I had a great question sent in by a reader last week:
Some trauma centers receive a number of transfers from referring hospitals. Much of the time, a portion of the workup has already been done by that hospital. If the patient meets one or more of your trauma activation criteria, do you still need to activate your team when they arrive?
And the answer is: sometimes. But probably not that often.
Think about it. The reason you should be activating your team is that you suspect the patient may have an injury that demands rapid diagnosis and treatment. The purpose of any trauma activation is speed. Rapid evaluation. Fast lab results. Quick access to CT scan or OR. If a significant amount of time has already passed (transported to an outside hospital, worked up for an hour or two, then transported to you), then it is less likely that a trauma activation will benefit the patient.
There are four classes of trauma activation criteria. I’ll touch on each one and the need to activate in a delayed fashion if present, in priority order.
- Physiologic. If there is a significant disturbance in vital signs while in transit to you (hypotension, tachycardia, respiratory problems, coma), then you must activate. Something else is going on that needs to be corrected as soon as the patient arrives. And remember the two mandatory ACS criteria that fall into this category: respiratory compromise/need for an emergent airway, and patients receiving blood to maintain vital signs. But a patient who needed an airway who is already intubated and no longer compromised does not need to be a trauma activation.
- Anatomic. Most simple anatomic criteria (e.g. long bone or pelvic fractures) do not need a trauma activation unless the patient is beginning to show signs of physiologic compromise. However, anatomic criteria that require rapid treatment or access to the OR (proximal amputations, mangled or pulseless extremities, spinal cord injury) should be activated.
- Mechanism. Most of the vague mechanistic criteria (falls, pedestrian struck, vehicle intrusion) do not require trauma activation after transfer to you. But once again, if the mechanism suggests a need for further rapid diagnosis or treatment (penetrating injury to abdomen), then activate.
- Comorbidities. This includes underlying diseases, extremes of age, and pregnancy. In general, these will not require trauma activation after they arrive.
Bottom line: In many cases, the patient transferred in from another hospital will not need to be a trauma activation, especially if they have been reasonably assessed there. The patient should be rapidly eyeballed by your emergency physicians, and if there is any doubt about their condition, activate then.
However, if little workup was done at the outside hospital (my preference), and the injuries are “fresh” (less than a few hours old), then definitely call your team.
How do you get patients out of their clothes during a trauma resuscitation? Most of the time, I bet your answer is “with a pair of scissors.” And once they are off, what do you do with them? Admit it. You just throw them on the floor. And sometime later, someone’s job is to find it all, put it in a bag, and store it or hand it over to the police.
There are more problems than you might think with this approach. First, and most importantly to the patient, their stuff can get lost. Swept up with all the other detritus from a trauma activation. And second, their belongings may become evidence and it’s just been contaminated.
So here’s an easy solution. Create a specific place to put the clothes. Make it small, with a tiny footprint in your trauma room. Make it movable so it can be kept out of the way. And make sure it is shaped so it can contain a large paper bag to preserve evidence without contamination.
And here’s the answer:
Yes, it’s a plain old laundry basket. The perfect solution. And best of all, these are dirt cheap when you are used to seeing what hospitals charge for stuff. So your ED can buy several ($14.29 ea on Amazon.com) in case they can’t be cleaned anymore or just disappear.
Our elderly population is growing rapidly, and the average age of the patients on the trauma service is escalating. These patients offer a number of challenges throughout their presentation to the hospital and the rest of their stay. Some trauma centers are now organizing special teams or response types to deal with the unique needs of this population. A few have adopted a separate response type when injured elderly patients present to the ED.
The group at Reading Hospital implemented a separate trauma activation tier, “Tier 3”, driven by emergency physicians, to manage these patients. Tier 3 was designed to identify patients > 65 years of age with the potential for occult blunt injury to the head and torso. The normal activation criteria at this center would not have necessarily identified these patients. This study retrospectively looked at demographics and outcomes for two separate three year periods, one before and one after implementation of Tier 3.
Here are the factoids:
- Geriatric volume increased significantly from 1715 to 3688 patients (!!), and more received expedited workup as either a trauma activation or Tier 3
- There were statistically significant decreases in time to CT (102 vs 128 minutes) and ED length of stay (361 vs 432 minutes) (see my comments)
- Mortality decreased from 8% to 5% overall, and from 19% to 11% in patients with head AIS > 3, both of which were significant
- Regression analysis showed that implementation of the Tier 3 response was an independent predictor of improved survival
Bottom line: This poster shows results that suggest having a specific response for select elderly patients who don’t meet trauma activation criteria can be beneficial. However, the devil is in the details. Each center must develop criteria for the Tier 3 response that mesh with their own activation criteria. And the details of that response need to be clinically significantly better than the usual consult response.
Questions and comments for the authors/presenters:
- Be careful not to confuse statistical significance with clinical significance. Decreasing mean time to CT from 2:08 to 1:42 is not that big of a deal. The same applies to 7 hours in the ED vs 6.
- Please share the Tier 3 criteria and details of the ED response.
- Have you modified your Tier 3 criteria and/or response since inception, and if so, how and why?
Click here to go the the EAST 2017 page to see comments on other abstracts.
Reference: “Tier 3”: Long term experience with a novel addition to a two-tiered triage system to expedite care of geriatric trauma patients.. Poster #34, EAST 2017.
Yes, this is another one of my pet peeves. During a trauma activation, we all strive to adhere to the Advanced Trauma Life Support protocols. Primary survey, secondary survey, etc. Usually, the primary survey is done well.
But then we get to the secondary survey, and things get sloppy.
The secondary survey is supposed to be a quick yet thorough physical exam, both front and back. But all too often it’s quick, and not so thorough. There is the usual laying on of the hands, but barely. Abdominal palpation is usually done well. But little effort is put into checking stability of the pelvis. The extremities are gently patted down with the hope of finding fractures. Joints are slightly flexed, but not stressed at all.
Is it just a slow degradation of physical exam skills? Is it increasing (and misguided) faith in the utility of the CT scanner? I don’t really know. But it’s real!
Bottom line: Watch yourself and your team as they perform the secondary survey! Your goal is to find all the injuries you can before you go to imaging. This means deep palpation, twisting and trying to bend extremities looking for fractures, stressing joints looking for laxity. And doing a good neuro exam! Don’t let your physical exam skills atrophy! Your patients will thank you.
The Centers for Disease Control and Prevention (CDC) published a set of Guidelines for Field Triage two years ago. Click here to download them. They list 4 tiers of activation criteria to help prehospital providers triage patients appropriately to trauma centers.
Tier 1, which are physiologic criteria, and Tier 2 (anatomic criteria) are very accurate in predicting injury serious enough to require trauma team activation. Tier 3 contains mechanism criteria, and many centers who use these verbatim in their activation criteria end up with a fair amount of overtriage. Some centers even see a significant number of patients who meet Tier 3 criteria go home from the ED!
The Yale department of Emergency Medicine looked at intrusion into vehicle criteria (more than 12" near an occupant, more than 18" anywhere on the vehicle) to see if they are a valid predictor for admission or trauma center transport. It was a retrospective review of EMS transports to the Yale ED or to one satellite site.
Unfortunately, the number of vehicles that met intrusion criteria (48) was small compared to the number without significant intrusion (560). This makes the data a little less convincing than it may have been. The likelihood that intrusion would require trauma center admission (Positive Predictive Value) was only 26%. The likelihood that trauma center resources would be utilized (for issues like death, ICU stay, operation, spinal injury or intracranial hemorrhage) was only 13%. The authors recommend that the CDC guidelines be tweaked based on this data.
Bottom line: I think the numbers are far too small to convince the CDC to change their guidelines. But I would urge each trauma center that uses the intrusion criteria for activation to carefully study how many of those patients have minor injuries or go home from the emergency department. They may find that they can rely on other more accurate criteria and decrease their overtriage rate at the same time.
Reference: Motor vehicle intrusion alone does not predict trauma center admission or use of trauma center resources. Prehospital Emerg Care 15:203-207, 2011.