Incremental benefit of individual American College of Surgeons trauma triage criteria

Abstract

Objective: To determine the incremental benefit of individual American College of Surgeons (ACS) trauma triage criteria for prediction of severe injuries after consideration of concurrent physiologic, anatomic, mechanism, or "other" criteria.

Methods: A prospective cross-sectional study of motor vehicle crash victims transported to any of the 12 hospitals in a suburban/rural county by local ambulance services was performed. Demographic and individual ACS criteria were collected using structured data instruments. EDs provided patient disposition within 24 hours of patient arrival. Medical records were reviewed. Major outcomes were admission, operative interventions (OR), major nonorthopedic operative interventions or death (Maj-OR), and injury severity score (ISS). To optimize sensitivity and specificity of out-of-hospital triage decision rules, receiver operating characteristic (ROC) curves were derived.

Results: Of 1,545 patients, 13% were admitted; 6% had OR; 1% had Maj-OR; and 3% had ISSs > or = 16. For all outcomes, the most useful criteria were physiologic and anatomic. Some additional criteria (crash speed > 20 mph, > or = 30-inch vehicle deformity, axle displacement) substantially worsened specificity, with minimal or no improvement in sensitivity. For example, the optimal ROC curve for Maj-OR was determined by a systolic blood pressure < 90 mm Hg, Glasgow Coma Scale (GCS) score < 13, respiratory rate (RR) < 10 or > 29, death of a same-car occupant, penetrating injury, and/or > or = 24-inch opposite-side compartment intrusion (sensitivity, 85%; specificity, 87%). An ISS > or = 16 was predicted by GCS score < 13, RR < 10 or > 29, penetrating injury, 2 proximal long bone fractures, flail chest, > or = 24-inch opposite-side compartment intrusion, patient ejection, rollover, and/or age < 5 or > 55 years (sensitivity, 86%; specificity, 70%).

Conclusion: Physiologic and anatomic trauma triage criteria predicted increased hospital resource utilization and severe injury. On the other hand, when used concurrently with physiologic, anatomic, and "other" criteria, some mechanism criteria worsen specificity with negligible improvement in sensitivity. In particular, crash speed > 20 mph and > or = 30-inch vehicle deformity had little predictive value for all outcomes.