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Improving EMS Trauma Triage


Improving EMS Trauma Triage A Project of the Florida Department of Health Division Of Emergency Medical Operations Office of Trauma in Cooperation With The – PowerPoint PPT presentation

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Title: Improving EMS Trauma Triage

Improving EMS Trauma Triage
  • A Project of the
  • Florida Department of Health
  • Division Of Emergency Medical Operations
  • Office of Trauma in Cooperation With The
  • Emergency Medicine Learning Resource Center

  • This training program is not intended to replace
    or function as local emergency medical services
    treatment or transport protocol. For specific
    protocol guidance, contact your system EMS
    medical director.

Improving EMS Trauma Triage
  • Faculty
  • Joe Nelson, DO, MPH
  • EMS Medical Director
  • Bureau of EMS
  • Florida DOH
  • Tallahassee, Florida
  • Patricia Byers, MD, FACS Associate Professor,
    University of Miami Ryder Trauma Center Miami,
  • Grant Project Coordinators
  • Susan McDevitt, RN, MSN, MBA, MS, FACHCA
    Director, Office of Trauma Executive Director
    Community Health Nursing
  • Florida DOH
  • Tallahassee, Florida

  • Upon Completion of This Program the EMT/Paramedic
  • Understand of the need and methodology for a
    rapid assessment of the trauma patient.
  • Understand the importance of accurate trauma
    triage to an appropriate destination, especially
    in the rural setting.
  • Have a basic understanding of the
    characteristics/capabilities of various levels of
    Trauma Centers.

  • Upon Completion of This Program the EMT/paramedic
  • Be able to apply decision-making aids to
    recognize need for transport a Trauma Center.
  • Will be able to identify critical interventions
    on scene and during transport.
  • Will understand advantages and disadvantages
    emergency ground vs. air transport.

  • Each year, over 160,000 lives in the United
    States are lost due to trauma.
  • Trauma is the leading cause of death and
    disability in children and young adults.
  • The risk of death is significantly lower when
    care is provided in a trauma center than in a
    nontrauma center.

Role of Prehospital Care
  • The Emergency Medical Services system
    provides the first link
    to improved patient outcome.
  • Goal delivery of trauma victims to definitive
    care sites within the golden hour.
  • Rural EMS Services are challenged to provide
    timely trauma triage stabilization.

Making a Difference
  • Appropriate actions and triage decisions in the
    field can decrease in-hospital stay and the
    burden of injury.
  • For example, a single episode
    of hypotension in the patient
    with traumatic brain injury
    doubles mortality.

Trauma Centers Save Lives
  • 15-19 reduction in injury-related mortality with
    trauma system implementation.
  • Risk of death was decreased by 25 when care is
    provided at trauma centers.
  • 678,000 injury victims across the nation have
    benefited from evaluation and treatment in a
    regional trauma center.

Triage to a Trauma Center
  • Currently, appropriate pre-hospital triage to a
    trauma center occurs in 33-71 percent of cases.
  • A reasonable EMS system goal for appropriate
    trauma center triage rate is 65 percent.

The Need For Accurate Triage
  • Especially acute in the rural setting.
  • In Florida more than 95 of the citizens have
    access to a trauma center by ground or air
    evacuation in less than 85 minutes.
  • Transport decision must be made early in rural
    setting due to prolonged transport times.

Barriers to Rural Trauma Care
  • Delay in discovery of the victim or accident.
  • Time lag for notification of 911.
  • Prolonged time for prehospital mobilization and
  • Prolonged scene time.
  • Extended pre-hospital transport.

Rural Trauma Challenges
  • 2005 Florida Department of Health sponsored study
    A Comprehensive Assessment of the Florida Trauma
    System (Flint L. Orban B, Durham R, et al).
  • Counties in Florida without trauma centers had
    the highest fatality rates.
  • Study Focused on rural counties in northwestern
    Florida and the Panhandle.

Scene Size up
  • Personal safety BSI
  • Scene Safety
  • Safety of you and your partner
  • Safety of patient and bystanders
  • High index of suspicion

Do You Need Help?
  • Determine the total number of patients
  • If you MIGHT need help - request it early
  • Begin triage
  • Minimize scene time

Mechanism of Injury (MOI)
  • Can help you focus on suspected injuries
  • Helps to guide the assessment
  • Trauma triage tools combined with paramedic
    judgment have been demonstrated to have the
    greatest predictive value in identifying
    seriously injured patients

Significant Mechanism of Injury
  • Ejection from vehicle
  • Death in same
  • passenger
  • compartment
  • Roll-over of vehicle
  • High-speed vehicle collision
  • Vehicle-pedestrian collision

Significant Mechanism of Injury
  • Falls greater than 20 feet Adults
  • Falls greater than 10 feet Children
  • Motorcycle crash

Hidden Injuries
  • Seat belts
  • If buckled, may have produced injuries
  • If patient had seat belt on, it does not mean
    they do not have injuries
  • Airbags
  • May not be effective without seat belt
  • Patient can hit wheel after deflation
  • Lift the deployed airbag and look at the steering
    wheel for deformation

Child Safety Seats
  • Injury patterns with airbags.
  • Proper use in vehicles with airbags.
  • For older children, The lap
    belt should fit snug and low
    over the upper thighs.
    If it rides up on
    the abdomen,
    it could cause serious injuries
    in a crash.

Additional Infant Child Considerations
  • Falls gt10 feet
  • Bicycle collision
  • Vehicle in medium speed collision

Initial Assessment
  • Goal-to identify and treat immediate,
    life-threatening conditions.
  • General impression.
  • Evaluate mental status (AVPU) and ABCs.
  • Take C-spine control or delegate to someone while
    you continue the assessment.
  • Age gt 55 or lt 16 special caution

CNS Trauma Center Transport
  • Adults
  • Best Motor Response (BMR) lt 5 (less than
    localizing pain)
  • GCS lt 12 independent of other criteria
  • Pediatric
  • Any altered mental status (including loss of
    consciousness) other than amnesia
  • Adult or Pediatric
  • Paralysis, loss of sensation, suspicion of spinal
    cord injury

Assess Airway
  • Responsive patient
  • Talking or crying open airway
  • Check for signs of inadequate breathing
  • Unresponsive patient
  • Open airway by appropriate means
  • Check for signs of inadequate breathing

Airway Trauma Center Transport
  • Adults/Children
  • ACTIVE airway assistance
    required (i.e., more than supplemental O2
    without airway adjunct)

Airway Treatment
  • GCS lt8, severe facial or cervical injury,
    respiratory insufficiency
  • Patients without airway need emergency intubation
    with in line traction
  • Alternative airway techniques
  • needle cricothyroidotomy
  • esophageal obturator types-combitube
  • Confirm tube placement

Assess Breathing
  • Assess rate and depth
  • Look for equal chest rise and fall
  • Use high flow O2 by Non Re-breather oxygen mask
    for patients with inadequate breathing
  • For adults breathing lt8 bpm or gt24 bpm, consider
    assisting ventilations with BVM
  • Ventilate at age-appropriate rate for any
    patients not breathing

Breathing Trauma Center Transport
  • Adult patients with sustained respiratory rate
    less than 10 per minute or greater than 29 per
  • Pediatric patients breathing assistance beyond
    supplemental O2 and one-time need for suctioning
    without airway adjunct.

Breathing Treatment
  • All trauma patients should have oxygen therapy
  • May need supplemental breathing with bag valve
  • Tension pneumothorax should be relieved primarily
    by decompression
  • Monitor O2 saturation  
  • Sucking chest wound partially occlusive
  • Flail chest bulky dressing taped to chest wall

Assess Circulation
  • Assess pulse
  • Look for and control
    external bleeding
  • Assess skin color, moisture and temperature

Circulation Trauma Center Transport
  • Adult shock
  • No radial pulse AND heart rate gt 120 OR
  • BP lt 90 systolic
  • Sustained heart rate gt 120 with radial pulse
    and BP gt 90 systolic

Circulation Trauma Center Transport
  • Pediatric shock
  • No palpable pulses OR
  • Weak carotid or femoral pulse OR
  • Systolic BP lt 50
  • Good carotid or femoral pulse with absent distal
    pulses OR
  • Systolic BP 50-90

Circulation Treatment
  • Control bleeding
  • Tourniquet as a last resort
  • Splint deformities of extremities
  • Large bore IVs in uninjured
  • Prehospital controversy
  • Field resuscitation of intravascular
  • MAST

Rapid Trauma Assessment
  • Continue spinal stabilization
  • Reconsider transport decision
  • Assess mental status
  • Rapid Head to toe survey to rule out
    immediate life threats

Head and Neck
  • Assess the head, inspect and palpate for injuries
    or signs of injury
  • Assess the neck, inspect and palpate
    for injuries or signs of
  • Apply cervical spinal immobilization collar

Head and Neck Trauma Center Transport
  • Adult/Pediatric
  • Paralysis, loss of sensation, suspicion of spinal
    cord injury
  • Penetrating injury to head, neck, torso,
    excluding superficial wounds
  • Pediatric patient who is not awake and appropriate

Head and Neck Treatment
  • C-collar
  • Long spine board
  • Control bleeding

Chest Assessment
  • Assess the chest
  • Inspect
  • Palpate
  • Auscultative
    exam with

Chest Trauma Center Transport
  • Any penetrating injury, especially sucking chest
  • Flail chest
  • Difficulty breathing or hypoxia (Low oxygen
    saturation) with evidence chest trauma
  • Hoarseness or subcutaneous

Chest Trauma Center Transport
  • Suspected pneumothorax (especially tension
  • Tracheal deviation
  • Difficulty breathing
  • Chest Pain after trauma

Chest Treatment
  • Seal sucking chest wounds immediately
  • Treat Flail Chest immediately
  • Treat pneumothorax only if tension pneumothorax
    is suspected
  • Monitor O2 saturation

Abdomen Pelvis Assessment
  • Assess the abdomen, inspect and palpate for
    injuries or signs of injury.
  • Assess the pelvis, inspect and palpate for
    injuries or signs of injury.
  • Include inspection of perineal (genital) area if
    mechanism warrants exam.

Abdomen and Pelvis Trauma Center Transport
  • Any penetrating injury, especially evisceration
  • Any Rigidity or Tenderness with palpation
  • Unstable pelvis Crepitus or pain with palpation
  • Blood noted upon inspection of perineal area
  • Visible seat belt marks or contusions with

Abdomen and Pelvis Treatment
  • Treat for shock
  • Reevaluate upper abdominal injuries for chest
  • Cover eviscerations with moist sterile dressing
  • MAST suit may be useful for unstable pelvic

Extremities Back Assessment
  • Assess all four extremities, inspect palpate
    for injuries or signs of injury
  • Examine pulses, motor sensory function
  • Roll patient with spinal precautions assess
    posterior body, inspect palpate, examining for
    injuries or signs of injury

Extremities and Back Trauma Center Transport
  • Amputation proximal to wrist or ankle
  • Degloving injury or flap avulsion gt 5 inches
  • Multiple long bone fracture sites
  • Single long bone fracture site due to MVC
  • Single long bone fracture site due to fall from
    gt 10 feet

Extremities and Back Treatment
  • Splint during transport if possible
  • Document pulse, motor and sensation before and
    after splinting
  • Apply gentle traction to fracture or dislocation
    ONLY if pulses are absent
  • Ice packs and
    elevation to injured
    extremity, if possible

Skin Trauma Center Transport
  • Adults gt 15 BSA 2nd and 3rd degree burns
  • Pediatric gt 10 BSA 2nd 3rd degree burn
  • Third-degree burns greater than 5 of the body
    surface area in any age group
  • Second or third-degree thermal
    or chemical burns involving
    vital areas

Skin Trauma Center Transport
  • Electrical burns, including lightning injury
  • Burns associated with other significant major
    injury or pre-existing
  • Burn injury with
    inhalation injury

Skin Treatment
  • Burn dressings
  • Treat for shock
  • IV volume replacement
  • Do NOT rupture blisters
  • Do NOT put ointment,
    etc. on burns

Detailed Physical Exam
  • Look for medical identification devices
  • Assess baseline vital signs
  • Assess patient history (SAMPLE)
  • On blood thinners?
  • Perform a detailed physical examination

On-going Assessment
  • Unstable patient, repeat and record vital signs
    at a minimum every 5 minutes
  • Reassess mental status
  • Reassess airway
  • Monitor breathing rate
    and quality
  • Reassess circulation
  • Re-establish patient

Helicopter Use
  • Call air transport early with accurate patient
    condition evaluate weather
  • Notify receiving hospital by radio with
    information which allows them to prepare
  • Intubation and vent support
  • Thoracostomy tubes
  • O Negative
  • Operating room

Indications for Helicopter Use
  • Prolonged transport time
  • Lengthy extrication
  • Poor access to patient
  • Multiple patients
  • Anticipated need of whole blood
  • Multi-system trauma requiring
    rapid surgical
  • intervention

  • Rural Trauma Triage presents special challenges
  • Accuracy is needed to get the patient transported
    to an appropriate Trauma Center
  • A rapid, thorough exam is necessary
  • Do only critical interventions on scene
  • When indicated, call helicopter early

  • Anderson Ronald, Trunkey Donald, et al. U.S.
    Trauma Center Crisis Lost in the Scramble for
    Terror Resources. 2004. National Foundation for
    Trauma Care Irvine, CA
  • Flint L. Orban B, Durham R, et al.
  • A Comprehensive Assessment of the Florida
    Trauma System. 2005. University of South
    Florida, University of Florida, Office of Trauma,
    Florida Department of Health, Division of
    Emergency Medical Operations.
  • Florida Adult Trauma Scorecard Methodology. 2005.
    Ch 64E-2.017 Florida Administrative Code.
  • Florida Pediatric Trauma Scorecard Methodology.
    2005. Ch 64E-2.0175 Florida Administrative Code.
  • MacKenzie Ellen J., et al. A National Evaluation
    of the Effect of Trauma-Center Care on
    Mortality. N Engl J Med 2006354366-78.
  • Ma MH, MacKenzie EJ, Alcorta, R, Kelen GD.
    Compliance with prehospital triage protocols for
    major trauma patients. J Trauma 1999
  • Petersen Scott R. Interfacility Transfer of
    Injured Patients Guidelines for Rural
    Communities. 2002. American College of Surgeons
    Committee on Trauma. Chicago, IL.
  • United States. CDC Acute Injury Care Research
    Agenda Guiding Research for the Future. 2005.
    Office of Statistics and Programming, National
    Center for Injury Prevention and Control, Centers
    for Disease Control and Prevention. Atlanta, GA
  • United States. EMT-Basic National Standard
    Curriculum. 1995. United States Department of
    Transportation National Highway Traffic Safety
    Administration. Washington, DC.
  • United States. Paramedic National Standard
    Curriculum. 1998. United States Department of
    Transportation National Highway Traffic Safety
    Administration. Washington, DC.
  • United States. Trauma System Agenda For The
    Future. 2002. American Trauma Society and U.S.
    Department of Transportation, National Highway
    Traffic Safety Administration. Washington, DC.