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Overview :
It is important
for emergency squad personnel to be able to triage patients at the site of
injury into those that can be treated locally and those that should be referred
to trauma centers. It is important that those who need specialized treatment be
sent rapidly to trauma centers, but not to send those who are only mildly
injured.
Revised Triage Scale
Three of the
measures (eye opening, verbal response, motor response) are shared with the
Glasgow Coma Scale.
Parameters for
the revised triage scale:
(1) systolic
blood pressure
(2) eye opening
(3) verbal
response
(4) motor
response
(5) extrication
(6) penetrating
abdominal injury
(7) penetrating
neck injury
(8) penetrating
chest injury
(9) penetrating
cranial injury
(10) motor cycle
accident
(11) car or
truck occupant
(12) flail chest
(13) fall from
height
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Parameter
|
Finding
|
Points
|
|
systolic blood
pressure
|
>= 90 mm Hg
|
0
|
|
|
< 90 mm Hg
|
1
|
|
eye opening
|
spontaneous
|
0
|
|
|
to voice
|
2
|
|
|
to pain
|
4
|
|
|
no eye opening
|
6
|
|
verbal
response
|
appropriate
words
|
0
|
|
|
inappropriate
words
|
1
|
|
|
incomprehensible
sounds
|
2
|
|
|
no verbal
response
|
2
|
|
motor response
|
obeys commands
|
6
|
|
|
purposeful
movement to pain
|
5
|
|
|
withdraws from
pain
|
4
|
|
|
flexion
response
|
3
|
|
|
extension
response
|
2
|
|
|
no motor
response
|
1
|
|
extrication
|
not required
|
0
|
|
|
required
|
1
|
|
penetrating
abdominal injury
|
absent
|
0
|
|
|
present
|
1
|
|
penetrating
neck injury
|
absent
|
0
|
|
|
present
|
1
|
|
penetrating
chest injury
|
absent
|
0
|
|
|
present
|
1
|
|
penetrating
cranial injury
|
absent
|
0
|
|
|
present
|
1
|
|
motorcycle
injury
|
motorcyclist
without blunt abdominal injury
|
0
|
|
|
motorcylist
with blunt abdominal injury
|
1
|
|
car or truck
occupant at time of accident
|
not involved
in car or truck accident
|
1
|
|
|
involved in a
car or truck accident
|
0
|
|
flail chest
|
absent
|
0
|
|
|
present
|
5
|
|
fall from
height
|
none
|
0
|
|
|
from <= 15
feet
|
0
|
|
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from > 15
feet
|
1
|
where:
• It appears that a motorcyclist could be
scored both for the motorcycle injury and for not being an occupant of a car or
truck.
total score =
= SUM(points for
all of the parameters)
Interpretation:
• minimum score:
0
• maximum score:
28
• If the score
is > 7, then the patient should be referred to a trauma center.
NOTE: The motor response scoring does not
make sense. The footnote to Table IV (page 484) states that the scoring is not
an error. It compensates for weighting of the verbal response and eye opening.
Revised Triage Checklist
Revised triage
checklist:
(1) no spontaneous eye opening
(2) abnormal capillary refill
(3) penetrating cranial injuries
(4) penetrating neck injuries
(5) penetrating chest injuries
(6) penetrating abdominal injuries
(7) blunt thoracic trauma with systolic
blood pressure less than 90 mm Hg
(8) involvement in motor vehicle vs
pedestrian accidents (patient is a pedestrian) and sustaining blunt abdominal
trauma
(9) flail chest
(10) involvement in motorcycle accident
(as a motorcyclist) and sustaining blunt abdominal trauma
(11) fall greater than 15 feet
(12) age less than 5 or greater than 65
years
Interpretation:
• If any of the
above is present, then refer the patient to a trauma center.
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