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Introduction   

The current pre-hospital triage of motor vehicle crash victims relies on specific physiologic criteria and paramedic judgment to assess the scene and identify serious injuries based on the crash mechanism and characteristics. The mechanism of injury, included in the American College of Surgeons (ACS) trauma triage criteria, requires consistent application in the pre-hospital setting to avoid over triage / under triaging of trauma patients [1]. A study found that standard EMS documentation underreports ACS trauma triage mechanism criteria, leading to biased outcome analyses towards worse outcomes and higher resource utilization [2].  

Overtriage, as defined by the ACS, reflects the number of patients with an Injury Severity Score (ISS) of 1 to 9 admitted to level I trauma centers, while under-triage, referring to patients with an ISS greater than or equal to 15 admitted to non-trauma hospitals, can lead to severe morbidity and mortality if life-threatening injuries are not recognized and treated [1] [3]. 

Field triage criteria established by the ACS include physiologic, anatomic, and mechanism of injury criteria to justify transport to a trauma center. Paramedics often use their judgment to ensure the evaluation of injured patients at a trauma center. The ACS accepts an overtriage rate of 25–50% to achieve this goal [1][4]. The principles of trauma care, guided by the Advanced Trauma Life Support (ATLS) framework, streamline the assessment and treatment of trauma patients, enabling all interprofessional team members to treat patients under one standardized method to improving patient outcomes. 

Key assessment tools include: 

• Glasgow Coma Scale (GCS): Used to assess the level of consciousness in trauma patients [5]. 

• Revised Trauma Score (RTS): A scoring system that assesses the severity of a traumatic injury based on GCS, systolic blood pressure, and respiratory rate [6]. 

• Abbreviated Injury Scale (AIS): A standardized injury severity scoring system [7]. 

Epidemiology  

Trauma is a major cause of mortality worldwide. Road traffic injuries are the leading cause of death among individuals aged 18 to 29 across the globe, and in the United States, trauma is the leading cause of death in young adults, accounting for 10% of all deaths among both men and women [8]. According to the World Health Organization (WHO) trauma will become the third leading cause of disability worldwide by 2030 [9].  

The National Highway Traffic Safety Administration (NHTSA) has released its latest projections for traffic fatalities in 2023, estimating an increase in miles driven and a decrease in fatality rates compared to 2022. The agency projects that 40,990 people died in motor vehicle traffic crashes in 2023, marking a 3.6% decline from the 42,514 fatalities reported in 2022 [10]. The fourth quarter of 2023 represents the seventh consecutive decline in fatalities since the second quarter of 2022 [10]. The estimated fatality rate for 2023 has decreased to 1.26 deaths per 100 million vehicle miles traveled (VMT), down from 1.33 per 100 million VMT in 2022. Estimates indicate that VMT in 2023 increased by 67.5 billion miles, a 2.1% rise over 2022 [10][11]. 

Treatment at a designated trauma center reduces the likelihood of mortality or morbidity in patients with serious traumatic injuries [12]. Older age, obesity, and major comorbidities are associated with worse outcomes following trauma [12]. In patients with significant hemorrhage, a lower Glasgow Coma Scale (GCS) score and older age are each associated with increased mortality [13][14]. Hemorrhage, multiple organ dysfunction syndrome, and cardiopulmonary arrest are the most common causes of mortality from trauma [15]. Most trauma-related deaths occur either at the scene or within the first four hours after the patient reaches a trauma center, with few patients dying after the first 24 hours following injury [12]. The “golden hour” concept emphasizes the critical importance of rapid intervention during the first hour of care following major trauma [16].  

Primary Survey 

Trauma care begins before the patient arrives at the hospital, with rescue personnel providing pre-hospital care grounded in basic life support (BLS), advanced cardiac life support (ACLS), pediatrics advanced life support (PALS), and pre-hospital trauma life support (PHTLS) [19]. Understanding the capabilities and limitations of local rescue teams allows the hospital team to better forecast what will be present upon arrival. As a call comes in from the field, the trauma team should triage the patient based on factors such as age, mechanism of injury, and coagulation status. Preparation includes gathering necessary equipment and donning personal protective equipment (PPE). The hospital must coordinate all relevant services (e.g., blood bank, lab, X-ray, respiratory therapy) and assign specific roles to team members to ensure immediate and organized intervention upon the patient’s arrival. 

When a trauma patient arrives, the primary survey follows the A.B.C.D.E. approach: Airway, Breathing, Circulation, Disability, and Exposure/Environmental Control [17]. Repeat each step throughout the patient’s care and after interventions. Airway assessment includes checking for obstructions and maintaining cervical-spine alignment. A compromise airway requires immediate intervention with maneuvers or artificial airways (OPA, NPA, LMA, ETT, or surgical airways). Indications for endotracheal intubation include altered mental status, poor ventilation, and poor oxygenation [18]. 

Providers can calculate the ease or difficulty of intubation using the L.E.M.O.N. criteria (Look, Evaluate, Mallampati, Obstruction, Neck) [20]. After securing the airway, the provider assesses breathing, focusing on ventilation mechanics and treating any underlying issues causing ventilatory compromise. The provider should inspect, auscultate, palpate, and percuss the chest, and imaging may be necessary to confirm findings.  

The next priority is circulation, assessing the cardiovascular status through vital signs, pulse strength, skin inspection, and imaging. Common trauma-related circulatory issues include hemorrhage, myocardial contusions, and pressure-related injuries like cardiac tamponade and tension pneumothorax [21]. Treatment focuses on addressing the underlying issues, with fluid replacement and blood products used for hemorrhage management.  

Conduct disability assessment using a neurological exam with the Glasgow Coma Scale (GCS), pupillary response, and imaging if stable [22]. Exposure involves removing all clothing to inspect for hidden injuries and maintaining the patient’s core body temperature. Quick coverage and warming measures are necessary to prevent hypothermia, which can worsen coagulation and acidosis, increasing mortality [23]. By following these structured steps and reassessing, the trauma team can provide effective and comprehensive care to trauma patients. 

Secondary Survey  

Once the primary survey is complete, the provider must gather more details about the events leading to the patient’s injuries and their medical history to tailor the treatment plan. Providers can utilize any adjunct laboratory testing and imaging throughout the secondary survey. ATLS and PALS recommend using the acronym ‘SAMPLE’ for obtaining a focused history [24]. This systematic approach involves gathering information on Symptoms (S), Allergies (A), Medications (M), Past medical history (P), Last oral intake (L), and Events (E) surrounding the presenting complaint [24]. 

In MVCs, frontal collisions can cause unique injuries to the pelvis, whereas lateral collisions have different presentations [19]. For instance, in cases of motor vehicle collisions, it is important to evaluate whether airbags were activated, if the patient was wearing a seatbelt or was thrown from the vehicle, the condition of other occupants (such as fatalities within the same vehicle compartment), the speed of the vehicle(s) at the time of the crash, and whether a medical event contributed to the patient’s loss of control. Regardless of the mechanism, this approach helps the provider understand the extent of the damage, consider other medical factors, and determine if law enforcement should be involved. 

Case Study  

EMS arrives at the scene of a restrained driver involved in a motor vehicle collision (MVC) on the expressway. There is 15-20 inches of metal intrusion at the dashboard due to a frontal impact. The windshield and steering indicate direct impact. The patient, a 45-year-old male named John Doe, is complaining of severe substernal chest pain, and is holding his arm against his chest to splint while breathing. 

Primary Assessment 

• Airway: Patent 

• Breathing: Dyspneic; rapid, shallow, and labored respirations with redness and abrasions on the chest wall; no paradoxical movement; SpO2 90%; breath sounds present but diminished 

• Circulation: Radial pulses equal but rapid, weak, and thready; skin pale, cool, clammy 

• Level of Consciousness: Awake; responds to verbal stimuli 

Secondary Assessment 

• Vital Signs: BP: 92/50; P: 116; RR: 26 and shallow 

• HEENT: All WNL 

• Neck: Trachea midline; jugular veins flat 

• Chest: Contusion over sternum; pain noted on palpation; ECG shows sinus tachycardia with multifocal PVCs 

• Abdomen: Soft and non-tender 

• Skin: Cool, pale, diaphoretic 

• Neuro: GCS 14; pupils equal and reactive to light; strength and movement intact in all extremities 

• Pain: 9/10 

Assessment Tool Findings 

• Glasgow Coma Score (GCS): 14 

The Glasgow Coma Score (GCS) requires three parameters: Eye Opening (E), Verbal Response (V), and Motor Response (M). For Eye Opening (E), the scores are: Spontaneous (4), To sound (3), To pressure (2), and None (1). For Verbal Response (V), the scores are: Oriented (5), Confused (4), Words (3), Sounds (2), and None (1). For Motor Response (M), the scores are: Obeys commands (6), Localizes to pain (5), Withdraws from pain (4), Abnormal flexion (3), Abnormal extension (2), and None (1). 

From the secondary assessment, the scores are as follows: Eye Opening: Spontaneous (4), Verbal Response: Confused (4), and Motor Response: Obeys commands (6). The GCS calculation is E: 4, V: 4, and M: 6, resulting in a total GCS of 4 + 4 + 6 = 14. 

• Revised Trauma Score (RTS): 12 

The Revised Trauma Score (RTS) requires three parameters: GCS, Systolic Blood Pressure (SBP), and Respiratory Rate (RR). Parameters receive a score from 0 to 4. For the GCS component, the scores are: GCS 13-15: 4, GCS 9-12: 3, GCS 6-8: 2, GCS 4-5: 1, and GCS 3: 0. For the SBP component, the scores are: SBP > 89 mmHg: 4, SBP 76-89 mmHg: 3, SBP 50-75 mmHg: 2, SBP 1-49 mmHg: 1, and SBP 0: 0. For the RR component, the scores are: RR 10-29: 4, RR > 29: 3, RR 6-9: 2, RR 1-5: 1, and RR 0: 0. 

From the provided vital signs, the scores are GCS: 14, SBP: 92 mmHg, and RR: 26. The RTS calculation is: GCS: 4, SBP: 4, and RR: 4, resulting in a total RTS of 4 + 4 + 4 = 12. 

Primary Survey at the Emergency Department 

Upon arrival at the emergency department, the trauma team initiated the primary survey. Blood and vomitus obstructed John’s airway. The trauma team cleared the airway and performed endotracheal intubation to secure it. Breathing assessment revealed diminished breath sounds on the left side, indicating a potential pneumothorax, confirmed by a chest X-ray. An inserted chest tube re-expanded the lung. The circulatory assessment showed weak central pulses and a blood pressure of 80/40 mmHg, suggesting hemorrhagic shock. The team initiated rapid fluid resuscitation and blood transfusion. Disability assessment using the Glasgow Coma Scale (GCS) resulted in a score of 6, indicating severe head injury. Exposure revealed multiple lacerations and a deformed left femur, necessitating further imaging and orthopedic consultation. 

Secondary Survey 

The secondary survey focused on obtaining a detailed history and assessing all organ systems. The team conducted a thorough physical examination and ordered adjunct tests. The paramedics provided a history of the accident, noting the high-speed collision, airbag deployment, and seatbelt use. John’s medical history revealed no known allergies, a list of antihypertensive medications, and a recent knee surgery.  

Additional imaging confirmed a left femoral fracture, rib fractures, and a small liver laceration. Laboratory tests showed significant blood loss and a coagulopathy. The team took John to the operating room for surgical fixation of the femur and management of internal injuries. Throughout his hospital stay, he received multidisciplinary care, including neurosurgery, orthopedics, and critical care. 

Conclusion

John Doe’s case underscores the critical importance of a structured and methodical approach to trauma care. The pre-hospital triage, guided by physiologic criteria and paramedic judgment, plays a pivotal role in the early identification and management of serious injuries [25]. Despite the challenges in applying the ACS trauma triage criteria, providers can enhance triage accuracy by incorporating specific crash variables such as age, collision type, impact location, airbag deployment, steering wheel deformity, intrusion, and restraint use.  

Upon arrival at the hospital, the primary survey, following the A.B.C.D.E. approach, ensured that John received immediate and appropriate interventions for his compromised airway, breathing difficulties, and circulatory instability. The rapid identification and management of his pneumothorax, hemorrhagic shock, and other critical conditions were crucial in stabilizing his condition. The secondary survey provided a comprehensive evaluation of John’s injuries and medical history, guiding further treatment and management. Detailed history-taking and physical examination, along with adjunct testing, confirmed multiple injuries, including a femoral fracture, rib fractures, and a liver laceration.  

The coordinated efforts of the trauma team, involving multiple specialties such as neurosurgery, orthopedics, and critical care, exemplify the importance of interprofessional collaboration in trauma care. 

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