Ohio Department of Public Safety Division of Emergency Medical Services

1
Ohio Department of Public SafetyDivision of
Emergency Medical Services

• Ohio Prehospital Trauma Triage Rules
• Revised January 2009

2
In accordance with ORC 4765.16, this
presentation on trauma was developed under the
direction of Carol A. Cunningham, MD, FACEP,
FAAEM State Medical
Director Ohio Department of Public Safety,
Division of EMS and John Crow, MD, FACS
Chair of the
Trauma Committee of the State EMS Board
3
The standards and criteria in this presentation
were developed for Emergency Medical Technicians
operating in the prehospital setting to determine
if a person has suffered injuries severe enough
to require treatment at a trauma center.
4
Ohio Trauma Triage RulesLEARNING OBJECTIVES

• Describe Ohios legal definition of trauma
• Discuss the definition of a trauma center and
  what the different levels of trauma center
  designation mean
• List the anatomic and physiologic criteria to be
  used when evaluating pediatric, adult, and
  geriatric trauma victims
• Discuss the role that mechanism of injury and
  special considerations play in trauma patient
  destination
• State the five exceptions to transporting trauma
  patients directly to trauma centers
• Describe the key aspects of regional trauma
  triage protocols
• Discuss the importance of EMS documentation of
  trauma triage criteria

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Ohio Prehospital TraumaTriage RulesLegal
Definitions
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• The Ohio General Assembly establishes laws in
  the Ohio Revised Code (ORC).
• Laws are amplified by State Boards and agencies
  through rules established in the Ohio
  Administrative Code (OAC).

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• The General Assembly established laws in ORC
  sections 4765.01 and 4765.40 which define
• Traumatic injury
• Trauma patient / trauma victim
• Trauma care
• Trauma center
• Trauma triage
• These definitions are expanded and clarified for
  EMS providers by the State Board of Emergency
  Medical Services in OAC chapters 4765-1 and
  4765-14

8

• Trauma patients or trauma victims are legally
  defined as those who have sustained a traumatic
  injury. Traumatic injury is legally defined as
  damage to or destruction of tissue that
  satisfies both of the following conditions
• Poses a significant risk of
• Loss of life
• Loss of limb
• Permanent disfigurement
• Permanent disability
• Is caused by
• Blunt or penetrating injury
• Exposure to electromagnetic, chemical or
  radioactive energy
• Drowning, suffocation or strangulation
• A deficit or excess of heat

9

• Trauma care is legally defined as assessment,
  diagnosis, transportation, treatment, or
  rehabilitation of a trauma victim by emergency
  medical service personnel or by a physician,
  nurse, physician assistant, respiratory
  therapist, physical therapistlicensed to
  practice as such in this state...

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• The qualifications for a hospital to become a
  trauma center are also defined in law.
• A hospital is designated as a trauma center by
  the State of Ohio when it
• Receives verification from the American College
  of Surgeons as an adult or pediatric trauma
  center
• or
• Operates under Ohios Provisional Trauma Center
  laws
• or
• Is located in another state and is licensed or
  designated as a trauma center by that state

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Ohio Prehospital TraumaTriage RulesTrauma
Centers
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• What makes a hospital a trauma center?
• A trauma center is a hospital which has the
  immediate availability of specialized surgeons,
  physician specialists, anesthesiologists, nurses,
  resuscitation and life support equipment, and
  operating rooms on a 24-hour basis to care for
  severely injured patients.

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• Why take seriously injured patients directly to a
  trauma center?
• The definitive care of internal bleeding or
  traumatic brain injury cannot occur in the
  prehospital setting or in a routine and timely
  manner at a non-trauma center hospital
• Trauma centers have 24-hour availability of
  emergency medicine and surgical services which
  allow the patient to be taken directly to the
  operating room, if needed
• Studies of over 250,000 Ohio trauma patient
  records have shown that trauma patients taken to
  a non-trauma center hospital spend, on average,
  over four hours at that hospital before transfer
  to a trauma center is initiated.

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What are the levels of trauma centers and how are
they different?

• Trauma centers are designated as Level 1 through
  Level 4
• The differences in levels are based on the depth
  of the resources available to treat the trauma
  victim
• The differences in the levels are not based on
  quality of care all trauma centers are required
  to have a commitment to high quality of care

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What are the levels of trauma centers and how are
they different?

• Level I A regional resource trauma center that
  must have the capability of providing total care
  for every aspect of injury, from prevention
  through rehabilitation. Level I trauma centers
  also have responsibility of providing leadership
  in education, research, and system planning.

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What are the levels of trauma centers and how are
they different?

• Level II A trauma center that provides initial
  definitive trauma care, regardless of the
  severity of the injury. Depending on location
  and available resources, Level II trauma centers
  may not be able to provide the same comprehensive
  care as a Level I trauma center. The Level II
  trauma center assumes responsibility for
  education and system leadership in areas where a
  Level I trauma center does not exist.

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What are the levels of trauma centers and how are
they different?

• Level III Level III trauma centers are meant to
  serve communities that do not have immediate
  access to a Level I or II trauma center. Level
  III trauma centers can provide prompt assessment,
  resuscitation, emergency operations and
  stabilization of the trauma patient, as well as
  arrange for possible transfer to a facility that
  can provide a higher level of definitive trauma
  care.

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What are the levels of trauma centers and how are
they different?

• Level IV Level IV trauma facilities provide
  advanced trauma life support prior to patient
  transfer in remote areas where a higher level of
  care is not available.

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Key Concept

• The law requires that all trauma victims be
  transported directly to a trauma center.
• There are five exceptions to this mandatory
• transport law. These will be discussed later.

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Ohio Designated Trauma Centers
2
Erie, PA
1
3
3
1
1
2
2
1
1
2
3
3
3
3
3
2
3
2
1
1
1
Ft. Wayne, IN
3
3
2
2
2
2
2
1 1 1 1
Pittsburgh, PA
4
Weirton, WV
3
3
2
2
Wheeling, WV
1
1
1
2
2
1
4
2
3
New Martinsville, WV
3
3
3
Parkersburg, WV
4
1
1
4
Point Pleasant, WV
2
2
Huntington, WV
Locations within each county not exact
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Ohio Prehospital TraumaTriage Rules Trauma
Patient / Trauma VictimDefinitions
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• There are three age groups for trauma patients
• Pediatric
• Age 0 15 years
• Adult
• Age 16 69 years
• Geriatric
• Age 70 years and older

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• A trauma patient or trauma victim is a person who
  has suffered an injury that
• 1) Poses a significant risk of loss of life loss
  of limb permanent disfigurement or permanent
  disability
• and
• 2) Is caused by blunt or penetrating injury
  exposure to electromagnetic, chemical or
  radioactive energy drowning, suffocation or
  strangulation or a deficit or excess of heat

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• Body region means a portion of the trauma
  victims body divided into the following areas
• Brain
• Head, face and neck
• Chest
• Abdomen and pelvis
• Extremities
• Spine
• Evidence of hemorrhagic shock includes any of
  the following
• Delayed capillary refill (greater than 2 seconds)
• Cool, pale, diaphoretic skin
• Decreasing systolic blood pressure with narrowing
  pulse pressure (the difference between the
  systolic and diastolic pressures becoming
  smaller)
• Altered level of consciousness

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• Evidence of neurovascular compromise includes
  one or more of the following (The 5 Ps)
• Paresthesia (numbness/tingling)
• Pain (severe)
• Paralysis
• Pallor / pale
• Pulselessness
• Evidence of poor perfusion means one or more of
  the following
• Weak distal pulses
• Pallor / paleness
• Cyanosis
• Delayed capillary refill (greater than 2 seconds)
• Tachycardia (appropriate for the patients age)

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• Evidence of respiratory distress includes one
  or more of the following
• Stridor
• Grunting
• Retractions
• Cyanosis
• Hoarseness
• Difficulty speaking
• Evidence of traumatic brain injury means signs
  of external trauma and physiologic indicators
  that the brain has suffered an injury caused by
  external force including, but not limited to
• Decrease in level of consciousness from the
  victims baseline
• Unequal pupils
• Blurred vision
• Severe or persistent headache
• Nausea or vomiting
• Change in neurological status

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• Proximal long bone is the humerus or femur
• Seat belt sign is bruises or abrasions on the
  chest and/or abdomen resulting from the use of a
  seat belt during a motor vehicle crash
• Signs and symptoms of spinal cord injury
  include
• Paralysis
• Weakness
• Numbness / tingling

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• When evaluating an injured person for triage to
  a trauma center, EMS providers must look for
  certain indicators of serious injury. These
  indicators will be either
• - Anatomic the injuries suffered
• - Physiologic the bodys response to the
  injury, or
• - Mechanistic cause of injury (geriatrics
  only).
• If the patient is found to have any of these
  indicators, they are required to be transported
  directly to a trauma center, unless one of the
  five exceptions apply.
• There are also special circumstances surrounding
  the injury that should be considered by EMS
  providers when deciding the injured patients
  destination.
• There are differences in the indicators for
  pediatric, adult and geriatric trauma patients.

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• If an injured person has any of the following
  indicators, they should be transported directly
  to a trauma center.

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• Pediatric Anatomic Indicators
• Penetrating injury to the head, neck or torso
• Significant penetrating injury to the
  extremities, proximal to the knee or elbow, with
  neurovascular compromise
• Visible crush of head, neck or torso
• Abdominal tenderness, distention or seat belt
  sign
• Flail chest
• Pelvic fracture

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• Pediatric Anatomic Indicators
• Injuries to the extremities with
• Visible crush
• or
• Evidence of neurovascular compromise
• Amputations proximal to the wrist or ankle
• Fracture of 2 or more proximal long bones
  (humerus or femur)
• Signs and symptoms of spinal cord injury
• Serious burns
• 2nd or 3rd degree burns over more than 10 of
  total body surface area
• or
• Involving face, airway, hands, feet, genitalia

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• Pediatric Physiologic Indicators
• Glasgow Coma Score of 13 or less
• Loss of consciousness for greater than 5 minutes
• Failure to localize pain (GCS motor score 4 or
  less)
• Evidence of poor perfusion
• Weak distal pulse, pallor, cyanosis, delayed cap
  refill, or tachycardia
• Evidence of respiratory distress or failure
• Stridor, grunting, retractions, cyanosis,
  hoarseness, difficulty speaking

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• Adult Anatomic Indicators
• Penetrating injury to the head, neck or torso
• Significant penetrating injury to the
  extremities, proximal to the knee or elbow, with
  neurovascular compromise
• Visible crush of head, neck or torso
• Abdominal tenderness, distention or seat belt
  sign
• Flail chest
• Pelvic fracture (this does not include isolated
  hip fractures)

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• Adult Anatomic Indicators
• Injuries to the extremities with
• Visible crush
• or
• Evidence of neurovascular compromise
• Amputations proximal to the wrist or ankle
• Fracture of 2 or more proximal long bones
  (humerus or femur)
• Signs and symptoms of spinal cord injury
• Serious burns
• 2nd or 3rd degree burns over more than 10 of
  total body surface area
• or
• Involving face, airway, hands, feet, genitalia

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• Adult Physiologic Indicators
• Glasgow Coma Score of 13 or less
• Loss of consciousness for greater than 5 minutes
• Failure to localize pain (GCS motor score 4 or
  less)
• Respiratory rate less than 10 or greater than 29
• Requires endotracheal intubation
• Requires relief of tension pneumothorax
• Pulse rate greater than 120 with evidence of
  hemorrhagic shock
• Systolic blood pressure less than 90 mm Hg

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• Geriatric Indicators
• Geriatric trauma indicators are similar to adult.
• Differences are marked with an asterisk

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• Geriatric Anatomic Indicators
• Penetrating injury to the head, neck or torso
• Significant penetrating injury to the
  extremities, proximal to the knee or elbow, with
  neurovascular compromise
• Visible crush of head, neck or torso
• Abdominal tenderness, distention or seat belt
  sign
• Flail chest
• Pelvic fracture (this does not include isolated
  hip fractures)
• Injury sustained in two or more body regions

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• Geriatric Anatomic Indicators
• Injuries to the extremities with
• Visible crush
• or
• Evidence of neurovascular compromise
• Amputations proximal to the wrist or ankle
• Fracture of 2 or more proximal long bones
  (humerus or femur)
• Signs and symptoms of spinal cord injury
• Serious burns
• 2nd or 3rd degree burns over more than 10 of
  total body surface area
• or
• Involving face, airway, hands, feet, genitalia

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• Geriatric Physiologic Indicators
• Glasgow Coma Score of 13 or less
• Glasgow Coma Score less than 15 with a known or
  suspected traumatic brain injury
• Loss of consciousness for greater than 5 minutes
• Failure to localize pain (GCS motor score 4 or
  less)
• Respiratory rate less than 10 or greater than 29
• Requires endotracheal intubation
• Requires relief of tension pneumothorax
• Pulse rate greater than 120 with evidence of
  hemorrhagic shock
• Systolic blood pressure less than 100 mm Hg

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• Geriatric Mechanism Indicators
• Fracture of 1 or more proximal long bones
  (humerus or femur) sustained in a motor vehicle
  crash
• Pedestrian struck
• Falls from any height including standing with
  evidence of a traumatic brain injury

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• Remember, if an injured person has any of the
  indicators just listed, they must be transported
  directly to a trauma center.

42

• As taught in your EMT-B, EMT-I and EMT-P
  courses, EMS personnel also must be concerned
  about mechanism of injury special
  considerations when determining whether or not to
  transport to a trauma center.
• These should be used as additional factors in
  decision making, not as stand-alone conditions
  that will triage a patient to a trauma center.

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• Mechanism of injury
• Motor vehicle crashes with
• Ejection
• Rollover
• Extrication greater than 20 minutes
• Death in same passenger compartment
• Evidence of high speed crash
• Speed greater than 40 miles per hour
• Major auto deformity (greater than 20 inches)
• Intrusion into passenger compartment greater than
  12 inches

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• Mechanism of injury
• Auto vs. pedestrian, greater than 5 mph.
• Auto vs. bicycle, greater than 5 mph.
• Motorcycle crash greater than 20 mph.
• Motorcycle crash with rider separated from bike
• Falls greater than 20 feet

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• Special Considerations
• Pregnancy
• Co-morbid conditions
• Cardiac or respiratory disease
• Liver failure or cirrhosis
• Insulin-dependant diabetes (Type 1)
• Compromised immune system
• Cancer, HIV, Transplant
• Bleeding disorders or on anti-coagulants
• Morbidly obese

46

• Remember, mechanism of injury and special
  considerations should not be the only reason to
  decide whether or not to transport to a trauma
  center.

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Ohio Prehospital TraumaTriage Rules Five
Exceptions
48

• The law requires that trauma patients be
  transported directly to a trauma center.
• There are five exceptions to this requirement

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Five Exceptions to Mandatory Transport

• Medical necessity for initial assessment and
  stabilization
• Unsafe or medically inappropriate due to adverse
  weather conditions or excessive transport time
• It would cause a shortage of local EMS resources
• No trauma center is able to receive and provide
  care to the patient without undue delay
• Before transport begins, the patient (or
  parent/guardian) requests transportation to a
  hospital that is not a trauma center

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Five Exceptions to Mandatory Transport

• It is medically necessary to transport the
  patient to a hospital without a trauma center for
  initial assessment and stabilization before
  transfer.
• These must be legitimate, immediately
  life-threatening medical reasons.
• Unable to open or maintain airway
• Traumatic arrest
• Uncontrollable external bleeding
• EMS agency protocols should provide guidance on
  when this is appropriate

51
Five Exceptions to Mandatory Transport

• Unsafe or medically inappropriate due to adverse
  weather conditions or excessive transport time.
• In cases of bad weather or when transport time to
  the nearest trauma center is excessive, a patient
  may be better served by stopping at the nearest
  hospital for stabilization and transfer.
• Consider other methods of transport, such as air
  medical
• Local and regional protocols should provide
  guidance on when this is appropriate
• Use your best professional judgment

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Five Exceptions to Mandatory Transport

• It would cause a shortage of local resources.
• Many EMS jurisdictions have limited resources
  equipment and/or personnel to provide for the
  emergency medical needs of their community. If
  transporting to a trauma center causes a shortage
  of these resources, it may be better to transport
  to the closest hospital where transfer can be
  arranged.
• Each community must assess its available
  resources, including air medical services and
  mutual aid, to understand when this exception
  applies.

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Five Exceptions to Mandatory Transport

• No trauma center is able to receive and provide
  care to the patient without undue delay.
• This exception was originally intended to address
  situations where trauma centers were diverting
  trauma patients. However, with todays mature
  state and regional trauma systems, this is mostly
  a thing of the past. Trauma centers avoid trauma
  patient diversion.
• If, for some unusual reason, a trauma center
  diverts your patient, you must use your best
  judgment, along with guidance from medical
  control, to determine the next best destination
  for your trauma patient.

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Five Exceptions to Mandatory Transport

• Before transport of a trauma patient begins, the
  patient requests to be transported to a hospital
  that is not a trauma center. This request may
  also be made by the parents / legal guardian of a
  trauma patient who is a minor, or by a legal
  representative of the patient.
• Competent patients have the right to have input
  into where they will receive treatment. EMS
  personnel should attempt to convince the patient
  of the need for treatment at a trauma center but
  should respect the competent patients wishes.

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Ohio Prehospital TraumaTriage Rules Overtriage
and Undertriage
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• Undertriage
• Transporting a severely injured patient to a
  hospital that is not a trauma center.
• Worst case scenario? The patient dies or
  suffers complications or disabilities that are
  avoidable.
• Trauma systems aim for 0 undertriage

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• Overtriage
• Transporting a minimally injured patient to a
  trauma center.
• Worst case scenario? Trauma center overload
  unnecessary, expensive transfers of the patient
  inconvenience for the patient and their family.
• Trauma systems accept a certain amount of
  overtriage in order to keep life-threatening
  undertriage low.

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Ohio Prehospital TraumaTriage Rules Regional
Variations
59
Lake
Lucas
Ashtabula
Fulton
9
Williams
Ottawa
Geauga
4
Cuyahoga
Wood
Trumbull
Erie
Defiance
Henry
Sandusky
Lorain
Portage
10
8
Huron
Seneca
Summit
Paulding
Medina
Hancock
Putnam
Mahoning
Ashland
Van Wert
Wayne
Wyandot
Crawford
Richland
Stark
7
3
Columbiana
Allen
Hardin
Marion
Carroll
Auglaize
Holmes
Mercer
Morrow
Jefferson
Tuscarawas
Logan
Knox
Coshocton
Union
Harrison
Shelby
Delaware
Darke
Licking
5
Champaign
Miami
2
Guernsey
Franklin
Belmont
Muskingum
Franklin
Clark
Madison
Noble
Fairfield
Monroe
Perry
Montgomery
Preble
Greene
Pickaway
Morgan
Fayette
Hocking
6
Washington
Butler
Clinton
Warren
Athens
Ross
1
Vinton
Hamilton
Highland
Meigs
Pike
Ohios EMS Regions
Clermont
Jackson
Brown
Scioto
Adams
Gallia
Lawrence
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• The law allows for regional variations to Ohios
  trauma triage protocols as long as the following
  criteria are met
• Ohios minimum triage criteria are met
• The appropriate Regional Physician Advisory
  Board (RPAB) submits the variation to the EMS
  Board
• The EMS Boards Trauma Committee has the
  opportunity to review and comment
• They are approved by the EMS Board

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• Prior to submission of a regional variation to
  the EMS Board, the RPAB must consult with
• Neighboring RPABs
• Hospitals and trauma centers in their region
• State-level EMS, physician and nursing
  organizations
• EMS instructors in their region

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• Regional trauma triage protocol variations
• Must require that EMS transport trauma victims
  to trauma centers
• May include any of the 5 exceptions to mandatory
  transport but cannot create additional exceptions
• Must seek to minimize overtriage and undertriage
• Supersede Ohios protocols once approved by the
  EMS Board
• Are automatically amended to meet the state
  triage protocol if the EMS Board updates the
  state protocol.

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Ohio Prehospital TraumaTriage Rules Periodic
Review
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The law requires that Ohios trauma triage
protocols be reviewed and updated every three
years by the State EMS Board in order to minimize
overtriage and undertriage. These reviews are
done through public hearings, public comment
periods and examination of the data in the EMS
Incident Reporting System (EMSIRS) and the Ohio
Trauma Registry (OTR).
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EMS documentation is very important to
effectively perform these reviews. Each EMS run
report should record what, if any, trauma triage
criteria were met by the injured patient, as well
as their vital signs and the Glasgow Coma Score.
This information is submitted to EMSIRS and used
by the EMS Board to study how the EMS portion of
the trauma system is functioning. This means
your run data is being used to improve the care
given to all injured patients.
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Ohio Prehospital TraumaTriage RulesSummary
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Ohio Prehospital Trauma Triage Rules Summary

• Questions every EMS provider should consider when
  evaluating an injured patient and making the
  decision on where to transport
• Is this patient at risk of losing life or limb?
• Is this patient at risk for disability or
  disfigurement?

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Ohio Prehospital Trauma Triage Rules Summary

• Questions every EMS provider should consider when
  evaluating an injured patient and making the
  decision on where to transport
• Is there evidence of respiratory distress or
  failure?
• Is there evidence of poor perfusion or
  hemorrhagic shock?
• Are there significant neurological symptoms?
• Are there signs/symptoms of spinal cord injury?
• Is there neurovascular compromise in an
  extremity?

69
Ohio Prehospital Trauma Triage Rules Summary

• Questions every EMS provider should consider when
  evaluating an injured patient and making the
  decision on where to transport
• Are there penetrating wounds to the head, neck or
  torso?
• Are there visible crush injuries?
• Is there abdominal distention, tenderness or seat
  belt sign?
• Are there signs of a pelvic fracture or flail
  chest?
• Are there amputations above the wrist or ankle?
• Are there significant, serious burns?

70
Ohio Prehospital Trauma Triage Rules Summary

• If the answer is yes to any of those questions,
  the patient must be transported to a trauma
  center.

Prehospital assessment is key to rapid transport
to the appropriate medical facility
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Ohio Prehospital Trauma Triage Rules Summary
Trauma centers are capable of providing 24-hour
surgical care to allow the trauma patient to be
taken directly to the operating room, if
needed. Transporting a trauma patient to a
non-trauma center hospital can result in
significant delay in the patients arrival at a
trauma center for definitive care.
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Ohio Prehospital Trauma Triage Rules Summary
Undertriage - Transporting a severely injured
patient to a hospital that is not a trauma
center. - Can result in death or disability of
the trauma patient. - Every trauma systems
goal is to have NO undertriaged trauma
patients. Overtriage - Transporting a
minimally injured patient to a trauma center. -
Can create a burden on system resources. - Most
trauma systems need 25 - 30 overtriage to
ensure ALL severely injured patients get to a
trauma center.
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Ohio Prehospital Trauma Triage Rules Summary
Your documentation is very important to improving
Ohios trauma system. Accurate documentation of
the trauma triage criteria an injured person
meets (if any), along with all vital signs,
allows the EMS Board to improve the efficiency of
the system.
74
Ohio Prehospital Trauma Triage Rules References
and Resources

• ATLS Advanced Trauma Life Support, 7th Edition.
  2004. American College of Surgeons Chicago, IL.
• Basic Trauma Life Support for the EMT-B and First
  Responder, 4th Edition. 2003. Campbell JE and
  Alabama Chapter of Emergency Physicians. Dothan,
  AL.
• Basic Trauma Life Support for Advanced Providers,
  5th Edition. 2003. Campbell JE and Alabama
  Chapter of Emergency Physicians. Dothan, AL.
• PHTLS Basic and Advanced Prehospital Trauma
  Life Support, 4th Edition. 1999. Eds. Paturas
  JL, Wertz EM and McSwain NE, Jr. Mosby, St.
  Louis, MO.
• Ohio Revised Code, 4765.01, 4765.06, 4765.16,
  4765.40, 4765.41
• Ohio Administrative Code, 4765-14-01,
  4765-14-02, 4765-14-03, 4765-14-04,
  4765-14-05, 4765-14-06, 4765-15-01,
  4765-16-01, 4765-17-01