Email

Pop Quiz: Part 1

Okay, this one’s tough! This is by far the hardest one I have posted. I don’t think anyone has a clue! It’s so hard, I’m going to post another image as a hint tomorrow. Then on Friday, I’ll show the after photo so you can tell me what the final problem was. Answer Monday!

Have a look at the image below and tell me what you think. Seems simple, right? How did it happen? What other injuries might be present? Comment below or tweet or email your thoughts!

Print Friendly, PDF & Email