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Overview :
The Triage Index
provides a measure of injury severity. It can be combined with historical and
clinical findings to triage trauma patients.
|
Parameter |
Finding |
Points |
|
visual
inspection of chest wall movement (respiratory
expansion) |
normal |
0 |
|
|
shallow |
1 |
|
|
retractive |
2 |
|
|
none |
3 |
|
nail bed
or finger pad pressure (capillary refill) |
immediate
( <= 2 seconds) |
0 |
|
|
delayed (
> 2 seconds) |
2 |
|
eye
opening to spoken or shouted verbal command or standard pain
stimulus |
spontaneous |
0 |
|
|
voice |
1 |
|
|
to
pain |
2 |
|
|
none |
3 |
|
conversational ability (verbal
response) |
oriented |
0 |
|
|
confused |
1 |
|
|
inappropriate
words |
2 |
|
|
incomprehensible
sounds |
3 |
|
|
none |
4 |
|
spoken or
shouted verbal commands or standard pain stimulus (motor
response) |
obedience |
0 |
|
|
withdrawal |
1 |
|
|
flexion |
2 |
|
|
extension |
3 |
|
|
none |
4 |
where:
• shallow respiratory expansion is
assigned 2 points in the original paper, but think that 1 point was
intended
• eye opening + conversational ability +
motor response correspond to the Glasgow Coma Score; the Glasgow Coma Score for
eye opening is (4 - points above), for verbal response is (5 - points above),
and for motor response is (6 - points above)
triage score
=
= (points for
respiratory expansion) + (points for capillary refill) + (points for eye
opening) + (points for verbal response) + (points for motor response)
Interpretation:
• minimum score
0
• maximum score
16
Triage Algorithm
Historical
Criteria:
(1) Has the patient been struck by an
auto, bus, truck, train, etc.?
(2) Has the patient had a fall from more
than 15 feet?
(3) Has the patient had an auto accident
at more than 25 miles per hour?
(4) Has the patient been thrown from the
vehicle?
(5) Has the patient had a motorcycle
accident?
(6) Has the patient sustained a
burn:
• involving more than 20% of BSA (5% if
child)
• involving the hands, feet, face or
perineum
• with inhalation
injuries
• caused by electrical
energy
• associated with other
trauma?
Vital Signs
Criteria:
(1) Has the
patient a Triage Score of 4 or more?
(2) Has the
patient a systolic blood pressure < 90 mm Hg?
Physical
Examination:
(1) Has the patient a head injury with
depressed level of consciousness (Glasgow Coma Scale of 10 or
less)?
(2) Has the patient a penetrating injury
of the chest, abdomen, head, neck or groin?
(3) Has the patient a spinal cord
injury?
(4) Has the patient a fractures of 3 or
more long bones?
(5) Has the patient an amputation or
degloving injury?
(6) Has the patient any injury involving
2 or more body systems (CNS, cardiovascular, pulmonary, GI,
GU)?
Interpretation:
• If an answer to any of the questions
above is affirmative, then the patient is triaged to Trauma
Center
• If answers to all of the questions
above are negative, then the patient is triaged to the Emergency
Department
| References: | |
Champion HR, Sacco WJ, et al. Assessment
of injury severity: the Triage Index. Crit Care Med. 1980; 8:
201-208
Ford EG. Chapter 4: Trauma Triage. pages
95-117. IN: Ford EG, Andrassy RJ. Pediatric Trauma - Initial Assessment and
Management. W.B. Saunders Company. 1994.
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