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Adult Trauma Triage Guidelines
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Statement of INTENT:
The following trauma triage guidelines are provided to assist in determining the disposition of adult trauma patients. These guidelines are intended to be utilized in conjunction with clinical judgment. It is understood that these are guidelines only and are to be used whenever possible in communication with a base station physician.
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STEP 1: PHYSIOLOGY
- Glasgow Coma Scale +/-12 or AVPU = P or U
- Systolic BP < 90
- Pulse < 60/min or > 130/min
- Respiration < 10/min or > 29/min
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To TRAUMA CENTER
with ALS
if available |
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| STEP II: ANATOMY |
- Penetrating Injuries (ex., Gunshot Wounds,
Stab Wounds) to Head, Neck, Torso, Extremities
(above the elbow and knee)
- Flail Chest
- Fractures - More Than One Fracture Involving
Humerus and/or Femur
- Pelvic Fractures
- Paralysis or Evidence of a Spinal Cord Injury
- Amputation Above Wrist or Ankle
- Burns When Combined with Other Major Injuries
- High Voltage Electrical Injury
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TRAUMA CENTER
with ALS
if available |
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| STEP III : MECHANISM OF INJURY (Required Consult with Medical Command, when Available) |
- Ejection from Motor Vehicle
- Extrication > 20 min with an injury
- Falls > 20 feet
- Unrestrained Passenger in Vehicle Roll Over
- Pedestrian, Motorcyclist or Pedalcyclist
Thrown or Run Over
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To TRAUMA CENTER
with ALS
if available |
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Pediatric Trauma Triage Guidelines
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STATEMENT OF INTENT: The following pediatric trauma triage guidelines are provided to assist in determining the disposition of children 12 years of age or younger. Use the adult trauma triage guidelines for children older than 12 years of age. It is understood that these are guidelines only and are to be used, whenever possible, in communication with a base station physician. These guidelines are intended to be utilized in conjunction with clinical judgment.
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STEP 1: PHYSIOLOGY (any one of the parameters listed below)
- AVPU = responsive to voice, pain, or unresponsive
- Evidence of poor perfusion (skin pallor, cool extremities, weak distal pulses, cyanosis/mottling, etc.)
- Heart rate:
child < 5 yr old: < 80/min or > 180/min
child > 6 yr old: < 60/min or > 160/min
- Respiratory rate > 60, or respiratory distress, or apnea
- Capillary refill > 2 seconds (evaluated on warm body part)
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TRAUMA CENTER
with ALS
if available |
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| STEP II: ANATOMY (any one present) |
- Penetrating injuries (ex. gunshot/stab wounds) to the head, neck, torso or extremities (above the elbow and knee)
- Flail chest
- Difficulty or inability to maintain a patent airway
- Fractures - more than one involving the humerus and/or femur
- Pelvic fractures
- Paralysis or evidence of spinal cord injury
- Amputation above the wrist or ankle
- Burns when combined with other major injuries
- Seat belt mark on the torso
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TRAUMA CENTER
with ALS
if available |
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| STEP III : MECHANISM OF INJURY (any one present) |
- Ejection from motor vehicle
- Falls > 3x patient's height
- Extrication time > 20 mins with an injury
- High voltage electrical injury
- Unrestrained passenger in vehicle roll over
- Pedestrian, motorcyclist or pedalcyclist thrown or run over
- Front seat passenger with deployment of air bag (same side)
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TRAUMA CENTER
with ALS
if available |
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