Triage in Hospital 1

7/28/2019 Triage in Hospital 1

http://slidepdf.com/reader/full/triage-in-hospital-1 1/22

Recommendations and Reports

MMWR / January 13, 2012 / Vol. 61 / No. 1 1

Guidelines for Field Triage of Injured Patients

Recommendations of the National Expert Panel on Field Triage, 2011Prepared by

Scott M. Sasser, MD1,2

Richard C. Hunt, MD1

Mark Faul, PhD1

David Sugerman, MD1,2

William S. Pearson, PhD1

Theresa Dulski, MPH1

Marlena M. Wald, MLS, MPH1

Gregory J. Jurkovich, MD3

Craig D. Newgard, MD4

E. Brooke Lerner, PhD5

Arthur Cooper, MD6

Stewart C. Wang, MD, PhD7

Mark C. Henry, MD8

Jerey P. Salomone, MD2

Robert L. Galli, MD9

1Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia 2 Emory University School of Medicine, Atlanta, Georgia

3University of Washington, Seattle, Washington4 Oregon Health and Science University, Portland, Oregon5 Medical College of Wisconsin, Milwaukee, Wisconsin

6 Columbia University Medical Center affiliation at Harlem Hospital, New York, New York 7 University of Michigan Health System, Ann Arbor, Michigan

8 Stony Brook University, Stony Brook, New York 9 University of Mississippi, Jackson, Mississippi

Summary

In the United States, injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient’s injuries, and decide the most appropriate destination

hospital for the individual patient. These destination decisions are made through a process known as “field triage,” which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its “Field Triage Decision Scheme.” This guidance was updated with each version of the decisionscheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons.Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC

published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]).

In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working toimplement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic,

The material in this report originated in the National Center or Injury Prevention and Control, Linda Degutis, DrPH, Director, and the

Division o Injury Response, Richard C. Hunt, MD, Director, incollaboration with the National Highway Traic Saety Administration,Oice o Emergency Medical Services, and in association with the

American College o Surgeons, John Fildes, MD, Trauma MedicalDirector, Division o Research and Optimal Patient Care, and MichaelF. Rotondo, MD, Chair, Committee on Trauma.Corresponding preparer: David Sugerman, MD, Division o Injury Response, National Center or Injury Prevention and Control, CDC,4770 Buord Highway, MS F-62, Atlanta, GA 30341-3717. Telephone:770-488-4646; Fax: 770-488-3551; E-mail: [email protected].




2 MMWR / January 13, 2012 / Vol. 61 / No. 1

Introduction

Purpose of This ReportEmergency Medical Services (EMS) providers in the United

States make decisions about the most appropriate destinationhospital or injured patients daily. These decisions are madethrough a decision process known as “ield triage,” whichinvolves an assessment not only o the physiology and anatomy o the injury but also o the mechanism o the injury andspecial patient considerations. The goal o the ield triageprocess is to ensure that injured patients are transported toa trauma center* or hospital that is best equipped to managetheir speciic injuries, in an appropriate and timely manner,as the circumstances o injury might warrant.

Since 1986, the American College o Surgeons Committee onTrauma (ACS-COT) has published a resource manual that providedguidance or the ield triage process through a ield triage decisionscheme (1). This guidance was updated and published with eachversion o the resources manual during 1986–1999 ( 2–5 ). In2009, CDC published guidelines on the ield triage process (theGuidelines) (6 ). This guidance provided background material ontrauma systems, EMS systems and providers, and the ield triage

process. In addition, it incorporated the 2005–2006 deliberationsand recommendations o the National Expert Panel on Field Triage(the Panel), provided an accompanying rationale or each criterionin the Guidelines, and ensured that existing guidance or ield triagerelected the current evidence. In April 2011, CDC reconvened thePanel to evaluate any new evidence published since the 2005–2006revision and examine the criteria or ield triage in light o any new indings. The Panel then modiied the Guidelines on the basiso its evaluation. This report describes the Panel’s revisions to theGuidelines and provides the rationale or the changes, including a description o the methodology or the Panel’s review.

This report is intended to help prehospital-care providers intheir daily duties recognize individual injured patients who aremost likely to beneit rom specialized trauma center resourcesand is not intended as a triage tool to be used in a situationinvolving mass casualties or disaster (i.e., an extraordinary event with multiple casualties that might stress or overwhelm locaprehospital and hospital resources).

BackgroundIn the United States, unintentional injury is the leading

cause o death or persons aged 1–44 years (7 ). In 2008injuries accounted or approximately 181,226 deaths in theUnited States (8 ). In 2008, approximately 30 million injuries were serious enough to require the injured person to visit ahospital emergency department (ED); 5.4 million (18%) othese injured patients were transported by EMS personnel (9 )

Ensuring that severely injured trauma patients are treated attrauma centers has a proound impact on their survival (10 )Ideally, all persons with severe, lie-threatening injuries wouldbe transported to a Level I or Level II trauma center, and alpersons with less serious injuries would be transported to lower-level trauma centers or community EDs. However, patient

dierences, occult injuries, and the complexities o patienassessment in the ield can aect triage decisions.

The National Study on the Costs and Outcomes o Trauma(NSCOT) identiied a 25% reduction in mortality or severelyinjured adult patients who received care at a Level I traumacenter rather than at a nontrauma center (10 ). Similarly, aretrospective cohort study o 11,398 severely injured adultpatients who survived to hospital admission in OntarioCanada, indicated that mortality was signiicantly higherin patients initially undertriaged† to nontrauma centers(odds ratio [OR] = 1.24; 95% conidence interval [CI] =1.10–1.40) (11).

In 2005, CDC, with inancial support rom the NationaHighway Traic Saety Administration (NHTSA), collaborated with ACS-COT to convene the initial meetings o the Panel

* Trauma centers are designated Level I–IV. A Level I center has the greatest amounto resources and personnel or care o the injured patient and provides regionalleadership in education, research, and prevention programs. A Level II acility oers similar resources to a Level I acility, possibly diering only in continuousavailability o certain subspecialties or suicient prevention, education, andresearch activities or Level I designation; Level II acilities are not required to beresident or ellow education centers. A Level III center is capable o assessment,resuscitation, and emergency surgery, with severely injured patients being transerred to a Level I or II acility. A Level IV trauma center is capable o providing 24-hour physician coverage, resuscitation, and stabilization to injuredpatients beore transer to a acility that provides a higher level o trauma care.

† Inaccurate triage that results in a patient who requires higher-level care notbeing transported to a Level I or Level II trauma center is termed undertriageThe result o undertriage is that a patient does not receive the timely specializedtrauma care required. Overtriage occurs when a patient who does not requircare in a higher-level trauma center nevertheless is transported to such a centerthereby consuming scarce resources unnecessarily.

mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.





The Panel comprises persons with expertise in acute injury care, including EMS providers and medical directors, stateEMS directors, hospital administrators, adult and pediatricemergency medicine physicians, nurses, adult and pediatrictrauma surgeons, persons in the automotive industry, publichealth personnel, and representatives o ederal agencies.

The Panel is not an oicial advisory committee o CDC anddoes not have a ixed membership or an oicially organizedstructure. The Panel is responsible or periodically reevaluating the Guidelines, determining i the decision criteria areconsistent with current scientiic evidence and compatible withadvances in technology, and, as appropriate, making revisionsto the Guidelines.

During 2005 and 2006, the Panel met to revise theGuidelines, and the end product o that comprehensiverevision process (Figure 1) was published by ACS-COT in2006 (7). In 2009, CDC published a comprehensive review o the revision process and the detailed rationale or thetriage criteria underlying the 2006 version o the Guidelines(1); the Guidelines were endorsed by multiple proessionalorganizations.§

In 2011, the Panel reconvened to review the 2006 Guidelinesin the context o recently published literature as well asthe experience o states and local communities working toimplement the Guidelines and to make recommendationsregarding any changes or modiications to the Guidelines. A major outcome o the Panel’s meetings was the revision o theGuidelines (Figure 2).

Dissemination and Impact of theField Triage Criteria

Since 2009, CDC has undertaken an eort to ensuredissemination, implementation, and evaluation o theGuidelines (Box 1) including the development o training guides, educational material, and resources or EMS providers(e.g., pocket guides). In addition, the 2009 report wasreprinted in its entirety in the Journal o Emergency MedicalServices (JEMS), an EMS trade journal with a circulation o approximately 51,000 (12 ). The Guidelines were reproduced

in multiple textbooks targeting the EMS, emergency medicineand trauma care community (7,13–16 ). In 2010, the Nationa Association o EMS Physicians and ACS-COT issued a joinposition paper recommending adoption o the Guidelines orlocal trauma and EMS systems (17 ). The National Registry oEmergency Medical Technicians adopted the Guidelines as a

standard upon which all certiication examination test itemsrelating to patient disposition will be based. The Guidelineshave been endorsed by the Federal Interagency Committee onEmergency Medical Services (FICEMS), which was establishedby Public Law 109-59, section 10202 (18 ). FICEMS comprisesrepresentatives rom the U.S. Department o Health andHuman Services, the U.S. Department o Transportation, theU.S. Department o Homeland Security, the U.S. Departmeno Deense, and the Federal Communications Commission.

CDC also has worked closely with multiple states, throughsite visits (to Colorado, Georgia, New Mexico, and Virginia)grants (in Kansas, Massachusetts, and Michigan), andpresentations and technical assistance eorts (in CaliorniaMissouri, and North Carolina), to learn rom their experiencein using and implementing the Guidelines at the state and localevel. This process has given CDC insight into the experienceo implementing national guidelines at a local level.

Three publications have examined the overall use and impaco the Guidelines since the 2006 revision. A survey o publiclyavailable state EMS and health department websites indicatedthat 16 states used public websites to document that they hadadopted a partial or complete version o the 2006 Guidelines (19 )

A 2-year prospective observational study o 11,892 patient

at three Level 1 trauma centers indicated that use o the 2006Guidelines would have resulted in EMS providers identiying1,423 ewer patients (12%; 95% CI = 11%–13%) or transportto a trauma center at the expense o 78 patients (6%) beingundertriaged ( 20 ).

Finally, using the National Trauma Databank (NTDB) andthe National Hospital Ambulatory Medical Care Survey, acost impact analysis that compared the 1999 Guidelines to the2006 Guidelines concluded that ull implementation o the2006 Guidelines would produce an estimated national savingso $568 million per year ( 21).

Use of These GuidelinesThe Guidelines provided in this report are not intended or

mass casualty or disaster triage; instead, they are designed oruse with individual injured patients and provide guidance orEMS providers who care or and transport patients injuredin U.S. communities daily through motor-vehicle crashesalls, penetrating injuries, and other injury mechanisms. Thireport provides guidelines or ield triage o injured patients

§ The Air and Surace Transport Nurses Association, the Air Medical Physician Association, the American Academy o Pediatrics, the American College o Emergency Physicians, the American College o Surgeons, the American Medical

Association, the American Pediatric Surgical Association, the American PublicHealth Association, the Commission on Accreditation o Medical TransportSystems, the International Association o Flight Paramedics, the JointCommission, the National Association o Emergency Medical Technicians, theNational Association o EMS Educators, the National Association o EMSPhysicians, the National Association o State EMS Oicials, the National Native

American EMS Association, and the National Ski Patrol. The National Highway Traic Saety Administration concurred with the Guidelines.





FIGURE 1. Field triage decision scheme — United States, 2006

Measure vital signs and level of consciousness

Glasgow Coma Scale <14

Systolic blood pressure (mmHg) <90 mmHg

Respiratory rate <10 or >29 breaths per minute

(<20 in inant aged <1 year*)

Take to a trauma center.† Steps One and Two attempt to identiy the most seriously

injured patients. These patients should be transported preerentially to the highest

level o care within the trauma system.

Take to a trauma center. Steps One and Two attempt to identiy the most seriously

injured patients. These patients should be transported preerentially to the highest

level o care within the trauma system.

Transport to closest trauma center, which, depending on the trauma system, need

not be the highest level trauma center.§§

Contact medical control and consider transport to a

trauma center or a specifc resource hospital.

When in doubt, transport to a trauma center

Transport according

to protocol.¶¶¶

t"MMQFOFUSBUJOHJOKVSJFTUPIFBEOFDLUPSTP

and extremities proximal to elbow and knee

t'MBJMDIFTU

t5XPPSNPSFQSPYJNBMMPOHCPOFGSBDUVSFT

t$SVTIFEEFHMPWFEPSNBOHMFEFYUSFNJUZ

t"NQVUBUJPOQSPYJNBMUPXSJTUBOEBOLMF

t1FMWJDGSBDUVSFT

t0QFOPSEFQSFTTFETLVMMGSBDUVSF

t1BSBMZTJT

"TTFTTNFDIBOJTNPG

injury and evidence o

IJHIFOFSHZJNQBDU

"TTFTTTQFDJBMQBUJFOUPS

system considerations.

No

No

No

NoYes

Yes

Yes

Yes

t'BMMT

"EVMUTGFFUPOFTUPSZJTFRVBMUPGFFU

— Children¶GFFUPSUXPUPUISFFUJNFTUIFIFJHIUPGUIFDIJME

t)JHISJTLBVUPDSBTI

*OUSVTJPOJODIFTPDDVQBOUTJUFJODIFTBOZTJUF

— Ejection (partial or complete) rom automobile

— Death in same passenger compartment

— Vehicle telemetry data consistent with high risk o injury

t"VUPWTQFEFTUSJBOCJDZDMJTUUISPXOSVOPWFSPSXJUITJHOJöDBOUNQIJNQBDU††

t.PUPSDZDMFDSBTINQI

t"HF

— Older adults¶¶3JTLPGJOKVSZEFBUIJODSFBTFTBGUFSBHFZFBST

$IJMESFO4IPVMECFUSJBHFEQSFGFSFOUJBMMZUPQFEJBUSJDDBQBCMFUSBVNBDFOUFS

t"OUJDPBHVMBUJPOBOECMFFEJOHEJTPSEFST

t#VSOT

8JUIPVUPUIFSUSBVNBNFDIBOJTNUSJBHFUPCVSOGBDJMJUZ

8JUIUSBVNBNFDIBOJTNUSJBHFUPUSBVNBDFOUFS

t5JNFTFOTJUJWFFYUSFNJUZJOKVSZ†††

t&OETUBHFSFOBMEJTFBTFSFRVJSJOHEJBMZTJT

t1SFHOBODZXFFLT

t&.4§§§ provider judgment

"TTFTT

anatomy

o injury.

Step One

Step Two§

Step Three§

Step Four

See Figure 1 footnotes on the next page.





by EMS providers and represents the Panel’s opinions aterreview o the published medical literature and reports romcommunities that are implementing the Guidelines regarding their experience. The Panel recognizes that these Guidelinescannot address the speciic circumstances o each EMS system

in the United States or all circumstances that might arise at thescene o injury or while the patient is being transported to a hospital or trauma center. The Guidelines discuss core elementso any well-managed ield triage process; these guidelinesshould be adapted to it the speciic needs o local environments within the context o deined state, regional, or local trauma systems and in accord with an analysis o local data. In areaso uncertainty, or in those not addressed by the Guidelines,local EMS systems should rely on direction rom local EMSmedical directors, regulations, policies, and protocols.

MethodsPublished peer-reviewed research was the primary basis or

making any revisions to the Guidelines. To identiy articlesrelated to the overall ield triage process, a structured literaturesearch was conducted in Medline. English language peer-reviewed articles published between January 1, 2006 (the yearo the 2006 revision) and May 1, 2011, were searched. Becauseno single medical subject heading (MESH) is speciic to ieldtriage, multiple search terms were used. The ollowing terms weresearched as MESH vocabulary, keyword, natural language, andtruncated terms in order to maximize retrieval o relevant articles:

“trauma,” “wound,” “injury,” “pre-hospital,” “emergency medicalservices,” “ambulance,” “transport,” and “triage.” In addition, toidentiy articles related to speciic steps within the Guidelinesthat might have been missed by the general ield triage searchstrategy described above, researchers used terminology romeach criterion o the 1999 and 2006 guidelines as MESHvocabulary, keyword, natural language, and truncated termsto maximize retrieval o relevant articles. Examples o termsused include “physiology,” “lail chest,” “accidental alls,” and

“anticoagulation.” Both search strategies excluded case reportsletters to the editor, editorials, review articles, classic/historicreprints, continuing medical education, trade journal newsarticles, non-English language publications, and articles relatedto disasters and terrorism. Articles also were excluded i they

included the MESH terms “mass casualty incidents,” “disasters,”“blast injuries,” or “terrorism;” i they were addresses, lecturesletters, case reports, congressional testimony, or editorials; or ithey were written in a language other than English.

A total o 2,052 articles (389 on overall ield triage and 1,663that were step-speciic) were identiied or urther review. FouCDC injury researchers reviewed abstracts o each article basedon the relevance o the article to the Guidelines and ratedeach article as either “include” or “exclude” or urther reviewby the Panel. An individual article was selected or inclusioni it addressed the ield triage o injured patients (i.e., triagemethodology, guidelines, or decision schemes) or examined

a speciic criterion in the Guidelines (e.g., systolic bloodpressure) in the context o ield triage. Articles were includedi two or more researchers identiied them or selection. Dataon this rating were collected, and an agreement statistic wascalculated to assess the reliability o agreement among the ouraters. Statistical programming or calculating Fleiss’ Kappa wasdownloaded rom the proceedings o the 30th annual SAS UseGroup International Congress, and all analyses were conductedusing SAS ( 22 ). Results indicated substantial agreement withk = 0.73 and standard deviation = 0.009. This process identiieda total o 241 unique articles pertaining to ield triage.

To supplement the structured literature searches, a workinggroup o the Panel met in March 2011 to review the selectedarticles, identiy additional relevant literature that had notbeen examined, and make initial recommendations regardingindividual components o the Guidelines. This processidentiied an additional 48 articles, which, together with theoriginally identiied 241 articles, were provided to the Panelor review. Several articles were noted to be relevant to multiplesteps in the Guidelines.

Source:Adapted rom American College o Surgeons. Resources or the optimal care o the injured patient. Chicago, IL: American College o Surgeons; 2006. Footnotehave been added to enhance understanding o ield triage by persons outside the acute injury care ield.

* The upper limit o respiratory rate in inants is >29 breaths per minute to maintain a higher level o overtriage or inants† Trauma centers are designated Level I–IV, with Level I representing the highest level o trauma care available.§ Any injury noted in Steps Two and Three triggers a “yes” response.¶ Age <15 years.

** Intrusion reers to interior compartment intrusion, as opposed to deormation which reers to exterior damage.†† Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with estimated impact >20 mph with a motor vehicle.§§ Local or regional protocols should be used to determine the most appropriate level o trauma center; appropriate center need not be Level I.¶¶ Age >55 years.

*** Patients with both burns and concomitant trauma or whom the burn injury poses the greatest risk or morbidity and mortality should be transerred to a burncenter. I the nonburn trauma presents a greater immediate risk, the patient may be stabilized in a trauma center and then transerred to a burn center.

††† Injuries such as an open racture or racture with neurovascular compromise.§§§ Emergency medical services.¶¶¶ Patients who do not meet any o the triage criteria in Steps One through Four should be transported to the most appropriate medical acility as outlined in loca

EMS protocols.





FIGURE 2. Guidelines for field triage of injured patients — United States, 2011

Transport to a traumacenter.† Steps One and Twoattempt to identiy themost seriously injuredpatients. These patientsshould be transportedpreerentially to thehighest level o care withinthe defned trauma system.

Measure vital signs and level of consciousness

No

No

No

No

Yes

Yes

Yes

Assess anatomyo injury

Assess mechanism o injury and evidence o

high-energy impact

Assess special patient orsystem considerations

Transport accordingto protocol†††

When in doubt, transport to a trauma center

Transport to a traumacenter, which, dependingupon the defned traumasystem, need not be thehighest level traumacenter.§§

Step One

Step Two§

Step Three§

Step Four

Transport to a traumacenter or hospital capableo timely and thoroughevaluation and initialmanagement o potentiallyserious injuries. Considerconsultation with medical

control.

t"MMQFOFUSBUJOHJOKVSJFTUPIFBEOFDLUPSTPBOEFYUSFNJUJFTQSPYJNBMUPFMCPXPSLOFFt$IFTUXBMMJOTUBCJMJUZPSEFGPSNJUZFHøBJMDIFTUt5XPPSNPSFQSPYJNBMMPOHCPOFGSBDUVSFTt$SVTIFEEFHMPWFENBOHMFEPSQVMTFMFTTFYUSFNJUZt"NQVUBUJPOQSPYJNBMUPXSJTUPSBOLMFt1FMWJDGSBDUVSFTt0QFOPSEFQSFTTFETLVMMGSBDUVSFt1BSBMZTJT

t'BMMT"EVMUTGFFUPOFTUPSZJTFRVBMUPGFFU— Children¶GFFUPSUXPPSUISFFUJNFTUIFIFJHIUPGUIFDIJMEt)JHISJTLBVUPDSBTI*OUSVTJPOJODMVEJOHSPPGJODIFTPDDVQBOUTJUFJODIFTBOZTJUF&KFDUJPOQBSUJBMPSDPNQMFUFGSPNBVUPNPCJMF— Death in same passenger compartment7FIJDMFUFMFNFUSZEBUBDPOTJTUFOUXJUIBIJHISJTLPGJOKVSZt"VUPWTQFEFTUSJBOCJDZDMJTUUISPXOSVOPWFSPSXJUITJHOJöDBOUNQIJNQBDU††

t.PUPSDZDMFDSBTINQI

(MBTHPX$PNB4DBMF ź

4ZTUPMJD#MPPE1SFTTVSFNN)H NN)H

3FTQJSBUPSZSBUF PSCSFBUITQFSNJOVUF

JOJOGBOUBHFEZFBSor need or ventilatory support

t0MEFSBEVMUT¶¶

3JTLPGJOKVSZEFBUIJODSFBTFTBGUFSBHFZFBST4#1NJHIUSFQSFTFOUTIPDLBGUFSBHFZFBST-PXJNQBDUNFDIBOJTNTFHHSPVOEMFWFMGBMMTNJHIUSFTVMUJOTFWFSFJOKVSZt$IJMESFO— Should be triaged preerentially to pediatric capable trauma centerst"OUJDPBHVMBOUTBOECMFFEJOHEJTPSEFST1BUJFOUTXJUIIFBEJOKVSZBSFBUIJHISJTLGPSSBQJEEFUFSJPSBUJPOt#VSOT— Without other trauma mechanism: triage to burn acility***

— With trauma mechanism: triage to trauma center***t1SFHOBODZXFFLTt&.4QSPWJEFSKVEHNFOU

See Figure 2 footnotes on the next page.





In April 2011, the Panel met to discuss the articles,recommendations o the working group, and the experientiabase rom states and communities implementing the Guidelines

and to reairm or revise the Guidelines. In the sources reviewedInjury Severity Score (ISS) >15, where available, was used as thethreshold or identiying severe injury; however, other actors (e.g.need or prompt operative care and intensive care unit [ICU]admission) also were considered. A threshold o 20% positivepredictive value (PPV) to predict severe injury was used to placecriteria into discussion or inclusion as mechanism-o-injurycriteria. A review o NHTSA’s National Automotive SamplingSystem-Crashworthiness Data System (NASS-CDS) ( 23) andCrash Injury and Research Engineering Network (CIREN) ( 24)inormation also was undertaken to inorm the Panel on the

high-risk automobile-crash criterion. The inal recommendationo the Panel were based on the best available evidence. Whendeinitive research evidence was lacking, the Panel based itsrevisions and recommendations on the expert opinion o itsmembers. Consensus among the Panel members on speciicrecommendations and modiications was not required.

2011 Field Triage GuidelineRecommendations

Modiications to the previously published Guidelines (1) havebeen summarized (Box 2). The sections that ollow discuss thechanges made and provide the rationale o the Panel or makingthese changes. The 2011 Guidelines have been endorsed bymultiple proessional organizations and ederal governmentagencies. ¶ The national Highway Traic Saety Administrationconcurs with these Guidelines. An updated list o endorsingorganizations is available at http://www.cdc.gov/ieldtriage.

BOX 1. Selected examples of CDC’s efforts to ensure dissemination,implementation, and evaluation of the 2006 guidelines for field triage*

Disseminationt %JTTFNJOBUFEGJFMEUSJBHFFEVDBUJPOBM

materialst &NBJMFEXJUIQFSNJTTJPOGSPNUIF/BUJPOBM3FHJTUSZ

o Emergency Medical Technicians, approximately 150,000 emergency medical services (EMS) providerscopies o the ield triage continuing educationmaterials

t .BJMFEUSBJOJOHHVJEFTGPS&.4MFBEFST(available at http://www.cdc.gov/FieldTriage/pd/EMS_Guide-a.pd) to local, state, and regionalemergency medical services, academia, proessional

organizations, ire departments, ambulance servicesand trauma centers nationwide

Implementationt %FWFMPQFEBXFCQBHFGPSGJFMEUSJBHFBWBJMBCMFBU

http://www.cdc.gov/ieldtriage) that has had 73,636page views, 8,060 downloads o the 2009 guidelines,and 2,641 downloads o the training materials

t 1SPWJEFEDPOUJOVJOHFEVDBUJPOUP&.4providers, physicians, and nurses

Evaluationt 4VSWFZFE&.4FNFSHFODZNFEJDJOFBOE

trauma care providers regarding the guidelines

*CDC. Guidelines or ield triage o injured patients: recommendationso the National Expert Panel on Field Triage. MMWR 2009;58(No.RR-1).

Abbreviation: EMS = emergency medical services.* The upper limit o respiratory rate in inants is >29 breaths per minute to maintain a higher level o overtriage or inants.† Trauma centers are designated Level I-IV. A Level I center has the greatest amount o resources and personnel or care o the injured patient and provides regiona

leadership in education, research, and prevention programs. A Level II acility oers similar resources to a Level I acility, possibly diering only in continuousavailability o certain subspecialties or suicient prevention, education, and research activities or Level I designation; Level II acilities are not required to beresident or ellow education centers. A Level III center is capable o assessment, resuscitation, and emergency surgery, with severely injured patients beingtranserred to a Level I or II acility. A Level IV trauma center is capable o providing 24-hour physician coverage, resuscitation, and stabilization to injured patientbeore transer to a acility that provides a higher level o trauma care.

§ Any injury noted in Step Two or mechanism identiied in Step Three triggers a “yes” response.¶ Age <15 years.

** Intrusion reers to interior compartment intrusion, as opposed to deormation which reers to exterior damage.†† Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with estimated impact >20 mph with a motor vehicle.§§ Local or regional protocols should be used to determine the most appropriate level o trauma center within the deined trauma system; need not be the highest-leve

trauma center.¶¶ Age >55 years.

*** Patients with both burns and concomitant trauma or whom the burn injury poses the greatest risk or morbidity and mortality should be transerred to a burncenter. I the nonburn trauma presents a greater immediate risk, the patient may be stabilized in a trauma center and then transerred to a burn center.

††† Patients who do not meet any o the triage criteria in Steps One through Four should be transported to the most appropriate medical acility as outlined in locaEMS protocols.

¶ A list appears on page 20.





Name of the GuidelinesThe name o the Guidelines remains unchanged. The

Panel recognized that many dierent names have beenattached to the Guidelines, creating potential conusion orpersons, communities, and states attempting to implementthe Guidelines. In addition, the Panel reviewed eedback thatindicated that conusion exists as to whether this represents

mass casualty triage or “routine” daily triage o injured patientsThe Guidelines apply to “routine” daily triage o injuredpatients. Ater deliberations, the Panel decided not to changeor modiy the name o the decision scheme because creating anew and dierent name would likely only add to or increaseany conusion or misunderstanding that exists, many states

and locales have begun implementation o the decision schemebased on its name as given and to change it at this point mightunduly burden those systems; and even i a new name wasadded, end-users might attach a dierent name to it, and theproblem would remain unresolved. The Panel recommendedthat CDC continue to provide educational materials thadescribe the purpose o the Guidelines and that the decisionscheme be called either the “ield triage decision scheme” orthe “guidelines or ield triage o injured patients.” The Panealso recommended that the Guidelines not be reerred to as a“national protocol” because using the term “protocol” has anunintended proscriptive inerence or the end-user that couldrestrict local adaptation required or optimal implementation

Step One: Physiologic CriteriaIn Step One, the Glasgow Coma Scale, and Respiratory Rate

criteria were modiied. Step One is intended to allow or rapididentiication o critically injured patients by assessing level oconsciousness (Glasgow Coma Scale [GCS]) and measuringvital signs (systolic blood pressure [SBP] and respiratory rate)Vital sign criteria have been used since the 1987 version othe ACS Field Triage Decision Protocol (8 ). These criteriademonstrate high predictive value or severe injury. O 289

reerences identiied rom the structured literature review, 82(28%) were relevant to Step One. SBP <90 and respiratory rate<10 or >29 remain signiicant predictors o severe injury andthe need or a high level o trauma care. Multiple peer-reviewedarticles published since 2006 support this threshold ( 25–28 )

The Panel recommended transport to a acility that providethe highest level o care within the deined trauma system iany o the ollowing are identiied:t (MBTHPX$PNB4DBMFǙPSt 4#1PGNN)HPSt SFTQJSBUPSZSBUFPGPSCSFBUITQFSNJOVUFJO

inant aged <1 year), or need or ventilatory support.

Glasgow Coma Scale: Criterion Clarified

Experience with the 2006 Guidelines has indicated thatmany readers and end-users perceived that the criterion o($4SFDPNNFOEFEUBLJOHQBUJFOUTXJUIB($4PGǙto trauma centers. To reduce any uture conusion, the PaneWPUFEVOBOJNPVTMZUPSFXSJUFUIFDSJUFSJPOBT($4Ǚ

BOX 2. Changes in 2011 Guidelines for Field Triage of Injured Patientscompared with 2006 guidelines

Step One: Physiologic Criteria t $IBOHF($4UP($4Ǚt "EEiPSOFFEGPSWFOUJMBUPSZTVQQPSUwUP

respiratory criteria

Step Two: Anatomic Criteria t $IBOHFiBMMQFOFUSBUJOHJOKVSJFTUPIFBEOFDL

torso and extremities proximal to elbow and knee”to “all penetrating injuries to head, neck, torso andextremities proximal to elbow or knee”

t $IBOHFiGMBJMDIFTUwUPiDIFTUXBMMJOTUBCJMJUZPSdeormity (e.g., lail chest)”

t $IBOHFiDSVTIFEEFHMPWFEPSNBOHMFEFYUSFNJUZwto “crushed, degloved, mangled, or pulselessextremity”

t $IBOHFiBNQVUBUJPOQSPYJNBMUPXSJTUBOEBOLMFwto “amputation proximal to wrist or ankle”

Step Three: Mechanism-of-Injury Criteria t "EEiJODMVEJOHSPPGwUPJOUSVTJPODSJUFSJPO

Step Four: Special Considerationst "EEUIFGPMMPXJOHUPPMEFSBEVMUDSJUFSJB

—SBP <110 might represent shock ater age 65 years—Low-impact mechanisms (e.g., ground-level alls)

might result in severe injury t "EEiQBUJFOUTXJUIIFBEJOKVSZBSFBUIJHISJTL

or rapid deterioration” to anticoagulation andbleeding disorders criterion

t 3FNPWFiFOETUBHFSFOBMEJTFBTFSFRVJSJOHEJBMZTJTwand “time-sensitive extremity injury”

Transition Boxest $IBOHFMBZPVUPGUIFGJHVSFt .PEJGZTQFDJGJDMBOHVBHFPGUIFUSBOTJUJPOCPYFT

Abbreviation: GCS = Gasgow Coma Scale; SBP = systolic blood pressure.





Need for Ventilatory Support: Criterion Added

The need or ventilatory support (including both bag-mask ventilation and intubation) was added to “respiratory rate o <10 or >29 breaths per minute (<20 in an inant aged <1 year). Although it has been assumed that patients requiring ventilatory support would meet the respiratory rate criterion, three studiessuggest that this is not necessarily the case and demonstratethe importance o considering ventilatory support, in additionto respiratory rate, in identiying seriously injured patients. Among 6,259 adults meeting Step One criteria across 11 sitesin North America, an advanced airway attempt (i.e., intubationor supraglottic airway placement) was the strongest predictoro death or prolonged hospital stay among all physiologicmeasures ( 29 ). Among 955 injured children meeting StepOne criteria rom the same sites, little dierence was reportedin the proportion o children with abnormal respiratory rates who were seriously injured compared with those whose injuries

were not serious (44% and 47%, respectively); however, theneed or ventilatory assistance was highly discriminating between the two groups (46% and 3%, respectively) and again was determined to be the strongest physiologic predictor o serious injury ( 30 ). Another study involving 3,877 injuredchildren had similar indings, with ield intubation attemptbeing second only to GCS in identiying children in needo trauma center care ( 31). Thereore, ater reviewing theliterature and considering the evidence, the Panel added “orneed or ventilatory support” to the respiratory rate criterion,recognizing that adults and children requiring advanced airway interventions represent a very high-risk group, whether or not

other physiologic abnormalities (including speciic respiratory rate values) are present and to ensure that patients requiring airway support receive the highest level o trauma care withinthe deined trauma system.

Additional Physiologic Concerns Discussed by theExpert Panel

The ollowing sections describe additional physiologiccriteria topics that were discussed by the Panel and or whichno changes were recommended.

Glasgow Coma Scale Motor

Although the Panel considered adding the motor portiono the Glasgow Coma Score (GCSm) as an alternative tothe GCS total (GCSt), which includes verbal, eye opening,and motor components, no change was made. The motorscore has been demonstrated to be associated with the needor liesaving interventions ( 32,33). Debate occurred as to whether using only the motor score would be easier or EMSpersonnel than the GCSt; however, because o the lack o conirmatory evidence, the long standing use o the GCSt and

its amiliarity among current EMS practitioners, the inclusiono the motor score within the GCSt, and complications becauseo the diiculty o comparative scoring systems, the Panerecommended no change at this time.

Systolic Blood Pressure in Older Adults and

ChildrenThe Panel discussed including a systolic blood pressure

(SBP) threshold o <110 or patients aged >65 years. Aterdeliberation, the Panel decided to account or physiologicdierences in older adults in Step Four under “Older Adults”the rationale and clinical evidence are discussed in that sectionThe Panel maintained the decision to retain the SBP<90mmHgthreshold in children. Because o the substantial proportion oyoung children with no ield measurement o blood pressure( 31), the Panel believed this decision would have minimaimpact on overtriage.

Shock Index A retrospective chart review o 2,445 patients admitted ove

a 5-year period at an urban Level I trauma center determinedthat shock index (heart rate divided by systolic blood pressure)is an accurate prehospital predictor o mortality ( 34 ). Howeverthe Panel identiied no evidence to suggest that shock indeximproves ield identiication o seriously injured patientsbeyond the existing physiologic measures, and noted thatutilization o the shock index requires a calculation in the ieldand its value during ield triage remains unclear. The Panenoted that the use o shock index or triage decisions might be

more applicable in the uture as vital signs and triage criteriabecome routinely recorded and collected on mobile devices

Step Two: Anatomic CriteriaIn Step Two, the criteria pertaining to chest and extremity

injuries were modiied. Step Two o the Guidelines recognizethat certain patients, on initial presentation to EMS providershave normal physiology but have an anatomic injury that mightrequire the highest level o care within the deined traumasystem. O the 289 reerences identiied rom the structuredliterature review, 57 (20%) were relevant to Step Two. Most othe literature supported Step Two o the 2006 Guidelines, andthe majority o Step Two criteria thereore remain unchanged

The Panel recommended transport to a acility that providethe highest level o care within the deined trauma system iany o the ollowing are identiied:t BMMQFOFUSBUJOHJOKVSJFTUPIFBEOFDLUPSTPBOEFYUSFNJUJFT

proximal to elbow or knee;t DIFTUXBMMJOTUBCJMJUZPSEFGPSNJUZFHGMBJMDIFTUt UXPPSNPSFQSPYJNBMMPOHCPOFGSBDUVSFT





t DSVTIFEEFHMPWFENBOHMFEPSQVMTFMFTTFYUSFNJUZt BNQVUBUJPOQSPYJNBMUPXSJTUPSBOLMFt QFMWJDGSBDUVSFTt PQFOPSEFQSFTTFETLVMMGSBDUVSFTPSt QBSBMZTJT

Crushed, Degloved, Mangled, or Pulseless Extremity:Criterion Modified

This criterion was modiied to include “pulseless” extremities.Several published articles highlighted vascular injury as animportant injury requiring specialized care ( 35–40 ). In a retrospective analysis o 73 patients with arterial injuries, 37patients (51%) had associated injuries (e.g., bone and nerve),and ive patients (7%) required amputation ( 37 ). In a 5-yearretrospective review o 52 patients with upper extremity vascularinjury, 41 patients (79%) had associated nerve or bone injury, 14patients (27%) required asciotomies, and seven patients (13%)required amputation. In addition, the patients in this study wereseverely injured, with a mean ISS o 17.52 (40 ). Ater review o the evidence, the Panel decided to add “pulseless” to the criterionor crushed, degloved, or mangled extremity because vascularinjury o the extremity might lead to signiicant morbidity and mortality, require a high level o specialized trauma careinvolving multiple medical specialties, and be present in theabsence o a crushed, degloved, or mangled extremity ( 37 ).

Chest Wall Instability or Deformity (e.g., Flail Chest):Criterion Modified

This criterion was modiied to read “Chest wall instability

or deormity (e.g., lail chest).” The Panel identiied no new evidence that speciically addressed the ield triage o patients with lail chest. The Panel recognized that the ield diagnosiso a lail chest is rare and that this criterion might be overly restrictive. In a 5-year retrospective study o the Israel NationalTrauma Registry, lail chest was identiied in 262 (0.002%)o 118,211 patients and in only 262 (0.02%) o 11,966 chestinjuries (41). Flail chest occurs in approximately 75 (0.002%)per 50,000 patients (42 ). In this context, the Panel thoughtthat as written, “lail chest” might ail to identiy all o thechest injuries that require that the patient be transported to a acility that provides the highest level o care within the deined

trauma system. The Panel decided that the criterion should bechanged to “chest wall instability or deormity (e.g., lail chest)”because “lail chest” rarely is diagnosed by EMS providers;the terminology “chest wall instability or deormity” moreaccurately describes what EMS providers are asked to identiy in the ield environment, and the broader terminology ensuresthat additional blunt trauma to the chest (e.g., multiple ribractures) will be identiied and the patient transported to theappropriate acility.

All Penetrating Injuries to Head, Neck, Torso,and Extremities Proximal to Elbow or Knee:Criterion Modified

This criterion was modiied to read “elbow or knee.” Duringits discussions, the Panel noted that penetrating injuries to the

extremities proximal to the elbow or knee might signiy severeinjuries requiring surgical intervention or intensive care unit(ICU) admission. Thereore, the Panel modiied the wordingo this criterion rom “elbow and knee” to “elbow or knee” torecognize that these types o injuries generally occur separatelyand that each can represent a severe injury.

Amputation Proximal to Wrist or Ankle:Criterion Modified

This criterion was modiied to read “wrist or ankle.” Duringits discussions, the Panel noted that amputations proximal tothe wrist or ankle might signiy severe injuries requiring the

patient to be taken to an operating theater or admitted toan ICU. Thereore, the Panel modiied the wording o thiscriterion rom “wrist and ankle” to “wrist or ankle” to recognizethat these types o injuries most commonly occur separatelyand that each can represent a severe injury.

Additional Anatomic Concerns Reviewed bythe Panel

The ollowing sections describe additional anatomic criteriatopics that were discussed by the Panel and or which nochanges were recommended.

Tourniquet UseSuccessul medical treatment o soldiers on the battleield

prompted researchers to explore the potential use otourniquets or the rapid treatment o vascular injuries seenin the civilian population. Recent battleield experienceindicate that tourniquet use reduces mortality by limitingexsanguinations (43,44 ). A retrospective review o 75,000trauma visits at two Level 1 trauma centers in Texas identiied14 patients with penetrating extremity injuries who arrivedat the hospital dead, required emergency thoracotomy, orunderwent cardiopulmonary resuscitation. Eight decedents(57%) were identiied as having extremity injuries that might

have been amenable to application o a tourniquet in theprehospital environment (45 ).

Ater review o the literature and subsequent discussion, thPanel elected not to include tourniquet use as an independenStep Two criteria because evidence is limited regarding the useo tourniquets in the civilian population; use o tourniquetsamong EMS systems varies; inclusion o tourniquet use as acriterion could lead to overuse o tourniquets instead o basic





hemorrhage control methods and thus potentially result inovertriage; and the “crushed, degloved, mangled, or pulselessextremity,” “all penetrating injuries to head, neck, torso, andextremities proximal to elbow or knee,” and “amputationproximal to wrist or ankle” criteria were as likely to identiy severely injured patients regardless o tourniquet use. The Panel

recommended urther study o the use o this intervention.

Pelvic Fractures

Patients with pelvic ractures should receive rapid andspecialized care because o the possibility o internalhemorrhage and other associated injuries. The Panel discussed whether the term “pelvic racture” was the most appropriateterm or the Guidelines to use to aid EMS proessionals inidentiying patients in need o trauma center care, recognizing that certain states and communities have changed thisterminology to read “unstable pelvic racture,” “suspected pelvicracture,” or “pelvic instability.” Ater extensive discussion, the

Panel decided to retain the term “pelvic ractures” as writtenbecause no compelling evidence exists that a dierent name would identiy the patients in need o trauma center caremore accurately, or the sake o simplicity, and because adding “suspected” or “tenderness” to this criterion might increaseovertriage unnecessarily.

Step Three: Mechanism of InjuryIn Step Three, the intrusion criterion was modiied to include

roo intrusion. An injured patient who does not meet Step Oneor Step Two criteria should be evaluated in terms o mechanism

o injury (MOI) to determine i the injury might be severe butoccult. Evaluation o MOI will help to determine i the patientshould be transported to a trauma center. Although dierentoutcomes have been used, recent studies have demonstratedthe useulness o MOI or ield triage decisions. A retrospectivestudy o approximately 1 million trauma patients indicatedthat using physiologic and anatomic criteria alone or triage o patients resulted in undertriage, implying that using MOI ordetermining trauma center need helped reduce the problemo undertriage (46 ). Another study o approximately one hal million patients determined that MOI was an independentpredictor o mortality and unctional impairment o blunttrauma patients (47 ). Among 89,441 injured patients evaluatedby EMS providers at six sites, physiologic and anatomic criteria identiied only 2,600 (45.5%) o 5,720 patients with anISS >15, whereas MOI criteria identiied an additional 1,449(25.3%) seriously injured patients with a modest (10%)incremental increase in overtriage (rom 14.0% to 25.3%) (48 ).

O the 289 reerences identiied rom the structured literaturereview, 85 (29%) were relevant to Step Three. Articles that were

considered to provide either compelling evidence or changeto the Guidelines or articles that provided insight into speciicmechanisms are discussed below.

The Panel recommended transport to a trauma center i anyo the ollowing are identiied:t GBMMT

— adults: >20 eet (one story = 10 eet)— children: >10 eet or two to three times the height o

the childt IJHISJTLBVUPDSBTI

— intrusion, including roo: >12 inches occupant site>18 inches any site

— ejection (partial or complete) rom automobile— death in same passenger compartment— vehicle telemetry data consistent with a high risk o

injury;t BVUPNPCJMFWFSTVTQFEFTUSJBOCJDZDMJTUUISPXOSVOPWFS

or with signiicant (>20 mph) impact; ort NPUPSDZDMFDSBTINQI

High-Risk Automobile Crash: Intrusion, IncludingRoof >12 Inches to the Occupant Site; >18 Inchesto Any Site: Criterion Modified

This criterion was modiied to include roo intrusion. InB TUVEZPG DIJMESFOǙ ZFBSTJOUSVTJPO JOEFQFOEFOo other actors such as age, restraint use, seating row anddirection o impact was a signiicant and strong predictoro a severe injury measured by an Abbreviated Injury Scores(AIS) >2 or >3. Furthermore, these analyses demonstrated that

each additional centimeter o intrusion increased the oddso an AIS >2 or >3 by 2.9% (49 ). Another study identiiedsimilar results indicating that drivers whose vehicles sueredside impact collisions had nearly our times (OR = 3.8195% CI = 1.26–11.5) the odds o suering an AIS >3 orhave severe head injury compared with drivers whose vehicleshad dierent collision characteristics; these results urthesuggested that drivers who had intrusion into the passengercompartment at the driver’s position were signiicantly morelikely to have severe injury regardless o damage distributionacross the rontal plane o the vehicle (50 ).

Data rom CIREN and NASS-CDS suggest that intrusion

o >12 inches at an occupant site or intrusion o >18 incheat any site is a signiicant predictor o severe injury requiringtrauma care. These data also indicate that roo intrusion ispredictive o the need or trauma care (51).

Ater deliberations, the Panel decided to add “includingroo” to the intrusion category because the 2006 guidelinesdid not convey clearly that vertical roo intrusion has the sameimplication or increased injury severity as horizontal intrusion





into the vehicle occupant space, and a review o the literatureconirms that intrusion, including vertical roo intrusion, isan important predictor o trauma center need.

Additional Mechanism-of-Injury ConcernsDiscussed by the Panel

The ollowing sections describe additional MOI criteria topics that were discussed by the Panel and or which nochanges were recommended.

Extrication

Prolonged extrication has been reported to be an independentpredictor (OR = 2.3; 95% CI = 1.2–4.6) o emergency surgery need in hypotensive (SBP <90 mmHg) trauma patients (52 ). An earlier Australian study, reviewed by the Panel in 2005,determined that prolonged extrication time was associated withmajor injury (53). However, neither o these studies used ISS>15 as a threshold, nor did they examine whether prolonged

extrication was an independent predictor o serious injury aterSteps 1 and 2. During the 2006 revision, the Panel consideredpoor standardization in the literature regarding the deinitiono extrication time as well as its dependence on local resources,scene conditions, and extrication expertise in its decision toeliminate prolonged extrication. The Panel concluded at thattime that the vehicle intrusion criterion should be an adequatesurrogate or prolonged extrication. During this latest revision,examination o CIREN data conirmed that the currentintrusion criterion was more speciic or ISS >15 injury thanneed or physical extrication o the vehicle occupant (lengtho extrication unknown) (51).

Recent data collected over a 2-year period rom 11,892interviews with EMS personnel regarding transport o injuredpatients to a regional trauma center indicated that o the9,483 patients who did not meet the anatomic or physiologiccriteria, extrication time >20 minutes (as estimated by the EMSprovider) suggested that occupants o motor-vehicle crasheshad a signiicantly greater likelihood o being admitted to anICU, needing nonorthopedic surgery in the irst 24 hours aterinjury, or dying (sensitivity: 11%; speciicity: 98%; positivelikelihood ratio: 5.0) (54 ).

Although these data would appear to support the inclusion

o “prolonged extrication time” as a mechanism criterion oridentiying a major trauma patient, the Panel concluded thatthis was not an independent predictor in that the intrusioncriterion addressed this mechanism event adequately, and theimprecise nature o this data was diicult to interpret reliably andinclude. The Panel concluded that no compelling evidence existsto reinstitute prolonged extrication time as a criterion in MOI.

Rollover

Rollover vehicle crash events are less common than planarcrashes o vehicles into other vehicles or ixed objects, but theyare more dangerous overall (51,55 ). In 2004, NHTSA reported11,728,411 motor-vehicle crashes. O these, the 275,637(2.4%) rollover crashes were associated with one third o alloccupant deaths (56,57 ). Two recent studies highlight theimportance o rollover as a predictor o severe injury (49,57 )However, both studies were limited because they did not controor Step One and Step Two criteria when determining the needor transport to a trauma center. A study was conducted thaused 11,892 EMS provider interviews regarding transport oinjured patients to identiy injured patients who did not meethe physiologic or anatomic criteria to determine i rollover wasa predictor o trauma center need. A total o 523 rollover caseoccurred, and the sensitivity or trauma center need (deinedas death, admission to ICU, or nonorthopedic surgery within

24 hours o arrival) was 13% (range: 8.2%–18.0%) and thespeciicity was 87% (range: 86.2%–88.3%). When the data were analyzed by the number o quarter turns, only minimaimprovement in positive likelihood ratios was reported, andnone was >1.7 (54 ).

The Panel reexamined other data rom rollover crashes todetermine whether subsets o rollover crashes might warrantinclusion as a criterion in MOI. NASS-CDS rollover crashdata were analyzed to determine the eect o the number oquarter turns, the inal position o the vehicle, the extent oroo intrusion as well as partial and ull ejection o the occupanrom the vehicle. Rollover crashes with roo intrusion o 24

inches were associated with a 19.3% risk o ISS >15 injury. Anyejection (partial or ull) was associated with a 21.5% risk oISS >15 injury, and complete occupant ejection was associated with a 27.4% risk o ISS >15 injury (51).

The Panel thought that the existing ejection and intrusioncriterion, and the previously discussed modiication to includeroo intrusion, adequately addressed ield triage o this subseo severe rollover crashes. The Panel concluded that rolloverevent, as a standalone criterion, has <9% PPV or ISS >9 andis insuicient to meet the 20% PPV or ISS >15 targeted as athreshold or inclusion in Step Three.

As a crash mechanism, rollover might result in one or more

occupants sustaining severe injuries. The Panel reiterated itsopinion that patients involved in rollover crashes should beevaluated by EMS personnel to determine i they have injuriesthat meet Step One, Step Two, or other Step Three criteriaPatients involved in rollover crashes who meet Step One orStep Two criteria should be transported preerentially to thehighest level o care within the deined trauma system. Patient





involved in rollover crashes who meet only Step Three (butnot Step One or Step Two) criteria should be transported to a trauma center that, depending on the deined trauma system,need not be the highest-level trauma center. The Panel notedthat the increased injury severity associated with rollovercrashes results rom an occupant being ejected either partially

or completely rom the vehicle, and partial or completeejection is already a criterion or transport to a trauma center.Thereore, the previous decision to remove rollover rom the2006 Guidelines was reairmed, and no changes were maderegarding rollover. In addition, the Panel noted that adding “including roo” under the intrusion criterion will identiy rollover crashes with signiicant roo intrusion.

Vehicle Telemetry

Several studies have indicated that mechanical aspects o collisions can be predictors o injury in motor vehicle crashes. A study that used 10 years o NASS-CDS data determined that

seat belt use, direction o impact, and Delta V (i.e., a change invelocity) were the most important predictors o an ISS >15 (58 ).The study also concluded that an event data recorder (EDR)system could provide emergency personnel with good estimateso injury status based solely on data such as seat belt use, directiono impact, and Delta V, which can be collected rom the vehicle.Other research has suggested that actors that can be recordedby a vehicle EDR system such as Delta V (59,60 ), high speedvelocity (61), location o impact (62 ), and vehicle weight andtype (63) are predictors o severe injury. The Panel recognizedthe increasing availability o vehicle telemetry in newer vehiclesand reairmed its position that vehicle telemetry might havean important role in the triage o injured patients as the crashtechnology, data transmission, and telemetry availability continueto expand. An explanation o how vehicle telematics could beused in ield triage has been published previously (64 ).

Falls

Research conducted on alls is limited because o theinability to study the impact o measured all height directly.However, three studies were identiied that added insight intothis mechanism. One study o 63 cases o alls indicated thatamong children aged <2 years, height o all >2 meters (>6.6

eet) is a predictor o injury (65 ). A similar study o 72 childrenaged 4 months–5 years indicated that alls rom <1 meter(3.3 eet) could cause a skull racture i the all occurred on a hard surace (66 ). Furthermore, another study conducted inFrance o 287 victims o alls rom height indicated that heighto all, hard impact surace, and having the head being the irstbody part to touch the ground were independent predictors o mortality (67 ). On the basis o these three studies with limited

sample sizes and the overall limited data on alls, no changes were made to this section.

Step Four: Special ConsiderationsIn Step Four, the criteria or older adults and anticoagulation

were modiied, and the criteria or end stage renal diseaserequiring dialysis and time-sensitive extremity injury wereremoved. In Step Four, EMS personnel must determine whether persons who have not met physiologic, anatomicor mechanism steps have underlying conditions or comorbidactors that place them at higher risk o injury or that aid inidentiying the seriously injured patient. Persons who meet StepFour criteria might require trauma center care. A retrospectivestudy o approximately 1 million trauma patients indicatedthat using physiologic (Step One) and anatomic (Step Two)criteria alone or triage o patients resulted in a high degreeo under triage, implying that using special considerations or

determining trauma center need helped reduce the problem ounder triage (46 ). Among 89,441 injured patients evaluatedby EMS providers at six sites, physiologic, anatomic, andmechanism o injury criteria identiied 4,049 (70.8%) patient with an ISS >15; Step Four o the Guidelines identiied anothe956 (16.7%) o seriously injured patients, with increase inovertriage rom 25.3% to 37.3%. (48 ).

O the 289 reerences identiied rom the structured literaturereview, 77 (27%) were relevant to Step Four. No changes were made to the Step Four criteria or burns, pregnancy, andEMS provider judgment. The Panel recommended transportto a trauma center or hospital capable o timely and thorough

evaluation and initial management o potentially seriousinjuries or patients who meet the ollowing criteria:t PMEFSBEVMUT

— risk or injury/death increases ater age 55 years— SBP <110 might represent shock ater age 65 years— low impact mechanisms (e.g., ground-level alls) migh

result in severe injury t DIJMESFO

— should be triaged preerentially to pediatric capabletrauma centers

t BOUJDPBHVMBOUTBOECMFFEJOHEJTPSEFST— patients with head injury are at high risk or rapid

deteriorationt CVSOT

— without other trauma mechanism: triage to burn acility— with trauma mechanism: triage to trauma center

t QSFHOBODZXFFLTt &.4QSPWJEFSKVEHNFOU





Older Adults: Criterion Modified

This criterion was modiied to include statements thatrecognize that a SBP <110 might represent shock ater age65 years and that low-impact mechanisms (e.g., ground-levelalls) might result in severe injury. The Panel recognized thatadults aged >65 years are not transported consistently to thehospital best equipped to manage their injuries (high rateso undertriage relative to other age groups). A retrospectiveanalysis o 10 years o prospectively collected data in theMaryland Ambulance Inormation System identiied a higherundertriage rate or patients aged ≥65 years compared withthose aged <65 years (49.9% and 17.8%, respectively; p<0.001)(68 ). On subsequent multivariate analysis, the authors noteda decrease in transport to trauma centers or older patientsbeginning at age 50 years (OR = 0.67; 95% CI = 0.57–0.77), with a second decrease at age 70 year s (OR = 0.45;95% CI = 0.39–0.53) compared with those patients aged

<50 years. In a 4-year retrospective study o 13,820 patientsin the Washington State Trauma Registry, those patients agedZFBSTXFSFMFTTMJLFMZUIBOUIPTFBHFEǙZFBSTUPIBWFhad the prehospital system or the trauma team activated. Inaddition, use o multivariate logistic regression indicated thatphysiologic triage variables (e.g., blood pressure and heart rate) were unreliable predictors o mortality or interventions in thehospital (69 ).

Several studies suggest that dierences in the physiologicresponse to injury and high-risk mechanisms in older adultsmight partly explain undertriage rates in this age group.In a retrospective chart review o 2,194 geriatric patients

(aged ≥65 years) at a Level 1 trauma center, mortality wasnoted to increase at a SBP o <110 mmHg (70 ). A retrospectivereview o 106 patients aged >65 years at a Level II trauma centerindicated that occult hypotension (i.e., decreased perusionthat is not evident by standard vital sign criteria) was presentin 42% o patients with “normal” vital signs (71).

In addition, the Panel reviewed literature that indicated thatolder adults might be severely injured in low-energy events(e.g., ground-level alls). An analysis o deaths reported by the King County Medical Examiner’s Oice (King County, Washington) indicated that ground level alls accounted or237 (34.6%) o all deaths (684) in patients aged ≥65 years

(72 ). A study o 57,302 patients with ground-level allsdemonstrated higher rates o intracranial injury and in-hospitalmortality among adults aged ≥70 years (73).

On the basis o its review, the Panel elected to strengthen thecriterion regarding older adults in Step Four. “SBP <110 mightrepresent shock ater age 65” and “low-impact mechanisms(e.g., ground-level alls) might result in severe injury” wereadded under “Older Adults” in Step Four because undertriage

o the older adult population is a substantial problem, theevidence reviewed suggests that the physiologic parametersused in younger patients might not apply to older adults, occulinjury is likely to be greater among older adults, low-energytransers (e.g., ground-level alls) might result in serious injuriesin this population, and ield identiication o serious injury

among older adults must be more proactive.

Anticoagulation and Bleeding Disorders: Patientswith Head Injury Are at High Risk for RapidDeterioration: Criterion Modified

The Panel modiied this criterion to highlight the potentiaor rapid deterioration in anticoagulated patients with headinjuries. Anticoagulation use has been associated with anincreased risk or intracranial hemorrhage ollowing headinjury (72,73–77 ) and longer hospital stays (72,78 ). Aretrospective review o 141 Level II trauma center patients who were taking wararin or clopidogrel, had minor head injuriesand had a GCS o 15 indicated that 41 (29%) had intracraniahemorrhage (74 ). A study o 237 patients who died ollowingground-level alls indicated that 71 (30%) patients wereanticoagulated with aspirin, wararin, clopidogrel, heparinor multiple anticoagulants (72 ). Preinjury use o wararinhas been associated with higher mortality among adults aged>65 years with mild head injuries using a GCS measure o14 or 15 (74 ). In a retrospective, case-controlled study o131 patients with traumatic intracranial hemorrhage who were taking aspirin, clopidogrel, or wararin beore they wereinjured, anticoagulated patients taking clopidogrel had higher

mortality rates (OR = 14.7; 95% CI = 2.3–93.6) and weremore likely to be discharged to a long-term acility (OR = 3.2595% CI = 1.06–9.96) (78 ).

Ater reviewing this literature, the Panel elected to strengthenthis criterion, underscoring the potential or anticoagulatedpatients who do not meet Step One, Step Two, or Step Threecriteria but who have evidence o head injury to undergo rapiddecompensation and deterioration. The panel recognizedthat patients who meet this criterion should be transportedpreerentially to a hospital capable o rapid evaluationand imaging o these patients and initiation o reversal oanticoagulation i necessary.

End-Stage Renal Disease Requiring Dialysis:Criterion Removed

The panel reviewed this speciic criterion, which wasadded to the 2006 Guidelines because o the potential risk oanticoagulation in these patients and the need or special resource(e.g., dialysis) to be used in this patient population. Howeverin 2011, the Panel elected to remove this criterion, noting thatresearch demonstrating the value o dialysis as a triage criterion or





identiying patients with serious injury is lacking and that concernsregarding anticoagulation in this population are addressed underthe anticoagulation and bleeding disorders criterion. The Panelthought that transport decisions regarding patients requiring dialysis are best made in consultation with medical control orbased on local transport protocols or such patients.

Time-Sensitive Extremity Injury: CriterionRemoved

With the addition o “pulseless” to Step Two criteria, thepanel thought this criterion was redundant, and removed itrom the 2011 Guidelines.

Transition Boxes and Flow of the 2011Schematic: Format Modified

The transition boxes in the schematic (Figures 1 and 2)provide destination guidance to the prehospital provider or

patients meeting criteria outlined in the preceding Step. Aterreviewing input rom providers, states, and local EMS agencies,the Panel recognized the need to simpliy the appearance o the Guidelines, modiy the transition boxes, clariy the intento the Guidelines, and simpliy communication o action stepsin the Guidelines across a variety o providers and systems.

To do this, the Panel took action both to improve the layouto the decision scheme and to modiy speciic wording withinthe boxes. To improve the layout o the transition boxes,the Panel took two steps. First, because the transition boxesbetween Step One and Step Two communicate the exact sameinormation and thus were thought to be redundant, they were consolidated into one box. Second, all action steps weremoved to the right side o the page or easier readability anddetermination o outputs or patients meeting dierent stepsin the Guideline (Figure 2).

Next, the Panel modiied the language within the boxes toensure consistency between transitions in the Guideline. Theirst word in all transition boxes was changed to “transport” toensure consistency between all boxes. Next, to emphasize theneed or state, regional, and local trauma systems to deine theparameters o their trauma systems (including the “highest level o care”), the word “deined” was added in ront o “trauma system”

or transition boxes ollowing Steps One, Two, and Three. Thischange recognizes that the highest level o trauma care shouldbe determined by the regional/state trauma system design andauthority. In most systems, this is a Level I center, but in givencircumstances, the highest level o care available might be a LevelII, III, or IV acility or a local, critical access hospital serving theregion. Third, in the transition box ollowing Step Three, the words “closest appropriate’’ were removed. This change, with theaddition o “deined” as above, makes this transition box consistent

with the wording in the remainder o the Guidelines. Finallyregarding the transition box ollowing Step Four in the 2006Guidelines, the Panel recognized that many EMS systems operatevia indirect (o-line) medical control (using medical director–approved protocols in a sanctioned, algorithmic process) and notdirect (online) medical control (in which direct communication

can take place between a physician and an EMS provider viaradio or telephone or a speciic patient interaction). Thereorethe Panel removed mandatory contact with medical control andemphasized that online control with verbal consultation mightbe appropriate. The wording o this box also was modiied toemphasize that these patients need to go to a acility at which theycan be evaluated readily with appropriate initial management orinjury, whether or not this is a trauma center.

Future Research for Field Triage

The Panel noted an increase in the peer-reviewed publishedliterature regarding ield triage rom the 2006 Guideline to thicurrent revision. The current revision process identiied andreviewed 289 articles during 2006–2011 (~48 articles/year)directly relevant to ield triage, 24 times the annual number oarticles during 1966–2005 (~2/year) cited in the 2006 Guidelines(1). Despite this increase in the number o articles, the Paneconcluded that ensuring that the Guidelines are based on thebest clinical evidence requires expanded surveillance (Box 3)ocused research using robust study designs, and consistentoutcome measures. The preponderance o existing triage studiesreviewed by the Panel used retrospective data, trauma registry

samples, single EMS agencies, and single trauma centers, all o which can result in biased estimates and reduced generalizabilityProspective triage research is needed that includes multiplesites, multiple EMS agencies, trauma and nontrauma hospitalsand population-based study designs that reduce selection biasand increase the generalizability o study indings. In additionrelatively little triage literature exists that evaluates the Guidelinesin their entirety (as opposed to an individual criterion orcomponent steps o the decision scheme) and the contributiono each step to the ull Guidelines. Prospective studies evaluatingthe ull Guidelines among the broad injury population servedby EMS are needed to assess the accuracy o the Guidelines

appropriately and to better identiy targets or improvementFurther, the process o ield triage in rural settings, includingthe impact o geography on triage, issues regarding proximityto trauma centers, use o air medical services, integration olocal hospitals or initial stabilization, and secondary triage atnontrauma hospitals, is poorly understood. As a substantiveportion o the U.S. population lives >60 minutes rom the closesmajor trauma center, and 28% o U.S. residents are only able





to access specialized trauma care within this time window by helicopter (79 ), ield triage in nonurban environments needs tobe understood better.

Current peer-reviewed triage literature has described multipleoutcome measures, including injury severity, clinical outcomes,need or trauma center resources (with or without a measureo timeliness), or a combination o these metrics. The mostcommon clinical outcome measure is ISS >15, although the AIS ≥3 has also been used. Trauma center need has beenmeasured by use o blood products, interventional radiology,

major nonorthopedic surgery, or ICU stay. This variability inoutcome measures limits comparability among studies and isnot always consistent with literature identiying the subgroupo patients most likely to beneit rom trauma center care.Future research should address these issues and attempt tomatch triage evaluation to patients most likely to beneit romtrauma center care and clearly deine the standard o measure.

Ongoing collaboration among local, state, and regional EMSagencies with governmental, non-governmental, academia,

and public health agencies and institutions will allow thecontinuing analysis and evaluation o the 2011 Guidelines andits impact on the care o acutely injured patients. StatewideEMS and trauma databases provide opportunities or statewidequality improvement o ield triage, research, and adaptationo the Guidelines to meet state speciic circumstances. Largenationally representative databases (e.g., the National EMSInormation Systems database, the National Trauma DataBank–National Sample Program, the Healthcare Cost andUtilization Project–National Inpatient Sample, the Nationa

Hospital Ambulatory Medical Care Survey, and NASS-CDScould be utilized or uture triage research i advances are madeto link these data iles across phases o care (i.e., prehospitato in-hospital). Finally, uniorm deinitions o prehospitavariables (including triage criteria) with a standardized datadictionary and data standards (e.g., HL7 messaging) couldprovide comparable data across study sites and assist withlinking data iles rom the prehospital to the hospital setting

BOX 3. Field triage key variables*

Step One: Physiologic Criteria t (MBTHPX$PNB4DPSFǙt 4ZTUPMJD#MPPE1SFTTVSFNN)H t 3FTQJSBUPSZ3BUFPSCSFBUITQFSNJOVUF

(<20 in inants aged <1 year) or need orventilatory support

Step Two: Anatomic Criteria t "MMQFOFUSBUJOHJOKVSJFTUPIFBEOFDLUPSTPBOE

extremities proximal to elbow or kneet $IFTUXBMMJOTUBCJMJUZPSEFGPSNJUZFHGMBJMDIFTUt "NQVUBUJPOQSPYJNBMUPXSJTUPSBOLMFt 5XPPSNPSFQSPYJNBMMPOHCPOFGSBDUVSFTJF

emur and humerus)t $SVTIFEEFHMPWFENBOHMFEPSQVMTFMFTTFYUSFNJUZt 1FMWJDGSBDUVSFT

t 0QFOPSEFQSFTTFETLVMMGSBDUVSFt 1BSBMZTJT

Step Three: Mechanism of Injury Criteria t "EVMUGBMMTGFFUt $IJMESFOGBMMTGFFUt *OUSVTJPOJODMVEJOHSPPGJODIFTPDDVQBOUTJUF

>18 inches any sitet &KFDUJPOQBSUJBMPSDPNQMFUFGSPNBVUPNPCJMFt %FBUIJOTBNFQBTTFOHFSDPNQBSUNFOU

t 7FIJDMFUFMFNFUSZEBUBDPOTJTUFOUXJUIBIJHISJTLPGJOKVSZ t "VUPWTQFEFTUSJBOCJDZDMJTUUISPXOSVOPWFSPS

with signiicant (>20mph) impactt .PUPSDZDMFDSBTINQI

Step Four: Special Considerationst "HFZFBSTt 4ZTUPMJDCMPPEQSFTTVSFJOQFSTPOTBHFEZFBSTt 'BMMTJOPMEFSBEVMUTFHHSPVOEMFWFMGBMMTt 1FEJBUSJDUSBVNBUSBOTQPSUt "OUJDPBHVMBOUVTFBOECMFFEJOHEJTPSEFSTt #VSOTt 1SFHOBODZXFFLTt &NFSHFODZNFEJDBMTFSWJDFTQSPWJEFSKVEHNFOU

Outcome VariablesClinical outcomes

t *OKVSZTFWFSJUZTDPSF†t "CCSFWJBUFE*OKVSZ4DPSFǚt %FBUIQSJPSUPIPTQJUBMEJTDIBSHF

Trauma center needt #MPPEQSPEVDUUSBOTGVTJPOt *OUFSWFOUJPOBMSBEJPMPHZQSPDFEVSFt .BKPSOPOPSUIPQFEJDTVSHFSZXJUIJOIPVSTt "ENJTTJPOUPJOUFOTJWFDBSFVOJU

* Variables and cut-o values should be used at a minimum in evaluation o ield triage guidelines. The criteria preceding the criterion o study should be includedin the analysis to control or those patients captured by the previous step(s).

† Minimum outcome variable or inclusion.





Areas for Specific Research Using the2011 Field Triage Guidelines

Several new technologies, which emerge rom research inthe remote noninvasive monitoring o casualties in austereenvironments, will likely be commercially available in the

near uture. O these innovations, the noninvasive monitoring o heart rate complexity and variability (80–83), respiratory rate (84 ), tissue oxygenation, and point-o-care lactate testing (85 ) appear promising or uture ield triage, but require moreresearch.

The GCSm o the GCSt is used in state triage guidelines (e.g.,Colorado) and has some support in peer-reviewed literature, asnoted in the preceding sections. However, additional research isneeded to evaluate the use o GCSm in the context o ield triageand the practical implications o changing this Step One criterion.

Advanced automatic collision notiication shows promisein improving accuracy o ield triage o patients involved in

motor-vehicle crashes. Further eort is required to integratethis technology into trauma and EMS systems and evaluateits eectiveness.

The issue o undertriage in older adults was viewed by thePanel as a major priority or uture research. There is a needto understand the basis or undertriage in this age group andhow the Guidelines might be modiied to reduce this problem.Related topics include the role o age in predicting seriousinjury, dierent physiologic responses to injury among olderadults, dierent injury-producing mechanisms in older adults,emergency and trauma care providers’ attitudes and behaviorsregarding triage in older adults, older adults’ health-carepreerences or injury care, end-o-lie issues and their relevanceto triage, new criteria to identiy serious injury in older adults,the role o trauma centers in caring or older injured adults,and other aspects o better matching patient need with hospitalcapability or this population. How systems respond to patientand/or amily preerences regarding hospital destinationsthat dier rom the recommendations in these Guidelinesshould be explored in the context o patient’s rights and themoral imperative to provide the optimal chance or improvedoutcomes rom trauma.

Finally, the cost o trauma care, the implications o ield triage

on cost, and the cost-eiciency o dierent approaches to ieldtriage require more research. Even ater accounting or injury severity and important conounders, the cost o care is notably higher in trauma centers (86,87 ). Though the cost eectivenesso trauma center care has been demonstrated among seriously injured patients (AIS ≥ 4) (87 ), it is possible that modest shitsin overtriage might have substantial inancial consequences.For example, a recent study that compared the 2006 and1999 Guidelines identiied a potential $568 million cost

savings at an assumed overtriage rate o 40% ( 21). Howeverurther studies are needed to discover new ways to maximizethe eiciency and cost-eectiveness o trauma systems andensure that patients are receiving optimal injury care whileconsidering the importance o the research, education, andoutreach mission o trauma centers.

ConclusionThe Guidelines provided in this report are based on curren

medical literature, the experience o multiple states andcommunities working to improve ield triage, and the expertopinion o the Panel members. This guidance is intended toassist EMS and trauma systems, medical directors, and providers with the inormation necessary to make critical decisions thahave been demonstrated to increase the likelihood o improvedoutcomes in severely injured trauma patients (5 ).

Improved ield triage o injured patients can have a prooundimpact on the structure, organization, and use o EMS andtrauma systems, the costs associated with trauma care, and mosimportantly, on the lives o the millions o persons injured everyyear in the United States. As is noted throughout this reportimproved research is needed to assess the impact o ield triageon resource allocation, health-care inancing and unding, andmost importantly, patient outcomes.

AcknowledgmentsThe ollowing persons assisted in producing this report: John

Seggerson, McKing Consulting Company, Atlanta, Georgia, BobBailey, MA, McKing Consulting Corporation, Raleigh, NorthCarolina, Lisa C. McGuire, PhD, Karen Ledord, Terica Scott, Likang

Xu, MD, Division o Injury Response, National Center or InjuryPrevention and Control, CDC.

References1. American College o Surgeons. Resources or the optimal care o th

injured patient: 2006. Chicago, IL: American College o Surgeons; 20062. American College o Surgeons. Hospital and prehospital resources o

the optimal care o the injured patient: appendices A through J. ChicagoIL: American College o Surgeons; 1986.

3. American College o Surgeons. Resources or the optimal care o thinjured patient: 1990. Chicago, IL: American College o Surgeons; 1990



6. CDC. Guidelines or ield triage o injured patients: recommendations othe National Expert Panel on Field Triage. MMWR 2009;58(No. RR-1)

7. CDC. WISQARS: web-based injury statistics query and reportingsystem: injury the leading cause o death among persons 1–44. Availableat http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html. AccessedDecember 13, 2011.





8. CDC. WISQARS: web-based injury statistics query and reporting system: injury mortality reports, 2008, United States. Available at http://

www.cdc.gov/injury/wisqars/atal.html. Accessed December 13, 2011.9. CDC. National Ambulatory Medical Care Survey (NHAMCS): 2007

emergency department ile. Available at http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm#public_use. Accessed December 13, 2011.

10. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation o the eect o trauma center care on mortality. N Engl J Med 2006;354:366–78.

11. Haas B, Gomez D, Zagorski B, Stukel TA, Rubeneld GD, Nathens AB.Survival o the ittest: the hidden cost o undertriage o major trauma.

J Am Coll Surg 2010;211:804–11.12. Sasser SM, Hunt RC, Sullivent EE, Wald MM. Guidelines or ield

triage o injured patients: recommendations o the National Expert Panelon Field Triage. JEMS 2009. Available at http://www.jems.com/sites/deault/iles/cdc_ield_triage_web_tcm16-205307.pd. AccessedDecember 13, 2011.

13. Mistovich JJ, Limmer D. Transition series: topics or the EMT. UpperSaddle River, NJ: Pearson; 2011.

14. Mistovich JJ, Karren KK. Prehospital emergency care. 9th ed. UpperSaddle River, NJ: Pearson; 2010.

15. Gross E, Martel M. Multiple trauma. In: Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s emergency medicine. 7th ed. Philadelphia,

PA: Mosby; 2010.16. Prehospital Trauma Lie Support Committee o the National Association

o Emergency Medical Technicians in cooperation with the Committeeon Trauma o the American College o Surgeons. PHTLS: Prehospitaltrauma lie support. 6th ed. St. Louis, MO: Mosby; 2007.

17. National Association o EMS Physicians. Field triage o the injuredpatient. Available at http://www.naemsp.org/documents/FieldTriageotheInjuredPatient.pd. Accessed December 13, 2011.

18. US Department o Transportation, Federal Highway Administration.Sae, Accountable, Flexible, Eicient Transportation Equity Act: a legacy or users. 42 USC § 300d-4 (2006).

19. Sasser SM, Ossmann E, Wald MM, Lerner EB, Hunt RC. Implementationstatus o the 2006 Field Triage Decision Scheme, October 2009–April2010. West J Emerg Med 2011;12:275–83.

20. Lerner EB, Shah MN, Swor RA, et al. Comparison o the 1999 and

2006 trauma triage guidelines: where do patients go? Prehosp Emerg Care 2011;15:12–7.21. Faul M, Wald MM, Sullivent EE, et al. Large cost savings realized rom

the 2006 Field Triage Guidelines: reduction in overtriage to US trauma centers. Prehosp Emerg Care 2012. In press.

22. Chen B, Zaebst D, Seel L. A macro to calculate Kappa statistics orcategorizations by multiple raters [Presentation no. 155-30]. Proceedingso the 30th Annual SAS User Group International (SUGI) Conerence,Philadelphia, Pennsylvania; April 10–13, 2005.

23. US Department o Transportation. National Highway Traic Saety Administration. National Automotive Sampling System 2011. Availableat http://www.nhtsa.gov/Data/National+Automotive+Sampling+System+(NASS)/NASS+Crashworthiness+Data+System. Accessed December13, 2011.

24. US Department o Transportation. National Highway Traic Saety Administration. Crash Injury Research (CIREN). Available at http:// www.nhtsa.gov/CIREN. Accessed December 13, 2011.

25. Cherry RA, King TS, Carney DE, Bryant P, Cooney RN. Trauma teamactivation and the impact on mortality. J Trauma 2007;63:326–30.

26. Edelman DA, White MT, Tyburski JG, Wilson RF. Post-traumatichypotension: should systolic blood pressure o 90–109 mmHg beincluded? Shock 2007;27:134–8.

27. Codner P, Obaid A, Porral D, Lush S, Cinat M. Is ield hypotension a reliable indicator o signiicant injury in trauma patients who arenormotensive on arrival to the emergency department? Am Surg 2005;71:768–71.

28. Lipsky AM, Gausche-Hill M, Henneman PL, et al. Prehospitahypotension is a predictor o the need or an emergent, therapeuticoperation in trauma patients with normal systolic blood pressure in theemergency department. J Trauma 2006;61:1228–33.

29. Newgard CD, Rudser K, Hedges JR, et al. A critical assessment o thout-o-hospital trauma triage guidelines or physiologic abnormality. JTrauma 2010;68:452–62.

30. Newgard C, Rudser K, Atkins DL, et al. The availability and use oout-o-hospital physiologic inormation to identiy high-risk injuredchildren in a multisite, population-based cohort. Prehosp Emerg Care2009;13:420–31.

31. Newgard CD, Cudnik M, Warden CR, Hedges JR. The predictive valueand appropriate ranges o prehospital physiological parameters or highrisk injured children. Pediatr Emerg Care 2007;23:450–6.

32. Holcomb JB, Niles SE, Miller CC, Hinds D, Duke JH, Moore FAPrehospital physiologic data and liesaving interventions in traumapatients. Mil Med 2005;170:7–13.

33. Holcomb JB, Salinas J, Mcmanus JM, Miller CC, Cooke WH, ConvertinoVA. Manual vital signs reliably predict need or lie-saving interventionsin trauma patients. J Trauma 2005;59:821–28; discussion 828–9.

34. Cannon CM , Braxton CC, Kling-Smith M, Mahnken JD, Carlton EMoncure M. Utility o the Shock Index in predicting mortality intraumatically injured patients. J Trauma 2009;67:1426–30.

35. Ball CG, Rozycki GS, Feliciano DV. Upper extremity amputations atemotor vehicle rollovers. J Trauma 2009;67:410–2.

36. Bernstein ML, Chung KC. Early management o the mangled uppeextremity. Injury 2007;38(Suppl 5):S3–7.

37. Heis HA, Bani-Hani KE, Elheis MA. Overview o extremity arteriatrauma in Jordan. Int Angiol 2008;27:522–8.

38. Menakuru SR, Behera A, Jindal R, Kaman L, Doley R, Venkatesan RExtremity vascular trauma in civilian population: a seven-year reviewrom North India. Injury 2005;36:400–6.

39. Ozyürekoğlu T, Napolitano M, Kleinert JM. Hay baler injuries to theupper extremity. J Trauma 2007;63:62–9.

40. Prichayudh S, Verananvattna A, Sriussadaporn S, et al. Management oupper extremity vascular injury: outcome related to the MangledExtremity Severity Score. World J Surg 2009;33:857–63.

41. Borman JB, Aharonson-Daniel L, Savitsky B, Peleg K; Israeli Trauma

Group. Unilateral lail chest is seldom a lethal injury. Emerg Med J2006;23:903–5.42. Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion

Semin Thorac Cardiovasc Surg 2008;20:39–45.43. Beekley AC, Sebesta JA, Blackbourne LH, et al. 31st Combat Suppor

Hospital Research Group. Prehospital tourniquet use in Operation IraqFreedom: eect on hemorrhage control and outcomes. J Trauma2008;64(Suppl):S28–37; discussion S37.

44. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evaluationo tactical combat casualty care interventions in a combat environment

J Am Coll Surg 2008;207:174–8.45. Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality rom isolated

civilian penetrating extremity injury. J Trauma 2005;59:217–22.46. Brown JB, Stassen NA, Bankey PE, Sangosanya AT, Cheng JD, Gestring

ML. Mechanism o injury and special consideration criteria still matteran evaluation o the National Trauma Triage Protocol. J Trauma2011;70:38–44; discussion 44–5.

47. Haider AH, Chang DC, Haut ER, Cornwell EE, Eron DT. Mechanismo injury predicts patient mortality and impairment ater blunt trauma

J Surg Res 2009;153:138–42.48. Newgard C, Zive D, Holmes JF, et al. A multi-site assessment and

validation o the ACSCOT ield triage decision scheme or identiyingseriously injured children and adults. JACS. In press.

49. Evans SL, Nance NL, Arbogast KB, Elliott MR, Winston FK. Passengecompartment intrusion as a predictor o signiicant injury or childrenin motor vehicle crashes. J Trauma 2009;66:504–7.





50. Conroy C, Tominaga GT, Erwin S, et al. The inluence o vehicle damageon injury severity o drivers in head-on motor vehicle crashes. Accid

Anal Prev 2008;40:1589–94.51. Wang, SW. Review o NASS CDS and CIREN data or mechanism

criteria or ield triage. National Expert Panel on Field Triage meeting,Las Vegas, Nevada; April 28, 2011.

52. Kaiser M, Ahearn P, Nguyen XM, et al. Early predictors o the need oremergent surgery to control hemorrhage in hypotensive trauma patients.

Am Surg 2009;75:986–90.53. Palanca S, Taylor DM, Bailey M, Cameron PA. Mechanisms o motor

vehicle accidents that predict major injury. Emerg Med (Fremantle)2003;15:423–8.

54. Lerner EB, Shah MN, Cushman JT, et al. Does mechanism o injury predict trauma center need? Prehosp Emerg Care. In press.

55. National Highway Traic Saety Administration, National Center orStatistics and Analysis. Traic saety acts 2009: a compilation o motorvehicle crash data rom the Fatality Analysis Reporting System and theGeneral Estimates System. Available at http://www-nrd.nhtsa.dot.gov/Pubs/811402.pd. Accessed December 13, 2011.

56. National Highway Traic Saety Administration, National Center orStatistics and Analysis. An analysis o motor vehicle rollover crashes andinjury outcomes. DOT HS 810 741. Washington, DC: NationalHighway Traic Saety Administration, National Center or Statistics

and Analysis; 2007.57. Champion HR, Lombardo LV, Shair EK. The importance o vehicle

rollover as a ield triage criterion. J Trauma 2009;67:350–7.58. Kononen DW, Flannagan CAC, Wang SC. Identiication and validation

o a logistic regression model or predicting serious injuries associated with motor vehicle crashes. Accid Anal Prev 2011;43:112–22.

59. Talmore D, Thompson KM, Legedza ATR, Nirula R. Predicting severehead injury ater light motor vehicle crashes: implications or automaticcrash notiication systems. Accid Anal Prev 2006;38:767–71.

60. Otte D, Haasper C, Eis V, Schaeer R. Characteristics o pole impactsto side o passenger cars in European traic accidents and assessment o injury mechanisms–analysis o German and UK in-depth data. StappCar Crash J 2008;52:349–62.

61. Michette CP, Hanna R, Crandall JR, Fahkry SM. Contemporary analysiso thoracic aortic injury: importance o screening based on crash

characteristics. J Trauma 2007;63:18–24; discussion 24–5.62. Newgard CD, Lewis RJ, Kraus JF, McConnell KJ. Seat position and therisk o serious thoracoabdominal injury in lateral vehicle crashes. Accid

Anal Prev 2005;37:668–74.63. Nirula R, Talmor D, Brasel K. Predicting serious torso trauma. J Trauma

2005;59:132–5.64. CDC. Recommendations rom the expert panel: advanced automatic

collision notiication and triage o the injured patient. Atlanta, GA: USDepartment o Health and Human Services, CDC; 2008.

65. Hansoti B, Beattie T. Can the height o all predict long bone racturein children under 24 months? Eur J Emerg Med 2005;12:285–6.

66. Johnson K, Fischer T, Chapman S, Wilson B. Accidental head injuriesin children under 5 years o age. Clin Radiol 2005;60:464–68.

67. Lapostolle F, Gere C, Borron SW, et al. Prognostic actors in victims o alls rom height. Crit Care Med 2005;33:1239–42.

68. Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Undertriage o elderly trauma patients to state-designated trauma centers. Arch Surg 2008;143:776–81; discussion 782.

69. Lehmann R, Beekley A, Casey L, Salim A, Martin M. The impact oadvanced age on trauma triage decisions and outcomes: a statewideanalysis. Am J Surg 2009;197:571–4; discussion 574–5.

70. Heernan DS, Thakkar RK, Monaghan SF, et al. Normal presentingvital signs are unreliable in geriatric blunt trauma victims. J Trauma2010;69:813–20.

71. Martin JT, Alkhoury F, O’Connor JA, Kyriakides TC, Bonadies JA‘Normal’ vital signs belie occult hypoperusion in geriatric traumapatients. Am Surg 2010;76:65–9.

72. Chisholm KM, Harru RC. Elderly deaths due to ground-level alls Am J Forensic Med Pathol 2010;31:350–4.

73. Spaniolas K, Cheng JD, Gestring ML, Sangosanya A, Stassen NA, BankeyPE. Ground level alls are associated with signiicant mortality in elderlypatients. J Trauma 2010;69:821–5.

74. Brewer ES, Reznikov B, Liberman RF, et al. Incidence and predictoro intracranial hemorrhage ater minor head trauma in patients takinganticoagulant and antiplatelet medication. J Trauma 2011;70:E1–5.

75. Howard JL 2nd, Cipolle MD, Horvat SA, et al. Preinjury wararin worsens outcome in elderly patients who all rom standing. J Trauma2009;66:1518–22; discussion 1523–4.

76. Ott MM, Eriksson E, Vanderkolk W, Christianson D, Davis A, ScholtenD. Antiplatelet and anticoagulation therapies do not increase mortalityin the absence o traumatic brain injury. J Trauma 2010;68:560–3.

77. Tauber M, Koller H, Moroder P, Hitzl W, Resch H. Secondaryintracranial hemorrhage ater mild head injury in patients with low-doseacetylsalicylate acid prophylaxis. J Trauma 2009;67:521–5.

78. Wong DK, Lurie F, Wong LL. The eects o clopidogrel on elderlytraumatic brain injured patients. J Trauma 2008;65:1303–8.

79. Branas CC, MacKenzie EJ, Williams JC, et al. Access to trauma centerin the United States. JAMA 2005;293:2626–33.

80. Batchinsky AI, Skinner JE, Necsoiu C, Jordan BS, Weiss D, Cancio LCNew measures o heart-rate complexity: eect o chest trauma andhemorrhage. J Trauma 2010;68:1178–85.

81. Batchinsky AI, Salinas J, Kuusela T, Necsoiu C, Jones J, Cancio LCRapid prediction o trauma patient survival by analysis o heart ratecomplexity: impact o reducing data set size. Shock 2009;32:565–71.

82. Batchinsky AI, Cancio LC, Salinas J, et al. Prehospital loss o R-to-Rinterval complexity is associated with mortality in trauma patients. J

Trauma 2007;63:512–8.83. King DR, Ogilvie MP, Pereira BM, et al. Heart rate variability as a triagetool in patients with trauma during prehospital helicopter transport. JTrauma 2009;67:436–40.

84. Chen L, Reisner AT, Gribok A, McKenna TM, Reiman J. Can wimprove the clinical utility o respiratory rate as a monitored vital signShock 2009;31:574–80.

85. Vandromme MJ, Griin RL, Weinberg JA, Rue LW 3rd, Kerby JDLactate is a better predictor than systolic blood pressure or determiningblood requirement and mortality: could prehospital measures improvtrauma triage? J Am Coll Surg 2010;210:861–7;867–9.

86. Goldarb MG, Bazzoli GJ, Coey RM. Trauma systems and the costo trauma care. Health Serv Res 1996;31:71–95.

87. MacKenzie EJ, Weir S, Rivara FP, et al. The value o trauma center care J Trauma 2010;69:1–10.





National Expert Panel on Field Triage of Injured PatientsMembership as of December 2011

Chair: Gregory J. Jurkovich, MD, Harborview Medical Center, Seattle, Washington.

Members: John H. Armstrong, MD, University o South Florida, Tampa, Florida; Bob Bailey, MA, McKing Consulting, Raleigh, North Carolina; Robert RBass, MD, Maryland Institute or Emergency Medical Services Systems, Baltimore, Maryland; Eileen Bulger, MD, University o Washington, Seattle, Washington

Alasdair Conn, MD, Massachusetts General Hospital, Boston, Massachusetts; Arthur Cooper, MD, Columbia University Medical Center, ailiation at HarlemHospital, New York, New York; Theodore Delbridge, MD, East Carolina University, Greenville, North Carolina: John Fildes, MD, University o Nevada, Las

Vegas, Nevada; Robert L. Galli, MD, University o Mississippi, Jackson, Mississippi; Catherine Gotschall, ScD, National Highway Traic Saety Administration Washington, District o Columbia; Daniel G. Hankins, MD, Mayo Clinic, Rochester, Minnesota; Mark C. Henry, MD, Stony Brook University, Stony BrookNew York; Teresita Hogan, MD, University o Chicago, Northbrook, Illinois; Richard C. Hunt, MD, Division o Injury Response, National Center or InjuryPrevention and Control, CDC, Atlanta, Georgia; Jorie Klein, Parkland Health and Hospital System, Dallas, Texas; Douglas F. Kupas, MD, Geisinger HealthSystem, Danville, Pennsylvania; D. Randy Kuykendall, Colorado Department o Public Health and Environment, Denver, Colorado; E. Brooke Lerner, PhDMedical College o Wisconsin, Milwaukee, Wisconsin; Robert C. MacKersie, MD, University o Caliornia San Francisco, Caliornia; N. Clay Mann, PhDUniversity o Utah, Salt Lake City; Gregg Margolis, PhD, US Department o Health and Human Services, Bethesda, Maryland; Craig Newgard, MD, OregonHealth and Science University, Portland; Robert E. O’Connor, MD, University o Virginia, Charlottesville, Virginia; Eric Ossmann, Duke University Schooo Medicine, Durham, North Carolina; Ritu Sahni, Oregon Emergency Medical Services and Trauma Systems, Lake Oswego, Oregon; Jerey P. Salomone,MD, Emory University School o Medicine, Atlanta, Georgia; Nels Sandall, American College o Surgeons, Chicago, Illinois; Scott M. Sasser, MD, EmoryUniversity School o Medicine and Division o Injury Response, National Center or Injury Prevention and Control, CDC, Atlanta, Georgia; Sean Siler, MD,National Disaster Medical System, Washington, District o Columbia; John Sinclair, KittitasValley Fire Rescue, Ellensburg, Washington; Chris Van Gorder,Scripps Health, San Diego, Caliornia; Gary Wallace, ATX Group/Cross Country Automotive, Irving, Texas; Stewart C. Wang, MD, PhD, FACS, Universityo Michigan, Ann Arbor, Michigan; Christopher E. Way, Emergency Services, Parsons, Kansas; Robert Winchell, MD, Maine Medical Center, Portland,Maine; Joseph Wright, MD, Children’s National Medical Center, Washington, District o Columbia.

Organizations and Federal Agencies Endorsing the Guidelines for Field Triage of Injured PatientsList as of December 2011

Air Medical Physician Association, American Academy o Orthopedic Surgeons, American Academy o Pediatrics, American Association o Critical-CarNurses, American Association or Respiratory Care, American Association or the Surgery o Trauma, American Burn Association, American College oEmergency Physicians, American College o Osteopathic Surgeons, American College o Surgeons, American Public Health Association, American TraumaSociety, Association o Air Medical Services, Association o Critical Care Transport, Association o Public-Saety Communications Oicials–International,

Association o State and Territorial Health Oicials, Brain Trauma Foundation, Commission on Accreditation o Medical Transport Systems, Eastern Associationor the Surgery o Trauma, Emergency Nurses Association, International Academies o Emergency Dispatch, International Association o Emergency Medical

Services Chies, International Association o Fire Chies, International Association o Flight and Critical Care Paramedics, National Association o EmergencyMedical Technicians, National Association o EMS Educators, National Association o EMS Physicians, National Association o State EMS Oicials, NationalEMS Inormation System, National EMS Management Association, National Volunteer Fire Council, Sae States Alliance, Society or Academic EmergencyMedicine, Society or the Advancement o Violence and Injury Research, Society o Emergency Medicine Physician Assistants, Trauma Center Association o

America, Western Trauma Association, Federal Interagency Committee on Emergency Medical Services (comprising representatives rom the U.S. Departmeno Health and Human Services, the U.S. Department o Transportation, the U.S. Department o Homeland Security, the U.S. Department o Deense, andthe U.S. Federal Communications Commission).

The National Highway Traic Saety Administration concurs with these Guidelines.



U.S. Government Printing Ofce: 2012-523-043/21095 Region IV ISSN: 1057-5987

The Morbidity and Mortality Weekly Report (MMWR)Series is prepared by the Centers or Disease Control and Prevention (CDC) and is available ree o charge in electronic ormat. To receive an electronic copy each week, visit MMWR’s ree subscription page at http://www.cdc.gov/mmwr/mmwrsubscribe.html . Paper copy subscriptions are available through the Superintendent o Documents, U.S. Government Printing Oice, Washington, DC 20402;telephone 202-512-1800.

Address all inquiries about the MMWR Series, including material to be considered or publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600Cliton Rd., N.E., Atlanta, GA 30333 or to [email protected].

All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

Use o trade names and commercial sources is or identiication only and does not imply endorsement by the U.S. Department o Health and Human Services.

Reerences to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement o these organizationsor their programs by CDC or the U.S. Department o Health and Human Services. CDC is not responsible or the content o these sites. URL addresseslisted in MMWR were current as o the date o publication.




This content is in the Public Domain.

Date post:	03-Apr-2018
Category:	Documents
Upload:	setanpikulan
View:	223 times
Download:	0 times