---

Triage in Management of Trauma

Concise Notes for MD Anaesthesiology Examination

---

1. Definition & Concept

• Triage - from French trier (to sort); process of rapid patient evaluation to prioritise care based on injury severity and available resources
• Goal (routine): Identify the most seriously injured patient and ensure rapid, prioritised care
• Goal (disaster/MCI): Do the MOST good for the MOST people - shifts from individual patient focus to population focus
• Concept first used during Napoleon's wars; modern systematic approach formalised by ATLS and ACS-COT

---

2. Three ATLS Principles Governing Triage

1. Treat the greatest threat to life first
2. Lack of definitive diagnosis should never impede application of an indicated treatment
3. A detailed history is NOT essential to begin evaluation of acute injuries

---

3. Trauma System Framework (ACS-COT)

Trauma Center Levels

• Significant improvement in in-hospital and 1-year mortality when injured patients are managed in trauma centers vs non-trauma centers
• Undertriage rate: Acceptable ≤5%
• Overtriage rate: Acceptable up to 50% (intentionally generous)

---

4. Triage and Trauma System Entry Criteria (CDC / Tintinalli)

A. Physiologic Criteria

• Systolic BP < 90 mmHg
• GCS score < 14
• Inadequate airway or need for immediate intubation

B. Anatomic Criteria

• Penetrating wound to head, neck, or torso
• Gunshot wound to extremities proximal to elbow or knee
• Extremity with neurovascular compromise
• Amputation proximal to wrist or ankle
• CNS injury / paralysis
• Flail chest
• Suspected pelvic fracture

C. Mechanism of Injury

• MVC with intrusion into passenger compartment >12 inches
• MVC with major vehicular deformity >20 inches
• Ejection from vehicle
• MVC with entrapment / prolonged extrication >20 min
• Fall >20 feet (adults)
• MVC with fatality in same compartment
• Auto-pedestrian/bicycle collision >5 mph
• Motorcycle crash >20 mph

D. Special Considerations (Clinical Judgment)

• Elderly patients
• Advanced pregnancy
• Head injury in patients on anticoagulants
• Clinical judgment of prehospital clinician

---

5. Field Triage: Single Incident - CDC Algorithm

1. Vital Signs - SBP <90, GCS <14 → transport to Level I/II
2. Anatomic - injury patterns above → transport to Level I/II
3. Mechanism - as above → consider Level I/II
4. Special patient factors - age, comorbidities, anticoagulation → clinical judgment

---

6. Mass Casualty Incident (MCI) Triage

A. START Triage (Simple Triage And Rapid Treatment)

• Most widely used; only system evaluated in an actual disaster (2002 Placentia Linda train crash)
• RPM mnemonic: Respirations, Perfusion, Mental Status
• Takes seconds per patient; only interventions = open airway + direct pressure on hemorrhage

• Can walk? → GREEN
• Not walking → Check respirations:
  • No respirations after airway opening → BLACK
  • RR >30/min → RED
  • RR ≤30 → Check perfusion:
    • Radial pulse absent OR capillary refill >2 sec → RED
    • Pulse present/CRT ≤2 sec → Check mental status:
      • Cannot follow simple commands → RED
      • Can follow commands → YELLOW

Under true disaster: CPR is generally NOT performed

B. JumpSTART (Pediatric MCI Triage)

• Modification of START for children
• Key additions: 5 rescue breaths for apneic child with pulse before tagging black
• Modified criteria for hypoventilation, tachypnea, and decreased mental status
• Pediatric Triage Tape (PTT) - uses size-based criteria (50-80 cm in length, etc.)
• No pediatric system has proven clear superiority; team training > system choice

C. SALT Triage (Sort, Assess, Lifesaving Interventions, Treatment/Transport)

• Proposed as national US standard (consensus-based, 2011 Model Uniform Core Criteria)
• Differences from START:
  • Qualitative assessment of respiratory distress (not numeric rate)
  • Requires certain lifesaving interventions (chest decompression) during triage
  • Unstructured survivability estimate
• No real-disaster validation data - START preferred until evidence emerges

D. SAVE Triage (Secondary Assessment of Victim Endpoint)

• Used under catastrophic/austere conditions when prolonged delay to definitive care
• Identifies patients most likely to benefit under resource-poor conditions
• Used by: (1) providers in disaster zone with prolonged delays; (2) hospitals where demand exceeds supply (surge capacity)
• Intended for combined use with START (START first → SAVE for prolonged care scenarios)

E. Compartmentalised Disasters

• Patients "converge" on nearest hospital → overwhelms closest, bypasses farther hospitals
• Triage becomes decentralised, occurring simultaneously at multiple sites

---

7. Trauma Scoring Systems (for Triage & Prognosis)

A. Physiologic Scoring

Revised Trauma Score (RTS)

• Total RTS: 0-12 (higher = better prognosis)
• New Trauma Score (NTS) replaces RR with SpO₂ (range 3-23)

Glasgow Coma Scale (GCS)

• Range: 3-15; components: Eye opening + Verbal + Motor
• Motor component has most statistical power for predicting survival in TBI

B. Anatomic Scoring

Abbreviated Injury Scale (AIS)

• Scores each body region:

Injury Severity Score (ISS)

• ISS = A² + B² + C² (squares of AIS scores of 3 most injured body regions)
• Body regions: Soft tissue, Head/Neck, Chest, Abdomen, Extremity/Pelvis
• Range: 0-75
• ISS automatically = 75 if any region scored AIS 6
• ISS >15 → ~10% mortality (polytrauma threshold)
• Limitation: uses only one injury per body region
• NISS (New ISS): uses top 3 AIS scores regardless of region - more predictive for multiple injuries in one region

C. Combined Scoring

---

8. Prehospital Phase - Key Anaesthesia Points

Scene Safety FIRST

• Environmental toxins, chemical exposure, armed/hostile environments
• Access may be delayed pending police/fire/utility securing the scene
• "Tactical units" - specially trained EMS for hostile environments

Time-Critical Intervals

• ~50% of preventable deaths from exsanguination occur before hospital arrival
• Mortality increases with prehospital time in hemorrhaging/penetrating trauma patients
• Scene time independently associated with increased 24h and 30-day mortality (ISS >8)
• Scoop and run vs stay and play - balance of rapid transport vs stabilisation

Point-of-Care Diagnostics for Triage

• POCUS (ultrasound): First POC device widely adopted at front line; portable, reliable, evidence-based
• Telemedicine/telemetry: Live feeds to receiving hospital enable expedited OR/surgical team preparation
• Future: automated crash notification (OnStar, crash detection systems)

Prehospital Analgesia

• Fentanyl - short-acting, less haemodynamic compromise than morphine; may need repeat dosing
• Ketamine - IM/IV; effective analgesia; dissociative state possible; no convincing evidence it raises ICP
• Acetaminophen (oral) - for ambulatory patients

Air Medical Triage

• AMPT score (Air Medical Prehospital Triage) - identifies patients likely to benefit from HEMS
• HEMS patients: more likely to have hypotension, GCS <9, AIS 5

---

9. Hospital Triage - Emergency Department

Pre-arrival preparation:

• EMS notification: mechanism, suspected injuries, vital signs, exam findings, treatments given
• Task assignment to team members
• Equipment preparation
• Surgical consultants called in advance
• If non-trauma centre: immediately consider transfer + appropriate pre-transfer stabilisation

Primary Survey (ABCDE)

• A - Airway + C-spine control
• B - Breathing (100% O₂, SpO₂ monitoring)
• C - Circulation + hemorrhage control
• D - Disability (GCS, pupils)
• E - Exposure + environment

"Treat the greatest threat to life first; do NOT wait for definitive diagnosis"

---

10. Psychological Aspects of Triage

• Critical incident stress management - should be planned before an event
• Psy-START - psychological triage tool for mass casualty events
• Plan for needs of vulnerable populations: children, elderly, disabled

---

11. High-Yield Exam Points

---