Medic Basics

Prehospital and transport

Field Triage of Injured Patients Algorithm

Where to take one injured patient: the 2021 national guideline, red then yellow

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Any red injury pattern?

  • Summary of the 2021 national field triage guideline (ACS-COT; Newgard 2022) for single-patient 9-1-1 trauma, not mass casualties; see the full ACS algorithm
  • Penetrating wound to the head, neck, torso or proximal limbs
  • Skull deformity or suspected skull fracture; suspected spinal injury with new weakness or numbness
  • Unstable or deformed chest wall (suspected flail chest); suspected pelvic fracture; two or more suspected proximal long-bone fractures
  • Crushed, degloved, mangled or pulseless limb; amputation above the wrist or ankle; bleeding that needs a tourniquet or packing with pressure

Yes → step 2No → step 3

2 Red: highest-level trauma center

  • Transport to the highest-level trauma center within the regional system (Newgard 2022)
  • Children meeting red criteria: a pediatric-capable trauma center is preferred (Newgard 2022)
  • Prenotify early

Unstable airway, severe shock or traumatic arrest → step 4Stable enough for the drive → step 5

3 Red mental status or vital signs?

  • All ages: cannot follow commands (motor GCS under 6); respiratory rate under 10 or over 29; respiratory distress or need for respiratory support; room-air SpO₂ under 90% (Newgard 2022)
  • Age 0–9: SBP under 70 + (2 × age in years) (Newgard 2022)
  • Age 10–64: SBP under 90, or heart rate greater than SBP (Newgard 2022)
  • Age 65 or more: SBP under 110, or heart rate greater than SBP (Newgard 2022)

Yes → step 2No → step 6

4 In extremis: closest hospital may come first

  • A patient who cannot keep an airway, is in severe shock or is in traumatic arrest may need the closest hospital for stabilization, then transfer to a level I or II center (Newgard 2022)
  • Follow your regional protocol and medical direction
  • Traumatic arrest: use the Traumatic Cardiac Arrest algorithm

End of this path.

5 En route: prenotify and reassess

  • Give the receiving team the criteria met, vital signs and ETA
  • Repeat vital signs and mental status; any new red finding changes the destination if a closer suitable center allows
  • Document which criteria were met and why the destination was chosen

End of this path.

6 Any yellow mechanism?

  • Vehicle crash: ejection (partial or complete), significant intrusion, need for extrication, a death in the same passenger compartment, vehicle telemetry suggesting severe injury
  • Child 0–9 unrestrained or in an unsecured child safety seat (Newgard 2022)
  • Rider separated from a motorcycle, ATV, horse or similar with significant impact
  • Pedestrian or cyclist thrown, run over or struck with significant impact
  • Fall from more than 10 ft, any age (Newgard 2022)

Yes → step 7No → step 8

7 Yellow: a trauma center

  • Transport to a trauma center; it need not be the highest level (Newgard 2022)
  • Reassess on the way: new red findings move the patient up

Prenotify and reassess → step 5

8 EMS judgment: any risk factor?

  • Low-level fall with significant head impact at age 5 or under, or 65 or more (Newgard 2022)
  • Anticoagulant or antiplatelet use; pregnancy beyond 20 weeks (Newgard 2022)
  • Burns together with other trauma: a trauma center with burn care; if none, the trauma center comes before a burn center (Newgard 2022)
  • Suspected child abuse; special high-resource health care needs

Yes → step 9No → step 10

9 Yellow (EMS judgment): a trauma center

  • EMS judgment criteria are yellow: transport to a trauma center; it need not be the highest level (Newgard 2022)
  • Weigh them against the resources of your regional trauma system, and consider online medical direction (Newgard 2022)

Prenotify and reassess → step 5

10 No criteria met

  • Transport to the closest appropriate hospital per local protocol
  • Criteria miss injuries: if your exam worries you, call medical direction about the destination

Patient is 65 or older → step 11Prenotify and reassess → step 5

11 Older adult: look again

  • The red SBP line is higher at 65 or more: under 110, or heart rate greater than SBP (Newgard 2022)
  • Beta-blockers and pacemakers can hide shock; anticoagulants and a head strike from standing are EMS judgment criteria
  • Seriously injured older adults should be managed in trauma centers (Newgard 2022)

A risk factor applies → step 9None applies → step 5

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