CRAMS: What's It All About? by Frank Thomas, M.D.

Medical care for t rauma pat ients has i m p r o v e d t h roughou t Salt Lake City and Coun ty in recent years, with the fo rmat ion of an I n t e rm oun t a i n T r a u m a Complex and the initiation of the CRAMS Triage Sys t em as examples of significant advances .

Studies sugges t that severely t r auma t i zed pat ients do bet ter in tert iary care (Level I) t r auma centers. H o w e v e r , the m o v e m e n t of all t r auma pat ients to such centers, regardless of injury, wou ld o v e r w h e l m the area ' s Level I hospitals , mak ing their special ized and intensive care less effective. Such a se tup wou ld also inflict economic ha rdsh ips on o ther local hospitals .

A m e a n s of p roper ly ident i fying t r auma pat ients who require tert iary care and those who can be appropr i a t e ly t reated at the local hospi ta l is necessary. To be effective, however , a t r auma triage sys t em mus t be funct ional within the field u p o n initial evaluat ion of the patient. It m u s t dictate a reliable and verifiable m e a n s of identifying, assess ing and sort ing pat ients rapidly.

Several pre-hospi ta l field triage scoring sys t ems are current ly in use for onsite evaluat ion of t r auma pat ients , however , the CRAMS score, deve loped by Dr. Steven Gormican , has been judged the mos t effective for use in Salt Lake City and County . This

scoring sys tem consists of a f ive-par t evaluat ion of the pat ient ' s Circulation, Respirat ion, Abdomina l exam, Motor exam and Speech (see Table 1).

Modificat ions in the original CRAMS test have been m a d e for use in Salt Lake City and County . Respirat ions which are labored, shallow, or greater than 35 per minute are cons idered abnormal , as are pene t ra t ing injuries to the abdomen . In addit ion, the score m a n d a t i n g ter i tary care was lowered f rom Gormican ' s sugges ted level of 8 to a score of 6. This was done to assure that only the mos t critically in jured pa t ien ts - - those with a CRAMS score of 6 or less - - are t ransfer red to the teri tary care centers.

Evaluat ing and scoring a pat ient on the CRAMS scale takes less than one minute . A recent s tudy done by Dr. Terry Clemmer , LDSH director of critical care medicine, et al, has s h o w n that the CRAMS score is easy to app ly and accurately identifies bo th the critically in jured who should be t r iaged to the Leve l ' I center, and the less critically in jured who can be ably cared for at Level II and III centers.

The current applicat ion of CRAMS scoring in Salt Lake City and Coun ty assures that the mos t critical pat ients will be t r anspor ted to a T r a u m a Complex hospital . Those with less

critical injuries will be referred to the closest hospital . Adult pat ients invo lved in accidents on or east of 700 East, and w h o have been t r iaged with CRAMS scores of 6 or less, will be t r anspor ted to the Univers i ty of Utah Medical Center. The same critically in jured adul t pat ients will be t r anspor ted to LDS Hospi ta l if the accident occurs west of 700 East. All pediatric pat ients (14 years or younger ) with CRAMS scores of 6 or less will be t r anspor ted to P r imary Chi ldren ' s Medical Center.

Al though the CRAMS score has been in use only a short per iod of t ime, it appea r s to be a rapid a n d effective m e a n s of tr iaging t r au ma patients. Cont inu ing studies are be ing done to further evaluate the sys t em ' s effectiveness in hand l ing the care and t ranspor t of t r auma pat ients .

Fur further information regarding the CRAMS scoring system, see the article entitled "Prospective Evaluation of CRAMS Scale for Triage of Major Trauma" by Terry Clemmer, M.D., Jim Orme, M.D., Frank Thomas, M.D., and Katherine Brooks, R.N., in the March 1985 issue of Journal of Trauma.

This article originally appeared in the Winter, 1985, issue of Fright Plan, a quarterly publication of LDS Hospital Life Flight (Salt Lake City), reprinted here with permission.

Circulation 2-Normal capillary refill and BP >

100mm Hg systolic 1-Delayed capillary refill or BP 85 - 99

mm Hg systolic o-No capillary refill or BP <85 mm Hg

systolic

Table 1 CRAMS SCORE

Respiration 2-Normal 1-Abnormal (labored, shallow or rate >

35 per minute) 0-Absent

Abdomen 2-Abdomen and thorax not tender 1-Abdomen or thorax tender 0-Abdomen rigid, thorax flail, or deep

penetrating injury to either chest or abdomen

Motor

2-Normal (obeys commands) 1-Responds only to pain; no posturing 0-Postures or no response

Speech 2-Normal (oriented) 1-Confused or inappropriate 0-No speech or unintelligible sounds

Total CRAMS score (sum of the five categories)

30 HOSPITAL AVIATION, JULY 1985