دستور العمل CDC جهت ترياژ بيماران در صحنه حادثه (ACS)

دستور العمل CDC جهت ترياژ بيماران در صحنه حادثه (ACS)
Please note: An erratum has been published for this issue. To view the erratum, please click here.
Morbidity and Mortality Weekly Report
www.cdc.gov/mmwr
Recommendations and Reports
January 23, 2009 / Vol. 58 / No. RR-1
Guidelines for Field Triage of Injured Patients
Recommendations of the National Expert Panel
on Field Triage
INSIDE: Continuing Education Examination
department of health and human services
Centers for Disease Control and Prevention
MMWR
The MMWR series of publications is published by the Coordinating
Center for Health Information and Service, Centers for Disease
Control and Prevention (CDC), U.S. Department of Health and
Human Services, Atlanta, GA 30333.
Suggested Citation: Centers for Disease Control and Prevention.
[Title]. MMWR 2008;57(No. RR-#):[inclusive page numbers].
Centers for Disease Control and Prevention
Julie L. Gerberding, MD, MPH
Director
Tanja Popovic, MD, PhD
Chief Science Officer
James W. Stephens, PhD
Associate Director for Science
Steven L. Solomon, MD
Director, Coordinating Center for Health Information and Service
Jay M. Bernhardt, PhD, MPH
Director, National Center for Health Marketing
Katherine L. Daniel, PhD
Deputy Director, National Center for Health Marketing
Editorial and Production Staff
Frederic E. Shaw, MD, JD
Editor, MMWR Series
Susan F. Davis, MD
(Acting) Assistant Editor, MMWR Series
Robert A. Gunn, MD, MPH
Associate Editor, MMWR Series
Teresa F. Rutledge
Managing Editor, MMWR Series
David C. Johnson
(Acting) Lead Technical Writer-Editor
Jeffrey D. Sokolow, MA
Project Editor
Martha F. Boyd
Lead Visual Information Specialist
Malbea A. LaPete
Stephen R. Spriggs
Visual Information Specialists
Kim L. Bright, MBA
Quang M. Doan, MBA
Phyllis H. King
Information Technology Specialists
Editorial Board
William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Virginia A. Caine, MD, Indianapolis, IN
David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
Margaret A. Hamburg, MD, Washington, DC
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA
John K. Iglehart, Bethesda, MD
Dennis G. Maki, MD, Madison, WI
Sue Mallonee, MPH, Oklahoma City, OK
Patricia Quinlisk, MD, MPH, Des Moines, IA
Patrick L. Remington, MD, MPH, Madison, WI
Barbara K. Rimer, DrPH, Chapel Hill, NC
John V. Rullan, MD, MPH, San Juan, PR
William Schaffner, MD, Nashville, TN
Anne Schuchat, MD, Atlanta, GA
Dixie E. Snider, MD, MPH, Atlanta, GA
John W. Ward, MD, Atlanta, GA
Contents
Introduction............................................................................... 2
Purpose of this Report.............................................................. 2
Burden of Injury...................................................................... 2
Reducing the Impact of Injury................................................... 2
Background ........................................................................... 5
Trauma Centers....................................................................... 6
EMS Providers and Systems...................................................... 8
Rating Scale for Injury Severity................................................. 9
Factors in Assessing the Effectiveness of Field Triage................... 9
Patient Morbidity and Mortality.............................................. 10
Economic Benefits of Accurate Field Triage.............................. 10
Methods.................................................................................. 11
Field Triage Decision Scheme Recommendations......................... 12
Step One: Physiologic Criteria................................................ 12
Step Two: Anatomic Criteria................................................... 15
Step Three: Mechanism-of-Injury Criteria................................. 17
Step Four: Special Considerations........................................... 23
Conclusion............................................................................... 30
References............................................................................... 31
Continuing Education Activity................................................. CE-1
Disclosure of Relationship
CDC, our planners, and our presenters wish to disclose they have no
financial interests or other relationships with the manufacturers of
commercial products, suppliers of commercial services, or commercial
supporters with the exception of Jeffrey P. Salomone, who wishes
to disclose he received an honorarium as a consultant and on the
Advisory Board for Schering-Plough Pharmaceuticals and Stewart C.
Wang, who received research grants from General Motors and Toyota
Motors while he served as a principal investigator of Grants.
Presentations will not include any discussion of the unlabeled use of
a product or a product under investigational use.
Vol. 58 / RR-1
Recommendations and Reports
Guidelines for Field Triage of Injured Patients
Recommendations of the National Expert Panel on Field Triage
Prepared by
Scott M. Sasser, MD1,2
Richard C. Hunt, MD1
Ernest E. Sullivent, MD1
Marlena M. Wald, MLS, MPH1
Jane Mitchko, MEd1
Gregory J. Jurkovich, MD3
Mark C. Henry, MD4
Jeffrey P. Salomone, MD2
Stewart C. Wang, MD, PhD5
Robert L. Galli, MD6
Arthur Cooper, MD7
Lawrence H. Brown, MPH8
Richard W. Sattin, MD9
1Division of Injury Response, National Center for Injury Prevention and Control, Atlanta, Georgia
2Emory University School of Medicine, Atlanta, Georgia
3University of Washington, Seattle, Washington
4Stony Brook University, Stony Brook, New York
5University of Michigan Health System, Ann Arbor, Michigan
6University of Mississippi, Jackson, Mississippi
7Columbia University Medical Center Affiliation at Harlem Hospital, New York, New York
8University of New Mexico Health Sciences Center, Albuquerque, New Mexico
9Medical College of Georgia, Augusta, Georgia
Summary
In the United States, injury is the leading cause of death for persons aged 1–44 years, and the approximately 800,000 emergency
medical services (EMS) providers have a substantial impact on the care of injured persons and on public health. At an injury scene,
EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to
transport the patient through a process called “field triage.” Although basic emergency services generally are consistent across hospital
emergency departments (EDs), certain hospitals have additional expertise, resources, and equipment for treating severely injured
patients. Such facilities, called “trauma centers,” are classified from Level I (centers providing the highest level of trauma care) to
Level IV (centers providing initial trauma care and transfer to a higher level of trauma care if necessary) depending on the scope of
resources and services available. The risk for death of a severely injured person is 25% lower if the patient receives care at a Level I
trauma center. However, not all patients require the services of a Level I trauma center; patients who are injured less severely might
be served better by being transported to a closer ED capable of managing milder injuries. Transferring all injured patients to Level I
trauma centers might overburden the centers, have a negative impact on patient outcomes, and decrease cost effectiveness.
In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the
basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is an algorithm that guides
EMS providers through four decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to determine
the most appropriate destination facility within the local trauma care system. Since its initial publication in 1986, the Decision
Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began
facilitating revision of the Decision Scheme by hosting a series of
meetings of the National Expert Panel on Field Triage, which
The material in this report originated in the National Center for Injury
includes injury-care providers, public health professionals,
Prevention and Control, Ileana Arias, PhD, Director, and the Division
of Injury Response, Richard C. Hunt, MD, Director, with financial supautomotive industry representatives, and officials from federal
port from the National Highway Traffic Safety Administration, Office
agencies. The Panel reviewed relevant literature, presented its
of Emergency Medical Services, and in association with the American
findings, and reached consensus on necessary revisions. The
College of Surgeons Committee on Trauma, J. Wayne Meredith, MD,
Chair (2002–2006).
revised Decision Scheme was published in 2006. This report
Corresponding preparer: Marlena Wald, MLS, MPH, Division of
describes the process and rationale used by the Expert Panel to
Injury Response, National Center for Injury Prevention and Control,
revise the Decision Scheme.
CDC, 4770 Buford Highway, MS F-62, Atlanta, GA 30341-3717.
Telephone: 770-488-4230; Fax: 770-488-3551; E-mail: [email protected]
1
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MMWR
Introduction
Purpose of this Report
At the scene of any crash or other event involving traumatic
injury, emergency medical services (EMS) providers must
identify those patients who are at greatest risk for severe injury
and must determine the most appropriate facility to which to
transport persons with different injury types and severities.
This decision process is known as “field triage” and is based
on a practice algorithm called a “decision scheme.” The first
Field Triage Decision Scheme was published by the American
College of Surgeons (ACS) in 1986 (1,2), with subsequent
updates in 1990, 1993, and 1999 (3–5). In 2005, with support from the National Highway Traffic Safety Administration,
CDC began facilitating revision of the Decision Scheme by
hosting a series of meetings of the National Expert Panel on
Field Triage, which includes injury-care providers, public health
professionals, automotive industry representatives, and officials
from federal agencies. In 2006, the most recent revision of
the Decision Scheme was published by the ACS Committee
on Trauma (ACS-COT) without an accompanying rationale
(6). To expand dissemination of the 2006 and future decision
schemes, CDC and ACS-COT have agreed to publication of
this report, which describes the process of revision and the
detailed rationale behind new triage criteria in the scheme
(Figure 1).
The 2006 version of the Decision Scheme reflects multiple
changes from the version published in 1999 (3). Certain
changes represent additions to the scheme, and others are
modifications of the 1999 criteria; in addition, certain criteria
have been removed altogether (Box 1).
The recommendations contained in this report have been
endorsed by the following organizations: the Air and Surface
Transport Nurses Association, the Air Medical Physician
Association, the American Academy of Pediatrics, the American
College of Emergency Physicians, the American College of
Surgeons, the American Medical Association, the American
Pediatric Surgical Association, the American Public Health
Association, the Commission on Accreditation of Medical
Transport Systems, the International Association of Flight
Paramedics, the Joint Commission, the National Association
of Emergency Medical Technicians, the National Association of
EMS Educators, the National Association of EMS Physicians,
the National Association of State EMS Officials, the National
Native American EMS Association, and the National Ski
Patrol. The National Highway Traffic Safety Administration
concurs with the contents of this report.
January 23, 2009
Burden of Injury
Injury is a major global public health problem. Approximately
5 million deaths worldwide are attributed each year to injuries
from all causes (7), representing approximately 10% of all
deaths (8,9). In addition, millions of persons are disabled either
temporarily or permanently every year as a result of injuries (8),
exacting a substantial toll on families, communities, and societies (10). The global burden of injury is expected to increase in
coming years, rising substantially by 2020 (11).
In the United States, injury is the leading cause of death for
persons aged 1–44 years (12). In 2005, injuries accounted for
approximately 174,000 deaths in the United States (13), with
an additional 41 million injuries serious enough to require
the injured person to visit a hospital emergency department
(ED) (14). Injuries also have a substantial economic cost. The
lifetime medical cost of injuries that occurred in 2000, the
most recent year for which data were available, was estimated
to be $80.2 billion (15).
Reducing the Impact of Injury
The optimal way to reduce the morbidity, mortality, and
economic consequences of injuries is to prevent their occurrence (10,16). However, when prevention fails and an injury
does occur, EMS providers must ensure that patients receive
prompt and appropriate emergency care at the scene and are
transported to a health-care facility for further evaluation and
treatment. Determining the appropriate facility to which an
injured patient should be transported can have a profound
impact on subsequent morbidity and mortality. Although basic
emergency services generally are consistent across EDs, certain
hospitals, called “trauma centers,” have additional expertise
and equipment for treating severely injured patients. Trauma
centers are classified into levels by ACS-COT depending on
the scope of resources and services available, ranging from Level
I, which provides the highest level of care, to Level IV, which
provides initial trauma care and transfer to a higher level of
trauma care if necessary (Box 2).
Not all injured patients can or should be transported to a Level
I trauma center. Patients with less severe injuries might be served
better by transport to a closer ED. Transporting all injured patients
to Level I trauma centers, regardless of the severity of their injuries,
could burden those facilities unnecessarily and make them less
available for the most severely injured patients.
The decision to transport a patient to a trauma center or
a nontrauma center can have an impact on health outcome.
The National Study on the Costs and Outcomes of Trauma
(NSCOT) identified a 25% reduction in mortality for severely
injured patients who received care at a Level I trauma center
rather than at a nontrauma center (17).
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FIGURE 1. Field triage decision scheme – United States, 2006
Measure vital signs and level of consciousness
Step One
Glasgow Coma Scale
Systolic blood pressure (mmHg)
Respiratory rate
<14
<90 mmHg
<10 or >29 breaths per minute
(<20 in infant aged <1 year*)
Yes
Take to a trauma center.† Steps 1 and 2 attempt to identify the most seriously
injured patients. These patients should be transported preferentially to the
highest level of care within the trauma system.
Step Two§
 All penetrating injuries to head, neck, torso,
and extremities proximal to elbow and knee
 Flail chest
 Two or more proximal long-bone fractures
 Crushed, degloved, or mangled extremity
Yes
Take to a trauma center. Steps 1 and 2 attempt to identify the most seriously
injured patients. These patients should be transported preferentially to the
highest level of care within the trauma system.
Step Three§
Assess
anatomy
of injury.
 Amputation proximal to wrist and
ankle
 Pelvic fractures
 Open or depressed skull fracture
 Paralysis
No
Assess mechanism
of injury and evidence
of high-energy impact.
 Falls
— Adults: >20 feet (one story is equal to 10 feet)
— Children¶: >10 feet or two or three times the height of the child
 High-risk auto crash
— Intrusion**: >12 inches occupant site; >18 inches any site
— Ejection (partial or complete) from automobile
— Death in same passenger compartment
— Vehicle telemetry data consistent with high risk of injury
 Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact††
 Motorcycle crash >20 mph
Yes
Transport to closest appropriate trauma center, which, depending on the
trauma system, need not be the highest level trauma center.§§
Step Four
No
No
Assess special patient or
system considerations.
 Age
— Older adults¶¶: Risk of injury/death increases after age 55 years
— Children: Should be triaged preferentially to pediatric-capable trauma centers
 Anticoagulation and bleeding disorders
 Burns
— Without other trauma mechanism: triage to burn facility***
— With trauma mechanism: triage to trauma center***
 Time sensitive extremity injury†††
 End-stage renal disease requiring dialysis
 Pregnancy >20 weeks
 EMS§§§ provider judgment
Yes
No
Contact medical control and consider transport to a
trauma center or a specific resource hospital.
Transport according
to protocol.¶¶¶
When in doubt, transport to a trauma center
See Figure 1 footnotes on the next page.
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MMWR
January 23, 2009
SOURCE: Adapted from American College of Surgeons. Resources for the optimal care of the injured patient. Chicago, IL: American College of Surgeons;
2006. Footnotes have been added to enhance understanding of field triage by persons outside the acute injury care field.
* The upper limit of respiratory rate in infants is >29 breaths per minute to maintain a higher level of overtriage for infants
† Trauma centers are designated Level I–IV, with Level I representing the highest level of trauma care available.
§ Any injury noted in Steps 2 and 3 triggers a “yes” response.
¶ Age <15 years.
** Intrusion refers to interior compartment intrusion, as opposed to deformation which refers 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 of trauma center; appropriate center need not be Level I.
¶¶ Age >55 years.
*** Patients with both burns and concomitant trauma for whom the burn injury poses the greatest risk for morbidity and mortality should be transferred to
a burn center. If the nonburn trauma presents a greater immediate risk, the patient may be stabilized in a trauma center and then transferred to a burn
center.
†††
Injuries such as an open fracture or fracture with neurovascular compromise.
§§§
Emergency medical services.
¶¶¶
Patients who do not meet any of the triage criteria in Steps 1–4 should be transported to the most appropriate medical facility as outlined in local EMS
protocols.
BOX 1. Changes in field triage decision scheme criteria from 1999 version — United States, 2006
Step One: Physiologic Criteria
• Add a lower limit threshold for respiratory rate in infants (aged <1 year) of <20 breaths per minute
• Remove Revised Trauma Score <11
Step Two: Anatomic Criteria
• Add crushed, degloved, or mangled extremity
• Change “open and depressed skull fractures” to “open or depressed skull fractures”
• Move combination trauma with burns and major burns to Step Four
Step Three: Mechanism-of-Injury Criteria
• Add vehicular telemetry data consistent with high risk of injury
• Clarify criteria for falls to include:
—— adults: fall >20 ft (two stories)
—— children aged <15 years: fall >10 ft or two to three times the child’s height
• Change “high-speed auto crash” to “high-risk auto crash” and modify to include any of the following:
—— intrusion >12 inches at occupant site
—— intrusion >18 inches at any site
—— partial or complete ejection from the vehicle
—— death of another passenger in the same passenger compartment
—— vehicle telemetry data consistent with high risk for injury
• Revise “auto-pedestrian/auto-bicycle injury with significant (>5 mph) impact” and “pedestrian thrown or run over” to
“Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact”
• Revise “motorcycle crash >20 mph with separation of rider from bike” to “motorcycle crash >20 mph”
• Remove “initial speed >40 mph, major auto deformity >20 inches, extrication time >20 min, and rollover”
Step Four: Special Considerations
• Add “time-sensitive extremity injury, end-stage renal disease requiring dialysis, and Emergency Medical Service provider
judgment”
• Add burns from Step Two
—— burns without other trauma mechanism: triage to burn facility
—— burns with trauma mechanism: triage to trauma center
• Clarify aged <5 years or >55 years to read:
—— older adults: risk of injury death increases after age 55 years
—— children: should be triaged preferentially to pediatric-capable trauma centers
• Change “patient with bleeding disorder or patient on anticoagulants” to “anticoagulation and bleeding disorders”
• Change “pregnancy” to “pregnancy >20 wks”
• Remove “cardiac disease, respiratory disease, insulin-dependent diabetes, cirrhosis, morbid obesity, and immunosuppressed patients”
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Recommendations and Reports
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BOX 2. Levels of trauma centers (TCs)
Level I
• Regional resource hospital that is central to trauma care system
• Provides total care for every aspect of injury, from prevention through rehabilitation
• Maintains resources and personnel for patient care, education, and research (usually in university-based teaching hospital)
• Provides leadership in education, research, and system planning to all hospitals caring for injured patients in the region
Level II
• Provides comprehensive trauma care, regardless of the severity of injury
• Might be most prevalent facility in a community and manage majority of trauma patients or supplement the activity of
a Level I TC
• Can be an academic institution or a public or private community facility located in an urban, suburban, or rural area
• Where no Level I TC exists, is responsible for education and system leadership
Level III
• Provides prompt assessment, resuscitation, emergency surgery, and stabilization and arrange transfer to a higher-level
facility when necessary
• Maintains continuous general surgery coverage
• Has transfer agreements and standardized treatment protocols to plan for care of injured patients
• Might not be required in urban or suburban area with adequate Level I or II TCs
Level IV
• Rural facility that supplements care within the larger trauma system
• Provides initial evaluation and assessment of injured patients
• Must have 24-hour emergency coverage by a physician
• Has transfer agreements and a good working relationship with the nearest Level I, II, or III TC
SOURCE: Adapted from the American College of Surgeons. Resources for the optimal care of the injured patient. Chicago, IL: American College of Surgeons; 2006.
Background
History of the Field Triage Decision Schemes
In 1976, ACS-COT began publishing resource documents to
provide guidance for designation of facilities as trauma centers
and appropriate care of acutely injured patients (1–6). Before
this guidance appeared, trauma victims were transported to the
nearest hospital, regardless of the capability of that hospital,
and often with little prehospital intervention (1).
ACS-COT regularly revised the resource document, which
included the Decision Scheme. During each revision, the
Decision Scheme was evaluated by a subcommittee of ACSCOT, which analyzed the available literature, considered
expert opinion, and developed recommendations regarding
additions and deletions to the Decision Scheme. Final approval
of the recommendations rested with the ACS-COT Executive
Committee. Since its initial publication in 1986, the Decision
Scheme has been revised four times: in 1990, 1993, 1999 (1),
and 2006 (6).
In recent years, CDC has taken an increasingly active role
in the intersection between public health and acute injury
care, including the publication in 2005 of an injury care
research agenda (18). In 2005, with financial support from the
National Highway Traffic Safety Administration (NHTSA),
CDC convened a series of meetings of the National Expert
Panel on Field Triage (the Panel) to guide the 2006 revision
of the Decision Scheme. The Panel* brought representatives
with additional expertise to the revision process (e.g., persons
in EMS, emergency medicine, public health, the automotive
industry, and other federal agencies). The Panel had multiple
objectives, including providing a vigorous review of the available
evidence supporting the Decision Scheme, assisting with the dissemination of the revised scheme and the underlying rationale
to the larger public health and acute injury care community,
emphasizing the need for additional research in field triage, and
establishing an evidence and decision base for future revisions.
A major outcome of the Panel’s meetings was the creation of
the 2006 Field Triage Decision Scheme (Figure 1).
*A list of the membership appears on page 35 of this report.
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MMWR
Development of Field Triage Criteria
The development of field triage criteria paralleled the
development of trauma centers, including the concept of
bypassing closer facilities in favor of those with enhanced
capabilities for treating severely injured patients. The initial
1976 guidance by ACS-COT (1) contained no specific triage
criteria but did include physiologic and anatomic measures
that allowed stratification of patients by injury severity. Also
in 1976, ACS-COT developed guidelines for the verification
of trauma centers, including standards for personnel, facility,
and processes deemed necessary for the optimal care of injured
persons. Studies conducted in the 1970s and early to mid 1980s
demonstrated a reduction in mortality in regions of the United
States with specialized trauma centers (19–21). These studies
led to a national consensus conference that resulted in publication of the first ACS field triage protocols, known as the Triage
Decision Scheme, in 1986. Since 1986, this Decision Scheme
has served as the basis for the field triage of trauma patients in
the majority of EMS systems in the United States (Figure 2).
The Decision Scheme continues to serve as the template for
field triage protocols in the majority of EMS systems across
the United States, with some local and regional adaptation.
Individual EMS systems may adapt the Decision Scheme to
reflect the operational context in which they function. For
example, the Decision Scheme may be modified to a specific
environment (densely urban or extremely rural), to resources
available (presence or absence of a specialized pediatric trauma
center), or at the discretion of the local EMS medical director.
Trauma Centers
Definition
A trauma center is an acute-care facility that has made preparations and achieved certain resource and personnel standards
to provide care for severely injured patients. In addition to
24-hour ED care, such a facility ensures access to surgeons,
anesthesiologists, other physician specialists, and nurses and
to resuscitation and life support equipment needed to treat
severely injured persons.
Designation and Verification
Trauma centers are designated as Level I, II, III, or IV on
the basis of the depth of their resources and available personnel (Box 2). These levels do not imply a differentiation in the
quality of care rendered (6). Through its resource document
(6), ACS-COT outlines the criteria for each level of trauma
center, but the designation of a trauma center is made by a state
or local regulatory authority (e.g., a state health department).
Although ACS-COT does not designate the level of the trauma
January 23, 2009
center, ACS-COT representatives will visit a hospital site to
verify the presence of the resources outlined in the document
at the request of a hospital, local community, or state authority
(6). ACS verification is designed to assist hospitals in the evaluation and improvement of trauma care and in the assessment
of their capabilities and performance.
Among trauma centers, a Level I center has the greatest
amount of resources and personnel for care of the injured
patient. Typically, it also is a tertiary medical care facility that
provides leadership in patient care, education, and research
for trauma, including prevention programs. A Level II facility
offers similar resources to a Level I facility, possibly differing
only by the lack of continuous availability of certain subspecialties or sufficient prevention and research activities for a Level I
designation. A Level III center is capable of assessment, resuscitation, and emergency surgery, if warranted; injured patients
are stabilized before transfer to a facility with a higher level of
care according to pre-existing agreements. A Level IV trauma
center is capable of providing 24-hour physician coverage,
resuscitation, and stabilization to injured patients before they
are transferred. In addition, although not formally recognized
by ACS-COT, certain states designate Level V centers; these
centers might be in areas (e.g., remote rural areas) in which a
higher level of care is not available and might consist of a clinic
staffed by a physician extender (nurse practitioner or physician’s
assistant) trained in trauma resuscitation protocols (6).
Role of Trauma Systems in the Public Health
Framework
Trauma centers are part of a broader integrated public
health framework that includes organized, coordinated efforts
to deliver a full range of care to all injured patients (22). This
framework conceptualizes traumatic injury as a disease involving an interaction among host, agent, and environment. It
recognizes that the impacts of injuries are physical, emotional,
and psychological, and that they are predictable and preventable. The effects of traumatic injuries can be both short term
and long term and can affect the lives of persons, their families, health-care workers, and society. The framework uses the
public health model to prevent the injury, mitigate the effects
of the injury if one occurs, and determine how to improve the
overall trauma system.
Trauma systems are termed either “inclusive” or “exclusive.”
An inclusive system takes an integrated approach to the management of trauma, recognizing a tiered approach to trauma
care among designated trauma centers. In an inclusive system,
all acute health-care facilities (even those not designated as
trauma centers) can provide care for minor injuries, with
severely injured patients transferred to a facility that provides a
higher level of care when necessary (1,6). An exclusive trauma
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FIGURE 2. Field triage decision scheme – United States, 1999
Measure vital signs and level of consciousness
Step One
Glasgow Coma Scale
Systolic blood pressure
Respiratory rate
Revised trauma score
<14, or
<90, or
<10 or >29
<11
Yes
No
Take to trauma center; alert trauma team. Steps 1 and 2 triage
attempt to identify the most seriously injured patients in the field. In
a trauma system, these patients would preferentially be transported
to the highest level of care within the system.
Step Two
 All penetrating injuries to head, neck, torso,
and extremities proximal to elbow and knee
 Flail chest
 Combination trauma with burns
 Two or more proximal long-bone fractures
Assess
anatomy
of injury.
 Pelvic fractures
 Open and depressed skull fracture
 Paralysis
 Amputation proximal to wrist and ankle
 Major burns
No
Yes
Take to trauma center; alert trauma team. Steps 1 and 2 triage
attempt to identify the most seriously injured patients in the field. In
a trauma system, these patients would preferentially be transported
to the highest level of care within the system.
Step Three
Evaluate for evidence of
mechanism of injury and
high-energy impact.
 Auto-pedestrian/auto-bicycle
 Ejection from automobile
 High-speed auto crash
 Death in same passenger
injury with significant
— Initial speed >40 mph
(>5 mph) impact
— Major auto deformity >20 inches
compartment
 Pedestrian thrown or run over
— Intrusion into passenger
 Extrication time >20 minutes
compartment >12 inches
 Motorcycle crash >20 mph
 Falls >20 feet
or with separation of rider
 Rollover
from bike
Yes
No
Contact medical direction and consider transport to a trauma center.
Consider trauma team alert.
Step Four
 Age <5 years or >55 years
 Cardiac disease, respiratory disease
 Insulin-dependent diabetes, cirrhosis, or morbid obesity
 Pregnancy
 Immunosuppressed patients
 Patient with bleeding disorder or patient on anticoagulants
No
Yes
Contact medical direction and consider transport to a trauma center.
Consider trauma team alert.
Reevaluate with
medical direction.
When in doubt, take to a trauma center
SOURCE: Adapted from American College of Surgeons. Resources for the optimal care of the injured patient. Chicago, IL: American College of Surgeons; 1999.
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system focuses only on the care provided at a particular specialized and designated trauma center (6).
Research studies demonstrate the effectiveness of inclusive
trauma systems that take a tiered approach to trauma care
among designated Level I–IV trauma centers. A 2001 retrospective cohort study of administrative discharge data for
61,496 patients with injuries rated as severe indicated that the
odds of death were significantly lower in the most inclusive
systems (those in which 38%–100% of acute-care hospitals
are designated as trauma centers) (odds ratio [OR]: 0.8; 95%
confidence interval [CI] = 0.6–0.99) compared with those
described as exclusive (those in which <13% of acute-care
hospitals are designated as trauma centers) (23). Certain studies
have suggested that smaller facilities that have been verified and
designated as lower-level trauma centers and are included in an
inclusive trauma system might have substantially better quality
of care than facilities outside the system (24). Other studies
have demonstrated that regionalized trauma systems and formal
protocols within a region for prehospital and hospital care can
improve patient outcomes (25–28). However, the Institute
of Medicine has indicated that the case for regionalization of
emergency services, although strong, is not absolute (29).
Having any trauma system, whether inclusive or exclusive,
is better than having no trauma system. A systematic review
of population-based assessments of the benefits of trauma
systems conducted in 1999 indicated that trauma systems
are beneficial to public health (30). Overall, trauma systems
reduced the risk for death among seriously injured trauma
patients 15%–20%. In 1999, a separate systematic review of
11 articles reporting data from trauma registries indicated that
the risk for trauma-related death in patients treated within
trauma systems was 15%–20% lower than Major Trauma
Outcomes Study (MTOS) norms† (25). An analysis of national
vital statistics and of Fatality Analysis Reporting System data
that compared injury mortality rates in states with regional or
statewide trauma systems to those that have no such systems
indicated that crude injury-related mortality rates were 9%
lower in the 22 states with regional trauma systems, and motorvehicle crash (MVC)–related mortality rates were 17% lower
(31). After controlling for age, speed limit laws, seatbelt laws,
and population, MVC-related mortality rates in states with
trauma systems were 9% lower than rates in states without
trauma systems.
† Led by ACS, MTOS was conducted during 1982–1989 and pooled demographic
and injury severity data on approximately 160,000 trauma patients from multiple
hospitals in the United States and Canada to develop survival norms.
January 23, 2009
EMS Providers and Systems
Working in approximately 15,000 different EMS systems
across the United States, approximately 800,000 EMS providers respond to nearly 16.6 million transport calls per year
(14,29); approximately 6.5 million (39%) calls are attributable
to injuries (32). The care provided in the field by an individual
EMS provider is dependent not only on certification and
state regulation but also on training and education, trauma
system design, and local medical oversight. In general, EMS
providers are certified at three primary levels. An Emergency
Medical Technician–Basic (EMT-B) provides first aid and other
procedures including cardiopulmonary resuscitation (CPR);
airway management using oropharyngeal and nasopharyngeal
airways and suction; oxygen administration with bag-valvemask ventilation; hemorrhage control using direct pressure,
elevation and pressure dressings; and spinal immobilization
and splinting of extremity fractures (33). Many states have
added defibrillation using semiautomatic defibrillators as an
EMT-B skill. An EMT-Paramedic (EMT-P) can apply more
advanced airway skills, including endotracheal intubation and
cricothyrotomy; can perform needle thoracostomy; and may
administer intravenous fluids and a wide range of medications
(34). In the majority of states, at least one intermediate level
of EMS provider (EMT-I) is recognized with a skill set that
exceeds that of an EMT-B but is not as advanced as an EMTP. The level of EMS provider expertise available in any given
locale varies and is affected by local needs, system design, financial resources, and volume of EMS calls. The 2006 Decision
Scheme provides the basis for trauma destination protocols
for EMS systems across the United States and can be used by
EMS providers of any certification level.
EMS providers in the United States are regulated by the
individual states; all states require EMS providers to operate
under the license and direction of one or more licensed physicians. Physician direction covers operational policies, quality
improvement activities, oversight of education programs, destination decision-making, and the clinical care provided in the
field. Medical direction and oversight provided only through
administrative or policy activities (e.g., quality improvement
and protocol development) is designated as indirect or offline
medical direction. Direct or online medical direction involves
direct communication between a physician and an EMS provider via radio or telephone for a specific patient interaction.
Because online medical direction is time consuming, both for
EMS providers at the scene and for busy ED physicians, the
majority of EMS systems operate with a combination of direct
and indirect medical direction. This permits the EMS provider
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Recommendations and Reports
to assist each patient by using medical director–approved protocols in a sanctioned, algorithmic process while maintaining
the option to call for online physician assistance to perform
certain advanced procedures (e.g., needle thoracostomy or
cricothyrotomy), administer medications (e.g., narcotics or
anxiolytics), or ask specific questions regarding the care of a
patient.
9
TABLE 1. Abbreviated Injury Scale (AIS)
AIS score
Injury
1
Minor
2
Moderate
3
Serious
4
Severe
5
Critical
6
Probably lethal*
*Although a perfect linear correlation with an AIS of 6 and mortality does
not exist, survivability is unlikely.
Rating Scale for Injury Severity
Various standardized definitions and systems have been
developed to classify the type and severity of injuries. These
permit comparison of the medical outcomes of patients with
different types and extent of injuries who receive different
treatment and care regimens. Worldwide, the most widely
accepted injury-severity scale is the Abbreviated Injury Scale
(AIS), which ranks each injury in every body region with a
numerical score according to an ordinal scale (range: 1 [minor
injury]–6 [probably lethal/maximum injury]) (Table 1).
In 1974, the Injury Severity Score (ISS) was developed as a
way to summarize and take account of the effect of multiple
injuries (35). The ISS was derived from AIS scores and uses
an ordinal scale (range: 1–75) (35), which is calculated by
assigning AIS scores to injuries in each of six body regions
(head/neck, face, thorax, abdomen/visceral pelvis, bony pelvis/extremities, and external structures) and then adding the
squares of the highest AIS scores in each of the three most
severely injured body regions (i.e., the three body regions
with the highest AIS scores). Only the most severe injury in
each body region is used in the score. If an AIS score of 6 is
assigned to any body region, the maximal ISS of 75 is assigned
(Table 2).
ISS is an accepted method of determining the overall severity
of injury (35) and correlates with mortality, morbidity, and
length of hospital stay (35–38). For example, ISS has been
used to predict mortality and risk for postinjury multiple
organ failure (39). In trauma research, ISS also has been used
to dichotomize trauma patients into severe injuries (ISS of
>15) and nonsevere injuries (ISS of <15) and to evaluate outcomes of patients with similar degrees of injury severity.§ For
example, during 1982–1987, data for 80,544 trauma patients
from 139 North American hospitals indicated that survival
from blunt and penetrating injuries decreased with increasing
ISS score; this decrease was more marked in persons aged >55
years. Patients with ISS of <15 had survival rates of >94%. For
patients with blunt trauma, survival decreased with increasing
ISS score (>16) and age (>55 years) (40).
§An
ISS of 15 is mathematically impossible.
TABLE 2. Sample Injury Severity Score (ISS)
Body region
Injury
Head/Neck
Face
Thorax
Abdomen
Extremity
External
No injury
No injury
Flail chest
No injury
Femur fracture
Contusion
Total ISS
*Abbreviated Injury Scale.
AIS*
0
0
4
0
3
1
Top three
AIS scores squared
16
9
1
26
Factors in Assessing the Effectiveness
of Field Triage
In responding to injury calls, EMS providers ascertain the
nature and severity of a patient’s injury, provide treatment,
and determine the most appropriate destination facility.
Determining the most appropriate facility for a given patient’s
injury is a complex process that involves the patient’s clinical
situation, patient and family member preferences, state laws
or regulations that might affect destination choices (e.g., mandating transport to the closest facility), and hospital and EMS
system capability and capacity.
Accuracy of Field Triage
The accuracy of field triage can be thought of as the degree
of match between the severity of injury and the level of
care. Sensitivity and specificity of screening tests are useful
indicators of accuracy (Figure 3). Maximally sensitive triage
would mean that all patients with injuries appropriate for a
Level I or Level II trauma center would be sent to such centers.
Maximally specific triage would mean that no patients who
could be treated at a Level III or Level IV center or community ED would be transported to a Level I or Level II center.
Triage that succeeded in transporting only patients with high
injury severity to a Level I or Level II center would maximize
the positive predictive value (PPV) of the process, and triage
that succeeded in transporting only patients with low injury
severity to a Level III, IV, or community ED would maximize
the negative predictive value (NPV).
10
MMWR
FIGURE 3. Measures of field triage accuracy*
Destination decision
Injury severity
Severe
Not severe
(Requires Level I or II)
(Requires Level III or IV)
Level
I or II
TC†
a
b
January 23, 2009
rather than minimizing overtriage. Target levels for undertriage
rates within a trauma system range from 0 to 5% of patients
requiring Level I or Level II trauma-center care, depending on
the criteria used to determine the undertriage rate (e.g., death
and ISS) (6). Target levels of overtriage vary (approximate
range: 25%–50%) (6). As field triage continues to evolve on
the basis of new research findings, overtriage rates might be
reduced while maintaining low undertriage rates.
Patient Morbidity and Mortality
Level
III or IV
TC
c
d
Sensitivity = a/(a + c)
Specificity = d/(b + d)
Rate of undertriage = c/(a + c)
Rate of overtriage = b/(b + d)
Positive predictive value = a/(a + b)
Negative predictive value = d/(c + d)
*In this figure, “a”, “b”, “c”, and “d” represent injured patients, categorized by
severity of injury and destination.
†Trauma center.
Ideally, all persons with severe, life-threatening injuries
would be transported to a Level I or Level II trauma center,
and all persons with less serious injuries would be transported
to lower-level trauma centers or community EDs. However,
patient differences, occult injuries, and the complexities of
patient assessment in the field preclude perfect accuracy in
triage decisions. Inaccurate triage that results in a patient who
requires higher-level care not being transported to a Level I
or Level II trauma center is termed undertriage. The result of
undertriage is that a patient does not receive the specialized
trauma care required. Overtriage occurs when a patient who
does not require care in a higher-level trauma center nevertheless is transported to such a center, thereby unnecessarily
consuming scarce resources. In the triage research literature,
all of these measures (sensitivity, specificity, PPV, NPV,
undertriage, and overtriage [Figure 3]) are used together with
measures of association (e.g., ORs) to assess the effectiveness
of field triage.
As with sensitivity and specificity applied to screening tests,
reductions in undertriage usually are accompanied by increases
in overtriage, and reductions in overtriage are accompanied by
increases in undertriage. Because the potential harm associated
with undertriage (i.e., causing a patient in need of traumacenter care not to receive appropriate care) is high and could
result in death or substantial morbidity and disability, trauma
systems frequently err on the side of minimizing undertriage
Experience with field triage has confirmed the importance
of making correct destination decisions. A study to evaluate
the effect of trauma-center care on mortality in moderately
to severely injured patients incorporated data from Level I
trauma centers and large nontrauma-center hospitals (i.e.,
hospitals that treated >25 major trauma patients each year) in
15 Metropolitan Statistical Areas in 14 states (17). Complete
data for 1,104 patients who died in the ED or hospital were
compared with 4,087 selected patients who were discharged
alive. After adjusting for differences in case mix, including age,
comorbidities, and injury severity, researchers determined that
1-year mortality was lower among severely injured patients
treated at Level I trauma centers than among those treated at
large nontrauma-center hospitals (10.4% and 13.8%, respectively) (risk ratio [RR]: 0.8; CI = 0.6–0.95). Those treated at
Level I trauma centers also had lower in-hospital mortality (RR:
0.8; CI = 0.66–0.98), fewer deaths at 30 days after injury (RR:
0.8; CI = 0.6–1.0), and fewer deaths at 90 days after injury
(RR: 0.8; CI = 0.6–0.98).
Economic Benefits of Accurate
Field Triage
Since 1993, crowding in EDs has increased greatly as a
result of reductions in the number of hospitals with EDs,
regionalization of surgical care, increases in nonemergency
patient visits to EDs, diversion of EMS, and personnel shortages (29,41–45). Increasing use of EDs by uninsured patients,
inadequate reimbursement from payers, rising insurance costs,
and physician-related issues (e.g., on-call coverage and physician commitment) all present economic challenges (22,29,46).
For example, in 2001, five public trauma centers in Texas had
a mean operating loss of $18.6 million (47). The initial cost
to establish a trauma center (e.g., verification process, staffing,
on-call coverage, outreach, and prevention) is substantial, and
the median annual fixed cost for trauma-center readiness has
been estimated at $2.7 million (48).
The cost of injury in the United States also is substantial,
exceeding $400 billion in 2000, the most recent year for
which data were available. The approximately 50 million
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persons whose injuries required medical treatment in 2000
were associated with an estimated $80 billion in medical costs
and an estimated $326 billion in productivity losses (Table 3)
(49). Injured persons treated in EDs in 2000 accounted for
$99 billion (24%) of the total cost of injury, with $32 billion
in medical costs and $68 billion in productivity losses (49).
During 1993–2003, the total number of annual ED visits for
all causes increased 26%, from 90.3 million in 1993 to 113.9
million in 2003 (29). In 2003, approximately 29.2 million
(26%) ED visits were for nonfatal injuries (50). By 2004, the
number of ED visits for nonfatal injuries exceeded 41 million
(14), and more than 6.5 million injured patients (16%) were
transported by ambulance (32).
The Decision Scheme is predicated on the assumption that
making appropriate destination decisions will reduce both
overtriage and undertriage. Accurate field triage is one part
of a complex solution for lowering injury costs. The cost of
treatment in a trauma center is almost twice that of treatment
in a nontrauma center (51). Overtriage results in an overutilization of financial and human resources (6), can contribute
to trauma-center overcrowding, and increases EMS transport
times and hospital turnaround times. For example, an ambulance that transports a patient with minor injuries unnecessarily to a Level I trauma center 30 miles away instead of to a
community hospital 5 miles away is unavailable for a longer
period. In a disaster or a situation involving mass casualties,
overtriage could have an adverse impact on patient care (6). A
review of data concerning 10 terrorist bombings demonstrated
a direct linear relationship between the rate of overtriage and
the mortality rate of those critically injured (52).
Methods
The National Expert Panel of Field Triage comprises 37
persons with expertise in acute injury care representing a range
of interested groups, including EMS providers and medical
directors, emergency medicine physicians and nurses, adult
and pediatric trauma surgeons, the automotive industry, public health personnel, and representatives of federal agencies.
Membership was determined on the basis of their national
leadership, expertise, and contributions in the fields of injury
prevention and control. The Panel is responsible for periodically
reevaluating the Decision Scheme, determining if the decision
criteria are consistent with current scientific evidence and compatible with advances in technology (e.g., vehicular telemetry),
and, as appropriate, recommending revisions to the Decision
Scheme. In May 2005, with support from NHTSA’s Office
of Emergency Medical Services, CDC convened the Panel
to evaluate and revise the 1999 Decision Scheme. The Panel
recognized that peer-reviewed studies would be the preferred
11
basis for deciding on revisions to the Decision Scheme but
noted that scientific studies regarding the Decision Scheme
and its component criteria were sparse. For this reason, the
Panel decided to use multiple approaches to identify as many
relevant published studies as possible and to consider other
sources of evidence (e.g., consensus and policy statements
from specialties and disciplines involved in injury prevention
and control). Finally, when definitive research, consensus, or
policy statements were lacking, the Panel based its revisions and
recommendations on the expert opinion of its members.
For the 2006 revision, a structured literature review (53) was
conducted by an epidemiologist to examine the four component steps of the Decision Scheme. English-language articles
published during 1966–2005 were searched in MEDLINE,
using the medical subject headings “emergency medical services,” “wounds and injury,” and “triage.” In addition, the
reference sections of these articles were searched to identify
other potential articles. Of 542 articles that were identified,
80 (15%) articles that specifically addressed field triage were
subsequently reviewed. Panel members also identified additional relevant literature that had not been examined during
the structured review. The Panel placed primary emphasis on
articles published since the development of the 1999 version
of the Decision Scheme.
In the sources reviewed, changes were considered statistically
significant if the measure of alpha error (p-value) was <0.1 or
if the CI for the OR or RR was not inclusive of 1.0. Given the
limitations of the evidence, no predetermined level of sensitivity or specificity ruled out a discussion of any evidence by
the Panel. In general, ISS of >15 was used as the threshold for
identifying severe injury; however, other factors (e.g., need for
prompt operative care, intensive care unit [ICU] admission,
and case-fatality rates) also were considered; in a few circumstances, the published evidence used different criteria or thresholds. A threshold of 20% PPV to predict severe injury (ISS of
>15), major surgery, or ICU admission was used to place new
criteria into discussion for inclusion as mechanism-of-injury
criteria. PPV of <10% was used as a threshold for discussing
whether to remove existing mechanism-of-injury criteria from
the Decision Scheme. In selecting the PPV thresholds, the
Panel recognized the limitations of data available in the relevant literature. Panel members also could nominate decision
criteria having PPV 10%–20% for further discussion. Final
consensus on the criteria in the Decision Scheme was reached
on the basis of supporting or refuting evidence, professional
experience, and the judgment of the Panel.
In May 2005, the Panel met and reviewed the 1999 ACS
Decision Scheme, and the proceedings from that meeting were
published in 2006 (1,46,54–67). Presentations and group
discussions at the May 2005 meeting addressed 16 topics
12
MMWR
January 23, 2009
TABLE 3. Number of injuries and total associated lifetime costs,* by outcome and treatment location — United States, 2000
Outcome/Location
No. injured
Medical costs
Productivity losses
Total cost
Nonfatal
Hospital
1,869,857
$33,737
$58,716
$92,453
Emergency department
27,928,975
31,804
67,288
99,092
Outpatient
590,554
526
1,553
2,079
Medical doctor visit
19,588,637
13,068
56,443
69,511
Fatal†
149,075
1,113
142,041
143,154
Total
50,127,098
$80,248
$326,041
$406,289
SOURCE: Adapted from Sattin RW, Corso PS. The epidemiology and costs of injury. In: Doll L, Bonzo S, Mercy J , Sleet D, eds. Handbook on injury and
violence prevention interventions. New York, NY: Kluwer Academic/Plenum Publishers; 2006:3–19.
*In millions of dollars.
†Authors did not subdivide fatal injuries by treatment location.
(Box 3). The Panel determined that the limited evidence was
most compelling in support of the physiologic (Step One)
and anatomic (Step Two) criteria of the Decision Scheme.
Agreement was unanimous that the mechanism-of-injury (Step
Three) criteria needed revision, and approximately half of the
Panel members recommended that the special considerations
(Step Four) criteria, which address comorbidity and extremes
of age, be revised. Ultimately, the Panel elected to undertake
limited revisions of the physiologic and anatomic criteria and
more substantive revision of the mechanism-of-injury and
special considerations criteria.
Working subgroups of the Panel then conducted a further
detailed review of the medical literature and developed recommendations regarding individual components of the Decision
Scheme, focusing on the determination of the accuracy of existing criteria and on identifying new criteria needed for Steps
Three and Four of the Decision Scheme. The recommendations of the working subgroups were presented to the entire
Panel in April 2006 for discussion, minor modification, and
formal adoption. The revised Decision Scheme was distributed
together with a draft description of the revision process to
relevant associations, organizations, and agencies representing
acute-injury care providers and public health professionals for
their review and endorsement.
Field Triage Decision Scheme
Recommendations
Step One: Physiologic Criteria
Step One of the Decision Scheme seeks to guide EMS
personnel in identifying critically injured patients rapidly
through measuring their vital signs and assessing their level of
consciousness. The instruction “measure vital signs and level
of consciousness” has been included since the 1986 version
of the ACS Field Triage Decision Protocol (2). The sensitivity of physiologic criteria to identify severely injured patients
has been reported to range from 55.6% to 64.8%, with PPV
of 41.8% and a specificity of 85.7% (68,69). A study of 333
patients transported by helicopter to a Level I trauma center
during January 1993–December 1994 indicated that physiologic criteria alone were specific (0.9) but not sensitive (0.6)
for identifying ISS of >15 (68). An evaluation of data in the
South Carolina EMS registry, conducted to determine undertriage and overtriage rates when EMS personnel used the 1990
version of the ACS field triage guidelines, determined that
physiologic criteria alone had a sensitivity of 0.65 and PPV
of 42% for severe injury (ISS of >15) for 753 trauma patients
transported to a Level I trauma center in Charleston, South
Carolina (69). Adults meeting such physiologic criteria treated
at Level I trauma centers had reduced odds of mortality compared with patients treated at lower level trauma center and
nontrauma-center hospitals (OR: 0.7; CI = 0.6–0.9).
The Panel recommended transport to a trauma center if any
of the following are identified:
• Glasgow Coma Scale of <14,
• systolic blood pressure (SBP) of <90 mmHg, or
• respiratory rate of <10 or >29 breaths per minute (<20 in
infant aged <1 year).
Glasgow Coma Scale <14:
Criterion Retained
First described in 1974, the Glasgow Coma Scale (GCS) is
a clinical scale for assessing coma (70). The scale, which ranges
from 3 (deep coma) to 15 (normal consciousness), comprises
three components: eye opening, verbal response, and motor
response. In 1985, these components were included in a
proposed triage scale on the basis of data from 937 patients
transported to Los Angeles–area hospitals (71). Since then,
several studies have evaluated the association between GCS and
trauma severity and outcomes. A prospective cross-sectional
study of 1,545 MVC victims in Suffolk County, New York,
that was designed to determine the incremental benefit of individual criteria included in the 1986 version of the ACS triage
guidelines determined through univariate analysis that GCS of
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Recommendations and Reports
BOX 3. Presentations and discussion topics from the first
meeting — National Expert Panel on Field Triage — Atlanta,
Georgia, May 2005
• History of trauma field triage development and the
American College of Surgeons criteria
• Trauma triage: New York experience
• Studies evaluating current field triage: 1966–2005
• Trauma triage: concepts in prehospital trauma care
• Prehospital triage of trauma patients: a trauma surgeon’s
perspective
• National Emergency Medical Services Information
System (NEMSIS)
• Innovation possibilities for prehospital providers
• Telematics
• Field triage in disasters
• Air medical transport of trauma patients
• Development of trauma care systems
• Emergency medical treatment and active labor act and
trauma triage
• HIPAA* privacy and security implications for field triage
• Specialty coverage at nontertiary care centers
• Field triage and the fragile supply of “optimal resources”
for the care of the injured patient
• The effect of ambulance diversions on the development
of trauma systems
* Health Insurance Portability and Accountability Act of 1996.
<13 was associated with increased odds of major operation or
death (OR: 67.8; CI = 26.0–176.9) and with ISS of >15 (OR:
33.1; CI = 16.2–67.6), although only the association with ISS
was sustained in multivariate analysis (OR: 7.7; CI = 2.4–24.4)
(72). A retrospective observational evaluation of adult patients
meeting the GCS physiologic triage criteria included in the
1999 Decision Scheme identified a mortality rate of 24.7%
for patients meeting the GCS <14 physiologic criteria (73).
A 5-month prospective cohort study of 1,005 trauma team
activations indicated that a triage criterion of GCS <10 had
a sensitivity for severe injury (defined as immediate surgical
intervention, ICU admission, or ED death) of approximately
0.7 and a specificity of approximately 0.1, and that patients
with GCS of <10 had increased odds of admission to the
ICU or operating room or of death in the ED (OR: 3.5; CI =
1.6–7.5) (74). An evaluation of the accuracy of triage criteria
in 1,285 injured children indicated that GCS of <12 had PPV
of 78% for identifying major injury (defined as major surgery,
admission to the ICU, or death in the ED) (75).
After reviewing and discussing the available evidence, the
Panel determined that the GCS criterion should be retained
13
in the 2006 Decision Scheme. The Panel’s decision was made
primarily on the basis of its conclusion that the totality of
existing studies indicated that GCS is a reasonably predictive
criterion for severe injury (ISS of >15, risk of death, need for
immediate surgical intervention, or other indicators). The
Panel also observed that no studies have refuted the usefulness
of GCS as a triage criterion, and no other measure of coma
has been demonstrated to be more effective. The Panel also
considered three additional factors. First, GCS has been a
Decision Scheme triage criterion since 1986, and field providers have become familiar with its use. Second, GCS scores can
be calculated quickly and easily in the field and communicated
easily to receiving hospitals as an effective summary measure of
closed-head injury while the patient is being transported, which
can assist in the activation of needed additional ED personnel
and resources before the patient’s arrival. Finally, GCS plays an
important role in triage and trauma outcomes research and for
that reason should continue to be used for field triage.
Systolic Blood Pressure <90 mmHg and
Respiratory Rate <10 or >29 Breaths Per
Minute: Criterion Retained
Blood pressure and respiratory rate are predictors of severe
injury and the need for a high level of trauma care. A prospective cross-sectional study of the 1986 triage criteria indicated
that SBP of <90 mmHg was associated with increased odds
for major surgery or death (OR: 142.2; CI = 50.4–400.7) and
ISS of >15 (OR: 46.5; CI = 19.4–111.4), although only the
association with major surgery or death withstood adjustment
in multivariate analysis (OR: 14.0; CI = 2.3–84.0) (72). A
2006 review of New York State Trauma Registry data reported
mortality rates of 32.9% for trauma victims with SBP of <90
mmHg and 28.8% for trauma victims with respiratory rates
of <10 or >29 breaths per minute (60). Transport to a Level I
trauma center was associated with reduced odds of mortality
for patients with respiratory rate of <10 or >29, compared with
transport to a lower level trauma center or nontrauma center
(OR: 0.6; CI = 0.4–0.8) (73). A study of 216 patients transported by helicopter to a Level I trauma center indicated that
patients with tachycardia, hypotension (SBP of <90 mmHg),
altered consciousness, respiratory impairment, or capillary refill
of >2 seconds had increased odds of requiring life-saving intervention (e.g., intubation, cricothyrotomy, tube thoracostomy, or
surgical intervention) as defined by a panel of experts (76).
Although published evidence is lacking, in accordance with
the precept that acceptance of a higher rate of overtriage is
justified among pediatric patients because of the need to avoid
poor outcomes sometimes associated with undertriage in this
vulnerable population, the Panel decided to retain the field
triage criterion for SBP (<90 mmHg) for children. Because
14
MMWR
the mean SBP in children is lower than in adults, the retained
criterion is thought to be highly sensitive for severe injury in
children. Also, although the generally accepted estimate for
age-specific hypotension for infants is <70 mmHg, the Panel
concluded that transporting an infant with SBP of <90 mmHg
to a trauma center (preferably a pediatric trauma center) carried
an acceptable risk of overtriage. The Panel also recognized that
obtaining accurate blood pressure readings in an infant or small
child in the field or during transport often is difficult.
Respiratory Rate of <20 Breaths Per Minute
in Infants Aged <1 year: Criterion Added
A respiratory rate of <10 breaths per minute predicts with
reasonable sensitivity those adults and children at risk for serious injury and needing a high level of trauma care. However,
the lower limit for a normal respiratory rate for infants aged
<1 year is approximately 20 breaths per minute (77). Although
assessing physiologic parameters in infants in the field is difficult, respiratory rate is the one vital sign that can be measured
easily. Measurement of respiratory rate is a particularly practical
triage criterion, even in infants, because it is easily observed
and because EMS providers are taught the importance of
respiratory rate assessment in infants (78).
The 1999 Decision Scheme included one simple triage
criterion for respiratory rate, a rate <10 or >29, for persons
of all ages. Although no studies have evaluated respiratory
rate specifically as a triage criterion for infants aged <1 year,
the Panel concluded that a triage criterion using a respiratory
rate of <20 breaths per minute in infants more appropriately
reflects the risk for severe injury requiring higher level care. The
Panel determined that a criterion for infants of <10 breaths per
minute, although appropriate for older children and adults, is
too low to serve as a triage criterion for infants.
In adding this triage criterion, the Panel also noted that
respiratory rates that are too fast or too slow can indicate
respiratory failure as a sequel to trauma (79). Further, knowing the respiratory rate improves identification of respiratory
depression or shock in infants aged <1 year. The Panel left
unchanged in the 1999 Scheme the respiratory rate criterion
for infants aged >1 year (>29 breaths per minute).
Other Physiologic Observations
Abnormal pulse rate and skin findings never have been
included in the Decision Scheme and are not included in the
revised version. However, as a matter of good practice, abnormal pulse or skin condition should prompt EMS providers to
seek other physiologic indications of severe injury.
January 23, 2009
Revised Trauma Score <11: Criterion Deleted
The Revised Trauma Score (RTS) is a modification of the
Trauma Score (TS), a physiological measure of injury severity
(range: 0–16) published in 1981 and developed on the basis of
a previously reported Triage Index (80). The TS results from the
sum of scores assigned to five variables: GCS (ranked 0–5), SBP
(ranked 0–4), respiratory rate (ranked 0–4), capillary return
(ranked 0–2), and respiratory expansion (ranked 0–1).
TS has been determined to be an insensitive triage criterion.
An evaluation of triage decisions in 631 patients transported
by EMS and entered into the Portland, Oregon, trauma system
database determined that using TS as a sole criterion would
have missed substantial injury in 8%–36% of seriously injured
patients (81). A study of 500 patients examined consecutively
by the trauma service at a community hospital indicated that
206 (41.2%) patients suffered significant injury as demonstrated by ISS of >15, ED TS score of <14, length of hospital
stay of >3 days, or death (82). Prehospital TS of <15 had a
sensitivity of 0.6 and a specificity of 0.8. Specificity improved
at lower TS thresholds, but sensitivity diminished rapidly
(Table 4). A retrospective analysis of 1,839 trauma registry
patients from Portland, Oregon, that evaluated the association
between TS and ISS in 898 trauma victims indicated that TS
of <12 correctly triaged 66% of patients, with an 8% rate of
overtriage (i.e., predicting severe injury when ISS was <15).
Additionally, TS of <12 had a 25.2% rate of undertriage (i.e.,
predicting minor injury when ISS was >15) (83). If a threshold
of <14 had been used instead, TS would have accurately triaged 69.6% of patients, with an overtriage rate of 13.6% and
an undertriage rate of 16.7%. A prospective study of 1,473
consecutive patients transported to trauma centers in Fresno
County, California, during 1986 indicated that TS of <14
had PPV of 49.7% for ISS of >15, with an undertriage rate of
22.7% and an overtriage rate of 5.5% (84).
Difficulty in accurate assessment of the components of TS in
the field led to its revision in 1989, resulting in the creation of
RTS and Triage-RTS (T-RTS) (85), which were developed on
the basis of an analysis of 2,166 patients treated consecutively
during a 3-year period by the Washington Hospital Center
Trauma Service. Validation was accomplished using a subset
of patient data from the MTOS. RTS and T-RTS retain three
variables of TS (GCS, SBP, and respiratory rate) while eliminating respiratory expansion (a measure of respiratory effort)
and capillary return. In these two scoring systems, GCS, SBP,
and respiratory rate each are assigned a value ranging from 0
to 4. In T-RTS, a simple sum of the three values results in the
score, permitting simple calculations in the field. RTS is more
complicated, as it is calculated by multiplying each value by an
assigned factor between 0 and 1 (GCS: 0.9; SBP: 0.7; respira-
Vol. 58 / RR-1
Recommendations and Reports
TABLE 4. Sensitivity and specificity of prehospital trauma
score (TS),* revised trauma score (T-RTS),† and mechanism
of injury§ to identify significant injury
Sensitivity
Specificity
Prehospital TS
<15
<14
<13
<12
TS threshold
0.61
0.45
0.37
0.24
0.79
0.94
0.98
1.00
T-RTS
<11
<10
<9
0.59
0.49
0.39
0.82
0.92
0.96
Mechanism
Fall >16 ft
0.04
0.96
MVC¶ >20 mph
0.09
0.94
Auto vs. pedestrian >5 mph
0.16
0.81
Penetrating neck or torso injury
0.18
0.85
Rollover
0.05
0.94
MVC >40 mph
0.24
0.72
*SOURCE: Knudson P, Frecceri CA, DeLateur SA. Improving the field triage
of major trauma victims. J Trauma 1988;28:602–6.
†SOURCE: Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA,
Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29:623–9.
§SOURCE: Knudson P, Frecceri CA, DeLateur SA. Improving the field triage
of major trauma victims. J Trauma 1988;28:602–6.
¶Motor vehicle crash.
tory rate: 0.3) and summing the results. Although providing
a more meaningful score by weighting physiologic variables,
calculation of the unwieldy formula yields an RTS score more
appropriate for quality assurance and outcomes measures than
for field work. In the MTOS-based validation study, T-RTS of
<11 had a sensitivity of 0.6 and a specificity of 0.8 for ISS of
>15. As with TS, the specificity of T-RTS improves at lower
thresholds, but only at the expense of sensitivity (Table 4).
After reviewing the studies and the practicality of RTS as a
triage criterion, the Panel determined that RTS is not useful
and deleted it from the 2006 Decision Scheme. The Panel
noted that the complexity of the formula used to calculate
RTS makes doing so in the field unwieldy, difficult, and timeconsuming. The Panel acknowledged that, in the normal course
of practice, EMS providers rarely calculate and use RTS as a
decision-making tool; rather, RTS is more useful for quality
improvement and outcome measures than for emergency
triage decisions. Finally, because each of the components of
RTS and T-RTS (GCS, SBP, and respiratory rate) is already
included in Step One, including RTS in the Decision Scheme
is redundant.
Transition from Step One to Step Two
Patients meeting the physiologic criteria of Step One have
potentially serious injuries and should be transported to the
highest level trauma center (i.e., Level I, if available). Two
retrospective reviews of New York State trauma registry data
for 1996–1998 indicated that adult trauma patients meeting
15
physiologic criteria who were transported to and treated at a
regional Level I trauma center had reduced odds of mortality
compared with those transported to and treated at a Level II
trauma-center or nontrauma-center hospital. The greatest odds
reduction was reported in patients with GCS of <14 (OR: 0.7;
CI = 0.6–0.9) or respiratory rate of <10 or >29 breaths per
minute (OR: 0.6; CI = 0.4–0.8) who were treated in a Level I
trauma center compared with those treated at Level II traumacenter or nontrauma-center hospitals (60,73). For patients
who do not meet Step One criteria, the EMS provider should
proceed to Step Two of the Decision Scheme.
Step Two: Anatomic Criteria
Step Two of the Decision Scheme recognizes that certain
patients, on initial presentation to EMS providers, might have
a severe injury and need care at a high-level trauma center but
have physiologic parameters that do not meet the criteria of
Step One. In these cases, reliance on physiologic criteria alone
might lead to undertriage. As noted previously, an evaluation
of data in the South Carolina EMS registry that was conducted
to determine undertriage and overtriage rates when EMS
personnel used the 1990 version of the ACS triage guidelines
indicated that physiologic criteria alone had a sensitivity of
0.7 and PPV of 42% for severe injury (ISS of >15) (69) for
753 trauma patients transported to the Level I trauma center
in Charleston, South Carolina. Anatomic criteria alone had
a sensitivity of 0.5 and PPV of 21.6%. Combining anatomic
and physiologic criteria to identify severely injured trauma
patients produced a sensitivity of 0.8 and PPV of 26.9%. A
prospective study of 5,728 patients treated by EMS providers
in Washington state included patients who were injured and
met at least one of the ACS triage criteria; patients were tracked
from EMS contact through hospital discharge (86). Triage
criteria were examined individually and in combination for
their ability to identify a major trauma victim (MTV) with ISS
of >15 or mortality. Anatomic criteria had a 20%–30% yield
for identifying major trauma victims and were associated with
a hospital admission rate of 86% and a mortality rate slightly
below the entire study population.
The Panel recommended transport to a trauma center if any
of the following are identified:
• all penetrating injuries to head, neck, torso, and extremities
proximal to elbow and knee;
• flail chest;
• two or more proximal long-bone fractures;
• crushed, degloved, or mangled extremity;
• amputation proximal to wrist and ankle;
• pelvic fractures;
• open or depressed skull fracture; or
• paralysis.
16
MMWR
All Penetrating Injuries to Head, Neck,
Torso, and Extremities Proximal to Elbow
and Knee: Criterion Retained
Of all penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee, the most compelling as a triage criterion is penetrating torso injuries because these might
require an emergency thoracotomy, a procedure not available
at all hospitals. For this reason, the Panel focused much of its
discussion on penetrating torso injuries. Noteworthy survival
rates have been documented in clinically dead (pulseless/
apneic) or critically ill and dying patients with penetrating
torso trauma who were transported to facilities with immediate surgical capabilities. One retrospective study analyzed 389
emergency thoracotomies performed during 1984–1989 in a
Houston-area trauma center on patients who arrived with thoracic or abdominal trauma with cardiopulmonary resuscitation
in progress and who had profound exsanguinating hemorrhage
and hypotension unresponsive to rapid crystalloid infusion or
who had suffered sudden hemodynamic deterioration in the
ED. The study identified an overall survival to hospital discharge rate of 8.3%; the rate was 15.2% for stab wounds and
7.3% for gunshot wounds (87). A retrospective analysis of 846
critically ill trauma patients (324 patients with no vital signs
on arrival at the ED and 522 with cardiopulmonary arrest in
the ED) with emergency thoracotomies at a single tertiary care
academic hospital in Johannesburg, South Africa, reported an
overall survival rate of 5.1% (8.3% for stab wounds and 4.4%
for gunshot wounds) (88). In 2000, a 25-year review of 24
studies reporting data from 17 locations reported a survival
rate of 8.8% after emergency thoracotomy for penetrating
injury (16.8% for stab wounds, 4.3% for gunshot wounds,
10.7% for penetrating chest wounds, and 4.5% for penetrating
abdominal wounds) (89).
On the basis of this evidence, the Panel decided to retain
penetrating torso injuries as a triage criterion. In addition to
torso injuries, the Panel determined that penetrating injuries
to the head, neck, or proximal extremities also represent a high
risk to the patient and concluded that this criterion should
be retained in the revised 2006 Decision Scheme. The Panel
concluded that the potential is high for severe injury and
adverse outcomes, including mortality, from such penetrating
injuries, which most often are caused by firearms and knives.
Surface examination of the wound in the field frequently does
not allow adequate analysis of the extent of underlying injury.
Penetrating injuries to the head, neck, torso, and proximal
extremities place vital systems (including the cardiopulmonary, vascular, and neurologic systems) at risk and often are
associated with severe injury. Vascular damage in these anatomic regions might result in life-threatening exsanguinating
January 23, 2009
hemorrhage, and nerve damage might result in permanent
disability. Damage to bones and complicated infections often
are associated with penetrating trauma. Rapid intervention
might be needed to prevent morbidity and mortality due to
these injuries. Because the management of these injuries might
require skills and resources not available at every hospital, triage
of patients who meet these criteria to the highest level trauma
center improves the likelihood of prompt access to trauma
surgeons, cardiothoracic surgeons, neurosurgeons, vascular
surgeons, and orthopedic surgeons and to properly equipped
ICUs and operating theaters. In addition, these injuries might
require early and careful coordination between acute care and
rehabilitation medicine, a process that might be available more
readily at higher level trauma centers.
Flail Chest, Two or More Proximal LongBone Fractures, Paralysis, Pelvic Fractures,
and Amputation Proximal to the Wrist and
Ankle: Criterion Retained
Limited evidence specifically addresses the field triage of
patients with flail chest, two or more proximal long-bone
fractures, paralysis, pelvic fractures, and amputation proximal
to the wrist and ankle. A study of 1,473 trauma patients transported by EMS providers indicated that both spinal injury and
amputation had PPV of 100% for ISS of >15, and proximal
long-bone fractures had PPV of 19.5% (84). Another study,
which evaluated the 1986 version of the Decision Scheme,
indicated that two or more long-bone fractures were associated
with increased odds for ISS of >15 (adjusted odds ratio [AOR]:
17.3; CI = 4.2–71.7) (72). A 2002–2003 review of New York
State Trauma Registry data identified the following case-fatality
rates: flail chest (7.5%), long-bone fracture (8.8%), pelvic fracture (11.5%), paralysis (7.1%), and amputation (10.1%) (60).
In reviewing this criterion, the Panel took into consideration
these high case-fatality rates, which place at risk vital systems,
including the cardiopulmonary, musculoskeletal, vascular, and
neurologic systems, and have the potential to require specialized
surgical and intensive care. Rapid intervention might be needed
to prevent morbidity and mortality. Because the management
of these injuries might require skills and resources not available at every hospital, triage of patients meeting these criteria
to the highest level trauma center improves the likelihood of
prompt access to trauma surgeons, cardiothoracic surgeons,
neurosurgeons, vascular surgeons, and orthopedic surgeons and
to properly equipped ICUs and operating theaters. In addition,
these injuries might require early and careful coordination
between acute care and rehabilitation medicine, a process that
might be more readily available at higher level trauma centers.
After considering all these factors, the Panel elected to retain
this criterion in the 2006 Decision Scheme.
Vol. 58 / RR-1
Recommendations and Reports
Crushed, Degloved, or Mangled Extremity:
Criterion Added
Although Step Two of the 1999 Decision Scheme addressed
extremity injuries, the Panel was concerned that the Scheme
did not explicitly identify the crushed, degloved, or mangled
extremity, a severe injury that results in extensive tissue damage. No evidence was identified in the literature on which to
base a triage recommendation for such injuries. However, on
the basis of expert opinion, the Panel reached a consensus that
the sensitivity for triage of these injuries to trauma centers
should be as raised. Therefore, the Panel elected to add to the
Decision Scheme the criterion “crushed, degloved, or mangled
extremity” (these terms are consistent with educational material
targeted at EMS providers).
In reaching its conclusion, the Panel took several factors into
account. Injuries that crush, deglove, or mangle extremities are
complex and might threaten loss of the limb or of the patient’s
life. Such injuries potentially involve damage to vascular, nerve,
bone, or soft tissue, singly or, more often, in combination.
Neurovascular injury is assumed in all injured extremities until
definitively excluded (90). Treatment of vascular injury within
6 hours is the major determinant of limb salvage (90). Further,
the risk for ischemia, wound infection, delayed union or
nonunion of fractures, and chronic pain associated with these
injuries is high. Therefore, these injuries frequently require a
rapid and coordinated multidisciplinary approach that might
include emergency medicine, trauma surgery, radiology, vascular surgery, orthopedic surgery, treatment of infectious disease,
and availability of operating theaters and management in an
ICU. The Panel determined that transporting patients with
such injuries to a facility that offers the highest level of care
available within the trauma system provides the best chance
for appropriate and rapid assessment and treatment.
Open or Depressed Skull Fracture:
Criterion Modified
Because no published literature addresses the triage of
patients with skull fractures in general or the triage of patients
with open or depressed skull fractures specifically, the Panel
relied on its expert opinion regarding this criterion. During its
discussions, the Panel noted that either an open or a depressed
skull fracture might signify severe injuries requiring high operating theater or ICU use. Therefore, the Panel modified the
wording of this criterion from “open and depressed” to “open
or depressed,” recognizing that these types of skull fractures
can occur separately but that each can represent a severe head
injury. The Panel decided to retain this modified criterion
and in doing so confirmed that patients with either open or
depressed skull fractures should be transported to the highest
level of trauma center available. In its deliberations, the Panel
17
noted that skull fractures, whether open or depressed, result
from considerable force to the skull and the seriousness of the
injury should not be underestimated. Initial field evaluation of
the patient might not reveal the extent of underlying neurologic
injury, any suspected or confirmed skull fracture might be
life-threatening, and all such injuries should receive immediate intervention. Neuroimaging of confirmed or suspected
skull fracture always is required, and not all hospitals have this
capability and the ability to offer immediate specialized neurosurgical care. In addition, prompt diagnosis and treatment of
open or depressed skull fractures commonly requires a rapid
multidisciplinary approach involving emergency medicine,
trauma surgery, radiology, and neurosurgery, specialized services typically only available at higher level trauma centers.
Major Burns: Criterion Moved From Step
Two to Step Four
Burn injury was moved from Step Two to Step Four in the
Decision Scheme to emphasize the need to determine whether
the burn occurred with other injuries. Patients sustaining isolated burns in which the burn injury poses the greatest risk for
morbidity and mortality are cared for optimally at a specialized
burn center. Patients sustaining burns associated with other
trauma, in which that other trauma poses the greater risk to
the patient, need evaluation at a trauma center. The Panel
recognized that providing care for patients with both burn
and nonburn injuries depends on available local resources,
individual physician clinical judgment, and local and regional
transfer protocols. Triage for burn injury is discussed further
in Step Four.
Transition from Step Two to Step Three
Patients meeting criteria in Step Two of the Scheme should
be transported to the highest level trauma center available in
the system, typically Level I or II. For patients who do not
meet Step Two criteria, the EMS provider should proceed to
Step Three of the Decision Scheme.
Step Three: Mechanism-of-Injury
Criteria
A patient who does not meet Step One or Step Two criteria
might still have severe, but occult, injury. In field triage, the
mechanism of injury should be evaluated next to determine
whether the injured person should be transported to a trauma
center.
The criteria for mechanism of injury have been widely studied. A study of patients treated consecutively by the trauma
service at a community hospital indicated that 206 (41.2%) of
500 patients suffered substantial injury (defined as ISS of >15,
18
MMWR
ED TS of <14, length of hospital stay of >3 days, or death) (82).
The sensitivity of various mechanisms of injury for predicting
substantial injury ranged from 0.04 to 0.24, with specificity
ranging from 0.72 to 0.96 (Table 4). A study of 1,839 trauma
registry patients that evaluated the association between mechanism of injury and ISS indicated that the mechanism-of-injury
criteria resulted in patients with ISS of >15 being routed to a
trauma center and patients with ISS of <15 being routed to
the nearest appropriate hospital 39%–84% of the time (83).
In this study, overtriage of patients with ISS of <15 to a trauma
center ranged from 16% to 61% (Table 5). A review of South
Carolina EMS registry data reported that 66 (16.1%) of 411
patients meeting mechanism-of-injury criteria had ISS of >15
and that 262 (63.7%) had mechanism of injury as the sole
indication (i.e., with no physiologic or anatomic criteria) of
serious injury (69). Mechanism-of-injury criteria alone had a
sensitivity of 0.5 and a PPV of 16.1% for identifying severe
injury. A prospective study of 3,147 trauma patients reported
that mechanism-of-injury criteria alone had a sensitivity of 0.7
for identifying patients with ISS of >16 (91). Although substantial similarities existed between the mechanism-of-injury
criteria used in these studies (Table 6), they were not uniform,
which limits the extent to which conclusions can be drawn.
However, the results of these studies considered together suggest that mechanism of injury is not an adequate sole criterion
for triage but instead must be combined with other criteria
(i.e., physiologic and anatomic).
A retrospective analysis of patient data from 621 MVCs
included in the Royal Melbourne Hospital trauma database
in Victoria, Australia, that was conducted to determine if
mechanism of injury alone accurately identified major injury
among crash victims indicated that 52 (20.5%) of 253 patients
with major injury after an MVC did not have a mechanism of
injury suggestive of major injury (92). A retrospective review of
830 trauma admissions to one Level I trauma center reported
that, of 414 patients who were triaged to the highest level of
care only on the basis of mechanism-of-injury criteria, 8%
had an ISS of >15, indicating an overtriage rate of 92% (93).
Conversely, only 33 (35%) of 95 patients with ISS of >15
met mechanism-of-injury criteria, indicating an undertriage
rate of 65%. However, combining physiologic and anatomic
criteria with mechanism-of-injury criteria identified at least
77 (81%) of 95 patients with ISS of >15. In addition, in a
1997 study of 3,147 patients transported from the City of
Calgary EMS in Alberta, Canada, the mechanism-of-injury
criteria alone would have missed 22 (26.5%) of 83 severely
injured patients; combining mechanism of injury and physiologic criteria improved sensitivity for ISS of >15 to 0.8, and
produced a specificity of 0.9 (91).
January 23, 2009
TABLE 5. Appropriate triage* and overtriage† rates of mechanismof-injury criteria
Criterion
Appropriate triage
(%)
Overtriage
(%)
Intrusion
56
44
Extrication >20 min
73
27
Ejected from vehicle
65
35
Fall >15 ft
59
41
Death of occupant
84
16
Child (age <12 yrs) struck by car
39
61
Pedestrian struck by car
64
36
SOURCE: Long WB, Bachulis BL, Hynes GD. Accuracy and relationship of
mechanism of injury, trauma score, and injury severity score in identifying
major trauma. Am J Surg 1986;151:581–4.
*Injured patients are appropriately transported to the facility best equipped
to manage their injuries.
†Occurs when a patient who does not require care in a higher-level trauma
center nevertheless is transported to such a center.
The Panel recommended transport to a trauma center if any
of the following are identified:
• falls
—adults: fall >20 feet (one story = 10 feet)
—children aged <15 years: fall >10 feet or two to three
times child’s height;
• high-risk auto crash
—intrusion: >12 inches to the occupant site or >18 inches
to any site
—ejection (partial or complete) from automobile
—death in same passenger compartment
—vehicle telemetry data consistent with high risk of
injury;
• auto versus pedestrian/bicyclist thrown, run over, or with
significant (>20 mph) impact; or
• motorcycle crash >20 mph.
Falls — Adults Who Fall >20 Feet:
Criterion Retained
The extent of injury from a fall depends on characteristics
of the person, the distance fallen, the landing surface, and
the position at impact (94). A 5-month prospective study of
trauma team activations at a Level I trauma center indicated
that 9.4% of victims who fell >20 feet (>6.1 meters) suffered
injuries serious enough to require ICU admission or immediate
operating room intervention (74). A retrospective review of
660 fatalities following a fall indicated that head injuries, the
most common cause of fall-related death, were associated most
frequently with falls of <7 meters (<22.9 feet) or >30 meters
(>98.4 feet); this bimodal result reportedly was attributable
to head orientation at impact for heights of <7 meters and
>30 meters (94). A prospective study of patients treated in
trauma centers in Fresno County, California, indicated that
a fall from a height of >15 feet had PPV of 14.3% for ISS of
>15 (84). A retrospective study of 1,643 consecutive patients
Vol. 58 / RR-1
Recommendations and Reports
19
TABLE 6. Comparison of mechanism-of-injury criteria
Criteria A*
Criteria B†
Criteria C§
Ejection from automobile
Ejection from vehicle
Ejection
Death in same passenger compartment
Death in the same vehicle
Occupant death
Extrication time >20 min
Extrication time >20 min
Extrication time >20 min
Fall >20 ft
Fall >15 ft
Fall >15 ft
Rollover
High-speed crash
• Speed >40mph
• Velocity change >20mph
• Major auto deformity >20 in.
• Passenger compartment intrusion >12 in.
Intrusion into patient space
Steering wheel deformity or structural intrusion >20 in.
Auto-pedestrian injury with impact >5mph
Child aged <12 yrs struck by car
Auto vs. pedestrian
Pedestrian thrown or run over
Pedestrian struck and thrown
Motorcycle crash >20 mph or with separation of rider
*SOURCE: Norcross ED, Ford DW, Cooper ME, Zone-Smith L, Byrne TK, Yarbrough DR. Application of American College of Surgeons’ field triage guidelines
by pre-hospital personnel. J Am Coll Surg 1995;181:539–44.
†SOURCE: Long WB, Bachulis BL, Hynes GD. Accuracy and relationship of mechanism of injury, trauma score, and injury severity score in identifying major
trauma. Am J Surg 1986;151:581–4.
§SOURCE: Bond RJ, Kortbeek JB, Preshaw RM. Field trauma triage: combining mechanism of injury with the prehospital index for an improved trauma
triage tool. J Trauma 1997; 43:283-7.
in Turkey who fell from roofs identified an overall mortality
rate of 5.8%; the mean fall height for adults who died from
their injuries was 9 meters (29.5 feet) (95).
In reaching its conclusion, the Panel noted that the fall height
criterion for adults of >20 feet has been a component of the
Decision Scheme since 1986 and is familiar to prehospital
providers and their medical directors. In addition, the Panel
took note of the established relationship between increase
in fall height and increased risk for head injury, death, ICU
admission, and the need for operating room care. The Panel
concluded that in the absence of new evidence that establishes
a definitive height for this criterion or that supports changing
or eliminating the criterion for falls of >20 feet for adults (with
10 feet equivalent to one story of a building), this criterion
should be retained, and adult patients who fall >20 feet should
be transported to the closest appropriate trauma center for
evaluation.
Falls — Children Who Fall >10 Feet or Two
to Three Times the Height of the Child:
Criterion Added
A new criterion for children aged <15 years who fall >10
feet or two to three times their height was added to the 2006
Decision Scheme. Evidence examining the field triage of
children who have sustained injuries from falls is limited,
but the existing literature indicates that children are more
likely than adults to sustain injuries from falls of comparable
heights (75,95,96,97). A retrospective study of falls from
rooftops indicated that, among fall fatalities in children, the
average fall height was 4.0 meters (13.1 feet), whereas among
such fatalities in adults, the average fall height was 9.0 meters
(29.5 feet) (95). A study of 1,285 injured children reported
that a fall from a height of >20 feet had a PPV of 33% for
major injury in children aged <15 years (75). A retrospective
study of 61 children aged <16 years who were admitted to the
Pediatric Surgical Services at Harlem (New York) Hospital
after a fall during a 10-year period indicated that 39 (64%)
children had multiple major injuries, and 16 (26%) had a
single major injury (98). The mortality rate was 23%; all the
fatalities occurred in children who fell more than three floors
(approximately 30 feet).
Although affected by individual circumstances, the threshold
for traumatic brain injury appears to be reached for falls from
a height of approximately six to 10 feet. However, occasional
deaths have been reported resulting from unintentional falls
from lesser heights. One reported series of 42 pediatric patients
who had neurologic signs after seemingly minor or trivial head
injuries constituted 4.3% of all pediatric patients evaluated
by a hospital neurologic staff for head injury (99). One of the
42 patients had an intracranial hematoma, and three children
died from uncontrollable cerebral edema. One of these three
children had jumped from a slow-moving cart, one fell from
a bicycle, and one fell from a skateboard. All three fatal falls
were from heights of <10 feet, and all three patients were alert
initially. All three falls were associated with additional forces
other than gravity alone, leading to the inference that falls from
a height of <10 feet are likely to result in death or significant
disability only if additional forces are involved or if the history is likely to be inaccurate, as in cases of injury inflicted by
child abuse. However, the majority of the 42 children in the
series recovered fully.
Reported fall heights for children might be inaccurate or
misleading. A retrospective study that examined data on 317
children who were admitted to the trauma center of a children’s
hospital in San Diego, California, with a history of falling indicated that seven (7%) of 100 children who were reported to
20
MMWR
have fallen only 1–4 feet died; however, three of these children
also had physical findings suggestive of abuse (96). A study of
398 consecutive fall victims who were admitted to a children’s
hospital in Oakland, California, indicated that of 106 children
whose falls were witnessed by an uninvolved person who
could verify the mechanism of injury, none who fell <10 feet
suffered life-threatening injury (97). By comparison, among
53 children for whom the mechanism of injury could not be
verified, 18 (34%) children reported to have fallen <5 feet had
severe injuries, and two (4%) died. These data illustrate that if
evidence at the scene other than fall height suggests potential
serious injury (e.g., suspicious parental behavior, with a child
reported to have fallen from a bed), EMS providers should
consider transporting the patient to a trauma center.
Because of suggestions in the scientific literature that children
might sustain greater injuries after falls from lower heights
than adults, the difficulty in estimating heights of falls, and
the potential for mechanisms of injury that are not apparent at
the scene, the Panel elected to set the fall criterion at >10 feet
or two to three times the height of the child, to increase the
sensitivity for identifying children with severe injuries.
High-Risk Auto Crash — Intrusion of >12
Inches at Occupant Site or >18 Inches at Any
Site: Criterion Modified
In the 1999 Decision Scheme, two criteria were related to
vehicle deformity or crush: “major auto deformity >20 inches”
and “intrusion into passenger compartment >12 inches.” In
the revised 2006 Decision Scheme, the criteria for vehicle
crash with cabin intrusion has been simplified slightly to an
intrusion of >12 inches for occupant site (i.e., the passenger
cabin or any site within the vehicle in which any occupant was
present at the time of the crash) or >18 inches for any site in
the vehicle. Intrusion refers to interior compartment intrusion,
as opposed to exterior deformation of the vehicle. The 2006
Decision Scheme also has been changed with regard to the
action indicated if intrusion criteria are met. Under the 1999
Scheme, both criteria prompted EMS personnel to “contact
medical direction and consider transport to a trauma center”
and to “consider trauma team alert.” Under the 2006 Decision
Scheme, if this criterion is met, the affected patients should be
transported to the closest appropriate trauma center, which,
depending on the trauma system, need not be the highest level
trauma center.
Three studies were available for consideration by the Panel.
A 2003 retrospective study of 621 MVC victims that did not
account for physiologic or anatomic criteria reported that cabin
intrusion of >30 cm (>11.8 inches) was associated in univariate
analysis (p = <0.0001) with major injury, defined as one of the
January 23, 2009
following: ISS of >15; ICU admission for >24 hours requiring
mechanical ventilation; urgent cranial, thoracic, abdominal,
pelvic-fixation, or spinal-fixation surgery; or death. However,
this association was not statistically significant in multivariate
analysis (OR: 1.5; CI = 1.0–2.3; p = 0.05) (92). Similarly, a
univariate analysis of New York state data that examined the
incremental benefit of the individual ACS triage criteria identified increased odds of severe injury (ISS of >15) for 30 inches
of vehicle deformity (OR: 4.0; CI = 2.1–7.8), 24 inches of
intrusion on the side of the vehicle opposite the victim (OR:
5.2; CI = 2.6–10.4), and 18 inches of intrusion on the same
side of the vehicle as the victim (OR: 7.1; CI = 3.8–13.0) (60).
However, none of these findings was statistically significant
in multivariate analysis. Data from the National Automotive
Sampling System Crashworthiness Data System (NASS CDS),
which includes statistical sampling of all crashes occurring in
the United States, indicated that a substantial crush depth (30
inches in frontal collisions and 20–24 inches in side-impact
collisions) was needed to attain a PPV of 20% for ISS of >15
injury to occupants (100). The Panel concluded that none of
these three studies supported the hypothesis that vehicle crush
depth or deformity is a useful indicator for severe injury.
The Panel also recognized that recent changes in vehicle
design and construction probably have reduced the effect of
crush on the risk for severe injury in crashes. Whereas older
vehicles were more likely to transmit the kinetic energy of
crashes to vehicle occupants and cause severe injuries, newer
vehicles are designed to crush externally and absorb energy,
protecting passenger compartment integrity and occupants.
Additionally, the Panel took note of the difficulty of using
deformity or crush criteria in the field. Crash sites are difficult
environments in which to estimate such measures, and little
might be left of a vehicle to serve as a reference point for determining crush depth. For example, in one study, only 1% of 94
cases with 30 inches or more of deformity were documented
by EMS personnel (60).
Despite this evidence, the Panel determined that removing all criteria for vehicle deformity or crush from the 2006
Decision Scheme would not be appropriate for four reasons.
First, although available research did not support the use of
such criteria to predict severe injuries, the existing studies were
few and limited, and additional research would be needed to
determine definitively that vehicle deformity or crush was
not predictive of severe injuries. Second, extensive anecdotal
experience in trauma practice indicates that increasing cabin
intrusion is indicative of an increasing amount of force on the
vehicle and potentially on the occupant. Third, side-impact
intrusions could present special clinical concerns that had
not been recognized fully in existing research, considering
the limited space between the impact and occupant. Finally,
Vol. 58 / RR-1
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although modern vehicles have better energy-absorbing capability, vehicle incompatibility (crash involving both a large
and a small vehicle) might be increasingly important in the
level of vehicle intrusion in crashes, a factor perhaps not fully
captured by available research, which could potentially increase
the predictive value of the magnitude of vehicle deformity or
crush.
High-Risk Auto Crash — Ejection (Partial
or Complete) from Automobile: Criterion
Retained
Ejection from a motor vehicle as a result of a crash is associated with increased severity of injury. A multivariate analysis
of data collected during 1996–2000 at the Royal Melbourne
Hospital in Victoria, Australia, examined 621 crashes and
found that ejection from the vehicle was associated with major
injury (defined as ISS of >15, ICU admission for >24 hours
requiring mechanical ventilation, urgent surgery, or death)
(OR: 2.5; CI = 1.1–6.0), compared with crashes without ejection (92). A retrospective evaluation of NASS data collected
during 1993–2001 was conducted to determine the crash
characteristics associated with substantial chest and abdominal
injuries; this evaluation indicated that the predictive model that
produced the best balance between sensitivity and specificity
included ejection as a variable (101).
In its discussions of the ejection criteria, the Panel noted that
a person who has been ejected from a vehicle as a result of a
crash has been exposed to a substantial transfer of energy with
the potential to result in severe life- or limb-threatening injuries. Lacking the protective effects of vehicle-restraint systems,
occupants who have been ejected might have struck the interior
multiple times before ejection (102). Further, ejection of the
patient from the vehicle increases the chance of death by 25
times, and one of three ejected victims sustains a cervical spine
fracture (102). The Panel concluded that the literature review
identified no studies that argued persuasively for removal of
this criterion. Therefore, on the basis of the available, albeit
limited, evidence, combined with the Panel’s experience, ejection from the vehicle was retained as a criterion.
Because the literature reviewed indicated that partial or complete ejection is associated with severe injury, ICU admission,
urgent surgery, or death, the Panel further concluded that even
if these patients do not meet physiologic or anatomic criteria,
they still warrant a trauma-center evaluation on the basis of
mechanism only. Additionally, ejections of vehicle occupants
are not frequent, and transporting all such patients for evaluation would not be expected to overburden the system. These
patients should be transported to the closest appropriate trauma
center, which, depending on the trauma system, need not be
the highest level trauma center.
21
High-Risk Auto Crash — Death in Same
Passenger Compartment: Criterion Retained
The death of an occupant in a vehicle is indicative of a substantial force applied to a vehicle and all its occupants. A prospective study of MVC victims in Suffolk County, New York,
indicated that the death of an occupant in the same vehicle
was associated with increased odds for major surgery or death
(AOR: 39.0; CI = 2.7–569.6) and ISS of >15 (AOR: 19.8;
CI = 1.1–366.3) (72). A prospective study of 1,473 patients,
which did not account for the impact of physiologic or anatomic criteria, indicated that three (21.4%) of 14 occupants
in a vehicle with a fatality had ISS of >15, resulting in PPV of
21.4% for severe injury by this mechanism (84). A review of
data concerning 621 crash victims indicated that occupants
of vehicles in which a fatality occurred comprised 11% of the
patients evaluated and 7% of the patients with major injury,
but fatality of an occupant was not statistically associated with
major injury (92). In its discussions, the Panel noted that two of
these three studies demonstrated PPV of >20% for ISS of >15
and increased odds for major surgery or death of occupants in a
vehicle in which a fatality occurs. Although the remaining study
did not show a statistical association with major injury, the Panel
determined that this single study was not compelling enough
to support deleting this criterion from the Decision Scheme. In
addition, Panel members affirmed that, in their clinical experience, death of an occupant in a vehicle often was associated with
a risk for severe injury to any surviving occupant.
After reviewing the evidence, the Panel concluded that death
in the same passenger compartment should be retained as a criterion for the 2006 Decision Scheme. Surviving passengers should
be transported to the closest appropriate trauma center.
High-Risk Auto Crash — Vehicle Telemetry
Data Consistent with High Risk of Injury:
Criterion Added
In earlier versions of the Decision Scheme, high vehicle
speed, vehicle deformity of >20 inches, and intrusion of >12
inches for unbelted occupants were included as mechanism-ofinjury criteria. NASS data indicate that risk for injury, impact
direction, and increasing crash severity are linked (100). An
analysis of 621 Australian MVCs indicated that high-speed
impacts (>60 km/hr [>35 mph]) were associated with major
injury, defined as ISS of >15, ICU admission for >24 hours
requiring mechanical ventilation, urgent surgery, or death (OR:
1.5; CI = 1.1–2.2) (92). Previously, the usefulness of vehicle
speed as a criterion had been limited because of the difficulty
in estimating impact speed accurately. However, new Advanced
Automatic Collision Notification (AACN) technology installed
in certain automobiles, now in approximately five million
vehicles in the United States and Canada (55), can identify
22
MMWR
January 23, 2009
vehicle location, measure change in velocity (delta V) during
a crash, and detect crash principal direction of force, airbag
deployment, rollover, and the occurrence of multiple collisions
(55,103). Recognizing that AACN systems will become more
available, the Panel added vehicle telemetry data consistent
with a high risk for injury (e.g., change in velocity and principal direction of force) as a triage criterion. The Panel did
not designate which specific components of telemetry should
be used as triage criteria, as additional evaluation of available
data is needed to define the exact components (e.g., speed
and delta V) consistent with a high risk for injury. CDC is
working with the automotive industry and experts in public
health, public safety, and health care to examine how AACN
data can be used to predict injury severity, conveyed to EMS
services and trauma centers, and integrated into the field triage process.
vehicle (77). At the other end of the lifespan, motor-vehicle
injuries to pedestrians are among the most lethal mechanisms
of injury for older adults (defined as persons aged >60 years).
A 1995 retrospective review indicated that of 243 older
trauma patients, 41 (17%) were struck by a vehicle; injuries
were fatal to 22 (54%) of those struck (104). On the basis
of their clinical experience, members of the Panel reported a
high incidence of ICU admission and operating room management for pedestrians struck by a vehicle and for bicyclists
thrown, run over, or struck with substantial impact. On the
basis of the Panel’s experience and the evidence reviewed, the
criterion was retained in the 2006 Decision Scheme to ensure
that pedestrians or cyclists who are victims of such vehicular
injuries are transported to a trauma center.
Auto Versus Pedestrian/Bicycle Thrown, Run
Over, or with Significant (>20 mph) Impact:
Criterion Retained
Motorcycle crashes can subject a rider’s body directly to
substantial force and energy. In a crash, the motorcycle itself
does not provide the rider with any external protection (as
does the frame of an automobile or a truck); any protection
comes from whatever gear the rider might wear (e.g., helmet,
leather, and boots) (102). However, wearing helmets is not
required uniformly in the United States, and motorcyclists
do not always wear them even when legally required to do so.
Motorcycles also lack the protective restraint systems provided
in automobiles and trucks. Thus, a motorcycle crash, by its very
nature, places the rider at an increased risk for injury compared
with occupants of automobiles or trucks in a similar or the
same crash event.
A prospective cohort study of trauma team activations
indicated that 4.6% of motorcycle riders who crashed at >20
mph and who did not meet physiologic or anatomic criteria
required admission to an ICU or operating room (74). The
Panel’s clinical experience indicated that such injuries (which
can be to the head, torso, and extremities) might be severe,
requiring the assessment and treatment resources afforded by
trauma centers. Although the evidence on the field triage of
motorcycle-crash patients was limited, the Panel also noted
that data were insufficient to justify the removal of motorcycle
crash as a triage criterion. Recognizing the need for further
research evaluating this criterion, the Panel elected to retain
motorcycle crash at >20 mph as a criterion for transport to a
trauma center.
Pedestrians and cyclists who are run over or struck by a
vehicle are at risk for major injuries. A prospective cohort study
of 1,005 trauma patients at San Francisco General Hospital
indicated that 10 (3.9%) of 254 pedestrians who were struck by
a vehicle and who did not meet physiologic or anatomic criteria
required admission to an ICU or operating room (74). A study
of trauma patients who were admitted to a community hospital
in Santa Clara County, California, indicated that a pedestrian
struck by an automobile moving at a speed of >5 mph had a
sensitivity of 0.2 and a specificity of 0.8 for substantial injury
(defined as death, hospitalization for >3 days, ED trauma
score of <14, or ISS of >15) (82). A prospective study of 1,473
patients that did not account for the impact of physiologic or
anatomic criteria indicated that 10 (18%) of 56 pedestrians
struck by an automobile had ISS of >15, resulting in PPV of
17.9% for severe injury by this mechanism (84). The consensus
of the Panel was that, in the absence of more evidence, the
benefits of trauma-center evaluation and care for pedestrians
struck by motor vehicles who do not have injuries identified by
physiologic or anatomic criteria outweigh concerns regarding
overtriage. A person who has been struck, thrown, or run over
by a vehicle might have been exposed to a substantial transfer
of energy and sudden forces that have the potential to result in
life- or limb-threatening severe injuries to the head, neck, torso,
and extremities, some of which might not be readily apparent
in the field. Typically, multiple impacts to the extremities, torso,
and head are sustained. Children are particularly susceptible
to severe injury, as the front end of a vehicle is likely to strike
them in the head and torso and, because they weigh less than
adults, children are more likely to be moved or dragged by a
Motorcycle Crash >20 mph:
Criterion Retained
Rollover Crash: Criterion Deleted
Panel members concluded that a rollover crash is not associated per se with increasing injury severity. The increased
injury severity associated with rollover crashes results from an
occupant of a motor vehicle being ejected either partially or
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23
completely from the vehicle, which occurs most frequently
when restraints are not used. Because partial or complete ejection is already a criterion for transport to a trauma center as
a mechanism of injury associated with a high-risk MVC, the
Panel chose to delete rollover crash from the 2006 Decision
Scheme.
Published data indicate that rollover crash is associated with
a PPV for severe injury of <10% (100). A multivariate analysis
of 621 crashes indicated that rollover crash was not associated
with ISS of >15 (92). Further, an analysis of contemporary
NASS CDS research confirmed that rollover crash (in the
absence of ejection) was not associated with increasing injury
severity (AIS of >3); however, rollovers with ejection were associated with increasing injury severity (105). Review of NASS
CDS data also indicated that a >20% risk of ISS of >15 was
not associated with the number of quarter turns in a rollover
crash, the landing position of the vehicle, or maximum vertical
or roof intrusion (100).
and Two. Which center is the most appropriate at any given
time will depend on multiple factors, including the level of
trauma center readily available, the configuration of the local
or regional trauma system, local EMS protocols, EMS system
capacity and capability, transport distances and times, and
hospital capability and capacity. Patients whose injuries meet
mechanism-of-injury criteria but not physiologic or anatomic
criteria do not necessarily require the highest level of care
available. At the time of evaluation, these patients are hemodynamically stable, have a GCS of >14, and have no anatomic
evidence of severe injury. Their risk lies only in the mechanism
by which they were injured. Thus, they require evaluation but
do not need immediate transport by EMS providers to a Level
I or Level II facility. If a severe injury is identified at the initial
hospital evaluation, these patients may be transferred subsequently to a higher level of trauma care. For patients who do
not meet Step Three criteria, the EMS provider should proceed
to Step Four of the Scheme.
Extrication Time >20 Minutes:
Criterion Deleted
Step Four: Special Considerations
The Panel discussed the value of retaining extrication time
of >20 minutes as a criterion in the 2006 Decision Scheme.
In its discussion, the Panel recognized potential problems with
field use of this criterion. EMS personnel can experience difficulty in determining exact times while managing the scene of
a crash and assessing and treating vehicle occupants. Adverse
weather conditions and darkness can complicate matters further. Additionally, because the majority of EMT personnel are
trained only to do light extrication and must call someone else
for heavy rescue, when EMS personnel should start the clock
for the 20-minute timeframe has remained unclear.
In any vehicular crash, the need for extrication is caused most
often by intrusion into the passenger compartment. The Panel
recognized that, although lengthy extrication time might be
indicative of increasing injury severity, new crush technology
in automobiles is causing an increase in the number of nonseriously injured patients who require >20 minutes for extrication.
Intrusion already is contained in the 2006 Decision Scheme as
a criterion for transport to a trauma center associated with a
high-risk MVC. The Panel determined that the modifications
made to the triage protocol for cabin intrusion adequately
addressed issues relevant to extrication time and elected to
delete extrication time as a criterion.
Transition from Step Three to Step Four
The answer of “yes” at Step Three of the Decision Scheme
mandates transport of the patient to the closest appropriate
trauma center, not necessarily to a center offering the highest level of trauma care available, as is the case in Steps One
In Step Four, EMS personnel must determine whether persons
who have not met physiologic, anatomic, or mechanism-ofinjury criteria have underlying conditions or comorbid factors
that place them at higher risk for severe injury. Persons with such
underlying conditions might require trauma-center care.
The Panel recognized that comorbidities are common
among injured persons. A population-based cohort study of
the prevalence of comorbid conditions in injured and noninjured persons that used 10 years of follow-up health data from
Manitoba, Canada, compared comorbidities among 21,032
injured patients with those of a sample of noninjured matched
controls (106). Persons sustaining an injury had a mean of 2.2
preexisting conditions, compared with a mean of 1.5 among
noninjured controls. On the Charlson Comorbidity Index
(CCI), which incorporates 19 comorbid conditions weighted
on the basis of their association with mortality, 5.9% of injured
persons had a score of >1, compared with 1.2% among noninjured persons. Injured persons were 1.9 times more likely
than noninjured matched controls to have been hospitalized
in the 12 months preceding the injury. A prospective study of
105 patients aged >40 years who were hospitalized under the
care of a trauma team in Auckland, New Zealand, indicated
that 71% had comorbid conditions and that comorbidities
were associated with longer hospital stays (107).
The Panel also noted that the presence of comorbid conditions is associated with worse outcomes among injured patients.
A study of 2,819 patients with complete data in the Victoria,
Australia, trauma registry that was conducted to determine
the association between comorbidities and trauma outcomes
24
MMWR
indicated that the CCI was associated with increased risk for
death among trauma patients (108). Compared with trauma
patients without comorbidity, those with CCI of 2 (OR: 3.5;
CI = 2.5–4.9) or 3 (OR: 4.1; CI = 1.2–13.4) had increased
odds of death. A review of published literature using data
from the United Kingdom (UK) Trauma, Audit, and Research
Network and Hope Hospital in Salford, UK, indicated that risk
for death increased with the number of comorbid conditions
in UK trauma victims (109).
Certain studies of the association between comorbidities and
trauma outcomes have evaluated specific comorbid factors. A
13-year review of Pennsylvania trauma data for patients aged
>65 years indicated that congestive heart failure (OR: 1.7; CI
= 1.5–2.1), steroid use (OR: 1.6; CI = 1.0–2.4), liver disease
(OR: 5.1; CI = 3.1–8.2), cancer (OR: 1.8; CI = 1.4–2.5),
chronic obstructive pulmonary disease (COPD) (OR: 1.5; CI =
1.2–1.8), and renal disease (OR: 3.1; CI = 2.3–4.3) were associated with increased odds of mortality after injury, controlling
for ISS (110). An evaluation of 8 years of the ACS National
Trauma Data Bank (NTDB) data indicated that certain comorbid factors were associated with increased risk for death across
all levels of ISS (111). For patients aged 50–64 years with ISS
of 16–25, increased risk for death was associated with heart
disease (RR: 1.5; CI = 1.3–1.8) and liver disease (RR: 1.9;
CI = 1.1–3.0). An increased risk for death also was identified
among patients aged >65 years who had heart disease (RR:
1.4; CI = 1.2–1.5), liver disease (RR: 1.8; CI = 1.1–2.9), or
respiratory disease (including COPD) (RR: 1.3; CI = 1.1–1.6).
An analysis of data concerning 1,172 critically injured trauma
patients admitted to the ICU at a trauma center in Maryland
identified nine common comorbid conditions, none of which
were associated with increased mortality (112). However, Type
1 diabetes was associated with increased risk for infection following injury (RR: 2.1; CI = 1.4–3.2), and both COPD and
Type 1 diabetes were associated with increased length of ICU
stay after controlling for age and ISS (COPD, RR: 1.3, CI =
1.2–1.4; Type 1 diabetes, RR: 2.3, CI = 1.6–3.2).
Step Four of the Decision Scheme focuses on identifying
patients who are at risk for severe injury and thus require a high
level of trauma care because of a comorbid condition despite
appearing to have no substantial injury after evaluation using
the physiologic, anatomic, and mechanism-of-injury criteria.
The Panel recommended that transport to a trauma center or
specific resource hospital be considered if any of the following
are identified:
• age
—adults aged >55 years
—children aged <15 years;
January 23, 2009
• anticoagulation and bleeding disorders;
• burns
—without other trauma mechanism: triage to burn
facility
—with trauma mechanism: triage to trauma center;
• time-sensitive extremity injury;
• end-stage renal disease requiring dialysis;
• pregnancy >20 weeks; or
• EMS provider judgment.
Age – Older Adults: Criterion Retained
Adult trauma victims aged >55 years are at increased risk for
injury and death. After controlling for ISS and other variables
(e.g., race, other comorbidities, and insurance status), NSCOT
determined that increased injury mortality is associated with
increasing age (17). Weighted 1-year mortality rates increased
from 6.9% for trauma patients aged 18–54 years to 32.2% for
patients aged 75–84 years (Table 7). Another study, a 13-year
review of a state trauma database, indicated that every 1-year
increase in age after age 65 years corresponded to a 6.8%
increase in mortality (110). A case-control study indicated
that older trauma victims who died from their injuries had a
lower ISS than younger victims who died (113).
Age also places trauma victims at increased risk for other
comorbidities associated with more severe injury and poor
outcomes. A study of NTDB data indicated that 24% of
trauma patients aged 50–64 years and 33% of trauma patients
aged >65 years had comorbidities associated with increased ISS
(111). A prospective study from New Zealand indicated that
the prevalence of major comorbid conditions likely to affect
outcomes increased with age, exceeding 40% by age 61 years
and reaching 50% by age 81 years (107).
Previous studies have identified inadequacies in the triage
of elderly trauma patients. A retrospective study of trauma
patients using 1997 statewide data from Pennsylvania indicated
that patients aged >65 years with ISS of >15 were less likely
to be treated in a trauma center than patients aged <65 years
with ISS of >15 (36.6% and 47.0%, respectively), even though
those treated at nontrauma centers had a high ISS (mean: 19.3),
leading the authors to conclude that the ability of EMS and
nontrauma center personnel to recognize severe injury among
the geriatric population is substantially lower than that among
younger patients (114). Similarly, a retrospective analysis of
injury-related admissions to Portland, Oregon–area hospitals
indicated that 56% of trauma patients aged >65 years with ISS
of >15 were admitted to nontrauma-center hospitals, compared
with 15% of severely injured patients aged <65 years (115).
These disparities are likely attributable, at least in part, to the
inadequacy of anatomic, physiologic, and mechanism-of-injury
Vol. 58 / RR-1
Recommendations and Reports
TABLE 7. Age-specific weighted injury mortality rates among
persons aged 18–84 years — National Study on the Costs and
Outcomes of Trauma, United States, July 2001–November 2002
Age group (yrs)
Patients
(No.)
Weighted 1-yr mortality
(%)
18–54
396
6.9
55–64
559
10.8
65–74
607
17.3
75–84
781
32.2
SOURCE: MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national
evaluation of the effect of trauma-center care on mortality. N Engl J Med
2006;354:366–78.
triage criteria for elderly trauma victims. A 2003 retrospective
evaluation of data from three New Jersey counties in which
age and other comorbid conditions were not included as triage criteria indicated that sensitivity of the triage guidelines to
identify severe injury (ISS>15) was 0.8 for patients aged >65
years and 0.9 for patients aged 25–64 years (116). For persons
aged >65 years, undertriage rates were 18% for men and 15%
for women, compared with 8% and 12%, respectively, for those
aged <65 years. Other possible reasons for undertriage of elderly
trauma patients include the difficulty that EMS providers
face in detecting impairments in physiologic reserve, eliciting
medication use, and identifying comorbidities that suggest
a need for higher-level care and the potential inadequacy of
many indices of injury severity (e.g., TS, RTS, T-RTS, AIS,
and ISS) in elderly populations (117). Those indices of injury
severity were derived from and validated using populations
with a greater representation of younger rather than older
persons and thus might be less than adequate in categorizing
persons aged >65 years.
In 2001, an extensive review of the literature concerning
age as a comorbid factor in trauma that evaluated more than
2,300 studies identified only two prospective or well-designed
retrospective clinical trials and concluded that the available
evidence was insufficient to support any standards regarding
triage of geriatric trauma patients (118). The review acknowledged that age acts as a continuous rather than dichotomous
variable and that poorer outcomes associated with age also are
likely to increase with increasing age. For this reasons, the Panel
concluded that advanced patient age should lower the threshold
for field triage directly to a trauma center. The 2006 Decision
Scheme is designed to be consistent with that finding.
Age – Children: Criterion Retained
Children aged <15 years who meet the criteria of Steps One
through Three should be transported to a pediatric trauma
center if one is available. The age that separates children from
adults for purposes of field triage is difficult to define with
certainty. ACS-COT defines pediatric patients as those aged
<15 years, and the Panel adopted this threshold.
25
Studies indicate that certain physiologic, anatomic, and
mechanism-of-injury triage criteria do identify severely injured
children. A study that used New York State Trauma Registry
data to evaluate criteria available to EMS personnel for prediction of trauma-related mortality in children aged <13 years
analyzed elements from the Pediatric Trauma Score (PTS).
The evaluated PTS components included 1) patient weight,
airway patency, SBP, presence of open wounds, presence of
skeletal trauma, and central nervous system status (awake,
obtunded, or coma); 2) GCS best motor response (range: 1
[none]–6 [obeys commands]) and eye-opening response (1
[none]–4 [spontaneous]); and 3) AVPU score (A = alert, V =
responds to voice, P = responds to pain, U = unresponsive).
Only a GCS best motor response of 1 and an AVPU score of
U were predictive of mortality in children (OR: 6.2 and 5.6,
respectively), with high specificity (0.9) and sensitivity (0.95)
(119). Another study that evaluated the accuracy of triage criteria in 1,285 injured children aged 0–15 years indicated that
certain criteria (i.e., systolic blood pressure, GCS, respiratory
rate, burns, and paralysis) were highly accurate in identifying
major injury (i.e., those patients who died in the ED, were
admitted to the pediatric ICU, or underwent a major surgical
procedure) (75). The most accurate criteria were SBP of <90
mmHg (PPV = 86%), second- and third-degree burns on
>15% of total body surface area (PPV = 79%), GCS of <12
(PPV = 78%), and respiratory rate of <10 or >29 breaths per
minute (PPV = 73%). Falls of >20 feet (PPV = 33%), penetrating trauma (PPV = 29%), ejection from a motor vehicle (PPV
= 24%), and pedestrian struck by a vehicle (PPV = 16%) were
less accurate. Regarding MVCs, an examination of NASS data
for 8,394 pediatric crash victims aged <15 years indicated that
GCS of <15 identified 15 (31.9%) of 47 children with ISS of
>15; vehicle intrusion of >6 inches identified an additional 23
(48.9%) severely injured children. Combined, the two criteria
identified 38 (80.9%) of 47 children with ISS of >15 (120).
Additional Pediatric Concerns Reviewed
by the Panel
Abdominal injuries and restraint use in children warrant
further mention. An analysis that used an insurance company
electronic claims database to determine the association between
restraint use, abdominal bruising, and intra-abdominal injury
has led certain experts to suggest that abdominal bruising
should be given special consideration in the field triage of
injured children. However, the Panel decided against including this finding as a special consideration. The cited study
reported that among 147,985 children aged 4–15 years
who were involved in 102,548 MVCs during December
1998–November 2002, a total of 1,967 (1.33%) children
26
MMWR
had abdominal bruising; these children were 232.1 times
(CI = 75.9–701.3) more likely to have sustained intra-abdominal injury (AIS of ≥2) (121). Abdominal bruising correlated
with substantial intra-abdominal injury; sensitivity, specificity, PPV, and NPV were 73.5%, 98.8%, 11.5%, and 99.9%,
respectively. However, among 1,967 children with abdominal
bruising, only 20 (1%) required an abdominal operation. The
Panel decided to not modify the Decision Scheme to contain
further information regarding abdominal wall bruising to the
2006 Decision Scheme for the following reasons: children
(aged <15 years) are already triaged preferentially to pediatriccapable trauma centers in the Decision Scheme; the majority
(1,947 of 1,967) of children with abdominal bruising in this
study did not require operative intervention; and practice
guidelines dictate that the need for operative intervention in
children with intra-abdominal injuries is itself determined
by abnormalities in physiologic criteria of injury (122), so
a finding of abdominal bruising associated with restraint
use would not appear to add appreciable discrimination to
the physiologic criteria outlined in this report. Similarly, a
study of 461 children aged <18 years that examined proper
and improper restraint use in crashes (123) indicated that, in
frontal crashes, proper restraint use increased GCS (13.4 and
12.6, respectively; p = 0.1) and survival to hospital discharge
(98% and 92%, respectively; p = 0.1). In lateral crashes, proper
restraint use compared with improper use increased ISS (23.8
and 19.9, respectively; p = 0.1) and decreased both GCS (10.4
and 11.1, respectively; p = 0.03) and survival (82% and 92%,
respectively; p = 0.13). The Panel decided not to modify the
Decision Scheme to contain further information on restraint
use in children for the following reasons: the data cited do
not appear to add appreciable discrimination to the proposed
physiologic, anatomic, or mechanism-of injury-criteria because
patients with the referenced GCS and ISS would have been
identified in Steps One, Two, or Three of the Decision Scheme;
and children (aged <15 years) are already triaged preferentially
to pediatric-capable trauma centers in the Decision Scheme.
No published data suggest that injured children, in the
absence of physiologic, anatomic, or mechanism-of-injury
triage criteria, are at risk for negative outcomes solely on the
basis of their age. The criteria in Steps One, Two, and Three
of the 2006 Decision Scheme are expected to identify nearly
all seriously injured children. Therefore, the Panel identified
no specific age below which all injured children should be
transported to a trauma center.
However, children meeting the revised field triage criteria
for transport to trauma centers in Steps One through Three
of the Decision Scheme should be transported preferentially
to pediatric-capable trauma centers. Recent studies indicate
that organized systems for trauma care contribute to improved
January 23, 2009
outcomes for children (124) and that seriously injured children
fare better in pediatric-capable trauma centers. Multiple reports
document improved survival in pediatric-capable trauma centers (125–129), including data from the Pennsylvania Trauma
Outcome Study registry that demonstrates absolute reductions
in injury mortality ranging from 3.8% to 9.7% (130) and
improved functional outcomes (e.g., feeding and locomotion)
(131) when children aged <16 years with ISS of >15 are treated
at pediatric trauma centers or at adult trauma centers that
have acquired additional qualifications to treat children. What
appears to matter most is the availability of pediatric-specific
resources, particularly the availability of a pediatric ICU, not
the designation as a pediatric trauma center per se (132,133).
Although some earlier studies concluded that injured children
treated in adult trauma centers had outcomes comparable to
those treated in pediatric trauma centers, those investigations
were conducted in hospitals with comprehensive pediatric
services, including pediatric emergency medicine, critical care
medicine, and nursing (134–140).
Anticoagulation and Bleeding Disorders:
Criterion Retained
Patients with coagulopathy or those undergoing treatment
with anticoagulants (e.g., warfarin or aspirin) are at increased
risk for intracranial hemorrhage, increased severity of hemorrhage, and associated morbidity and mortality. The Panel
reviewed several studies of the treatment of injured patients
on anticoagulant therapy. A retrospective study at one Level I
trauma center in Albany, New York, identified 35 consecutive
trauma patients taking warfarin. Among these patients, falls
(n = 19) and MVCs (n = 12) were the predominant mechanisms of injury, and 18 (51%) patients suffered intracranial
hemorrhage. Eight patients died in hospital, four as a result of
head injuries, and one patient died from intracranial hemorrhage after being discharged (141). In another retrospective
study of 2 years of trauma-registry data from one Level I trauma
center, 37 (10%) of 380 patients receiving anticoagulation
therapy suffered intracranial injury (142). The mortality rate
for these 37 patients was 38%, compared with 8% for headinjured patients not receiving anticoagulation therapy, even
though ISS for the two groups did not differ substantially. A
retrospective study of a cohort of closed head–injury patients
aged >55 years indicated that 9% of the patients used warfarin
(143). Use of warfarin was associated with increased odds of
a head AIS of 5 (OR: 2.4; CI = 1.1–5.2) and increased odds
of death (OR: 2.7; CI = 1.2–6.1). A case-control study of
1,916 injured persons taking warfarin and 1,470 injured,
nonwarfarin-using matched controls identified no differences in mortality between the two groups, but head-injured
patients not taking warfarin had better functional outcomes
Vol. 58 / RR-1
Recommendations and Reports
than head-injured patients taking warfarin, specifically with
regard to locomotion and feeding (144).
In addition to this evidence, the Panel noted that in the
head-injured anticoagulated patient, the severity and rapidity
with which intracranial hemorrhage might occur increases the
likelihood of long-term disability or death. Prompt provision of
neurosurgical services might be required for these patients. The
Panel further agreed that any patient who is on anticoagulants
or has a bleeding disorder and has an injury that does not meet
Step One, Two, or Three criteria might need treatment at a
facility that can do a prompt imaging and administer products rapidly to reverse anticoagulation. In conclusion, given
the increased risk for morbidity and mortality and potential
resource needs of these patients, the Panel recommended that
EMS contact medical control and consider transport to a
trauma center or a hospital with resources that will meet the
potential needs. For this reason, this criterion was retained in
the 2006 Decision Scheme.
Burns — With or Without Other Trauma:
Criterion Modified
Burns as a criterion was moved from Step Two (anatomic
criteria) to Step Four (special considerations) of the Decision
Scheme to emphasize the need to determine if the burn
occurred with or without other injuries. In the absence of
other trauma, burn patients should be transported to a burn
center rather than a trauma center. Because burn patients
who have concomitant trauma have greater risk for morbidity and mortality, ACS and the American Burn Association
recommend transfer to a burn center. If the nonburn injury
presents a greater immediate risk, the patient should be stabilized in a trauma center and then transferred to a burn center
(6,145,146). The Panel accepted this recommendation and
included burns as a special circumstance warranting consideration of trauma-center care.
Time-Sensitive Extremity Injury:
Criterion Added
Time-sensitive extremity injury (e.g., open fracture or fracture with neurovascular compromise) was not part of Decision
Schemes before 2006. Although the Panel did not identify
any studies that specifically evaluated the field triage of such
injuries, the members did discuss that fact that patients with
time-sensitive extremity injuries are at risk for both infection
and musculoskeletal and neurovascular deterioration of the
limb and that rapid intervention might be needed to preserve
the neurovascular status of the extremity and prevent loss of
limb function or amputation. Further, the Panel noted that the
resources required to evaluate whether additional intervention
is required to preserve the limb are not readily available at all
27
hospitals. Even when patients with such injuries do not meet
anatomic criteria, they are nonetheless at substantial risk for
morbidity. Field providers, in communication with their medical directors, should consider transport to a trauma center or
specific resource hospital with the capability to manage these
injuries. To ensure that such transport is considered, the Panel
added this criterion to the 2006 Decision Scheme.
End-Stage Renal Disease Requiring Dialysis:
Criterion Added
Although no studies were identified that evaluated the field
triage of renal disease or dialysis patients, the Panel noted that
because end-stage renal disease patients requiring dialysis often
are coagulopathic, these patients might be at increased risk for
hemorrhage and severity of hemorrhage, with the potential for
increased morbidity and mortality. Patients requiring dialysis
treatment and evaluation and treatment of injuries not identified in Steps One, Two, and Three thus need the resources
available at a trauma center or specific resource hospital capable
of managing both the end-stage renal disease and the injuries.
The Panel recommended that EMS personnel contact medical
control to consider these patients for transport to such facilities
and added this criterion to the 2006 Decision Scheme.
Pregnancy >20 Weeks: Criterion Modified
Pregnancy was included in Step Four of the 1999 Decision
Scheme. The Panel reviewed evidence indicating that the
primary risk associated with injury to a pregnant woman is to
the fetus, not to the mother, and therefore decided to modify
the criterion on the basis of gestational age. An analysis of the
factors associated with unsuccessful completion of pregnancy
after trauma in a case series of 38 patients involved in 39 different traumatic events (95% of which were MVCs) in which
9 (23.7%) of 38 patients suffered unsuccessful pregnancies
(involving six fetal deaths and three abortions) (147) indicated that the associated injury factors were higher ISS (mean:
22, compared with 9 for successful pregnancies) and higher
abdominal AIS (mean: 2.56, compared with 0.63 for successful pregnancies). A review of maternal and fetal outcomes for
pregnant trauma patients in the University of California at
San Diego trauma registry indicated that, although pregnant
women had morbidity and mortality rates similar to those
of nonpregnant women, fetal demise was the outcome in 15
(13.2%) of 114 cases. Of those 15 cases, 13 (86.7%) occurred
within hours of the injury, one at 8 days, and one at 18 days.
Fetal demise was rare (3.8%) in the first trimester; the rates of
fetal demise in the second and third trimesters were 17.3% and
14.0%, respectively (148). A prospective study of minor blunt
abdominal trauma among 270 pregnant women, five (1.9%)
of whom suffered multiple events, identified no cases of fetal
28
MMWR
demise, but one case of preterm labor resulted in the delivery
of a 34-week neonate weighing 2,350 grams (149).
In its deliberations, the Panel considered multiple factors.
Injury to a pregnant woman places both the mother and the
fetus at risk, with the primary risk to the fetus. For EMS providers, the primary focus of care continues to be the resuscitation
of the mother, which is essential both to mother and fetus
(150). However, anatomic and physiologic changes associated
with pregnancy make assessment and treatment more complex.
Evidence suggests that fetal demise is a greater risk in a severely
injured mother. Although patients with severe injuries might
be identified in the first three steps of the Decision Scheme,
the lack of specific evidence addressing pregnancy convinced
the Panel to retain this criterion, but with a modification.
Pregnant patients whose fetal gestational age is estimated to
be >20 weeks, whose injuries do not meet Step One, Two,
or Three criteria, might nonetheless require care at a trauma
center or specialized obstetrical care not available at all trauma
centers or hospitals. The Panel therefore determined that the
phrasing “pregnancy >20 weeks” captures more accurately
the association of fetal gestational age and potential viability
in this context and made this change for the 2006 Decision
Scheme. The Panel recommends that transport to a trauma
center or to a hospital with obstetrical resources should be
considered for injured women who are >20 weeks pregnant
and that the transport destination decision should be made
during the contact of EMS providers with medical control for
these patients.
EMS Provider Judgment: Criterion Added
The Panel recognized the impossibility of predicting all possible special circumstances that might exist at an injury scene.
EMS providers make triage decisions on a routine basis and
have the expertise and experience needed to make judgments
regarding atypical situations. Depending on the situation,
capabilities of the EMS and trauma systems, and local policies, EMS providers may decide independently or in association with online medical direction to transport a patient not
otherwise meeting the criteria in Steps One through Four to
a trauma center.
Cardiac Disease and Respiratory Disease:
Criterion Deleted
The Panel reviewed the limited data on the relationship of
cardiac or respiratory disease in the field triage setting. No
studies were identified that specifically addressed the risk for
increased ISS in the presence of patients with cardiac or respiratory disease undergoing field triage. In their discussions, the
Panel members noted that the presence of cardiac or respiratory
disease in a patient with a severe injury might increase mortal-
January 23, 2009
ity in the context of injury, but they do not hide the injury
and they are not, in and of themselves, effective in identifying
an injury. Further, although cardiac and respiratory diseases
are underlying medical conditions that can make the consequences of injuries more difficult to manage, in the absence of
physiologic, anatomic, mechanism-of-injury, or other special
considerations (e.g., age >55 years), the presence of the disease
itself should not mandate transfer to a trauma center or other
specific resource hospital. The resources of a trauma center are
designed to assess and treat injuries, not preexisting diseases.
Therefore, the Panel decided to remove this criterion from the
2006 Decision Scheme and instead recommended that patients
who do not meet other triage criteria but who have cardiac
disease, respiratory disease, or both should be assessed, evaluated, and transported according to local EMS protocols.
Insulin-Dependent Diabetes Mellitus:
Criterion Deleted
Insulin-dependent diabetes was included in Step Four of
the 1999 Decision Scheme. Because diabetes is a common
comorbid condition, the Panel reassessed this criterion. A
case-control study that used hospital discharge data from
California indicated that 2.8% of all patients with an injuryrelated International Classification of Diseases, Ninth Revision,
Clinical Modification diagnosis code had diabetes; for patients
aged >45 years, prevalence ranged from 3.0% to 7.3%, generally increasing with each decade of life (113). A 2-year prospective study of trauma patients in Baltimore, Maryland, that
evaluated the prevalence and impact of preexisting disease in
critically ill trauma patients reported a 3% prevalence of Type
1 diabetes among these patients (112).
An OR of 1.3 (CI = 1.0–1.6) has been reported for traumarelated deaths of patients with Type 1 diabetes compared
with nondiabetic patients (113). Similarly, a relative risk for
death of 1.7 (CI = 0.9–6.2) has been reported (112). Type 1
diabetes is associated with increased risk for infection (OR:
2.1; CI = 1.4–3.2) and length of ICU stay (OR: 2.3; CI =
1.6–3.2) (112) and with increased morbidity in patients with
ankle fractures (151). An analysis of approximately 160,000
patients with ankle fracture demonstrated that patients with
diabetes had increased mortality (0.3% and 0.1%, respectively), postoperative complications (4.6% and 3.3%), length
of stay (4.7 days and 3.6 days), and mean costs ($12,898 and
$10,794) compared with nondiabetic patients with ankle fracture (151). A report of a case series of 14 open ankle fractures
in 13 diabetic patients indicated that only three (21%) of the
fractures achieved bony union without complications (152).
At 1-year postinjury, 75% of the patients with Type 1 diabetes
had undergone amputation, compared with only 10% of the
patients with Type 2 diabetes.
Vol. 58 / RR-1
Recommendations and Reports
A retrospective study of patients admitted to the ICU at a
Level I trauma center during a 2-year period indicated that
of 516 nondiabetic patients, 483 (93.6%) had an elevated
serum glucose level (>110mg/dL) on the first or second day
of their admission (153). Both infection rates and mortality
rates increased with the severity of hyperglycemia (Table 8);
in multivariate logistic regression, a serum glucose level of
>200 mg/dL was an independent predictor of both infection
and mortality. A prospective evaluation of 942 consecutive
trauma patients indicated that hyperglycemia, independent
of the presence of a diagnosis of diabetes, also was associated
with poor outcomes (154). When multivariate logistic regression was used and adjusted for age and ISS, patients with high
glucose (>220 mg/dL) had more ventilator days (OR: 7.5; CI
= 2.5–12.5), longer ICU stays (OR: 6.4; CI = 3.6–9.1), and
increased mortality (OR: 1.4; CI = 1.4–10.0) compared with
euglycemic patients. The effect on mortality was more pronounced in patients with worsening (OR: 3.5; CI = 1.8–7.0)
or highly variable (OR: 3.2; CI = 1.8–5.8) glucose levels. A
prospective study of 1,003 consecutive trauma patients that
compared hyperglycemic with euglycemic trauma patients
reported increased infections (RR: 3.0; CI = 1.3–6.6), mortality (RR: 2.2; CI = 1.4–3.4), hospital length of stay (RR: 5.9;
CI = 1.5–7.9), ICU length of stay (RR: 6.9; CI = 1.1–9.8),
and ventilator days (RR: 4.9; CI = 1.1–7.6) for hyperglycemic
patients (155).
From the evidence reviewed, the Panel determined that,
although an injured patient with diabetes or hyperglycemia
might have more complications and a longer hospital stay than
a patient without diabetes, no evidence exists that the presence
of diabetes or hyperglycemia, in the absence of criteria for Steps
One, Two, or Three, should mandate transfer to a high-level
trauma center. These patients, who might have nonsevere injuries and complications related to diabetes or hyperglycemia,
may be managed effectively at lower level trauma centers or
at nontrauma hospitals. Recognizing that the resources of a
trauma center are designed to assess and treat injuries, not preexisting conditions such as diabetes mellitus, the Panel decided
to remove this criterion from the 2006 Decision Scheme.
Cirrhosis: Criterion Deleted
The Panel identified no specific literature or evidence base
examining cirrhosis in the field triage of injured patients.
Further, no evidence exists to suggest that, in the absence of
physiologic, anatomic, or mechanism-of-injury criteria, cirrhosis without coagulopathy increases the risk for severe injury
(e.g., liver laceration and hemorrhage). However, coagulopathy,
a substantial complication of cirrhosis, is of concern, and the
Panel noted that injured cirrhotic patients identified as having
or thought to have coagulopathy should be triaged as outlined
29
TABLE 8. Infection and mortality rates for patients with varying
degrees of hyperglycemia
Serum glucose level
Infection rate
(%)
Mortality rate
(%)
<110 mg/dL
6
9
>110 mg/dL
25
17
>150 mg/dL
31
13
>200 mg/dL
32
34
SOURCE: Laird AM, Miller PR, Kilgo PD, Meredith JW, Chang MC.
Relationship of early hyperglycemia to mortality in trauma patients.
J Trauma 2004;56:1058–62.
in the criterion regarding anticoagulation and bleeding disorders (Step Four, special considerations). Therefore, the Panel
decided that, as an isolated comorbid factor of trauma in a
patient who does not meet the criteria of Steps One, Two, or
Three, uncomplicated cirrhosis does not require trauma center
or specific resource hospital care and deleted this criterion from
the 2006 Decision Scheme.
Morbid Obesity: Criterion Deleted
Morbid obesity (BMI >35 kg/m2) was included in Step Four
of the 1999 Decision Scheme. Because obesity continues to
be a common comorbid condition in injured patients, the
Panel elected to reassess this criterion. Several studies have
demonstrated that obese trauma patients have a higher rate of
morbidity and mortality than nonobese patients. A case-control
study involving 242 consecutive patients admitted to ICUs
after blunt trauma indicated that mechanism of injury and ISS
were not different for obese patients compared with nonobese
patients, but obese patients had twice the crude mortality rate
(32% and 16%, respectively) (156). In multivariate analysis
controlling for age, ISS, head injury, and pulmonary contusion,
the odds of mortality were greater for obese trauma victims
compared with nonobese victims (OR: 5.7; CI = 1.9–19.6). A
retrospective review of all patients admitted to a Level I trauma
center during a 1-year period indicated that morbidly obese
patients had similar ISS to nonobese patients, although obese
patients had longer ICU stays, more ventilator days, and longer
hospital stays (157). Obese patients also had higher mortality
rates than nonobese patients (10.7% and 4.1%, respectively),
even in the subgroup of patients with ISS of >15 (38.5% and
15.1%, respectively). Obese patients also can present other
challenges to medical personnel, specifically in regard to transportation and movement, assessment, monitoring, procedures
(e.g., lumbar puncture), and interventions (e.g., endotracheal
intubation) (158).
The Panel considered whether to delete the morbid obesity
criterion in the 1999 Decision Scheme. If the obesity criterion
were deleted, severely injured obese trauma patients (i.e., those
who meet Step One, Two, or Three criteria) still would be
transferred to the appropriate trauma centers. The Panel took
30
MMWR
note of the evidence indicating that obese trauma patients
have higher rates of morbidity and mortality than nonobese
patients. However, the Panel concluded that this additional
morbidity and mortality would likely not be observed in
obese patients who failed to meet Step One, Two, or Three
criteria. Further, the Panel concluded that such patients may
be managed adequately at nontrauma hospitals. Indeed, many
nontrauma hospitals might be better equipped and staffed to
manage obese patients and complications. After considering
all these factors, the Panel deleted morbid obesity as a criterion
in the 2006 Decision Scheme.
Immunosuppressed Patients:
Criterion Deleted
This category of patients was removed as a criterion for
transfer to a trauma center because the Panel concluded
that immunosuppression by itself does not increase the risk
or severity of injury. In the absence of injuries necessitating
trauma-center care, immunosuppressed patients might be
served better by referral to hospitals that have the most experience caring for patients with these underlying conditions (e.g.,
a hospital with substantial resources dedicated to HIV/AIDS
care). Such services also might be available at institutions with
trauma centers, but trauma-center care per se is not required
for immunosuppressed patients who do not meet the triage
criteria in Steps One through Three of the Decision Scheme.
Additional Considerations
Step Four emphasizes the need to transport patients with
special circumstances or needs to the most appropriate hospital.
Although decisions might be dictated by standing protocols,
for patients meeting the criteria in Step Four, online medical
direction should be consulted to determine the most appropriate facility to treat patients requiring special consideration.
If patients do not meet criteria for triage to a trauma center
in Steps One through Four of the Decision Scheme, EMS
providers should use local protocols for transport without the
need to contact medical control.
When in Doubt
EMS providers are involved with triage decisions on a
routine basis. They have the field experience needed to make
specific judgments regarding care in their individual locales.
Accordingly, any gaps in these criteria should not be construed
as prohibiting transport of any patient to a trauma center.
Injury is complex and often does not lend itself to stepwise,
dichotomous checklists. The last line of the 2006 Decision
Scheme, essentially unchanged from previous versions, is
“When in doubt, transport to a trauma center” (Figure 1).
January 23, 2009
Conclusion
The revised 2006 Decision Scheme is meant to assist EMS
providers in making the critical decisions necessary to increase
the likelihood of favorable outcomes for patients. The Decision
Scheme also is important for trauma system leaders and planners, including state and local EMS medical directors, state
EMS directors, EMS providers, and public health professionals.
The revised Decision Scheme has been adopted officially by
ACS-COT and endorsed by multiple organizations and associations. It has been published previously by ACS-COT (6) and
the National Association of Emergency Medical Technicians
(77). This report is meant to provide the rationale used in 2006
to revise the Decision Scheme.
Implementation and updating of these protocols at the
local level will require a substantial educational and informative effort to ensure wide-scale implementation. CDC, with
additional funding from NHTSA, is developing an educational
toolkit for state and local EMS medical directors, state EMS
Directors, EMS providers, and public health officials. The tool
kit will provide teaching aids to help EMS providers understand why the Decision Scheme was revised and how those
revisions can be tailored to the needs of their communities.
CDC, through its partner organizations, will distribute the
tool kit to EMS jurisdictions throughout the United States.
This toolkit also will be available at no charge from CDC at
http://www.cdc.gov/FieldTriage.
The recommendations in this report were developed on the
basis of the best evidence available at the time. Limitations in
available data clearly indicate the need for additional research.
Conducting research in the prehospital environment and in
EMS presents multiple challenges, including a lack of trained
investigators, legal and regulatory barriers, the need for more
research among EMS providers, limited funding, and limited
infrastructure and information systems to support research
efforts (29,159). Efforts are underway to address these barriers,
including efforts to prioritize research (18,160) and to develop
new databases that can provide more useful information and
support data-driven decisions (e.g., NTDB and the National
EMS Information System) (49). Additional research efforts
specifically related to field triage are needed, including costeffectiveness research. Additional funding targeting research
into triage decisions and triage criteria will be necessary to
support these efforts. Also, research in triage represents an
important area in which public health and EMS can collaborate
to improve trauma surveillance and data systems and develop
the methodologies needed to carry out the continuing analysis
and evaluation of the 2006 Decision Scheme and its impact
on the care of acutely injured persons.
Vol. 58 / RR-1
Recommendations and Reports
The best way to reduce the burden of injuries is to prevent
them from occurring. However, when primary prevention fails,
acute care, public health, and public safety practitioners must
work together to provide the best available and most appropriate care for the injured. Trauma systems and trauma centers
save lives (17). The Decision Scheme is an essential component
of the trauma system, guiding EMS providers in transporting
injured patients to the most appropriate facility, ensuring
proper treatment, and thus reducing death and disability.
Acknowledgements
Robin Sloan, MA, John Seggerson, and Barbara Newhouse, MPH,
Division of Injury Response, National Center for Injury Prevention
and Control, CDC, contributed to this report.
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Vol. 58 / RR-1
Recommendations and Reports
35
National Expert Panel on Field Triage
Membership List as of April 2006
Chair: Gregory J. Jurkovich, MD, Professor of Surgery, Harborview Medical Center, Seattle, Washington.
Members: John H. Armstrong, MD, University of Florida College of Medicine, Gainesville, Florida; Bob Bailey, MA, McKing Consulting (contractor),
Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia; Jane Ball, DrPH, Emergency Medical Services for
Children, National Resource Center, Washington, District of Columbia; William Ball, OnStar, Troy, Michigan; Robert R. Bass, MD, Maryland Institute for
Emergency Medical Services Systems, Baltimore, Maryland; Alasdair Conn, MD, Massachussetts General Hospital, Boston, Massachusetts; Arthur Cooper,
MD, Columbia University Medical Center, affiliation at Harlem Hospital, New York, New York; Gail F. Cooper, technical liason, American College of Surgeons,
Committee on Trauma, Chicago, Illinois; Drew Dawson, National Highway Traffic Safety Administration, Washington, District of Columbia; Robert L. Galli,
MD, University of Mississippi, Jackson, Mississippi; Robert B. Giffin, PhD, Institute of Medicine, Washington, District of Columbia; Daniel G. Hankins,
MD, Mayo Clinic; Rochester, Minnesota; Jerris B. Hedges, MD, Orgeon Health and Science University, Portland, Oregon; Mark C. Henry, MD, Stony Brook
University, Stony Brook, New York; Richard C. Hunt, MD, Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta,
Georgia; James James, MD, DrPH, American Medical Association, Chicago, Illinois; Mark Johnson, MPA, State and Territorial Injury Prevention Directors
Association, Juneau, Alaska; Jorie Klein, Parkland Memorial Hospital, Dallas, Texas; Jon R. Krohmer, MD, Kent County Emergency Medical Services, Grand
Rapids, Michigan; Stanley Kurek, DO, Medical University of South Carolina, Charleston, South Carolina; E. Brooke Lerner, PhD, University of Rochester
Medical Center, Rochester, New York; Robert C. MacKersie, MD, University of California San Fransicso, San Francisco, California; LTC John McManus,
MD, MCR, U.S. Army Institute of Surgical Research, San Antonio, Texas; Michael G. Millin, MD Johns Hopkins University School of Medicine, Baltimore,
Maryland; Jane Mitchko, MEd, Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia; Rick Murray,
American College of Emergency Physicians, Dallas, Texas; Robert E. O’Connor, MD, Christina Care Health System, Newark, Delaware; Drexdal Pratt, North
Carolina Department of Health and Human Services, Raleigh, North Carolina; Jeffrey P. Salomone, MD, Emory University School of Medicine, Atlanta,
Georgia; Richard W. Sattin, MD, Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia; Scott M. Sasser,
MD, Emory University School of Medicine and Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia;
Roslyne D.W. Schulman, American Hospital Association, Washington, District of Columbia; John Shelton, North Carolina Emergency Management, Mount
Airy, North Carolina; Paul Taheri, MD, University of Michigan, Ann Arbor, Michigan; Stephen H. Thomas, MD, Harvard Medical School, Wellesley Hills,
Massachusetts; Stewart C. Wang, MD, PhD, FACS, University of Michigan, Ann Arbor, Michigan.
Recommendations and Reports
January 23, 2009 / Vol. 58 / RR-1
Morbidity and Mortality Weekly Report
www.cdc.gov/mmwr
Continuing Education Activity Sponsored by CDC
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EXPIRATION — January 23, 2012
You must complete and return the response form electronically or by mail by
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ACCREDITATION
Continuing Medical Education (CME). CDC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing
medical education for physicians. CDC designates this educational activity for a maximum of 2.5 AMA PRA category 1 credits. Physicians should only claim
credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education (CNE). CDC is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center’s
Commission on Accreditation. This activity provides 2.5 contact hours.
Certified Health Education Specialist (CHES). CDC is a designated provider of continuing education contact hours (CECH) in health education by the
National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 2.5 Category I contact hours in
health education, CDC provider number GA0082.
Continuing Education Unit (CEU). CDC has been approved as an Authorized Provider by the International Association for Continuing Education and
Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. CDC is authorized by IACET to offer 0.2 CEU’s for this program.
Continuing Education for Emergency Medical Services (CECBEMS). This continuing education activity is approved by the Continuing Education
Coordinating Board for Emergency Medical Services (CECBEMS)—CECBEMS Activity #: 08-CECB-F2-0879, CEH Number and Type: 2.0 Advanced.
Aditional information is available at http://www.cdc.gov/FieldTriage.
Department of Health and Human Services
Centers for Disease Control and Prevention
CE-2
MMWR
January 23, 2009
Goal and Objectives
This report provides a description of the 2006 revised Field Triage Decision Scheme and its current content. The goal of this report is to help guide policy
decisions by trauma system leaders; state, regional, and local Emergency Medical Services (EMS) medical directors and public health professionals in injury
and EMS-related roles; and on-scene triage decisions by the approximately 800,000 EMS providers in the United States. Upon completion of this educational
activity, the reader should be able to 1) describe the physiologic, anatomic, mechanism-of-injury, and special considerations criteria of the 2006 Field Triage
Decision Scheme; 2) describe the specific components and content of each of the four steps of the 2006 Field Triage Decision Scheme; and 3) describe
transportation decisions and destinations when Field Triage Criteria are met.
To receive continuing education credit, please answer all of the following questions.
1. Which of the following is not a component step in the 2006 Field
Triage Decision Scheme?
A. Physiologic criteria.
B. Transportation mode criteria.
C. Mechanism of injury criteria.
D. Anatomic criteria.
E. Special considerations criteria.
2. Recent evidence has demonstrated that care at a Level I trauma center
lowers the risk of death for severely injured patients compared with
treatment received at non-trauma centers by:
A. 2%.
D. 25%.
B. 10%.
E. 40%
C. 14%.
3. The physiologic criteria that mandate transport to a trauma center
include all of the following except…
A. respiratory rate of <10 breaths per minute or >29 breaths per minute
for persons aged >1 year.
B. systolic blood pressure of <90 mmHg.
C. Glasgow Coma Scale of <14.
D. respiratory rate of <18 breaths per minute in infants aged
<12 months.
4. Anatomic criteria that mandate transport to a trauma center include
all of the following except…
A. pelvic fractures.
B. paralysis.
C. crushed, degloved, or mangled extremity.
D. two or more proximal long bone fractures.
E. amputation of two or more digits.
5. Mechanism-of-injury criteria indicating a high-risk automobile
crash in the 2006 Field Triage Decision Scheme include all of the
following except…
A. vehicle telemetry data consistent with a high risk of injury.
B. death in the same passenger compartment or in the other vehicle.
C. extrication time of >20 minutes.
D. ejection (partial or complete) from automobile
E. intrusion of >12 inches in occupant site or >18 inches any site.
6. Mechanism-of-injury criteria for falls in the 2006 Field Triage
Decision Scheme include all of the following except…
A. for children, >10 ft.
B. for children, two to three times the height of the child.
C. for adults, >20 feet.
D. for adults, >15 feet.
E. A,B, and C.
7. Contact medical control and consider transport to a trauma center or a
specific resource hospital for all of the following special considerations
except…
A. pregnancy of >20 weeks.
B. anticoagulation and bleeding disorders.
C. immunocompromised patients.
D. end-stage renal disease requiring dialysis.
E. older adults: risk of injury death increases after age 55 years.
8. Which of the following steps attempt to identify the most seriously
injured patients, i.e., those who should be transported preferentially
to the highest level of care within the trauma system?
A. Physiologic and anatomic.
B. Physiologic and mechanism of injury.
C. Anatomic and mechanism of injury.
D. Anatomic and special considerations.
E. Special considerations.
9. Patients who meet the Step Three (mechanism of injury) criteria
require which of the following actions?
A. Transport to the closest appropriate trauma center which, depending
on the trauma system, need not be the highest level trauma center.
B. Contact medical control and consider transport to trauma center or
a specific resource hospital.
C. Transport according to establish protocol to the closest emergency
department.
D. Transport preferentially to the highest level of care within the trauma
system.
10.Patients who meet the Step Four (special considerations) criteria
require which of the following actions?
A. Transport to the closest appropriate trauma center which, depending
on the trauma system, need not be the highest level trauma center.
B. Contact medical control and consider transport to trauma center or
a specific resource hospital.
C. Transport according to established protocol to the closest emergency
department.
D. Transport preferentially to the highest level of care within the trauma
system.
11.Which best describes your professional activities?
A. Physician.
B. Nurse.
C. Health educator.
D. Office staff.
12.I plan to use these recommendations as the basis for …(Indicate all
that apply.)
A. health education materials.
B. insurance reimbursement policies.
C. local practice guidelines.
D. public policy.
E. other.
13.Overall, the length of the journal report was…
A. much too long.
D. a little too short.
B. a little too long.
E. much too short
C. just right.
14.After reading this report, I am confident I can describe the physiologic,
anatomic, mechanism of injury, and special considerations criteria
of the 2006 Field Triage Decision Scheme.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
Fax Number
Phone Number
CHES Credit
] B
] B
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Recommendations and Reports
Signature Date I Completed Exam
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18.The instructional strategies used in this report (text, tables, figures,
and boxes) helped me learn the material.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
] A
] A
] A
] A
] A
] A
] A
] A
] A
] A
] A
] A
] A
17.The learning outcomes (objectives) were relevant to the goals of this
report.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
1. [
2. [
3. [
4. [
5. [
6. [
7. [
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16.After reading this report, I am confident I can describe transportation
decisions and destinations when Field Triage Criteria are met.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
Fill in the appropriate blocks to indicate your answers. Remember, you must answer all of the
questions to receive continuing education credit!
ZIP Code
Check One
CME Credit
CME for
Nonphysicians
Credit
CEU Credit
CNE Credit
15.After reading this report, I am confident I can describe the specific
components and content of each of the four steps of the 2006 Field
Triage Decision Scheme.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
E-Mail Address
State
First Name
City
Apartment or Suite
Street Address or P.O. Box
Last Name (print or type)
To receive continuing education credit, you must
1. provide your contact information (please print or type);
2. indicate your choice of CME, CME for nonphysicians, CEU, CNE, or CHES credit;
3. answer all of the test questions;
4. sign and date this form or a photocopy;
5. submit your answer form by January 23, 2012.
Failure to complete these items can result in a delay or rejection of your
application for continuing education credit.
Guidelines for Field Triage of Injured Patients
Recommendations of the National Expert Panel on Field Triage
MMWR Response Form for Continuing Education Credit
January 23, 2009/Vol. 58/No. RR-1
Vol. 58/ No. RR-1
CE-3
19.The content was appropriate given the stated objectives of the
report.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
20.The content expert(s) demonstrated expertise in the subject
matter.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
21.Overall, the quality of the journal report was excellent.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
22.These recommendations will improve the quality of my practice.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
Detach or photocopy.
(Continued on pg CE-4)
Please note: An erratum has been published for this issue. To view the erratum, please click here.
MMWR
23.The availability of continuing education credit influenced my decision
to read this report.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
24.The MMWR format was conducive to learning this content.
A. Strongly agree.
B. Agree.
C. Undecided.
D. Disagree.
E. Strongly disagree.
January 23, 2009
25.Do you feel this course was commercially biased? (Indicate yes or
no; if yes, please explain in the space provided.)
A. Yes.
B. No.
26.How did you learn about the continuing education activity?
A. Internet.
B. Advertisement (e.g., fact sheet, MMWR cover, newsletter, or
journal).
C. Coworker/supervisor.
D. Conference presentation.
E. MMWR subscription.
F. Other.
Correct answers for questions 1–10.
1. B, 2. D, 3. D, 4. E, 5. C, 6. E, 7. C, 8. A, 9. A, and 10. B.
CE-4
MMWR
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of
charge in electronic format. To receive an electronic copy each week, send an e-mail message to [email protected] The body content should read SUBscribe
mmwr-toc. Electronic copy also is available from CDC’s Internet server at http://www.cdc.gov/mmwr or from CDC’s file transfer protocol server at ftp://ftp.cdc.
gov/pub/publications/mmwr. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington,
DC 20402; telephone 202-512-1800.
Data in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business
on Friday; compiled data on a national basis are officially released to the public on the following Friday. Data are compiled in the National Center for Public
Health Informatics, Division of Integrated Surveillance Systems and Services. Address all inquiries about the MMWR Series, including material to be considered
for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton 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 of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human
Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations
or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses
listed in MMWR were current as of the date of publication.
U.S. Government Printing Office: 2008-723-026/41146 Region IV ISSN: 1057-5987
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