Trauma scoring and prehospital triage

EDITOi ALS Trauma Scoring and Prehospital Triage Triage is the process of sorting patients in terms of priority, risk, or destination by identifying severity of illness or risk of death. In trauma care systems, prehospital triage provides a method for identifying injured victims who merit evaluation by trauma teams that are capable of performing immediate surgery. Although triage is but one component of such systems, along with medical direction, prevention, training, prehospital care, transportation, hospital care, rehabilitation, public participation, and medical audit, it constitutes an essential link in the trauma care chain. Without proper triage seriously injured patients may not receive the benefits of system care, and those with lesser injuries may bypass adequately equipped, nondesignated hospitals unnecessarily, Indices such as the Trauma Score 1 and the CRAMS Scale,2 which attempt to quantify injury severity based on physiologic status, have been used to assist prehospital triage, to assess case mix, and to predict outcome. Two reports in this issue of Annals address the prehospital use of these tools. Moreau and colleagues discuss the interrater reliability of the Trauma Score in the prehospital setting. Of 144 trauma patients assessed independently in the field, emergency medical technicians (EMTs) and a nurse observer derived identical scores 91% of the time and differed by only one point another 5% of the time. These findings are not surprising because the authors have reported similar results in both ED and military environments. Reproducibility, however, does not constitute the sole criterion of merit as a triage tool. Omato and associates, studying the ability of the Trauma Score and the CRAMS Scale to identify patients with major injuries, conclude that neither method is particularly useful for prehospital triage. Although both methods performed flawlessly in identifying patients dying in the field or in the ED, neither could match the EMTs' intuitive abilities to identify as serious those patients whose injuries eventually required transfer from the ED directly to the operating room. Accordingly the providers benefiting most from field scoring techniques were emergency medical techniciansambulance. These conclusions are not surprising either, because Champion previously has observed that physiologic scoring used alone does not provide an adequate basis for prehospital triage. 3 If triage criteria are to identify seriously injured patients accurately, they must address not only physiologic status but also anatomic injury and injury mechanism. 4 Of these approaches, physiologic status is the most specific but the least sensitive. As demonstrated by Omato and associates, protocols that depend solely on injury scoring

may produce significant undertriage, detecting only those patients who already have developed overt respirato~ cardiac, or neurologic signs. Intermediate in ability to detect serious trauma is anatomic injury, characterized by conditions such as amputations, severe bums, and penetrating injuries of the head, neck, torso, or groin. Although most such patients eventually exhibit physiologic decompensation, a significant proportion initially appear to be stable. Although it remains to be studied adequately, the most promising approach to minimizing undertriage resides in consideration of injury mechanism. Despite its lack of specificity, it offers the most sensitive method available for identifying patients at risk for occult, life-threatening injuries, such as those sustained by persons who are subjected to severe, acceleration or deceleration, who are ejected or require prolonged extrication from vehicles, or who survive accidents in which other individuals are killed. The goal of a trauma care system is to improve quality of care, thus reducing morbidity and mortality through improved prevention, treatment, and rehabilitation. To achieve this we must take three steps to improve prehospital triage. First we must optimize existing methods for identifying patients at risk for serious injur~, combining the elements of physiologic status, anatomic i n j u ~ and injury mechanism to maximize sensitivity and specificity, thereby minimizing inappropriate triage. Second we increasingly must involve emergency physicians in the medical direction of prehospital trauma care, both in developing off-line triage protocols and in assisting with on-line triage decisions. Finally we must continue to encourage research of trauma care systems, such as that by Morean and Omato. Richard H Cales, MD Associate Clinical Professor Division of Emergency Medicine Oregon Health Sciences University Portland, Oregon 1. Champion HR, Sacco WJ, Camazzo AJ, et al: The trauma score. Crit Care Med 1981;9:672-676. 2. Gormican SP: CRAMS scale: Field triage of trauma victims. Ann Emerg Mecl 1982;11:132-135. 3. Champion HR: Field triage of trauma patients (editorial). Ann Emerg Med 1982; 11:160-161. 4. Conference on Injury Severity Scoring and Triage. Sponsored by the US Army Medical Research and Development Command, Contract No DAMD 17-83-G-9259, and the American Trauma Society, Washington, DC, September 1983.

Diagnosis of Pregnancy in the ED The capability to diagnose pregnancy promptly and accurately should be both a goal and an expectation of every 108/1105

modem hospital's ED. The complaint of abnormal abdominal-pelvic pain and/or vaginal bleeding by women of re-

Annals of Emergency Medicine

14:11 November 1985