Assessment and Scoring Tools

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Jonah Barnett
5 years ago
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1 Assessment and Scoring Tools 2013

2 APGAR Scale 0 points 1 point 2 points Heart Rate Absent <100 >100 Respiratory Rate Absent Slow, irregular Good, drying Irritability Flaccid Some flexion Active motion Irritability No response Grimace Cough or sneeze Color Blue or Pale Pink with blue Extremities Fully pink 2012

3 Glasgow Coma Scale Eyes Opens Eyes Spontaneously 4 Opens eyes to Verbal Stimuli 3 Opens Eyes to Painful Stimuli 2 Fails to Open Eyes 1 Verbal Response Appropriate Conversation / 5 Oriented to Month and Year Confused and / or Disoriented 4 Inappropriate Conversation / Answers 3 Incomprehensible Sounds 2 No Verbal Response 1 Motor Response Follows Directions 6 Removes Pain Source 5 Withdraws From Pain Source 4 Non-purposeful Flexion (Decorticate) 3 Non-purposeful Extension (Decerebrate) 2 No Motor Response 1 Transfer total to Other Side (Trauma Score) 2012

4 A. Adult Trauma (age 16 and older) Trauma Alert Criteria Component BLUE Criteria (Any 2) RED Criteria (Any 1) Airway Respiratory rate > 30 Active airway assistance Circulation Sustained heart rate > 120 Lack of radial pules with sustained heart rate > 120 Blood Pressure < 90 mmhg Best Motor Response BMR of 5 BMR < 4 (Glascow Coma Scale) Suspicion of spinal cord injury: o Paralysis o Loss of sensation Cutaneous Soft tissue loss 2 nd or 3 rd degree burns to > 15% TBSA GSW to extremity Amputation proximal to wrist or ankle Penetrating injury to Head, Neck or Torso Fracture of 2 or more long bones Long Bone Fracture Single fracture site due to MVC Fall from > 10 feet Age 55 years or older N/A Mechanism of Injury Ejection from a vehicle N/A Deformed steering wheel Or judgment of EMT, paramedic, or other healthcare professional. (must be documented in the Patient care record).

5 B. Pediatric Trauma (Age < 16) Component BLUE Criteria (Any 2) RED Criteria (Any 1) Size Weight < 11 kg N/A Length < 33 in. (Broselow) Airway N/A Assisted Ventilation or Intubated Consciousness Amnesia Altered mental status Loss of Consciousness Coma Suspicion of spinal cord injury; o Paralysis or Loss of sensation Circulation Palpable carotid or femoral Faint or non-palpable carotid or pulse, but absent radial or femoral pulse pedal pulse SBP < 50mmHg SBP < 90mmHg Fracture Single closed long bone fracture Open long bone fracture Multiple fracture sites Multiple dislocations Major soft tissue disruption or flap Cutaneous N/A avulsion 2 nd or 3 rd degree burns to > 10% TBSA Amputation Penetrating injury to Head, Neck or Torso Or judgment of EMT, paramedic, or other healthcare professional. (must be documented in the Patient care record).

6 Adult Trauma Score Respiratory Rate minute minute 3 36 minute or greater minute 1 None 0 Respiratory Expansion Normal 1 Retractive 0 Systolic Pressure 90 mm Hg or greater mm Hg mm Hg mm Hg 1 No Pulse 0 Capillary Refill Normal 2 Delayed 1 None 0 Total GCS Score = = = = = 1 Total Trauma Score =

7 Pediatric Trauma Score PARAMETER AIRWAY No Respiratory Requires Requires Assistance Positioning Invasive Required Constant Procedures Observation WEIGHT > 20 kg kg < 10 kg CNS Fully Awake History of Syncope Coma or or Seizures Repeated Vomiting CIRCULATION Systolic B: > 90 Systolic BP Systolic BP < 50 SKELETAL INJURIES None Closed Deformity Open Fx. or Multiple Closed Fx. SKIN None Minor Wounds Major Open Wounds Abrasions, Penetrating Wounds Lacerations NOTE: Total possible score is +12; lowest possible score is -6. Children with a score lower than 8 generally have a poor outcome and should be transferred to a tertiary care facility. Source The Journal of Trauma. Volume 28, Number 4, pp

8 Infant / Child Vital Signs by Age Age Resp. Rate Pulse Systolic BP Newborn mm Hg 1 6 Weeks mm Hg 6 Months mm Hg 1 Year mm Hg 3 Years mm Hg 6 Years mm Hg 10 Years mm Hg

9 Rev. July 2015

ESCAMBIA COUNTY TRAUMA TRANSPORT

ESCAMBIA COUNTY TRAUMA TRANSPORT TRAUMA ALERT CRITERIA are established state mandated criteria. ADULT TRAUMA ALERT CRITERIA (Physical and anatomical characteristics of a person 16 years of age or older) Any 1 of the following: 1. Airway: