Getting There:Getting There:The Right Place at the Right TimeThe Right Place at the Right Time

Jeffrey P. Salomone, MD, FACS, NREMT-P

Associate Professor of SurgeryEmory University School of Medicine

Co-Director of Trauma andDeputy Chief of Surgery

Grady Memorial Hospital

Goal

10. . . in the right amount of time.

. . . to the right place

Get the right patient . . .

Guiding PrincipleGuiding Principle

Patient destination based upon

medical appropriateness

Accessibility to Trauma CentersAccessibility to Trauma Centers

Branas CC, et al; JAMA, 2005:

Almost 90% of the US population lives in areas accessible to designated trauma care (Level I, II or III centers) within a one hour

period of time

Access to Level I and II TC’s within 60 minsAccess to Level I and II TC’s within 60 minsGround EMS (5% land area, 60 % pop)Ground EMS (5% land area, 60 % pop)

Access to Level I and II TC’s within 60 minsAccess to Level I and II TC’s within 60 minsGround + Air Medical EMS Ground + Air Medical EMS (35% land area, 90% pop)(35% land area, 90% pop)

The RealityThe RealityNathens AB, et al; J Trauma, 2000:

500,000 injured persons in 18 statesFailed to receive care at designated trauma

facilities:– 56% of all trauma patients– 36% of major trauma patients

Access to Level I and II TC’s within 60 minsAccess to Level I and II TC’s within 60 minsGround EMS vs Ground + Air Medical EMSGround EMS vs Ground + Air Medical EMS

Land area 4%; 38% pop Land area 79%; 90% pop

The Right PlaceThe Right Place

Trauma CenterTrauma Center

An institution committed to the care of injured patients, from acute care to rehabilitation

Initial resuscitationOperative managementCritical careContinuing care

Trauma CenterTrauma Center

Immediate availability on a 24-hr basis: Specialized surgeonsPhysician specialistsNursesAllied health personnelResuscitation and life support equipment

TeamworkTeamwork Physicians:

– Surgery – EM– Ortho – etc

Therapists:– Respiratory– Physical– Occupational

Technologists:– Lab– Xray

Nurses: – ED– OR– ICU– Ward– Clinic

Trauma CenterTrauma Center

Trauma program: Trauma service Trauma team Trauma medical

director Coordinator / program

manager Performance

improvement/ registry

Trauma CentersTrauma Centers

Levels- established by ACS-COT:– Level IV– Level III– Level II– Level I

“Designated”- state agency“Verified”- ACS-COT site visit

Level IIILevel III

General Surgery- immediately available*Available 24 hrs: EM, Orthopedics, Plastics,

Radiology, Anesthesia– Neurosurgery is desirable

Required (24 hr) : Xray, CT, PACUDesirable (24 hr): Xray Tech, Resp Tech

* = within 15 minutes of patients arrival in ED

Level IILevel II

Level III Criteria, plus:Physicians*: Neurosurg, Hand, OB/GYN,

Ophth, OMFS, Thoracic, CCM 24 hr OR is desirableInjury Prevention outreach

*Inhouse trauma surgeons NOT required

Level ILevel ILevel II criteria, plus:Physicians*: Cardiac surg, MicrovascularServices: CPB, inhouse OR personnel,

inhouse SICU serviceTeaching facility (Surg residency, ATLS)ResearchAdmissions: 1,200/yr; 240 with ISS > 15Tertiary referral / resource center*Inhouse trauma surgeons NOT required

Exclusive vs InclusiveExclusive vs InclusiveTrauma SystemTrauma System

Level IVLevel IV

24 hrs: ED, LabDoes not need 24 hr Emer MedDesirable: 24 hr Gen Surg, AnesthInitial resuscitation

– Refer to higher level center

Hospitals that “lack a commitment to trauma care” have been associated with a higher incidence of unacceptable care and poor outcomes– Moylan JA, et al., J Trauma, 1976 – Detmer DE, et al., J Trauma, 1977

Lack of Trauma CentersLack of Trauma Centers

Comparison of Trauma SystemsComparison of Trauma SystemsWest JG, et al., Arch Surg, 1979Comparison of trauma patients who died

after arrival at a hospital– Orange Co., closest facility (n = 90) – San Francisco, single trauma center (n = 92)

“Preventable” deaths– Orange Co. 40 of 90 deaths (44%):

20/30 (66%) of non-CNS trauma 20/60 (33%) of CNS trauma pts

– SF: only one (about 1%)

Transfer of trauma patients to designated trauma centers has also been shown to improve outcomes:– West JG, et al., Arch Surg, 1983

Follow up to 1979 study Significant reduction in mortality by regionalization:

overall 20% preventable; TC 9% preventable– Shackford SR, et al., J Trauma, 1986– Waddell TK, et al., J Trauma, 1991

Trauma CentersTrauma Centers

Effect of Trauma-Center Care on Effect of Trauma-Center Care on MortalityMortality

Trauma patients managed at 18 Level I trauma centers compared to 51 non-trauma centers (14 states)

Complete records available for:– 1104 patients who died – 4087 patients discharged alive

CDC funded

MacKenzie EJ, et al, NEJM, 2006

Effect of Trauma-Center Care on Effect of Trauma-Center Care on MortalityMortality

In-hospital mortality :– Trauma center: 7.6%; relative risk 0.80– Non-trauma center: 9.5%

One year mortality rate:– Trauma center 10.4%, relative risk 0.75– Non-trauma center: 13.8%

Differences in mortality rates primarily confined to patients with more severe injuries

You (or your patient) are 25% more likely to survive if taken to a trauma center.

Level I vs Level IILevel I vs Level II

Traditionally outcome between Level II and Level I centers viewed to be equivalent– Criteria for clinical care nearly identical– Level I primarily teaching / research facility

Superiority of Level ISuperiority of Level IRetrospective review using NTDB

– pts > 14 yrs, ISS >15– One of the following injuries:

Aortic vena cava iliac vessels Cardiac Grade IV/V liver injuries quadriplegia complex pelvic fx

Demetriades D, et al., Ann Surg, Oct 2005

Superiority of Level I?Superiority of Level I?

Results– 12,254 pts met inclusion criteria– Level I centers had significantly:

Lower mortality (25.3% vs 29.3%, p = 0.004) Less severe disability at D/C ( 20.3% vs 33.8%, p =

0.001) Higher functional outcome

Trauma Center vs Closest HospitalTrauma Center vs Closest Hospital

Closest Hospital CRASH! 8 minute EMS response 10 min scene time 5 min transport time 10 min ED evaluation 30 min surgeon call-in 30 min OR call-in 5 min transfer to ORTotal Time, injury to OR= 98

mins

Trauma Center CRASH 8 minute EMS response 10 min scene time 15 min transport time 10 min ED evaluation 5 min transfer to ORTotal Time, injury to OR= 48

mins

The Right PatientThe Right Patient

OvertriageOvertriage

Transporting minimally injured trauma patients to a trauma center

Overtriage rate of up to 50% considered acceptable

Often a financial / resource issue

Failure to transport major trauma patients to a trauma center

Undertriage rate of 5 – 10 % considered unavoidable, and is associated with an overtriage rate of 30 – 50%

Often a political issue

UndertriageUndertriage

What is a What is a “Major Trauma Patient”?“Major Trauma Patient”?

Injury Severity Score (ISS) > 15 frequently usedCorrelates well with mortality over a broad range of ages

and injuries Knudson MM, et al., Arch Surg, 1994 Buckley SL, et al., J Pediatr Orthop, 1994 Gustilo RB, et al., Orthop, 1985 Jones JM, et al., J Trauma, 1995 Shedden PM, et al., Pediatr Neurosurg, 1990 Chen RJ, et al., Eur J Surg, 1995

Can’t be calculated in the prehospital setting

Major Trauma Patient

Injury Severity ScoreInjury Severity Score

Region InjuryDescription

AIS SquareTop Three

Head & Neck Cerebral Contusion 3 9

Face No Injury 0  

Chest Flail Chest 4 16

Abdomen Minor Contusion of LiverComplex Rupture Spleen

2 5

 25

Extremity Fractured femur 3  

External No Injury 0  

Injury Severity Score:   50

ISS - IssuesISS - Issues

Based primarily on motor vehicle crash data– Not as useful in penetrating trauma

Ignores multiple injuries in the same body region

Trauma Index– Kirkpatrick JR, Youmans RL, J Trauma, 1971

Trauma Score / Revised Trauma Score– Champion HR, et al., Crit Care Med, 1981– Champion HR, et al., J Trauma, 1989

CRAMS scale– Gormican SP, Ann Emerg Med, 1982

Prehospital Index– Koehler JJ, et al, Ann Emerg Med, 1986

Trauma Triage Rule– Baxt WG, et al., Ann Emerg Med, 1990

Each with limitations, lacking clear superiority over others

Other Trauma Scores

Alternatives to ISSAlternatives to ISS

Deaths in the ED or within 24 hrs of ED admission

Resource utilization:– Massive blood transfusions– Rapid operative intervention– Cessation of bleeding by interventional

angiography– Early intensive critical care

All difficult to determine in the field!

Field TriageField Triage

Field TriageField Triage

Committee on Trauma, American College of Surgeons / CDC

Components:– Physiologic– Anatomic– Mechanism of Injury– Special Considerations

CaseCase

29 y/o male fishing in small boat at 1 AM. Boat run over by speedboat.Airway: Intact

Breathing: shallow, 34/min, equal

Circulation: no radial pulses, SBP 80 mm Hg, significant hemorrhage from lower extremities

Disability: GCS 13 (E4, V4, M5)

Expose: No injuries to torso, head, upper extremities

Speedboat vs FishermanSpeedboat vs Fisherman

High flow O2, pulse oximetry

Tourniquets placed to bilateral thighs

Transport initiated Intravenous

resuscitation begun enroute

Physiologic CriteriaPhysiologic Criteria

Take to Trauma Center:Glasgow Coma Scale Score < 13Systolic blood pressure < 90 mm HgRespiratory rate < 10 or > 29

– <20 in infant (under one year of age)– Or need for ventilatory support

Physiologic derangement correlates well with severity of injury and can predict mortality– Baxt WB, et al., Ann Emerg Med, 1989

Patients with significant tachycardia and hypotension have typically lost 30 – 40% of their blood volume and often are in need of emergent transfusion and surgical intervention

Physiologic Criteria

CaseCase

55 y/o male, despondent over relationship, stabs self in left chest with kitchen steak knife

Airway: intact Breathing: 24, equal BS Circulation: HR 58, BP

114/68 Disability: GCS 14 Exposure: No other

injuries

Steak knife vs heartSteak knife vs heart

High flow O2, pulse oximetry

Initiate rapid transport to trauma center

Initiate IV therapy enroute

Anatomic CriteriaAnatomic CriteriaAll penetrating injuries to head, neck, torso

and extremities proximal to elbow or kneeChest wall instability or deformity ( i.e., flail

chestTwo or more proximal long bone fracturesCrush, degloved, mangled or pulselessAmputation proximal to wrist or anklePelvic fracturesOpen or depressed skull fracturesParalysis

Some patients with lethal injury may present with normal vital signs, especially if EMS response has been rapid– Reliance on only physiologic criteria may result in

undertriage

Anatomic Criteria

Several studies have documented noteworthy survival rates in patients with penetrating torso trauma transported to facilities with immediate surgical capabilities

Best survival rates are in patients with stab wounds to the chest that have vital signs upon arrival in the ED– Durham LA, et al., J Trauma, 1992– Velmahos GC, et al., Arch Surg, 1995– Rhee PM, et al., J Am Coll Surg, 2000

Anatomic Criteria:Penetrating Torso Trauma

CaseCase

8 y/o male backseat passenger of vehicle involved in frontal collision. Significant intrusion to passenger compartment

Airway: intact Breathing: RR 28, equal BS Circulation: Pulse 110 Disability: GCS 15 Expose: Seatbelt mark to

abdomen, abdomen tender

Child in MVCChild in MVC

High flow O2, pulse oximetry

Extrication to trauma board, complete spinal immobilization

Rapid transport to trauma center

IV lines initiated enroute

Mechanism of InjuryMechanism of Injury Falls

– Adults > 20 ft (one story is equal to 10 ft)– Children < 15 yrs: > 10 ft or 2-3 X height of the child

High-risk auto crash*– Intrusion, including roof: > 12” occupant site; > 18” any

site– Ejection (partial or complete) from automobile– Death in same passenger compartment– Vehicle telemetry data consistent with high risk of

injury Auto-pedestrian / auto-bicyclist thrown, run over, or with

significant (> 20 mph) impact Motorcycle crash >20 mph

* Removed: rollover, deformation to vehicle

MOI may aid in predicting serious injury– King AI, et al., J Trauma, 1995– Grande CM, et al., Crit Care Clin, 1990– Presswalla FB, Med Sci Law, 1978

MOI correlates least well with the presence of significant injury– Relying on these alone increases overtriage

rate

Mechanism of Injury Criteria

CaseCase 78 y/o restrained

female front seat passenger in high speed motor vehicle crash. PMH of A-fib, on warfarin

Airway: intact Breathing: RR 24,

slightly decreased BS on left

Circulation: HR 110, irreg; BP 148/90

Disability: GCS 15 Expose: multiple

contusions

Elderly female in MVCElderly female in MVC

High-flow O2, pulse oximetry

Spinal immobilization

Initiate transfer to a trauma center

Initiate IV therapy enroute

Special Circumstances

Older adults: – risk of injury death increases after age 55– SBP < 110 may represent shock after age 55– Low impact mechanisms (e.g., ground level falls)

may result in severe injuries Children: should be triaged preferentially to

pediatric-capable trauma center Anticoagulation and bleeding disorders

– Patients with head injury are at high risk for deterioration

Special Circumstances

Burns – Without other trauma: burn facility – With other trauma: trauma center

Pregnancy > 20 weeks EMS provider judgment

Field Triage Mobile AppField Triage Mobile Apphttp://www.cdc.gov/fieldtriage/mobile.htmlhttp://www.cdc.gov/fieldtriage/mobile.html

The Right Amount of TimeThe Right Amount of Time

EMS in PerspectiveEMS in Perspective

U.S.– Medics returning from

Viet Nam– Firefighters trained in

EMS– Seattle, Miami, Denver,

L.A.

Emergency! (1972-77)

Prehospital ALS for TraumaPrehospital ALS for Trauma

Adaptation of ALS care for medical / cardiac patients to trauma care

Management at scene focused on stabilizing the patient

Prehospital ALS for TraumaPrehospital ALS for Trauma

Scene stabilization of trauma patients by ALS crews were disastrous– Improved outcome when

victims of penetrating cardiac trauma were transported by BLS

“scoop and run”5/6 vs 0/7

Gervin A, J Trauma, 1982

Prehospital ALS for TraumaPrehospital ALS for Trauma

Authorities questioned the role of prehospital advanced life support

Is ALS necessary for pre-hospital trauma care?– Trunkey DD, J Trauma, 1984

Prehospital stabilization of critically injured patients: a failed concept– Smith J, et al, J Trauma, 1985

The “Ultimate Stabilization”The “Ultimate Stabilization”

EMS vs Private transportEMS vs Private transport

Los Angeles (USC+LAC)4856 EMS patients vs.

926 non-EMS patientsISS > 15

Demetriades D, Arch Surg, 1996

Above all, do no further harmAbove all, do no further harm

Mortality:– 28.8% EMS

Transport– 14.1% Private

Transport

Scene time– More than 20 mins

for both blunt and penetrating trauma

PreHospital TraumaPreHospital TraumaLife SupportLife Support

Based on ATLS

10

PlatinumPlatinum10 minutes10 minutes

Golden Golden PeriodPeriod

For critically injured patients, initiate transport to the closest appropriate facility within 10 minutes of arrival on scene.

PHTLSPHTLS

Limited, key field interventions:– Airway control– Oxygenation and ventilation support– Hemorrhage control– Spinal Immobilization– Rapid Transport to appropriate facility– Initiate IVs enroute

NOT “scoop and run”

IV FluidsIV Fluids

No data has ever documented improved survival based upon prehospital IV fluid therapy

One study suggests increased mortality rate in hypotensive trauma patients given prehospital fluid

TransportationTransportation

Gasoline (or diesel or JetA) is the most important fluid in prehospital trauma care

PHTLS works!Ali J, J Trauma, 1998

CaseCase

13 y/o male suffers single GSW. EMS called. On arrival:

Airway: intact Breathing: decreased BS on right Circulation: HR 110, strong radial pulse Disability: GCS 15 Exposure: bullet wound 5th ICS left parasternal;

bullet wound right 8th ICS posterior axillary line

13 y/o shot in chest13 y/o shot in chest

EMS treatment– High flow O2– Placed on gurney– Transport initiated ( 1 minute scene time!)– 2 IV lines placed en route

ED evaluation– BP 110/80– Pericardial US positive for fluid

13 y/o shot in chest13 y/o shot in chest

OR findings:– Blood in pericardium– Wound to anterior right ventricle near right

coronary artery (repaired)– Wound to lateral right atrium (repaired)– Normal transesophageal echocardiogram– Right lung repaired– Bleeding diaphragmatic vessel ligated

13 y/o shot in chest13 y/o shot in chest

The Right Patient. . . To the Right Place. . . In the Right Amount of Time

Thanks for your attention!Thanks for your attention!