Citation

Newgard CD, Richardson D, Holmes JF, Rea TD, Hsia RY, Mann NC, Staudenmayer K, Barton ED, Bulger EM, Haukoos JS, The Western Emergency Services Translational Research Network Westrn Investigators. Prehosp. Emerg. Care 2014; 18(4): 461-470.

Copyright

(Copyright © 2014, National Association of EMS Physicians, Publisher Informa - Taylor and Francis Group)

DOI

10.3109/10903127.2014.912707

PMID

24933614

Abstract

OBJECTIVE. To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the undertriage of seriously injured elders to non-trauma hospitals.

METHODS. This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was "serious injury," defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria.

RESULTS. A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1-9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3-15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%.

CONCLUSIONS. Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing overtriage to major trauma centers.

Language: en