Trauma Triage Education

Ohio Department of Public SafetyOhio Department of Public SafetyDivision of Emergency Medical ServicesDivision of Emergency Medical Services

Ohio Prehospital Trauma Triage Ohio Prehospital Trauma Triage RulesRules

Revised January 2009Revised January 2009

In accordance with ORC §4765.16, this In accordance with ORC §4765.16, this presentation on trauma was developed under presentation on trauma was developed under

the direction of the direction of

Carol A. Cunningham, MD, FACEP, FAAEM Carol A. Cunningham, MD, FACEP, FAAEM State Medical Director State Medical Director

Ohio Department of Public Safety, Division of EMSOhio Department of Public Safety, Division of EMS

and and

John Crow, MD, FACS John Crow, MD, FACS Chair of the Trauma Committee of the State EMS BoardChair of the Trauma Committee of the State EMS Board

The standards and criteria in this presentation The standards and criteria in this presentation were developed for Emergency Medical were developed for Emergency Medical

Technicians operating in the prehospital setting Technicians operating in the prehospital setting to determine if a person has suffered injuries to determine if a person has suffered injuries

severe enough to require treatment at a trauma severe enough to require treatment at a trauma center.center.

Ohio Trauma Triage RulesOhio Trauma Triage RulesLEARNING OBJECTIVESLEARNING OBJECTIVES

• Describe Ohio’s legal definition of traumaDescribe Ohio’s legal definition of trauma

• Discuss the definition of a trauma center and what the Discuss the definition of a trauma center and what the different levels of trauma center designation meandifferent levels of trauma center designation mean

• List the anatomic and physiologic criteria to be used when List the anatomic and physiologic criteria to be used when evaluating pediatric, adult, and geriatric trauma victimsevaluating pediatric, adult, and geriatric trauma victims

• Discuss the role that mechanism of injury and special Discuss the role that mechanism of injury and special considerations play in trauma patient destination considerations play in trauma patient destination

• State the five exceptions to transporting trauma patients State the five exceptions to transporting trauma patients directly to trauma centers directly to trauma centers

• Describe the key aspects of regional trauma triage protocols Describe the key aspects of regional trauma triage protocols

• Discuss the importance of EMS documentation of trauma Discuss the importance of EMS documentation of trauma triage criteria triage criteria

Ohio Prehospital TraumaOhio Prehospital TraumaTriage RulesTriage Rules

Legal DefinitionsLegal Definitions

The Ohio General Assembly establishes laws in The Ohio General Assembly establishes laws in the Ohio Revised Code (ORC).the Ohio Revised Code (ORC).

Laws are amplified by State Boards and agencies Laws are amplified by State Boards and agencies through rules established in the Ohio through rules established in the Ohio Administrative Code (OAC).Administrative Code (OAC).

The General Assembly established laws in ORC The General Assembly established laws in ORC sections 4765.01 and 4765.40 which define:sections 4765.01 and 4765.40 which define:– Traumatic injuryTraumatic injury– Trauma patient / trauma victimTrauma patient / trauma victim– Trauma careTrauma care– Trauma centerTrauma center– Trauma triageTrauma triage

TheseThese definitions are expanded and clarified for definitions are expanded and clarified for EMS providers by the State Board of Emergency EMS providers by the State Board of Emergency Medical Services in OAC chapters 4765-1 and Medical Services in OAC chapters 4765-1 and 4765-144765-14

‘‘Trauma patients’ or ‘trauma victims’ are legally defined as Trauma patients’ or ‘trauma victims’ are legally defined as those who have sustained a traumatic injury. ‘Traumatic those who have sustained a traumatic injury. ‘Traumatic injury’ is legally defined as “damage to or destruction of injury’ is legally defined as “damage to or destruction of tissue that satisfies tissue that satisfies bothboth of the following conditions: of the following conditions:– Poses a significant risk ofPoses a significant risk of

• Loss of lifeLoss of life

• Loss of limbLoss of limb

• Permanent disfigurementPermanent disfigurement

• Permanent disabilityPermanent disability

– Is caused byIs caused by• Blunt or penetrating injuryBlunt or penetrating injury

• Exposure to electromagnetic, chemical or radioactive energyExposure to electromagnetic, chemical or radioactive energy

• Drowning, suffocation or strangulationDrowning, suffocation or strangulation

• A deficit or excess of heat”A deficit or excess of heat”

‘‘Trauma care’ is legally defined as “assessment, Trauma care’ is legally defined as “assessment, diagnosis, transportation, treatment, or diagnosis, transportation, treatment, or rehabilitation of a trauma victim by emergency rehabilitation of a trauma victim by emergency medical service personnel or by a physician, medical service personnel or by a physician, nurse, physician assistant, respiratory therapist, nurse, physician assistant, respiratory therapist, physical therapist…licensed to practice as such in physical therapist…licensed to practice as such in this state...”this state...”

The qualifications for a hospital to become a The qualifications for a hospital to become a trauma center are also defined in law.trauma center are also defined in law.

A hospital is designated as a trauma center by the A hospital is designated as a trauma center by the State of Ohio when it:State of Ohio when it:– Receives verification from the American College of Receives verification from the American College of

Surgeons as an adult or pediatric trauma centerSurgeons as an adult or pediatric trauma center

oror– Operates under Ohio’s Provisional Trauma Center lawsOperates under Ohio’s Provisional Trauma Center laws

oror– Is located in another state and is licensed or designated Is located in another state and is licensed or designated

as a trauma center by that stateas a trauma center by that state


Trauma CentersTrauma Centers

What makes a hospital a trauma center?What makes a hospital a trauma center?

A trauma center is a hospital which has the A trauma center is a hospital which has the immediate availabilityimmediate availability of specialized surgeons, of specialized surgeons, physician specialists, anesthesiologists, nurses, physician specialists, anesthesiologists, nurses, resuscitation and life support equipment, and resuscitation and life support equipment, and operating rooms on a operating rooms on a 24-hour basis24-hour basis to care for to care for severely injured patients.severely injured patients.

Why take seriously injured patients directly to a Why take seriously injured patients directly to a trauma center?trauma center?

• The definitive care of internal bleeding or traumatic brain The definitive care of internal bleeding or traumatic brain injury cannot occur in the prehospital setting or in a injury cannot occur in the prehospital setting or in a routine and timely manner at a non-trauma center hospitalroutine and timely manner at a non-trauma center hospital

• Trauma centers have 24-hour availability of emergency Trauma centers have 24-hour availability of emergency medicine and surgical services which allow the patient to medicine and surgical services which allow the patient to be taken directly to the operating room, if neededbe taken directly to the operating room, if needed

• Studies of over 250,000 Ohio trauma patient records have Studies of over 250,000 Ohio trauma patient records have shown that trauma patients taken to a non-trauma center shown that trauma patients taken to a non-trauma center hospital spend, on average, hospital spend, on average, over four hoursover four hours at that at that hospital before transfer to a trauma center is initiated.hospital before transfer to a trauma center is initiated.

• Trauma centers are designated as Level 1 through Trauma centers are designated as Level 1 through Level 4Level 4

• The differences in levels are based on the depth of The differences in levels are based on the depth of the resources available to treat the trauma victimthe resources available to treat the trauma victim

• The differences in the levels are The differences in the levels are notnot based on based on quality of care – quality of care – allall trauma centers are required to trauma centers are required to have a commitment to high quality of carehave a commitment to high quality of care

What are the levels of trauma centers What are the levels of trauma centers and how are they different?and how are they different?

• Level I – A regional resource trauma center that Level I – A regional resource trauma center that must have the capability of providing total care for must have the capability of providing total care for every aspect of injury, from prevention through every aspect of injury, from prevention through rehabilitation. Level I trauma centers also have rehabilitation. Level I trauma centers also have responsibility of providing leadership in responsibility of providing leadership in education, research, and system planning.education, research, and system planning.


• Level II – A trauma center that provides initial Level II – A trauma center that provides initial definitive trauma care, regardless of the severity of definitive trauma care, regardless of the severity of the injury. Depending on location and available the injury. Depending on location and available resources, Level II trauma centers may not be able resources, Level II trauma centers may not be able to provide the same comprehensive care as a Level to provide the same comprehensive care as a Level I trauma center. The Level II trauma center I trauma center. The Level II trauma center assumes responsibility for education and system assumes responsibility for education and system leadership in areas where a Level I trauma center leadership in areas where a Level I trauma center does not exist.does not exist.


• Level III – Level III trauma centers are meant to Level III – Level III trauma centers are meant to serve communities that do not have immediate serve communities that do not have immediate access to a Level I or II trauma center. Level III access to a Level I or II trauma center. Level III trauma centers can provide prompt assessment, trauma centers can provide prompt assessment, resuscitation, emergency operations and resuscitation, emergency operations and stabilization of the trauma patient, as well as stabilization of the trauma patient, as well as arrange for possible transfer to a facility that can arrange for possible transfer to a facility that can provide a higher level of definitive trauma care.provide a higher level of definitive trauma care.


• Level IV – Level IV trauma facilities provide Level IV – Level IV trauma facilities provide advanced trauma life support prior to patient advanced trauma life support prior to patient transfer in remote areas where a higher level of transfer in remote areas where a higher level of care is not available.care is not available.


Key ConceptKey Concept

The law requires that all trauma victims The law requires that all trauma victims be transported directly to a trauma be transported directly to a trauma

center.center.

There are five exceptions to this mandatoryThere are five exceptions to this mandatory

transport law. These will be discussed later.transport law. These will be discussed later.

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Ft. Wayne, INFt. Wayne, IN

Huntington, WVHuntington, WV

Wheeling, WVWheeling, WV

Pittsburgh, PAPittsburgh, PA

Erie, PAErie, PA

Parkersburg, WVParkersburg, WV

44Weirton, WVWeirton, WV

44 New Martinsville, WVNew Martinsville, WV

44 Point Pleasant, WVPoint Pleasant, WV

44

Ohio Designated Trauma CentersOhio Designated Trauma Centers

Locations within each county not exactLocations within each county not exact

Ohio Prehospital TraumaOhio Prehospital TraumaTriage Rules Triage Rules

Trauma Patient / Trauma VictimTrauma Patient / Trauma VictimDefinitionsDefinitions

There are three age groups for trauma patients:There are three age groups for trauma patients:

• Pediatric Pediatric – Age 0 – 15 yearsAge 0 – 15 years

• AdultAdult– Age 16 – 69 yearsAge 16 – 69 years

• GeriatricGeriatric– Age 70 years and olderAge 70 years and older

A trauma patient or trauma victim is a person who A trauma patient or trauma victim is a person who has suffered an injury that: has suffered an injury that:

1) Poses a significant risk of loss of life; loss of 1) Poses a significant risk of loss of life; loss of limb; permanent disfigurement; or permanent limb; permanent disfigurement; or permanent disabilitydisability

andand2) Is caused by blunt or penetrating injury; exposure 2) Is caused by blunt or penetrating injury; exposure

to electromagnetic, chemical or radioactive to electromagnetic, chemical or radioactive energy; drowning, suffocation or strangulation; energy; drowning, suffocation or strangulation; or a deficit or excess of heator a deficit or excess of heat

““Body region” means a portion of the trauma victim’s body divided Body region” means a portion of the trauma victim’s body divided into the following areas:into the following areas:

– BrainBrain– Head, face and neckHead, face and neck– ChestChest– Abdomen and pelvisAbdomen and pelvis– ExtremitiesExtremities– SpineSpine

““Evidence of hemorrhagic shock” includes any of the followingEvidence of hemorrhagic shock” includes any of the following– Delayed capillary refill (greater than 2 seconds)Delayed capillary refill (greater than 2 seconds)– Cool, pale, diaphoretic skinCool, pale, diaphoretic skin– Decreasing systolic blood pressure with narrowing pulse pressure (the Decreasing systolic blood pressure with narrowing pulse pressure (the

difference between the systolic and diastolic pressures becoming smaller)difference between the systolic and diastolic pressures becoming smaller)– Altered level of consciousnessAltered level of consciousness

““Evidence of neurovascular compromise” includes one or more of the Evidence of neurovascular compromise” includes one or more of the following (“The 5 Ps”)following (“The 5 Ps”)

– Paresthesia (numbness/tingling)Paresthesia (numbness/tingling)

– Pain (severe)Pain (severe)

– ParalysisParalysis

– Pallor / palePallor / pale

– PulselessnessPulselessness

““Evidence of poor perfusion” means one or more of the following:Evidence of poor perfusion” means one or more of the following:– Weak distal pulsesWeak distal pulses

– Pallor / palenessPallor / paleness

– CyanosisCyanosis

– Delayed capillary refill (greater than 2 seconds)Delayed capillary refill (greater than 2 seconds)

– Tachycardia (appropriate for the patient’s age)Tachycardia (appropriate for the patient’s age)

““Evidence of respiratory distress” includes one or more of the Evidence of respiratory distress” includes one or more of the followingfollowing

– StridorStridor– GruntingGrunting– RetractionsRetractions– CyanosisCyanosis– HoarsenessHoarseness– Difficulty speakingDifficulty speaking

““Evidence of traumatic brain injury” means signs of external trauma Evidence of traumatic brain injury” means signs of external trauma andand physiologic indicators that the brain has suffered an injury physiologic indicators that the brain has suffered an injury caused by external force including, but not limited tocaused by external force including, but not limited to

– Decrease in level of consciousness Decrease in level of consciousness from the victim’s baselinefrom the victim’s baseline– Unequal pupilsUnequal pupils– Blurred visionBlurred vision– Severe or persistent headacheSevere or persistent headache– Nausea or vomitingNausea or vomiting– Change in neurological statusChange in neurological status

““Proximal long bone” is the humerus or femurProximal long bone” is the humerus or femur

““Seat belt sign” is bruises or abrasions on the chest and/or abdomen Seat belt sign” is bruises or abrasions on the chest and/or abdomen resulting from the use of a seat belt during a motor vehicle crashresulting from the use of a seat belt during a motor vehicle crash

““Signs and symptoms of spinal cord injury” includeSigns and symptoms of spinal cord injury” include – ParalysisParalysis

– WeaknessWeakness

– Numbness / tinglingNumbness / tingling

When evaluating an injured person for triage to a trauma center, When evaluating an injured person for triage to a trauma center, EMS providers must look for certain indicators of serious injury. EMS providers must look for certain indicators of serious injury. These indicators will be either:These indicators will be either:- Anatomic – the injuries suffered- Anatomic – the injuries suffered- Physiologic – the body’s response to the injury, or - Physiologic – the body’s response to the injury, or - Mechanistic – cause of injury (geriatrics only). - Mechanistic – cause of injury (geriatrics only).

If the patient is found to have any of these indicators, they are If the patient is found to have any of these indicators, they are required to be transported directly to a trauma center, unless one of required to be transported directly to a trauma center, unless one of the five exceptions apply.the five exceptions apply.

There are also special circumstances surrounding the injury that There are also special circumstances surrounding the injury that should be considered by EMS providers when deciding the injured should be considered by EMS providers when deciding the injured patient’s destination.patient’s destination.

There are differences in the indicators for pediatric, adult and There are differences in the indicators for pediatric, adult and geriatric trauma patients.geriatric trauma patients.

If an injured person has any of the following If an injured person has any of the following indicators, they should be transported indicators, they should be transported

directly to a trauma center.directly to a trauma center.

Pediatric Anatomic IndicatorsPediatric Anatomic Indicators• Penetrating injury to the head, neck or torsoPenetrating injury to the head, neck or torso• Significant penetrating injury to the extremities, Significant penetrating injury to the extremities,

proximal to the knee or elbow, with neurovascular proximal to the knee or elbow, with neurovascular compromisecompromise

• Visible crush of head, neck or torsoVisible crush of head, neck or torso• Abdominal tenderness, distention or seat belt signAbdominal tenderness, distention or seat belt sign• Flail chestFlail chest• Pelvic fracturePelvic fracture

Pediatric Anatomic IndicatorsPediatric Anatomic Indicators• Injuries to the extremities withInjuries to the extremities with

– Visible crushVisible crushoror

– Evidence of neurovascular compromiseEvidence of neurovascular compromise

• Amputations proximal to the wrist or ankleAmputations proximal to the wrist or ankle• Fracture of 2 or more proximal long bones (humerus or Fracture of 2 or more proximal long bones (humerus or

femur)femur)• Signs and symptoms of spinal cord injurySigns and symptoms of spinal cord injury• Serious burnsSerious burns

– 22ndnd or 3 or 3rdrd degree burns over more than 10% of total body degree burns over more than 10% of total body surface areasurface areaoror

– Involving face, airway, hands, feet, genitaliaInvolving face, airway, hands, feet, genitalia

Pediatric Physiologic IndicatorsPediatric Physiologic Indicators• Glasgow Coma Score of 13 or lessGlasgow Coma Score of 13 or less• Loss of consciousness for greater than 5 minutesLoss of consciousness for greater than 5 minutes• Failure to localize pain (GCS motor score 4 or less)Failure to localize pain (GCS motor score 4 or less)• Evidence of poor perfusionEvidence of poor perfusion

– Weak distal pulse, pallor, cyanosis, delayed cap refill, or Weak distal pulse, pallor, cyanosis, delayed cap refill, or tachycardiatachycardia

• Evidence of respiratory distress or failureEvidence of respiratory distress or failure– Stridor, grunting, retractions, cyanosis, hoarseness, difficulty Stridor, grunting, retractions, cyanosis, hoarseness, difficulty

speakingspeaking

Adult Anatomic IndicatorsAdult Anatomic Indicators• Penetrating injury to the head, neck or torsoPenetrating injury to the head, neck or torso• Significant penetrating injury to the extremities, Significant penetrating injury to the extremities,


• Visible crush of head, neck or torsoVisible crush of head, neck or torso• Abdominal tenderness, distention or seat belt signAbdominal tenderness, distention or seat belt sign• Flail chestFlail chest• Pelvic fracture (this does Pelvic fracture (this does notnot include isolated hip include isolated hip

fractures)fractures)

Adult Anatomic IndicatorsAdult Anatomic Indicators• Injuries to the extremities withInjuries to the extremities with







Adult Physiologic IndicatorsAdult Physiologic Indicators• Glasgow Coma Score of 13 or lessGlasgow Coma Score of 13 or less• Loss of consciousness for greater than 5 minutesLoss of consciousness for greater than 5 minutes• Failure to localize pain (GCS motor score 4 or less)Failure to localize pain (GCS motor score 4 or less)• Respiratory rate less than 10 or greater than 29Respiratory rate less than 10 or greater than 29• Requires endotracheal intubationRequires endotracheal intubation• Requires relief of tension pneumothoraxRequires relief of tension pneumothorax• Pulse rate greater than 120 with evidence of Pulse rate greater than 120 with evidence of

hemorrhagic shockhemorrhagic shock• Systolic blood pressure less than 90 mm HgSystolic blood pressure less than 90 mm Hg

Geriatric IndicatorsGeriatric Indicators

Geriatric trauma indicators are similar to adult.Geriatric trauma indicators are similar to adult.

Differences are marked with an asterisk *Differences are marked with an asterisk *

Geriatric Anatomic IndicatorsGeriatric Anatomic Indicators• Penetrating injury to the head, neck or torsoPenetrating injury to the head, neck or torso• Significant penetrating injury to the extremities, Significant penetrating injury to the extremities,


• Visible crush of head, neck or torsoVisible crush of head, neck or torso• Abdominal tenderness, distention or seat belt signAbdominal tenderness, distention or seat belt sign• Flail chestFlail chest• Pelvic fracture (this does Pelvic fracture (this does notnot include isolated hip include isolated hip

fractures)fractures)• Injury sustained in two or more body regions*Injury sustained in two or more body regions*

Geriatric Anatomic IndicatorsGeriatric Anatomic Indicators• Injuries to the extremities withInjuries to the extremities with







Geriatric Physiologic IndicatorsGeriatric Physiologic Indicators• Glasgow Coma Score of 13 or lessGlasgow Coma Score of 13 or less• Glasgow Coma Score less than 15 with a Glasgow Coma Score less than 15 with a knownknown or or

suspectedsuspected traumatic brain injury* traumatic brain injury*• Loss of consciousness for greater than 5 minutesLoss of consciousness for greater than 5 minutes• Failure to localize pain (GCS motor score 4 or less)Failure to localize pain (GCS motor score 4 or less)• Respiratory rate less than 10 or greater than 29Respiratory rate less than 10 or greater than 29• Requires endotracheal intubationRequires endotracheal intubation• Requires relief of tension pneumothoraxRequires relief of tension pneumothorax• Pulse rate greater than 120 with evidence of Pulse rate greater than 120 with evidence of

hemorrhagic shockhemorrhagic shock• Systolic blood pressure less than 100 mm Hg*Systolic blood pressure less than 100 mm Hg*

Geriatric Mechanism IndicatorsGeriatric Mechanism Indicators• Fracture of 1 or more proximal long bones (humerus or Fracture of 1 or more proximal long bones (humerus or

femur) sustained in a motor vehicle crash*femur) sustained in a motor vehicle crash*• Pedestrian struck*Pedestrian struck*• Falls from any height – including standing – Falls from any height – including standing – with with

evidence of a traumatic brain injuryevidence of a traumatic brain injury**

Remember, if an injured person has any of Remember, if an injured person has any of the indicators just listed, they must be the indicators just listed, they must be transported directly to a trauma center.transported directly to a trauma center.

As taught in your EMT-B, EMT-I and EMT-P As taught in your EMT-B, EMT-I and EMT-P courses, EMS personnel also must be courses, EMS personnel also must be concerned aboutconcerned about mechanism of injury mechanism of injury & & special considerationsspecial considerations when determining when determining whether or not to transport to a trauma center.whether or not to transport to a trauma center.

TheseThese should be used as additional factors in should be used as additional factors in decision making, not as stand-alone decision making, not as stand-alone

conditions that will triage a patient to a conditions that will triage a patient to a trauma center.trauma center.

Mechanism of injuryMechanism of injury

• Motor vehicle crashes withMotor vehicle crashes with– EjectionEjection– RolloverRollover– Extrication greater than 20 minutesExtrication greater than 20 minutes– Death in same passenger compartmentDeath in same passenger compartment– Evidence of high speed crashEvidence of high speed crash

• Speed greater than 40 miles per hourSpeed greater than 40 miles per hour

• Major auto deformity (greater than 20 inches)Major auto deformity (greater than 20 inches)

• Intrusion into passenger compartment greater than 12 Intrusion into passenger compartment greater than 12 inchesinches

Mechanism of injuryMechanism of injury

• Auto vs. pedestrian, greater than 5 mph.Auto vs. pedestrian, greater than 5 mph.

• Auto vs. bicycle, greater than 5 mph.Auto vs. bicycle, greater than 5 mph.

• Motorcycle crash greater than 20 mph.Motorcycle crash greater than 20 mph.

• Motorcycle crash with rider separated from bikeMotorcycle crash with rider separated from bike

• Falls greater than 20 feetFalls greater than 20 feet

Special ConsiderationsSpecial Considerations

• PregnancyPregnancy

• Co-morbid conditionsCo-morbid conditions– Cardiac or respiratory diseaseCardiac or respiratory disease– Liver failure or cirrhosisLiver failure or cirrhosis– Insulin-dependant diabetes (Type 1)Insulin-dependant diabetes (Type 1)– Compromised immune systemCompromised immune system

• Cancer, HIV, TransplantCancer, HIV, Transplant

– Bleeding disorders or on anti-coagulantsBleeding disorders or on anti-coagulants– Morbidly obeseMorbidly obese

Remember,Remember, mechanism of injury and special mechanism of injury and special considerations should not be the only reason considerations should not be the only reason

to decide whether or not to transport to a to decide whether or not to transport to a trauma center.trauma center.


Five ExceptionsFive Exceptions

The law requires that trauma patients be The law requires that trauma patients be transported directly to a trauma center.transported directly to a trauma center.

There are five exceptions to this requirementThere are five exceptions to this requirement

1.1. Medical necessity for initial assessment and Medical necessity for initial assessment and stabilizationstabilization

2.2. Unsafe or medically inappropriate due to Unsafe or medically inappropriate due to adverse weather conditions or excessive adverse weather conditions or excessive transport timetransport time

3.3. It would cause a shortage of local EMS It would cause a shortage of local EMS resourcesresources

4.4. No trauma center is able to receive and provide No trauma center is able to receive and provide care to the patient without undue delaycare to the patient without undue delay

5.5. Before transport begins, the patient (or Before transport begins, the patient (or parent/guardian) requests transportation to a parent/guardian) requests transportation to a hospital that is not a trauma centerhospital that is not a trauma center

Five Exceptions to Mandatory TransportFive Exceptions to Mandatory Transport

1.1. It is medically necessary to transport the patient to a It is medically necessary to transport the patient to a hospital without a trauma center for initial hospital without a trauma center for initial assessment and stabilization before transfer.assessment and stabilization before transfer.

These must be legitimate, immediately life-threatening medical These must be legitimate, immediately life-threatening medical reasons.reasons.

• Unable to open or maintain airwayUnable to open or maintain airway

• Traumatic arrestTraumatic arrest

• Uncontrollable external bleedingUncontrollable external bleeding

EMS agency protocols should provide guidance on when this is EMS agency protocols should provide guidance on when this is appropriateappropriate


2.2. Unsafe or medically inappropriate due to adverse Unsafe or medically inappropriate due to adverse weather conditions or excessive transport time.weather conditions or excessive transport time.

In cases of bad weather or when transport time to the nearest In cases of bad weather or when transport time to the nearest trauma center is excessive, a patient trauma center is excessive, a patient maymay be better served by be better served by stopping at the nearest hospital for stabilization and transfer.stopping at the nearest hospital for stabilization and transfer.

• Consider other methods of transport, such as air medicalConsider other methods of transport, such as air medical

• Local and regional protocols should provide guidance Local and regional protocols should provide guidance on when this is appropriateon when this is appropriate

• Use your best professional judgmentUse your best professional judgment


3.3. It would cause a shortage of local resources.It would cause a shortage of local resources.

Many EMS jurisdictions have limited resources – equipment Many EMS jurisdictions have limited resources – equipment and/or personnel – to provide for the emergency medical and/or personnel – to provide for the emergency medical needs of their community. If transporting to a trauma center needs of their community. If transporting to a trauma center causes a shortage of these resources, it causes a shortage of these resources, it maymay be better to be better to transport to the closest hospital where transfer can be transport to the closest hospital where transfer can be arranged.arranged.

Each community must assess its available resources, including air Each community must assess its available resources, including air medical services and mutual aid, to understand when this medical services and mutual aid, to understand when this exception applies.exception applies.


4.4. No trauma center is able to receive and provide care No trauma center is able to receive and provide care to the patient without undue delay.to the patient without undue delay.

This exception was originally intended to address situations where This exception was originally intended to address situations where trauma centers were diverting trauma patients. However, trauma centers were diverting trauma patients. However, with today’s mature state and regional trauma systems, this is with today’s mature state and regional trauma systems, this is mostly a thing of the past. Trauma centers avoid trauma mostly a thing of the past. Trauma centers avoid trauma patient diversion.patient diversion.

If, for some unusual reason, a trauma center diverts your patient, If, for some unusual reason, a trauma center diverts your patient, you must use your best judgment, along with guidance from you must use your best judgment, along with guidance from medical control, to determine the next best destination for medical control, to determine the next best destination for your trauma patient.your trauma patient.


5.5. Before transport of a trauma patient begins, the Before transport of a trauma patient begins, the patient requests to be transported to a hospital that is patient requests to be transported to a hospital that is not a trauma center. This request may also be made not a trauma center. This request may also be made by the parents / legal guardian of a trauma patient by the parents / legal guardian of a trauma patient who is a minor, or by a legal representative of the who is a minor, or by a legal representative of the patient.patient.

Competent patients have the right to have input into where they Competent patients have the right to have input into where they will receive treatment. EMS personnel should attempt to will receive treatment. EMS personnel should attempt to convince the patient of the need for treatment at a trauma convince the patient of the need for treatment at a trauma center but should respect the competent patient’s wishes.center but should respect the competent patient’s wishes.



Overtriage and UndertriageOvertriage and Undertriage

UndertriageUndertriage

Transporting a severely injured patient to a hospital Transporting a severely injured patient to a hospital that is not a trauma center.that is not a trauma center.

• Worst case scenario? The patient dies or suffers Worst case scenario? The patient dies or suffers complications or disabilities that are avoidable.complications or disabilities that are avoidable.

Trauma systems aim for 0% undertriageTrauma systems aim for 0% undertriage

OvertriageOvertriage

Transporting a minimally injured patient to a trauma Transporting a minimally injured patient to a trauma center.center.

• Worst case scenario? Trauma center overload; Worst case scenario? Trauma center overload; unnecessary, expensive transfers of the patient; unnecessary, expensive transfers of the patient; inconvenience for the patient and their family.inconvenience for the patient and their family.

Trauma systems accept a certain amount of Trauma systems accept a certain amount of overtriage in order to keep life-threatening overtriage in order to keep life-threatening

undertriage low.undertriage low.


Regional VariationsRegional Variations

Delaware

Madison

Union

Licking

Fairfield

Pickaway

Fayette

Clark

Champaign

Logan

HardinAllen

Hancock

Wyandot

Marion

Crawford

Huron

RichlandAshland

Morrow

KnoxCoshocton

Tuscarawas

Carroll

Harrison

BelmontGuernsey Muskingum

MonroeNoble

Perry

Morgan

Washington

Athens

Hocking

Meigs

Gallia

Vinton

Jackson

Lawrence

SciotoAdams

Pike

Ross

Highland

Shelby

Miami

MontgomeryGreene

Darke

Preble

MercerAuglaize

Van Wert

Paulding

Defiance

Williams

Putnam

Henry

Fulton

Wood

Lucas

Ottawa

Sandusky

Seneca

ErieLorain

Cuyahoga

Medina

Wayne

Holmes

Lake

Geauga

Ashtabula

Trumbull

Portage

Summit

Stark

Mahoning

Columbiana

Jefferson

Clinton

Brown

Clermont

WarrenButler

Hamilton

Franklin

Franklin

Ohio’s EMS Ohio’s EMS RegionsRegions

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88

7733

22 55

66

The law allows for regional variations to Ohio’s trauma The law allows for regional variations to Ohio’s trauma triage protocols as long as the following criteria are met:triage protocols as long as the following criteria are met:

• Ohio’s minimum triage criteria are metOhio’s minimum triage criteria are met

• The appropriate Regional Physician Advisory Board The appropriate Regional Physician Advisory Board (RPAB) submits the variation to the EMS Board(RPAB) submits the variation to the EMS Board

• The EMS Board’s Trauma Committee has the The EMS Board’s Trauma Committee has the opportunity to review and commentopportunity to review and comment

• They are approved by the EMS BoardThey are approved by the EMS Board

Prior to submission of a regional variation to the EMS Prior to submission of a regional variation to the EMS Board, the RPAB must consult with:Board, the RPAB must consult with:

• Neighboring RPABsNeighboring RPABs

• Hospitals and trauma centers in their regionHospitals and trauma centers in their region

• State-level EMS, physician and nursing State-level EMS, physician and nursing organizationsorganizations

• EMS instructors in their regionEMS instructors in their region

Regional trauma triage protocol variations:Regional trauma triage protocol variations:

• Must require that EMS transport trauma victims to Must require that EMS transport trauma victims to trauma centerstrauma centers

• May include any of the 5 exceptions to mandatory May include any of the 5 exceptions to mandatory transport but transport but cannotcannot create additional exceptions create additional exceptions

• Must seek to minimize overtriage and undertriageMust seek to minimize overtriage and undertriage

• Supersede Ohio’s protocols once approved by the Supersede Ohio’s protocols once approved by the EMS BoardEMS Board

• Are automatically amended to meet the state triage Are automatically amended to meet the state triage protocol if the EMS Board updates the state protocol.protocol if the EMS Board updates the state protocol.


Periodic ReviewPeriodic Review

The law requires that Ohio’s trauma triage protocols The law requires that Ohio’s trauma triage protocols be reviewed and updated every three years by the be reviewed and updated every three years by the

State EMS Board in order to minimize State EMS Board in order to minimize overtriage and undertriage.overtriage and undertriage.

These reviews are done through public hearings, These reviews are done through public hearings, public comment periods and examination of the data public comment periods and examination of the data

in the EMS Incident Reporting System (EMSIRS) and in the EMS Incident Reporting System (EMSIRS) and the Ohio Trauma Registry (OTR).the Ohio Trauma Registry (OTR).

EMS documentation is EMS documentation is veryvery important to effectively important to effectively perform these reviews.perform these reviews.

Each EMS run report should record what, if any, Each EMS run report should record what, if any, trauma triage criteria were met by the injured patient, trauma triage criteria were met by the injured patient,

as well as their vital signs and the Glasgow Coma as well as their vital signs and the Glasgow Coma Score. This information is submitted to EMSIRS and Score. This information is submitted to EMSIRS and

used by the EMS Board to study how the EMS used by the EMS Board to study how the EMS portion of the trauma system is functioning.portion of the trauma system is functioning.

This means yThis means yourour run data is being used to improve the run data is being used to improve the care given to all injured patients.care given to all injured patients.


SummarySummary

Questions every EMS provider should consider when evaluating an Questions every EMS provider should consider when evaluating an injured patient and making the decision on where to transport:injured patient and making the decision on where to transport:

Is this patient at risk of losing life or limb?Is this patient at risk of losing life or limb?

Is this patient at risk for disability or disfigurement?Is this patient at risk for disability or disfigurement?

Ohio Prehospital Trauma Triage RulesOhio Prehospital Trauma Triage RulesSummarySummary


Is there evidence of respiratory distress or failure?Is there evidence of respiratory distress or failure?

Is there evidence of poor perfusion or hemorrhagic shock?Is there evidence of poor perfusion or hemorrhagic shock?

Are there significant neurological symptoms?Are there significant neurological symptoms?

Are there signs/symptoms of spinal cord injury?Are there signs/symptoms of spinal cord injury?

Is there neurovascular compromise in an extremity?Is there neurovascular compromise in an extremity?



Are there penetrating wounds to the head, neck or torso?Are there penetrating wounds to the head, neck or torso?

Are there visible crush injuries?Are there visible crush injuries?

Is there abdominal distention, tenderness or seat belt sign?Is there abdominal distention, tenderness or seat belt sign?

Are there signs of a pelvic fracture or flail chest?Are there signs of a pelvic fracture or flail chest?

Are there amputations above the wrist or ankle?Are there amputations above the wrist or ankle?

Are there significant, serious burns?Are there significant, serious burns?


If the answer is yes to any of those If the answer is yes to any of those questions, the patient must be transported to questions, the patient must be transported to

a trauma center.a trauma center.


Prehospital assessment is key to rapid transport Prehospital assessment is key to rapid transport to the appropriate medical facilityto the appropriate medical facility


Trauma centers are capable of providing 24-hour surgical Trauma centers are capable of providing 24-hour surgical care to allow the trauma patient to be taken directly to the care to allow the trauma patient to be taken directly to the operating room, if needed.operating room, if needed.

Transporting a trauma patient to a non-trauma center Transporting a trauma patient to a non-trauma center hospital can result in significant delay in the patient’s hospital can result in significant delay in the patient’s arrival at a trauma center for definitive care.arrival at a trauma center for definitive care.


Undertriage – Undertriage – - Transporting a severely injured patient to a - Transporting a severely injured patient to a

hospital that is not a trauma center.hospital that is not a trauma center.- Can result in death or disability of the trauma - Can result in death or disability of the trauma

patient.patient.- Every trauma system’s goal is to have NO undertriaged - Every trauma system’s goal is to have NO undertriaged trauma patients.trauma patients.

Overtriage –Overtriage –- Transporting a minimally injured patient to a trauma - Transporting a minimally injured patient to a trauma center.center.- Can create a burden on system resources.- Can create a burden on system resources.- Most trauma systems need 25% - 30% overtriage to - Most trauma systems need 25% - 30% overtriage to ensure ALL severely injured patients get to a trauma ensure ALL severely injured patients get to a trauma center.center.


Your documentation is very important to improving Your documentation is very important to improving Ohio’s trauma system. Accurate documentation of the Ohio’s trauma system. Accurate documentation of the trauma triage criteria an injured person meets (if any), trauma triage criteria an injured person meets (if any), along with all vital signs, allows the EMS Board to along with all vital signs, allows the EMS Board to improve the efficiency of the system.improve the efficiency of the system.

• ATLS: Advanced Trauma Life Support, 7ATLS: Advanced Trauma Life Support, 7thth Edition. 2004. American College of Edition. 2004. American College of Surgeons; Chicago, IL.Surgeons; Chicago, IL.

• Basic Trauma Life Support for the EMT-B and First Responder, 4th Edition. 2003. Basic Trauma Life Support for the EMT-B and First Responder, 4th Edition. 2003. Campbell JE and Alabama Chapter of Emergency Physicians. Dothan, AL.Campbell JE and Alabama Chapter of Emergency Physicians. Dothan, AL.

• Basic Trauma Life Support for Advanced Providers, 5Basic Trauma Life Support for Advanced Providers, 5 thth Edition. 2003. Campbell JE Edition. 2003. Campbell JE and Alabama Chapter of Emergency Physicians. Dothan, AL.and Alabama Chapter of Emergency Physicians. Dothan, AL.

• PHTLS: Basic and Advanced Prehospital Trauma Life Support, 4PHTLS: Basic and Advanced Prehospital Trauma Life Support, 4 thth Edition. 1999. Edition. 1999. Eds. Paturas JL, Wertz EM and McSwain NE, Jr. Mosby, St. Louis, MO.Eds. Paturas JL, Wertz EM and McSwain NE, Jr. Mosby, St. Louis, MO.

• Ohio Revised Code, §4765.01, §4765.06, §4765.16, §4765.40, §4765.41Ohio Revised Code, §4765.01, §4765.06, §4765.16, §4765.40, §4765.41

• Ohio Administrative Code, Ohio Administrative Code, §4765-14-01, §4765-14-02, §4765-14-03, §4765-14-04, §4765-14-01, §4765-14-02, §4765-14-03, §4765-14-04, §4765-14-05, §4765-14-06, §4765-15-01, §4765-16-01, §4765-17-01§4765-14-05, §4765-14-06, §4765-15-01, §4765-16-01, §4765-17-01

Ohio Prehospital Trauma Triage RulesOhio Prehospital Trauma Triage RulesReferences and ResourcesReferences and Resources

Documents

Trauma Triage Education