Identifying trauma centre need in adult patients sustaining injury.
Date First Published:
February 14, 2017
Last Updated:
April 7, 2017
Report by:
Jamie Vassallo, Emergency Medicine Academic Clinical Fellow (Plymouth Hospital)
Search checked by:
Andrew Follows, Ryan Phillips, Plymouth Hospital
Three-Part Question:
In [adults sustaining traumatic injury] does [mechanism of injury or anatomical injury or physiological derangement] identify patients requiring [treatment at a major trauma centre]?
Clinical Scenario:
You are first on scene to a road traffic collision (RTC) involving a 32 year old male who has crashed his motorbike at 30mph. He is haemodynamically normal but complains of pain in his right chest and right hip and is unable to walk. You wonder whether the optimum management of this patient would be to bypass the nearby trauma unit for direct transfer to the closest major trauma centre.
Search Strategy:
Medline 1946 – May Week 3, 2016. [(trauma*.ti,ab OR exp WOUNDS AND INJURIES/ OR exp MULTIPLE TRAUMA/) AND (exp ADULT/) AND (mechanism.ti,ab OR anatom*.ti,ab OR “vital sign*”.ti,ab OR physiolog*.ti,ab) AND ((“trauma cent*”.ti,ab OR MTC.ti,ab OR “trauma unit”.ti,ab OR “emergency medical service”.ti,ab OR paramedic.ti,ab) AND (triage.ti,ab OR transfer.ti,ab))]
Outcome:
The search produced 241 articles. Following a review of title and abstract, 26 papers were identified to review in full. Following full text review 9 were removed as not directly relevant to the research question. The remaining 17 papers are presented below (Table 1).
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Accuracy and relationship of mechanisms of injury, trauma score, and injury severity score in identifying major trauma Long WB, Bachulis BL, Hynes GD. 1986 United States | 2511 trauma patients over a 16 month period | Retrospective cohort study | Correlation of the pre-hospital trauma score with the ISS | Prolonged extrication >20 minutes and death in same vehicle associated with ISS >16 | Single centre. Use of ISS as an output measurement. Not all patients had a trauma score calculated in the pre-hospital setting. |
| Accuracy of mechanism of injury at predicting ISS >15 | |||||
| Vehicular trauma triage by mechanism: avoidance of the unproductive evaluation Simon BJ, Legere P, Emhoff T, et al 1994 United States | Review of 1235 consecutive trauma team activations at a single hospital | Retrospective cohort study | To provide a secondary triage tool to reduce un-necessary trauma team activation. | Mechanism of injury alone has a PPV of 38% for serious injury. By introducing the vehicular checklist PPV increases to 61%. Abnormal physiology created false positives in uninjured patients. | List of life-saving interventions not exhaustive and not described in full. Both head on collision >30mph & vehicular intrusion had same proportion of minimally injured and severely injured patients, making it impossible to draw solid conclusions. |
| Do pre-hospital trauma center triage criteria identify major trauma victims? Esposito TJ, Offner PJ, Jurkovich GJ, et al 1995 United States | 5028 patients with pre-hospital criterion for treatment at trauma centre. Data collected from 222 pre-hospital provider agencies & 53 hospitals. | Prospective cohort study | Identify indicators of major trauma victims using ISS and mortality for each pre-hospital criterion: anatomical, physiological, mechanism of injury & clinical gestalt. High Yield >30%, Intermediate 20-30%, Low <20% (all with ISS >15) | Only 60% cases included had a single pre-hospital criteria. Pedestrian struck, prolonged pre-hospital time & abnormal physiology (SBP<90mmHg, 10>RR>29, GCS<13) associated with high yield ISS>15 Ejection & Vehicle deformity associated with intermediate yield. Fall >6m and clinician gestalt associated with low yield. | ISS only recorded for 45%, therefore large amount of missing data. ISS has been shown to not fully correlate with the resource requirements of a trauma patient |
| pplication of field triage guidelines by pre-hospital personnel: is mechanism of injury a valid guideline for patient triage? Cooper ME, Yarbrough DR, Zone-Smith L, et al 1995 United States | Questionnaires given to 112 Emergency Medical Services Personnel conveying trauma patients to a single centre. | Survey study | To identify the PPV of mechanism of injury in isolation at predicting trauma centre need. | 26% patients conveyed due to mechanism of injury alone. Mechanism of injury in isolation has a low PPV. | Study period not defined |
| Accuracy of trauma triage in patients transported by helicopter. Wuerz R, Taylor J, Smith JS 1996 United States | 333 patients transported by helicopter to a level 1 trauma centre | Case series | Performance characteristics of physiological criteria | Using ISS>15, physiological criteria under-triaged 44.3% (n=67) and mortality 16.1% (n=5) | Low median study age (26 years, IQR 19-42). Limited to helicopter transport only. |
| Ejection as a key word for the dispatch of a physician staffed helicopter: the Swiss experience. Schoettker P, Ravussin P, Moeschler O. 2001 Switzerland | Comparison of patients involved in RTC (cars) with ejected (n=71) vs non-ejected (n=539). patients from RTC | Prospective cohort study | Type of injury | No obvious evidence found | Outcome measures not matched between all groups. Patients who died had their ISS excluded from the study median calculation. |
| Pre-hospital vital signs | 43.7% (n=31) ejected had GCS <8 | ||||
| Hospital diagnosis | (not included in analysis) | ||||
| ISS (median) | Ejected = 17 vs non-ejected = 9 | ||||
| Need for ICU | ICU admission in 34% (n=21) of ejected patients | ||||
| Need for life-saving surgery | 38% of ejected patients (n=24) | ||||
| Outcome | 24% mortality (n=17) in ejected patients | ||||
| Situational criteria performance | Physiological criteria under-triaged 67 patients – addition of situational criteria reduced this by 86.6% (n=58) | ||||
| Pre-hospital physiologic data and lifesaving interventions in trauma patients. Holcomb JB, Niles SE, Miller CC, et al. 2005 United States | Helicopter transport of 216 patients to major trauma centre (2001-7) and who required admission to hospital. | Cohort study | Life-saving intervention both pre-hospital and in-hospital | 48/114 patients with pre-hospital HR >100 required life-saving intervention. 90% of patients with pre-hospital capillary refill >2s required life-saving intervention (OR 17.43). 73% with GCS motor score <6 and 37% with RR >24 required life-saving intervention. 87% with pre-hospital SBP <90 required life-saving intervention (OR 16.81). Using logistical regression patients with GCS motor score <6 and SBP<90mmHg have a 95% probability of requiring a life-saving intervention vs 21% in patients with GCS motor score 6 and SBP >90mmHg. | Convenience sampling. Limited analysis of life-saving interventions (only in-hospital and 5 pre-hospital listed), with no specific differentiation. No differentiation between which life-saving intervention is associated with which physiological derangement, and which of these life-saving interventions were performed in the pre-hospital environment. |
| Manual vital signs reliably predict need for life-saving interventions in trauma patients. Holcomb JB, Salinas J, McManus JM, et al. 2005 United States | Helicopter transfer of 793 pre-hospital trauma patients. | Retrospective cohort study | Correlation of physiological signs and need for life-saving intervention. Additional review of vital signs measured either manually or through automation. | Verbal and motor component of GCS, along with radial pulse, had the greatest predictive power at predicting the need for life-saving intervention. | Head injured patients (AIS > 3) were excluded retrospectively. Large amount of missing data, resulting in final analysis set of n=381 (48%). |
| Evaluation of pre-hospital trauma triage criteria: a prospective study at a Danish level I trauma centre. Kann SH, Hougaard K, Christensen EF. 2007 Denmark | Consecutive injured patients presenting to single hospital over 6 months. 848 patients included; 242 trauma team activations. | Prospective cohort study | Evaluation of rates of over-triage (inappropriate trauma team activation) from mechanism of injury in isolation. | 5/606 without trauma team activation had ISS>15. ISS < 15 for 78% trauma team activations. 60 patients had single mechanism of injury criterion responsible for trauma team activation. 92% had ISS<15. High speed RTC (>40mph) in isolation associated with ISS>15 in only 7%. | Reported that combination of abnormal physiology & mechanism of injury improve reliability of trauma team activation associated with ISS > 15 however results not documented. |
| Isolated rollover mechanism does not warrant trauma center evaluation. Haan JM, Glassman E, Hartsock R, et al 2009 United States | Mechanism of injury – vehicle rollover only. 569 patients not meeting other trauma triage criteria. |
Retrospective cohort study | Hospital admission | 35% of patients admitted | The surrogates used are not objectively transferable to a definition of trauma centre need. |
| Surgical intervention | 6 patients (1%) required urgent surgery <12 hours after admission. Further 124 (21.7%) required surgery at later date | ||||
| ICU admission | 8 patients (1.4%) required ICU admission. | ||||
| Mechanism of injury and special consideration criteria still matter: an evaluation of the National Trauma Triage Protocol. Brown JB, Stassen NA, Bankey PE, et al. 2011 United States | 1,086,764 patients from the National Trauma Databank. | Retrospective cohort study | Trauma centre need defined as ISS>15, ICU admission, urgent surgery Logistic regression analysis to identify individual factors linked with trauma centre need. | Physiological criteria outperform anatomical criteria at determining trauma centre need (sensitivity 32% vs 26%, specificity 91% vs 86%). Anatomical criteria best at predicting need for surgical intervention. Physiological criteria best at predicting ISS>15, but poor at predicting surgical need. Flail chest greatest predictor of trauma centre need. In order to reduce under-triage, mechanism of injury required in addition to anatomical & physiological criteria. | Retrospective database review with limited variables leading to ambiguity. Selection bias present due to database skewed to major trauma centres. |
| Does mechanism of injury predict trauma center need? Lerner EB, Shah MN, Cushman JT, et al. 2011 United States | Major trauma centre transfer on mechanism of injury alone (not fulfilling anatomical & physiological criteria). 9,483 patients with mechanism of injury of assault, motor vehicle crash, fall or pedestrian/ cyclist struck. | Prospective cohort study | Mechanism of injury as an indicator for major trauma centre need | 2,363 fulfilled mechanism of injury criteria. 9% (n=204) defined as requiring trauma centre need. Sensitivity 39.7%. LR >5 mechanism of injury predictors were death of another occupant; fall >20 feet; >20min extrication. | Use of interviews to determine mechanism of injury. |
| Mechanism of injury is not a predictor of trauma center admission Stuke LE, Duchesne JC, Hunt JP, et al. 2013 United States | Two groups: assessment of anatomical & physiological criteria (n= 6584) vs mechanism of injury alone (n=3315). | Retrospective cohort study | Discharge status 6 hours after ED admission. | 55% (n=3613) of anatomical & physiological patients admitted. 45% (n=2971) of mechanism of injury patients admitted. Removing mechanism of injury as sole admission criteria would have resulted in 2700 fewer admissions. | Emphasis on mechanism of injury and reduction in overtriage. |
| Does EMS Perceived Anatomic Injury Predict Trauma Center Need? Lerner EB, Roberts J, Guse CE, et al. 2013 United States | 11,892 patients brought to trauma centres by Emergency Medical Services. 1,274 excluded due to meeting other trauma triage criteria. |
Prospective cohort study | Anatomical injury as criteria for trauma centre need. Trauma centre need defined as ISS>15, need for non-orthopaedic surgery within 24 hours, ICU admission or death prior to discharge. | Anatomical criteria had 38% sensitivity and 91% specificity at predicting trauma centre need. Flail chest, paralysis, ≥2 long bone fractures & amputation had LR >5 for trauma centre need. 503 patients missed by anatomical & physiological criteria. 41% (n=204) would have been captured by mechanism of injury. | EMS perceived anatomical injury compared with ICD-9-CM codes attributed by billing teams. Subsequent to the study ‘flail chest’ was removed from guidelines & replaced with chest wall instability/deformity. |
| Not all mechanisms are created equal. Stuke LE, Duchesne JC, Greiffenstein P, et al. 2013 United States | Using mechanism of injury alone, 3,569 patients transported to trauma centre. | Retrospective cohort study | Mechanism of injury as an indicator for major trauma centre need. Trauma centre need defined as ISS >15, ED transfusion, ICU admission, laparotomy/thoracotomy/ vascular/surgery < 24 hours, pelvic fracture, >2 proximal long bone fractures or neurosurgical intervention. | 23% (n=821) with mechanism of injury required trauma centre need. LRs >5 defined as death in same passenger compartment; ejection from vehicle; > 20mins extrication; fall >20feet; pedestrian thrown/run over. | Missing data due to retrospective database review. From 2006 patients with mechanism of injury in isolation were transferred to Major Trauma Centre only at the patient’s request. |
| he sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre. Potter D, Kehoe A, Smith JE. 2013 United Kingdom | 171 patients with ISS>15 presenting to a single major trauma centre. | Retrospective cohort study | Sensitivity of Wessex Triage Tool (WTT) in identifying ISS>15 patients | Wessex triage tool demonstrates sensitivity of 53%. Performance reduced in older population with low energy trauma. | Missing data due to retrospective database review |
| Validation of pre-hospital trauma triage criteria for motor vehicle collisions. Davidson GH, Rivara FP, Mack CD, et al. 2014 United States | 85,761 patients involved in motor vehicle collisions. | Retrospective cross-sectional study | PPV of anatomical markers, physiological markers and mechanism of injury as indicators of severe trauma, defined as ISS >15. | Physiological criteria - PPV 20.8% Anatomical criteria - PPV 48.5% Mechanism of injury criteria - PPV 9.7% | Use of ISS >15 was used to define trauma centre need and not resource requirement. |
Author Commentary:
There is some evidence supporting the use of anatomical injury, mechanism of injury and physiological markers in the pre-hospital triage of injured patients. However, there is a paucity of high quality evidence in this field. Much of the literature is derived from the retrospective analysis of trauma registry databases, with the associated limitations of incomplete data capture and non-standardised outcome variables, often leading to contradictory results between studies. Additionally, selection bias is evident in a number of studies; patients exhibiting physiological derangement were removed from further analysis. This may limit analysis as patients with abnormal vital signs may be more likely to have endured a significant mechanism of injury or anatomical injury.
There is no consensus as to what constitutes a need for trauma centre care. It is vital that this is agreed in order to standardise outcomes by which to conduct further research. In a number of studies, the outcome measure defining trauma centre need was an Injury Severity Score (ISS) >15, which itself is a retrospective measurement. Although this is a definition of major trauma, it may not represent the optimal marker for trauma centre need and there is evidence to support a lack of correlation between ISS and the need for emergency procedures. Furthermore, statistical analysis is not standardised with a combination of performance characteristics being measured.
There is no consensus as to what constitutes a need for trauma centre care. It is vital that this is agreed in order to standardise outcomes by which to conduct further research. In a number of studies, the outcome measure defining trauma centre need was an Injury Severity Score (ISS) >15, which itself is a retrospective measurement. Although this is a definition of major trauma, it may not represent the optimal marker for trauma centre need and there is evidence to support a lack of correlation between ISS and the need for emergency procedures. Furthermore, statistical analysis is not standardised with a combination of performance characteristics being measured.
Bottom Line:
There is some evidence to support the use of anatomical injury, mechanism of injury and physiological parameters in predicting requirement of major trauma centre resources. However, there is no high-quality evidence supporting the use of any parameter either in isolation or in combination. Targeted research is required to establish the optimal method of pre-hospital identification of the seriously injured patient, thereby determining trauma centre need.
References:
- Long WB, Bachulis BL, Hynes GD. . Accuracy and relationship of mechanisms of injury, trauma score, and injury severity score in identifying major trauma
- Simon BJ, Legere P, Emhoff T, et al. Vehicular trauma triage by mechanism: avoidance of the unproductive evaluation
- Esposito TJ, Offner PJ, Jurkovich GJ, et al. Do pre-hospital trauma center triage criteria identify major trauma victims?
- Cooper ME, Yarbrough DR, Zone-Smith L, et al. pplication of field triage guidelines by pre-hospital personnel: is mechanism of injury a valid guideline for patient triage?
- Wuerz R, Taylor J, Smith JS. Accuracy of trauma triage in patients transported by helicopter.
- Schoettker P, Ravussin P, Moeschler O.. Ejection as a key word for the dispatch of a physician staffed helicopter: the Swiss experience.
- Holcomb JB, Niles SE, Miller CC, et al.. Pre-hospital physiologic data and lifesaving interventions in trauma patients.
- Holcomb JB, Salinas J, McManus JM, et al.. Manual vital signs reliably predict need for life-saving interventions in trauma patients.
- Kann SH, Hougaard K, Christensen EF.. Evaluation of pre-hospital trauma triage criteria: a prospective study at a Danish level I trauma centre.
- Haan JM, Glassman E, Hartsock R, et al. Isolated rollover mechanism does not warrant trauma center evaluation.
- Brown JB, Stassen NA, Bankey PE, et al.. Mechanism of injury and special consideration criteria still matter: an evaluation of the National Trauma Triage Protocol.
- Lerner EB, Shah MN, Cushman JT, et al.. Does mechanism of injury predict trauma center need?
- Stuke LE, Duchesne JC, Hunt JP, et al.. Mechanism of injury is not a predictor of trauma center admission
- Lerner EB, Roberts J, Guse CE, et al. . Does EMS Perceived Anatomic Injury Predict Trauma Center Need?
- Stuke LE, Duchesne JC, Greiffenstein P, et al. . Not all mechanisms are created equal.
- Potter D, Kehoe A, Smith JE.. he sensitivity of pre-hospital and in-hospital tools for the identification of major trauma patients presenting to a major trauma centre.
- Davidson GH, Rivara FP, Mack CD, et al. . Validation of pre-hospital trauma triage criteria for motor vehicle collisions.