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 Release 22.0, Sept. 2008
 
Chapter : ch29. Trauma & Emergency Medicine Section : Triage of the Trauma Patient
  Criteria to Identify the Unstable Patient After Trauma

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Overview :

Trauma patients may be triaged based by whether or not they are physiologically stable.

 

Criteria for being considered unstable:

(1) Glasgow coma scale <= 14

(2) pulse < 60 or > 120 beats per minute

(3) blood pressure < 90 mm Hg after a crystalloid fluid challenge of 2 liters

(4) systolic blood pressure > 190 mm Hg

(5) respiratory rate < 12 or > 24 breaths per minute

(6) poor gas exchange, with oxygen saturation < 90%

(7) temperature < 92°F (< 33°C)

(8) paralysis

(9) hoarseness or inability to talk

(10) labored respirations

(11) severe pain

(12) external hemorrhage

(13) combative

(14) severe deformity involving spine, neck, chest or extremities

(15) penetrating wound from head to popliteal fossa

 

Comorbid conditions increasing the risk for being unstable:

(1) age > 55 years

(2) history of coronary artery disease

(3) history of COPD

(4) history of liver disease

(5) history of coagulation disorder

(6) history of mental illness

(7) current insulin-dependent diabetes mellitus

(8) current anticoagulation therapy

(9) current pregnancy

 

where:

• I would think a Glasgow coma score of 14 might be considered stable.

• I would have thought that neonates might also be considered at risk.

 

  References:

Rhodes M. Chapter 13: Adult trauma resuscitation. pages 78-87 (Table 13.2, page 80). IN: Peitzman AB, Rhodes M, et al. The Trauma Manual, Second Edition. Lippincott Williams & Wilkins. 2002.

 

 

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