Section 1. Setting the Scene

Definition of Major Trauma

A definition of major trauma patients describes not only the population at whom the trauma system is targeted, but also provides a standard against which triage decisions can be retrospectively evaluated (Eastman et al 1987). The Taskforce considered that an appropriate definition of major trauma for defining the target population and for application in system evaluation and quality assurance involves the presence of at least one of the following:

Death after injury. Admission to an Intensive Care Unit for more than 24 hours, requiring mechanical ventilation. Serious injury to two or more body systems (excluding integumentary). Injury Severity Score (ISS)> 15. Urgent surgery for intracranial, intrathoracic, or intraabdominal injury, or for fixation of pelvic or spinal fractures.

The Taskforce recognised that such a definition requires retrospective assessment after diagnosis is complete. Clearly, full diagnosis is not always possible during resuscitation and early management. The patient's diagnostic status necessarily evolves over time with each phase of care, as diagnosis in the prehospital setting is largely limited to physical assessment, and because many serious occult injuries are only revealed with time. Patients seemingly uninjured soon after the incident may later be diagnosed with significant injury as clinical features emerge or diagnostic interventions are undertaken.

Undertriage, or failing to identify major trauma cases and activate a system response, potentially results in suboptimal clinical outcomes. Criteria are therefore required which are clinically applicable prospectively during early phases of care, which recognise the evolutionary nature of the diagnostic status in major trauma patients, and which are predictive of major trauma as defined above. The Taskforce has identified such criteria for use at the following points in the continuum of management, in order to give optimal inclusion of major trauma patients into the Victorian State Trauma System:

• Pre-hospital setting

These criteria are for triage purposes by ambulance and MICA paramedics. They incorporate current and widely used physiological, anatomical and mechanistic indicators and are contained in the endorsed triage guidelines (Appendix 7.2 - Prehospital Major Trauma Criteria).

• Emergency Department setting

These criteria will, in the Victorian Trauma System, identify those patients admitted to non-MTS hospitals whose management, including possible need for transfer, requires discussion with a Major Trauma Service. These criteria contain the same mechanistic indicators as the Prehospital Major Trauma Criteria, an expanded range of physiological and anatomical indicators in line with evolving diagnosis, and include patients whose physiology is deteriorating (Appendix 7.4 - Major Trauma Interhospital Transfer Guidelines).

• Post discharge

  These criteria are those contained in the definition of major trauma, as full diagnostic data is then available.