ATHS Summary

A Critical Issue in the United States

Trauma is the number-one cause of death between the age of one and 46 years of age. The total economic costs associated with trauma are greater than $580 billion dollars annually, making trauma America's most costly disease.

• Trauma is the number one leading cause of death of death for the age group (1-46) accounting for 47 % of all death in this age group (CDC, 2014).
• Each year trauma accounts for 41 million emergency department visits and 2.3 million hospital admissions in the United States.
• Trauma injuries accounts for 30% of all life years lost in the United States (Cancer accounts for 16% and heart disease accounts for 12%).
• There were 192,000 deaths due to injuries in 2014
• Economic burden associated with trauma was $585 billion (both health care cost and lost productivity) (CDC, 2014).

A Critical Issue in Alabama

Alabama has the fourth highest per capita highway trauma death rate in the United States. This death rate is twice as high in the rural areas as the municipal areas. Eighty percent of Alabama trauma cases involve blunt trauma (motor vehicle crashes and falls), and 20 percent involves penetrating trauma (gunshot wounds and stabbings). Without a trauma system, 60 percent of Alabama trauma patients initially go to the hospitals without trauma capabilities. Challenges are especially great in the rural areas because paramedics are often not available to provide prehospital care; emergency department care may not be provided by physicians who are experienced in managing critical trauma patients; most hospitals don't have the surgical specialists to provide definitive trauma care; and arranging transfer to definitive care often takes hours.

Trauma Center

Trauma centers are hospitals committed to providing a full range of care for severely injured patients 24 hours a day, seven days a week. Available trauma care includes ready-to-go teams that perform immediate surgery and other necessary procedures for people with life-threatening injuries.

Trauma System

A trauma system involves a trauma center working together with 9-1-1, emergency medical service personnel (EMSPs), ambulances, helicopters, and other health care resources in a coordinated and preplanned way. This network of care is designed to get seriously injured people to a place with the right resources as quickly as possible, thus preventing the patient from having to go through the lengthy transfer process.

Trauma System Patients

While a "trauma patient" is any patient with an injury, a "trauma system patient" is one who has life-threatening or potentially life-threatening injuries that require rapid, specialized evaluation and treatment. Only about 10 percent of trauma patients are serious enough to be entered into the trauma system. The other 90 percent will continue to be cared for at their local community hospital.

In the field, all injured patients go through two trauma triage processes. The primary triage is to determine if they should be entered into the trauma system. The patient is then triaged to determine what level of trauma hospital they should be taken to (this will vary slightly from region to region and is part of the regional trauma plan).

Four Criteria for a Patient to Enter the Trauma System

Physiologic Criteria
(Generally Triaged to a Level I Trauma Center)

• A systolic BP <90 mm/Hg in an adult or child 6 years or older
  <80 mm/Hg in a child five or younger.
  This includes any trauma related cardiac arrest that will be treated or transported to the hospital.
• Respiratory distress - rate < 10 or >29 in adults, or
  <20 or >60 in a newborn.
  <20 or >40 in a child three years or younger.
  <12 or >29 in a child four years or older.
• Head trauma with Glasgow Coma Scale score of 13 or less or head trauma with any neurologic changes in a child five years or younger.

Anatomic Criteria
(Generally Triaged to a Level I Trauma Center)

• The patient has a flail chest.
• The patient has two or more obvious proximal long bone fractures (humerus, femur).
• The patient has penetrating trauma to the head, neck, torso, or extremities proximal to the elbow or knee.
• The patient has in the same body area a combination of trauma and burns (partial and full thickness) of fifteen percent or greater.
• See Burns Protocol (3.08) for criteria to enter a burned patient into the trauma system.
• The patient has an amputation proximal to the wrist or ankle.
• The patient has one or more limbs which are paralyzed.
• The patient has a pelvic fracture, as evidenced by a positive “pelvic movement” exam.
• The patient has a crushed, degloved, mangled, or pulseless extremity.
• The patient has an open or depressed skull fracture.

Mechanism of Injury Criteria
(May Go to a Level II or III if Closer Than a Level I Trauma Center)

• A patient with the same method of restraint and in the same seating area as a dead victim.
• Ejection of the patient from an enclosed vehicle.
• Motorcycle/bicycle/ATV crash with the patient being thrown at least ten feet from the motorcycle/bicycle.
• Auto versus pedestrian with significant impact with the patient thrown, or run over by a vehicle.
• An unbroken fall of twenty feet or more onto a hard surface. Unbroken fall of 10 feet or 3 times the height of the child onto a hard surface.

EMSP Discretion Criteria
(May Go to a Level II or III if Closer Than a Level I Trauma Center)

• If the EMSP is convinced that the patient could have a severe injury which is not yet obvious, the patient should be entered into the Alabama Trauma System.

The EMT's suspicion of severity of trauma/injury may be raised by the following factors:

• Age >55
• Age
• Environment (hot/cold)
• Patient’s previous medical history
• Insulin dependent diabetes or other metabolic disorder
• Bleeding disorder or currently taking anticoagulant medication (coumadin, heparin)
• COPD/Emphysema
• Renal failure on dialysis
• Pregnancy
• Child with congenital disorder
• Extrication time >20 minutes with heavy tools utilized
• Motorcycle crash
• Head trauma with history of more than momentary loss of consciousness.

Hospitals will also be able to enter patients into the trauma system.

Some trauma cases are brought to the local hospital by private vehicle and others are under-triaged and not initially recognized as serious enough to put into the system. Physiologic, anatomic, and mechanism of injury criteria are the same as for EMS. There is no discretion criteria for hospitals.

Alabama's Trauma and Health System

Alabama's system is built around Level I hospitals. The goal is to have a Level I trauma center within 45 minutes of any place in Alabama. It is estimated that six Level I trauma centers will be needed to accomplish this goal. In this system, the majority of trauma system patients will go to the Level I trauma centers. The Level II and III trauma centers will usually get the less severe patients but will provide backup when a Level I center is unavailable.

Hospital participation as a trauma center is voluntary. Those hospitals wishing to participate will be inspected and designated for the level of service they can provide.

Trauma system patient routing will be done by a single high-tech communication center (the Alabama Trauma Communication Center - ATCC) that monitors the resources of every trauma center and coordinates patient transport to the appropriate ready trauma center. The ATCC can also facilitate the transfer of patients that must be stabilized locally before transfer to definitive care. Monitoring of the trauma center resources is done with a computer intranet system that maintains up-to-the minute status of all trauma hospitals and their resources. This allows hospital to always be in control of when they are available to accept a new patient.

All parts of the system will be monitored by the quality improvement process. For this reason participation in the Alabama Trauma Registry is required of all levels of trauma centers.