Patient Care Guidelines

Adult Trauma Response Levels

Objective:

  • To provide a uniform definition of patients for three levels of trauma response.
  • To define who responds at each level

Scope:

This guideline applies to all trauma patients of AUMedical Center who are 13 years of age and above.

Augusta University Medical Center is designated by the State of Georgia’s Department of Public Health as a Level One Trauma Center and as such is capable of providing Level One trauma care as defined by the American College of Surgeons Committee on Trauma. There are three defined levels of trauma team response; they are Trauma I; Trauma II; and Trauma III

Trauma I

This is the highest level of activation

Criteria for Trauma I

Physiologic Parameters:

  • Systolic blood pressure of < 90 mmHg
  • Decreased LOC, GCS 11, AVPU score of P or U, attributed to trauma
  • Respiratory rate <10 or >29, from respiratory compromise or obstruction

Anatomic Parameters:

  • Penetrating wounds to the neck, chest, abdomen, head or extremities proximal to the elbow or knee
  • Crushed, degloved or mangled extremity or amputation of extremity proximal to the wrist or ankle
  • Open depressed skull fracture
  • Paralysis related to the trauma
  • Injuries with massive uncontrolled bleeding, vascular compromise or need for tourniquet

Clinical Condition:

  • Transfer patients from other hospitals receiving blood to maintain vital signs
  • Intubated patients transferred FROM THE SCENE or patients with respiratory compromise (this DOES NOT include patients intubated at another facility who are stable from a respiratory standpoint)

Trauma II

This level requires a partial surgical team response

Criteria for Trauma II

Physiologic Criteria:

  • GCS 12 – 13 (does not include reported brief LOC on scene)

Anatomic Criteria:

  • Chest with instability or deformity (flail chest)
  • Two or more long bone fractures
  • Amputation proximal to wrist or ankle
  • Pelvic fracture

Mechanism of Injury:

  • Falls > 10 feet
  • Fall age >55 regardless of height if on anticoagulants
  • High Risk Auto Crash
  • Ejection (partial or complete)
  • Death at the scene
  • Intrusion: > 12in occupant site; 18in any site
  • Auto vs Pedestrian/bicycle thrown/run over/or with significant impact (> 20mph)

Clinical Parameters:

  • Burns
  • End stage renal disease requiring dialysis
  • Time sensitive injuries
  • Pregnancy > 20 weeks

Trauma III

This level requires an Emergency Medicine Team Response Only and is intended as a guideline for patients with significant mechanisms of trauma believed to have the potential to cause major injury but without overt signs or symptoms of serious injury.

Criteria for Level III

Physiologic Parameters:

  • Older adults
  • 55 years of age and one or more of the below mechanisms of injury
  • SBP < 110 if greater than 65 years of age
  • Pregnancy < 20 weeks

Anatomic Criteria:

  • Penetrating Injuries to the extremities distal to the elbow or knee

Mechanism of Injury:

  • Adult falls <10 feet, elderly ground level fall not on anticoagulants
  • MVC directed to the trauma center by medical control or medic decision for MOI only
  • Auto vs pedestrian/bicyclist with impact from < 20 mph
  • Low speed Motor Cycle Crash< 20mph

Trauma Response Policy Personnel Grid

Personnel

/ Trauma
I / Trauma
II / Trauma
III
Trauma Attending / X** / X**
Emergency Medicine Attending / X / X / X
Surgical Resident (PGY-4 or PGY-5) / X / X
Senior Emergency Medicine Resident (on TTL day) / X / X / X
Emergency Medicine Resident / X / X / X
Surgical Resident (below PGY 4)_ / X / X
ED Nurse / X / X / X
Respiratory Therapist / X / X
Radiology Tech / X / X / X
OR nurse / X
Anesthesia / X

** Evaluation and treatment may be started by a team lead by a senior general surgicalresident who is a member of AUMC’s surgical residency program. The trauma attending is required to be present within 15 minutes of patient arrival for the highest level of activation. Phone consultation is acceptable for Level II however admitted patients must be seen by an attending within 15 hours of arrival.

Escalation and De-escalation of response team members:

A secondary triage will take place upon arrival to the Trauma Resuscitation Bay, adjustments made to the response team will be made as needed based on patient’s clinical condition.

As appropriate a de-escalation of response resources will be called for patients presented as Level II trauma activations who meet the following criteria:

  • Very low or no potential for admission
  • Anticipation of discharged from the Emergency Department
  • Have no indication for surgical intervention at time of assessment

The determination of de-escalation must be made by an attending physician. Clear documentation in the EMR of the time of de-escalation and the attending faculty who is assuming responsibility for the patient is required. A page will be sent indicating the re-triage and new level of response activation for the patient. If known the patient location will also be included.

As appropriate an escalation of response resources will be called for patients who present as a Level II or III trauma who meet the following criteria:

  • Physiologic parameters have changed to Level 1 criteria
  • Indication for likelihood of immediate necessity for surgical intervention

The determination of escalation must be made by an attending physician. Clear documentation of reason for escalation and time of escalation is required.