Trauma Triage
Algorithm
New UPDATED 4/1/2019
Abnormal Vital Signs:
- Failure to follow commands due to decreased state of alertness OR
- Resp: < 12 or > 30 (adults/adolescents/children), OR
- Systolic BP: < 90 (adults/adolescents); < 80 (children 14 y/o and under)
▼
BHC → Meets Trauma Criteria → Trauma Center
Injuries:
Head Injuries
- Penetrating or open injury of the head,
- Depressed skull fracture
- Blunt or penetrating head injury with:
-
Loss of consciousness, OR
-
Focal neurologic deficit, OR
-
Asymmetric pupils, OR
-
Vomiting
- Blunt head injury with bruising in area of injury and known to be:
-
Taking anticoagulants or platelet inhibitors ("blood thinners"), excluding ASA OR
-
Known to have hemophilia OR
-
Known to be a dialysis patient
Neck Injuries
- Penetrating (appears for penetrate all skin layers) injury to the neck
- Seat belt bruising or abrasion of neck
Chest / Back Injuries
- Penetrating (appears for penetrate all skin layers) injury to the chest or back
- Seat belt bruising or abrasion of chest
- Blunt chest injury with abnormal respiration as defined above
Abdominal / Pelvic Injuries
- Penetrating (appears for penetrate all skin layers) injury to the abdomen or groin
- Seat belt bruising or abrasion of abdomen
- Reported or obviously pregnant women with blunt or penetrating abdominal injury
- Blunt abdominal injury, w/ palpable tenderness
- Unstable pelvic fractures
- Pelvic rim pain or deformity on palp (+ barrel hoop)
Extremity Injuries
- Penetrating (appears for penetrate all skin layers) injury to extremity above elbow or knee
- Extremity injury w/ poor circulation or w/o pulse
- Paralysis or paresthesia of arm or leg due to injury
- Fracture of 2 or more long-bones (femur/humerus)
- Amputation (partial or complete) above the wrist or ankle
- Crushed / de-gloved, or mangled extremity (excluding only fingers/toes)
▼
BHC → Meets Trauma Criteria → Trauma Center
Mechanism of Injury:
Falls:
- Adults / Adolescents: > 15 ft. (one story is equal to 10 ft.)
- Children: > 10 ft. or 2-3 times height of child
- Adults / Adolescents / Children: fall from galloping horse
▼
BHC → Meets Trauma Criteria → Trauma Center
High-Risk Auto Crash:
(heights, speeds, and distances are all estimates)
- Passenger space intrusion > 12 inches occupant site; > 18 inches any site w/in passenger space
- Ejection (partial or complete) from auto
- Death in same passenger compartment
- Dive and shore break injuries with suspected spinal cord injury
- Auto vs. pedestrian/bicyclist thrown any distance, run-over, or with significant (> 20 mph) impact
- Motorcycle crash including “laying bike down”, > 20 mph
▼
BHC → Meets Trauma Criteria → Trauma Center
Traumatic Full Arrests:
- Unmanageable Airway – Triage to a Trauma Center
- Traumatic Cardiopulmonary arrest - Triage to a Trauma Center