Hemorrhage of the Ramus Lumbalis of the Iliolumbar Artery as a Cause for Shock in Blunt Trauma Victims on Therapeutic Anticoagulation

Table 1

Activation criteria.

Criteria	Category I activation	Category II activation
Physiologic criteria	Blunt or penetrating trauma with unstable vital signs	Blunt trauma with stable vital signs; Penetrating extremity trauma not meeting category I anatomic criteria
	Hemodynamic compromise as evidenced by; (i) systolic or; (ii) systolic	No hemodynamic compromise
	Respiratory compromise as evidenced by; (i) Respiratory or >29 or; (ii) in an of age; Needing ventilator assistance; Altered mentation as evidenced by , persistent unconsciousness or focal signs (i.e., posturing), posttraumatic seizures, or pupillary anomalies; All patients (with or without sedation) requiring ET intubation; Inability to intubate and anticipation of surgical airway; Blood infusing to maintain vitals	No respiratory compromise; GCS of 11, 12, or 13; weeks (anything above is considered category I)
Anatomical criteria	Head and face; (i) Open or depressed skull fractures; (ii) Positive imaging for subdural hematoma, epidural hematoma, or subarachnoid bleed; Chest & abdomen; (iii) Chest trauma with instability/significant pain (i.e., flail chest and evidence of crush); (iv) Obvious signs of trauma (open pneumothorax, ongoing bleeding, extensive SQ emphysema); (v) Abdominal trauma with significant pain or obvious external signs (i.e., evisceration, open wounds, bleeding); (vi) Imaging evidence of tension pneumothorax or cardiac tamponade or a (+) E-FAST; (vii) Signs of an unstable pelvis and/or bleeding; Spinal cord; (viii) Documented injury with sensory deficits or new-onset paralysis; Extremities; (ix) Crush or degloving injury; (x) Pulselessness or evidence of impaired blood flow in the limb or ongoing bleeding; (xi) Two or more proximal long bone fractures; (xii) Traumatic amputation proximal to the wrist or the ankle; Other injuries to include in category I trauma; (i) Two or more body regions with potential life or limb threat; (ii) Combination trauma with ≥20% TBSA burn; (iii) Other injuries at the discretion of the ED MD	Blunt head trauma (except anticoagulation use: see below); History of blunt chest trauma with pain; History of blunt abdominal trauma; Blunt extremity trauma deemed significant but not meeting anatomic or physiologic criteria; Penetrating extremity trauma not meeting anatomic or physiologic criteria
Mechanism of injury	Penetrating injury to the head, neck, chest, or abdomen with the suspicion of trauma to underlying structure or cavity and/with any of the physiologic criteria above; Falls over 20 feet for adult patients; Falls over 2 times the height or length of a pediatric patient; MVC with any of the following: Prolonged extrication (≥20 min); (i) Rollover and/or ejection (partial or complete); (ii) Death in the same passenger compartment; (iii) Intrusion into passenger inches at the driver side or >18 inches at any other side; (iv) Motorcycle with a rider thrown from the vehicle; (v) Estimated speed above 20 MPH; Auto vs. pedestrian with significant impact (damage to the vehicle) or >20 MPH or pedestrian ran over or thrown at any distance	Blunt injury to the head, neck, chest, or abdomen with the suspicion of trauma to the underlying structure or cavity without any of the physiologic criteria above; Ground level or standing height falls while on any anticoagulation not meeting category I anatomic criteria; All deceleration injuries not meeting anatomic or physiologic category I criteria; MVC without significant impact (damage to the vehicle) or <20 MPH; Auto vs. pedestrian without significant impact (damage to the vehicle) or <20 MPH
Transfer in patients	Any patient that is transferred from another facility for further definitive care meeting the above criteria	Any patient that is transferred from another facility for further definitive care meeting the above criteria
Additional criteria	At the discretion of the ED physician for patients that do not strictly meet the above criteria	At the discretion of the ED physician for patients that do not strictly meet the above criteria

Sources: (1) Resources for Optimal Care of the Injured Patient 2014 (orange book)—ACS; (2) Guidelines for Field Triage of Injured Patients—CDC. BP: blood pressure; E-FAST: Focused Assessment with Sonography in Trauma with added limited echocardiography; ET: endotracheal; GCS: Glasgow Coma Scale; MVC: motor vehicle crash (including motorcycle crash); MPH: miles per hour of speed; SQ: subcutaneous.