Trauma Triage: Right Person, Right Place, Right Time
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TRAUMA TRIAGE:RIGHT PERSON,RIGHT PLACE, RIGHT TIME Author: Kathryn Moore, DNP, RN, CCRN, CEN, ACNP-BC, ANP-BC, Lexington, KY For correspondence, write: Ka- thryn Moore, DNP, RN, CCRN, CEN, ACNP-BC, ANP-BC, 3033 Shirlee Dr, Lexington, KY 40502 Section Editor: Kathryn Moore, RN, DNP, CCRN, CEN, ACNP-BC, ANP-BC Earn Up to 9 CE Hours. See page 201. T he “golden hour” concept in trauma care is attrib- uted to several individuals in 2 different time frames. Santy (1918) attributes the concept of the time factor between wounding and adequate shock treatment to the French from World War I data. 1 This work was subsequently used by R. Adams Cowley in the development of the “golden hour” concept. 2 The concept of time to surgical intervention in traumatic hemorrhage is further attributed to the works by Trunkey. 3 Recent pub- lications have questioned the validity of the concept of the “golden hour” of trauma care. 2,4,5 However, one point of agreement remains: A critical window of opportunity exists to stop the active bleeding and correct the cellular damage related to hemorrhage. 4,5 Patients with traumatic injuries must be quickly and critically assessed at the scene of the injury to determine the nature and extent of their injuries for appropriate inter- ventions in the field and transport to an appropriate facility for further care. At the scene of the injury, time and resources limit the ability of providers to determine the full extent of the injuries sustained. Important determinations about care and transport must be made in the field based on the limited information available. Field triage relies on the 3 physiologic variables of the Glasgow Coma Scale to assess neurologic response. Hemo- dynamic status is assessed by systolic blood pressure, and respiratory rate is the parameter used to assess both the sta- tus of the airway and the ability to breathe spontaneously. The concept of field triage was first published as the Trau- ma Score by Champion and associates in 1981 6 and later as the Revised Trauma Score (RTS) in 1989. 7 The RTS is the most widely used prehospital field triage tool but is limited when used without additional information. 8 The Glasgow Coma Scale and respiratory rate become limited in the face of drug administration or temporary loss of consciousness, leaving systolic blood pressure as the single parameter used to make triage determination in the field. Once the patient reaches the emergency department, additional information becomes available and additional scoring systems can be used to make determinations about the nature and severity of the injuries sustained as a result of the traumatic event. Several approaches are used with data obtained in the emergency department, including several variations of the Injury Severity Score (ISS). The ISS is an anatomic scoring system that provides a composite score for patients based on evaluation of multiple injuries. 9 The values for the ISS range from 0 to 75, and most literature supports the supposition that an ISS score greater than 16 is consistent with severe injuries. The ISS initially was derived from the scale developed in 1971 by the Committee on Medical Aspects of Automotive Safety, the Abbreviated Injury Scale (AIS). 10 The AIS is also an anatomic scoring sys- tem that ranks injury severity. The AIS uses a scale of 1 to 6. Additional information can be gained by adding infor- mation to the anatomic information calculated as the ISS; for example, if the International Classification of Diseases codes are included in the calculation; the score is called the International Classification of Diseases Injury Severity Score. 11,12 Unfortunately, this score generally is not avail- able until the full extent of all injuries is known. Another measure of injury severity is a combined anatomic and phy- siologic score, the Trauma Score–Injury Severity Score. 13 This score combines the anatomic criteria of the ISS with the physiologic criteria available from the RTS. To provide more patient specific information, the score also includes patient age and controls for blunt or penetrating trauma. The Trauma Score–Injury Severity Score uses multiple regression analysis to arrive at the calculated score and is used to determine the probability of survival based on the parameters included in the calculation. 13 Kathryn Moore, Member, Bluegrass Chapter, is Assistant Professor, University of Kentucky College of Nursing, Lexington, KY. For correspondence, write: Kathryn Moore, DNP, RN, CCRN, CEN, ACNP-BC, ANP-BC, 3033 Shirlee Dr, Lexington, KY 40502; E-mail: [email protected]. J Emerg Nurs 2012;38:193-4. Available online 7 February 2012. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2011.11.016 TRAUMA NOTEBOOK March 2012 VOLUME 38 • ISSUE 2 WWW.JENONLINE.ORG 193
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Transcript of Trauma Triage: Right Person, Right Place, Right Time
TRAUMA TRIAGE: RIGHT PERSON, RIGHT PLACE,RIGHT TIME
Author: Kathryn Moore, DNP, RN, CCRN, CEN, ACNP-BC, ANP-BC, Lexington, KY For correspondence, write: Ka-thryn Moore, DNP, RN, CCRN, CEN, ACNP-BC, ANP-BC, 3033 Shirlee Dr, Lexington, KY 40502
Section Editor: Kathryn Moore, RN, DNP, CCRN, CEN, ACNP-BC, ANP-BC
Earn Up to 9 CE Hours. See page 201.
The “golden hour” concept in trauma care is attrib-uted to several individuals in 2 different timeframes. Santy (1918) attributes the concept of
the time factor between wounding and adequate shocktreatment to the French from World War I data.1 Thiswork was subsequently used by R. Adams Cowley in thedevelopment of the “golden hour” concept.2 The conceptof time to surgical intervention in traumatic hemorrhage isfurther attributed to the works by Trunkey.3 Recent pub-lications have questioned the validity of the concept of the“golden hour” of trauma care.2,4,5 However, one point ofagreement remains: A critical window of opportunity existsto stop the active bleeding and correct the cellular damagerelated to hemorrhage.4,5
Patients with traumatic injuries must be quickly andcritically assessed at the scene of the injury to determinethe nature and extent of their injuries for appropriate inter-ventions in the field and transport to an appropriate facilityfor further care. At the scene of the injury, time andresources limit the ability of providers to determine the fullextent of the injuries sustained. Important determinationsabout care and transport must be made in the field basedon the limited information available.
Field triage relies on the 3 physiologic variables of theGlasgow Coma Scale to assess neurologic response. Hemo-dynamic status is assessed by systolic blood pressure, andrespiratory rate is the parameter used to assess both the sta-tus of the airway and the ability to breathe spontaneously.The concept of field triage was first published as the Trau-
ma Score by Champion and associates in 19816 and later asthe Revised Trauma Score (RTS) in 1989.7 The RTS is themost widely used prehospital field triage tool but is limitedwhen used without additional information.8 The GlasgowComa Scale and respiratory rate become limited in the faceof drug administration or temporary loss of consciousness,leaving systolic blood pressure as the single parameter usedto make triage determination in the field.
Once the patient reaches the emergency department,additional information becomes available and additionalscoring systems can be used to make determinations aboutthe nature and severity of the injuries sustained as a result ofthe traumatic event. Several approaches are used with dataobtained in the emergency department, including severalvariations of the Injury Severity Score (ISS). The ISS is ananatomic scoring system that provides a composite scorefor patients based on evaluation of multiple injuries.9 Thevalues for the ISS range from 0 to 75, and most literaturesupports the supposition that an ISS score greater than 16is consistent with severe injuries. The ISS initially wasderived from the scale developed in 1971 by the Committeeon Medical Aspects of Automotive Safety, the AbbreviatedInjury Scale (AIS).10 The AIS is also an anatomic scoring sys-tem that ranks injury severity. The AIS uses a scale of 1 to 6.
Additional information can be gained by adding infor-mation to the anatomic information calculated as the ISS;for example, if the International Classification of Diseasescodes are included in the calculation; the score is called theInternational Classification of Diseases Injury SeverityScore.11,12 Unfortunately, this score generally is not avail-able until the full extent of all injuries is known. Anothermeasure of injury severity is a combined anatomic and phy-siologic score, the Trauma Score–Injury Severity Score.13
This score combines the anatomic criteria of the ISS withthe physiologic criteria available from the RTS. To providemore patient specific information, the score also includespatient age and controls for blunt or penetrating trauma.The Trauma Score–Injury Severity Score uses multipleregression analysis to arrive at the calculated score and isused to determine the probability of survival based onthe parameters included in the calculation.13
Kathryn Moore, Member, Bluegrass Chapter, is Assistant Professor, Universityof Kentucky College of Nursing, Lexington, KY.
For correspondence, write: Kathryn Moore, DNP, RN, CCRN, CEN,ACNP-BC, ANP-BC, 3033 Shirlee Dr, Lexington, KY 40502; E-mail:[email protected].
J Emerg Nurs 2012;38:193-4.
Available online 7 February 2012.0099-1767/$36.00
Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.
doi: 10.1016/j.jen.2011.11.016
T R A U M A N O T E B O O K
March 2012 VOLUME 38 • ISSUE 2 WWW.JENONLINE.ORG 193
Regardless of the method, injury severity scoring is aprocess that takes complex, variable, and often missingdata and reduces that information to a single numberto describe the severity of the injuries sustained in multi-ple trauma. Several components are related to the even-tual outcome of the patient. Certainly the anatomicinjury and the physiologic injury are key elements indetermining the severity of the injury, but the patientreserve as determined by age and co-morbidities also playa role in determining the outcomes after severe trauma. Inmany instances, all the factors involved in measuringinjury are not available until the outcome has been deter-mined. In these instances, the standardized measures lendthemselves well to variables for research.
Trauma scoring systems were reviewed by Pohlman etal14; their conclusion was that attempting to summarize theseverity of injury in a trauma patient with a single number isdifficult at best.14 Multiple injury severity scoring systemshave been reviewed in the literature since the measure-ment of injury severity began 50 years ago, and each hasstrengths, weaknesses, and applicability.15 Trauma provi-ders in the field and in the emergency department con-tinue to search for the quick and concise informationthat will assist in patient triage.
REFERENCES1. Santy PMM. Da Shock Tramatique dan les blessures de Guerre, Analy-
sis d’observations. Bull Med Soc Chir. 1918;44:205.
2. Lerner EB, Moscati RM. The golden hour: scientific fact or medical“urban legend”? Acad Emerg Med. 2001;8(7):758-60.
3. Trunkey DD. Trauma. Accidental and intentional injuries account formore years of life lost in the U.S. than cancer and heart disease. Amongthe prescribed remedies are improved preventive efforts, speedier surgeryand further research. Sci Am. 1983;249(2):28-35.
4. Newgard CD, Rudser K, Hedges JR, et al. A critical assessment of theout-of-hospital trauma triage guidelines for physiologic abnormality.J Trauma. 2010;68(2):452-62.
5. Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medicalservices intervals and survival in trauma: assessment of the “goldenhour” in a North American prospective cohort. Ann Emerg Med.2010;55(3):235-46.e4.
6. Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Traumascore. Crit Care Med. Sep 1981;9(9):672-6.
7. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flana-gan ME. A revision of the Trauma Score. J Trauma. 1989;29(5):623-9.
8. Gabbe BJ, Cameron PA, Finch CF. Is the revised trauma score stilluseful? ANZ J Surg. 2003;73(11):944-8.
9. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severityscore: a method for describing patients with multiple injuries and eval-uating emergency care. J Trauma. 1974;14(3):187-96.
10. Rating the severity of tissue damage. I. The abbreviated scale. JAMA.1971;215(2):277-80.
11. Rutledge R. Injury severity and probability of survival assessment intrauma patients using a predictive hierarchical network model de-rived from ICD-9 codes. J Trauma. 1995;38(4):590-7; discussion597-601.
12. Rutledge R, Fakhry S, Baker C, Oller D. Injury severity grading in traumapatients: a simplified technique based upon ICD-9 coding. J Trauma.1993;35(4):497-506; discussion 506-7.
13. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISSmethod. Trauma Score and the Injury Severity Score. J Trauma.1987;27(4):370-8.
14. Pohlman TH, Bjerke HS, Offner P. Trauma scoring systems. emedicineWeb site. http://emedicine.medscape.com/article/434076-overview. Up-dated May 19, 2010.
15. Senkowski CK, McKenney MG. Trauma scoring systems: a review. J AmColl Surg. 1999;189(5):491-503.
Submissions to this column are encouraged and may be sent toKathryn Moore, DNP, RN, CCRN, CEN, ACNP-BC, [email protected]
TRAUMA NOTEBOOK/Moore
194 JOURNAL OF EMERGENCY NURSING VOLUME 38 • ISSUE 2 March 2012
