Course Trauma Care
THE FIELD TRIAGE
GOAL OF THE CHAPTER
Every trauma patient requires an appropriate categorisation in a "normal" accident and in the mass casualty; the Triage is the mean to easily and quickly identify the most serious trauma victims in every situation.
Triage is a French word originally used by the French wool traders, and its meaning is "to choose, to select". In medical meaning we find for the first time the term triage with Napoleon's surgeon Larrey.
The primary goal of triage was to identify quickly and prioritise the care for the battle's victims, and was in the military field that for the first time the problem related to the rescue with a little field resources, in little time for a great number of victims has been developed.
THE EUROPEAN SITUATION
Every trauma system in Europe recognise a particular and appropriate triage decision scheme; the principles of these different application of the triage are the same, but a little can change from a country to another because of the different trauma system organisation in each country.
In the same country itself the trauma system can change from a region to another.
THE TRIAGE PRINCIPLES
Triage is the classification of patients according to medical need.
There are three applications of this process in early management of the trauma victims:
1) field triage
2) inter hospital triage to specialised care facilities
3) mass casualty triage
Trauma patient require a high specialised center because of their severity. The patient should be triaged in the field to facilitate the rapid transport to the appropriate center.
Of the trauma victims who are going to die many of them do so before reaching a hospital; of the remaining who die in-hospital, a great part die in the first four hours.
The following factors must be considered in field triage:
A) the level of severity of the injured patient
B) medical control
C) the resources available to treat the patient, including time and distance.
To assess the severity of the patient we must consider:
1) abnormal physiologic signs presence
2) obvious anatomic injury
3) mechanism of injury
4) concurrent disease
The triage decision determines the level and intensity of initial management of the multiple trauma victims.
There are a lot of scoring system to use for the categorisation of the trauma patients, physiologic scores, anatomic scores and others.
The Revised Trauma Score (a physiologic score) seems to be the easiest to apply for the prehospital personnel staff. This score provides more accurate predictions for patients with serious head injury.
The RTS is based on the Glasgow Coma Scale, systolic blood pressure and respiratory rate.
Every variables have a score from 4 (normal) to 0.
THE REVISED TRAUMA SCORE
|Respiratory Rate||Variables||Score||Systolic Blood pressure||Variables||Score||GCS||Variables||Score|
|Breaths/ minute||10-24||4||mm Hg||>89||4||13-15||4|
Revised Trauma Score = Respiratory Rate + Systolic Blood Pressure + GCS
A proposal to select the patient for the trauma center can be achieved putting all
together some physiologic and anatomic principles together with information regarding the
trauma mechanism and the patient's medical history (Triage Decision Scheme, American
College of Surgeons).
But the prehospital team must consider that if any doubt exists they must to take the patient to the trauma center. While keeping in consideration the different organisation of the trauma system in the European Countries, where it is possible it is better to bring the patient to the most appropriate Trauma Center even if it is not the closest facility. This principle requires a good pre hospital (field) treatment of the trauma patient, a good communication system and good pre-hospital staff.
The vast majority of the deaths occur within a few hours of injury.
The triage decision is often germane to patient survival or death. It is for this reason that the highest available level of medical expertise should be brought into triage decision making process.
Usually this process will involve advice and guidance from physician who provide medical control to pre hospital personnel.
Management of the severely injured patient begins with the evaluation and treatment on
Surgeons, emergency physician, and pre-hospital care personnel should work together to develop pre hospital triage protocol for trauma patients. On line physician medical control is vitally important in emergency medical system for the trauma patient.
It has been clearly documented that there is a brief period of time in which the patient's resuscitation must be completed and definitive care for his injury begun; this treatment can better performed if a "on line" medical control is present to guide some procedures (intubation, drugs administration ecc.) when required by the scene.
The initial prehospital stabilisation should be limited to establishment of airway, C-spine immobilisation haemorrhage control and fractures immobilisation (with different splint devices, vacuum mattress ecc.). The insertion of an I.V. line should be a mandatory procedure in all the trauma patient.
In many trauma system the pre hospital personnel are allowed to perform a chest decompression (needle or tube) every time they consider the presence of a thorax lesion requiring it (tension pneumothorax, pneumothorax ecc.) and after medical authorisation, via radio.
This procedure can not be accepted as a fundamental field procedure because of the different level of capacity among the rescue units in all Europe
Both the level of available hospital resource and time / distance factors also are considered in making the triage decision. The system for trauma patients in an urban environment is considerably different from that in a rural environment. In the latter case access to any level of trauma care may involve a significant distance and time. Each country and each region should structure a trauma system in a manner to ensure the prompt access to appropriate care and minimise the risk of delay in diagnosis, delay in surgical intervention, and inadequate focused care, which are responsible for most of the preventable death that occur.