What are the triage guidelines for head injury?

Head Injury Triage Guidelines

All head-injured patients should be systematically evaluated using the CDC's four-step field triage algorithm, with immediate transport to a trauma center for those meeting physiologic or anatomic criteria. 1

Step One: Physiologic Criteria (Immediate Transport to Trauma Center)

Transport immediately if ANY of the following are present:

• Glasgow Coma Scale ≤13 2
• Systolic blood pressure <90 mmHg 2
• Respiratory rate <10 or >29 breaths per minute (in infants <1 year: <20 breaths per minute) 2
• Need for ventilatory support 2

These physiologic criteria identify the most severely injured patients who require the highest level of trauma care. 2

Step Two: Anatomic Criteria (Immediate Transport to Trauma Center)

Transport immediately if ANY of the following injuries are present:

• Open or depressed skull fracture 2
• All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee 2
• Paralysis (indicating potential spinal cord or severe neurologic injury) 2
• Chest wall instability or deformity 2
• Two or more proximal long-bone fractures 2
• Crushed, degloved, mangled, or pulseless extremity 2
• Amputation proximal to wrist or ankle 2
• Pelvic fractures 2

Step Three: Mechanism of Injury (High-Energy Impact)

Transport to trauma center if mechanism suggests high-energy impact:

Falls

• Adults: >20 feet (one story = 10 feet) 2
• Children (<15 years): >10 feet or two to three times the height of the child 2

High-Risk Auto Crash

• Intrusion (including roof): >12 inches occupant site; >18 inches any site 2
• Ejection (partial or complete) from automobile 2
• Death in same passenger compartment 2
• Vehicle telemetry data consistent with high risk of injury 2

Other High-Risk Mechanisms

• Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact 2
• Motorcycle crash >20 mph 2

Step Four: Special Patient Considerations

Older Adults (Age >55 years)

• Risk of injury/death increases after age 55 years 2
• After age 65: Systolic BP <110 mmHg may represent shock (not just <90 mmHg) 2, 1
• Low-impact mechanisms (e.g., ground-level falls) can result in severe injury 2, 1

Anticoagulation and Bleeding Disorders

• Patients with head injury on anticoagulants are at high risk for rapid deterioration 2, 1
• Transport to trauma center even with normal initial presentation 1

Children

• Should be triaged preferentially to pediatric-capable trauma centers 2

Other High-Risk Populations

• Pregnancy >20 weeks 2
• EMS provider judgment of clinical concern 2

Burns

• Without other trauma mechanism: triage to burn facility 2
• With trauma mechanism: triage to trauma center 2

Critical Decision-Making Principles

When in doubt, transport to a trauma center. 2, 1 This guiding principle should override hesitation when triage criteria are borderline or clinical judgment suggests concern. 1

Common Pitfalls to Avoid

Do not rely on normal initial presentation in anticoagulated patients - these individuals can deteriorate rapidly hours after injury despite initially reassuring examination. 1

Do not dismiss ground-level falls in elderly patients (>65 years) - age-related physiologic changes mean that mechanisms causing minimal injury in younger patients can be life-threatening in older adults. 1

Do not delay transport to obtain imaging at non-trauma centers - patients meeting Step One or Step Two criteria require immediate transport to facilities with neurosurgical capabilities, not preliminary CT scanning at facilities without neurosurgical support. 1

Do not use systolic BP <90 mmHg as the sole shock indicator in elderly patients - after age 65, systolic BP <110 mmHg may represent shock and warrants trauma center evaluation. 1

Trauma Center Designation

Trauma centers are designated Level I-IV based on resources and capabilities: 2

• Level I: Greatest resources and personnel for injured patients; provides regional leadership in education, research, and prevention 2
• Level II: Similar resources to Level I, possibly differing only in continuous availability of certain subspecialties 2
• Level III: Capable of assessment, resuscitation, and emergency surgery; severely injured patients transferred to Level I or II 2
• Level IV: Provides 24-hour physician coverage, resuscitation, and stabilization before transfer to higher level of care 2

Local or regional protocols should determine the most appropriate level of trauma center within the defined trauma system. 2

Inter-Hospital Transfer Considerations

For patients requiring transfer to neuroscience units, patients with brain injury should be accompanied by a clinician with appropriate training and experience in the transfer of patients with acute brain injury. 2 Transfer should not be delayed, and networks should work towards auto-acceptance criteria for brain-injured patients. 2