UTSW/BioTel EMS TRAINING BULLETIN
September 2014

EMS TB 14-005
PREHOSPITAL TRAUMA TRIAGE CRITERIA VS. IN-HOSPITAL TRAUMA ACTIVATION CRITERIA
Cross-Reference: BioTel 2014-2016 Trauma Treatment Guidelines (Rev D, pp. 62-65)
and BioTel 2014-2016 Destination Policy (Rev D, pp. 99-105)

Purpose:

1. To provide clarification about Prehospital/Field/EMS Trauma Triage Criteria (“Prehospital Trauma Triage Criteria”) and to explain differences between these criteria and In-hospital Dallas-area Uniform Trauma Activation Criteria (“In-hospital Trauma Activation Criteria”), with the goal of optimizing care and outcome for all trauma patients.

Background:

1. The newly adopted 2014-2016 UTSW/BioTel EMS Guidelines for Therapy and the Destination Policy include newly revised Prehospital Trauma Triage Criteria.

2. These new criteria have been selected for consistency with the Centers for Disease Control and Prevention (CDC) 2011 Field Triage Guidelines.
3. However, these local Prehospital Trauma Triage criteria have been adapted for the local EMS system. As such, they may be, in some cases, more inclusive than the CDC Guidelines.
4. Likewise, these Prehospital Trauma Triage Criteria may be more inclusive than a particular receiving hospital’s In-hospital Trauma Activation Criteria.
5. The UTSW/BioTel Trauma Treatment Guidelines and Destination Policy, including the Prehospital Trauma Triage Criteria, were developed in close collaboration with local Trauma Centers Emergency Departments, and the 2011 CDC Field Triage Guidelines.  They are consistent with the current recommendations of the American College of Surgeons Committee on Trauma (ACS COT) and other expert groups.
6. In contrast, the Dallas-area Trauma Centers have agreed upon a different set of INTERNAL, In-hospital Unified Trauma Activation Criteria (“In-hospital Trauma Activation Criteria”).

1. These in-hospital criteria delineate which patients (arriving either by EMS or by some other means) shall be seen initially by that hospital’s Trauma Team.
2. These criteria are In-hospital criteria developed by the Trauma Centers, not by the UTSW/BioTel Medical Direction Team.

Training Points:

1. The intent of the UTSW/BioTel Prehospital/Field/EMS Trauma Triage Criteria is to expedite direct EMS transport to a Trauma Center of appropriate patients who MAY need the Trauma Center’s specialized services and expertise.
1. The need for these services may not be initially apparent in the field, or even en route, as patients may deteriorate AFTER arrival, due to known or occult injuries.
2. In this scenario, valuable time may be lost during secondary transport to a Trauma Center.
2. Confusion has arisen when patients meeting Prehospital Trauma Triage Criteria have been transported to a Trauma Center, without that hospital’s activating their Trauma Team.
1. The decision whether or not to activate the in-hospital Trauma Team is a hospital decision, not an EMS decision.
2. As such, neither EMS Providers nor the UTSW/BioTel EMS Medical Direction Team exerts direct control over such a decision.
3. Differences between the Prehospital Trauma Triage Criteria and the In-hospital Trauma Activation Criteria may result in some trauma patients being transported initially to an Emergency Department without an immediate Trauma Team assessment.
1. This process has been implemented to facilitate initial evaluation, stabilization and management of many trauma patients by Emergency Department physicians, nurses and staff.
2. Such patients may be evaluated later by the Trauma Team, as needed.

4. CRITICAL MESSAGE: If EMS Providers EVER question whether a trauma patient has received appropriate care and concern upon arrival in ANY hospital Emergency Department, the agency EMS Supervisor should be contacted immediately.
1. The agency EMS Supervisor will convey concerns to agency EMS leadership, BioTel and the Trauma Center leadership, so that the case can be reviewed and appropriate remedial actions can be undertaken.
5. Summary:

6. Revised PREHOSPITAL Adult Trauma Triage Criteria:

Trauma patients meeting ANY of these criteria shall be transported to either a Level I or a Level II Accredited Trauma Center

1. Airway:
   1. Endotracheal intubation/advanced airway placement or attempted placement prior to arrival
2. Breathing:
   1. Respiratory compromise (obstruction, use of accessory muscles/respiratory distress or inhalation injury)
   2. Respiratory rate less than 10 or greater than 29
3. Circulation:
   1. Post-traumatic cardiac arrest
   2. Heart rate less than 50 or greater than 140
   3. Systolic BP less than 90 mm Hg (adult)
      1. Patients at least 65 years of age may be in shock with SBP less than 110 mm Hg
4. Disability:
   1. GCS 13 or less secondary to trauma
   2. Decreasing level of consciousness
5. Event – Anatomic Criteria:
   1. Penetrating wound to head, neck or torso, or proximal to the elbow or knee
   2. Chest wall instability of deformity (e.g. flail chest)
   3. Multiple (2 or more) long-bone fractures
   4. Mangled, crushed, degloved or pulseless extremity (including suspected compartment syndrome)
   5. Amputation proximal to the wrist or ankle
   6. Pelvic fracture
   7. Open or depressed skull fracture
   8. Paralysis (including new weakness or paralysis), or suspected spinal cord injury or spinal fracture
   9. Evisceration
6. Event – History/High-Energy Mechanism Within 72 Hours of Presentation:
   1. Fall at least 20 feet (2 stories)
   2. Drowning
   3. Hanging
   4. Pedestrian hit by automobile WITH ANY identified injury
   5. Bicyclist hit by automobile WITH ANY identified injury
   6. Motorcycle crash WITH ANY identified injury
   7. High-risk Motor Vehicle Crash (MVC), such as: significant intrusion, including roof (at least 12 inches at occupant site or at least18 inches at any site), or ejection (partial or complete), or death in the same passenger compartment
7. Special Patient or System Considerations:
   1. Age at least 55 years WITH ANY identified injury and/or criteria (including ground-level fall)
   2. Pregnancy at least 20 weeks estimated gestational age
   3. Burns:
      1. Greater than 20% TBSA (Burns greater than 10% should be transported directly to Parkland Hospital, if possible)
      2. Patients with any of the following criteria should be transported directly to Parkland Hospital, if possible (refer to the BURNS Treatment Guideline):
         1. Burns of face, eyes, ears, hands, feet, genitalia, perineum, or major joints
         2. Full-thickness (3rd-degree) burns of any size in any age patient
         3. Electrical burns (including lightning)
         4. Chemical burns
         5. Inhalation injury (including smoke inhalation)
         6. Burns with traumatic injuries (e.g. fractures)
         7. Burns in patients with pre-existing medical conditions or comorbidities
         8. Burns in patients needing special social, emotional or rehabilitative intervention
   4. EMS Provider or Medical Control Physician discretion – When in doubt, transport to a Trauma Center
   5. Transport of any patient with any of the above criteria to a destination other than an Accredited Trauma Center (e.g. because of patient preference) requires prior approval by an Online Medical Control Physician

See Trauma Treatment Guidelines