Trauma Patient Assessment & Transport

• Reducing the time from injury to definitive care decreases morbidity and mortality.
• These guidelines help emergency responders identify and transport trauma patients appropriately.
• Field assessments are subject to time, distance, patient condition, and level of care variables, so the guidelines are meant to support, but not replace, medic/EMT judgment.
• Fire and EMS agencies should review these guidelines annually.
• The Ohio Prehospital Trauma Triage Decision Tree SB214 can aid in determining the appropriate facility for the patient.

Key Concepts

• Rapid field evaluation, treatment, and transport are crucial for trauma patient outcomes.
• On-scene time should be limited to 10 minutes or less unless there are extenuating circumstances.
• Trauma Center refers to a facility with A.C.S. verification or one meeting A.C.S. guidelines with verification in process.
• Medical control is encouraged, particularly for difficult cases.
• Pre-arrival notification using the phrase "Trauma Alert" is essential.

Trauma Center Capabilities

• Level I and II Trauma Centers offer the same level of care and can be used interchangeably.
• Level III Trauma Centers provide initial assessment, resuscitation, and stabilization, possibly including emergency surgery.
• Level III Trauma Centers must have transfer agreements with the nearest Level I and II Trauma Centers.
• In areas where a Level III center is the only verified facility within 30 minutes, it serves as the primary receiving facility for critically injured patients.
• When a Level I or II center is within 30 minutes, EMS providers should use professional judgment to decide between immediate stabilization at a nearby Level III center versus direct transport to a Level I or II center.
• General acute care hospitals with 24-hour Emergency Departments can stabilize critically injured trauma patients, especially where no verified Trauma Centers are within 30 minutes.
• General acute care hospitals should have transfer agreements with the nearest Level I and II Trauma Centers.
• Pediatric trauma patients should be taken to the nearest Pediatric Trauma Center.
• Pregnant trauma patients should be transported to the nearest Adult Trauma Center.

Using the Guidelines

• Determine if the patient qualifies as a trauma patient, considering different criteria for pediatric (under 16 years), adult (16-65 years), and geriatric (over 65 years) patients.
• Decide the appropriate transport method and destination.
• Proceed to the chosen facility.

Hospital Transfer of Trauma Patients

• Written protocols and agreements between facilities are required for trauma patient transfer.
• EMS and local facilities should discuss each other's capabilities.
• The ED Capability Study can serve as a resource.
• The Ohio Department of Public Safety and the Ohio Department of Health publish a list of recognized trauma centers.

Exceptions

• Emergency personnel must transport a trauma victim to a qualified adult or pediatric trauma center unless:
  • It's medically necessary to go to another hospital for initial assessment/stabilization.
  • Adverse weather/ground conditions or excessive transport time make direct transport unsafe.
  • Transporting to a trauma center would cause a shortage of local EMS resources.
  • No appropriate trauma center can receive the patient without undue delay.
  • The patient (or their family/legal representative if the patient is a minor or unable to communicate) requests transport to a non-trauma center hospital.

Additional Notes

• Amendments to state trauma triage protocols automatically apply to regional/organizational protocols until the region updates its protocols.
• Level II and III trauma centers may offer different clinical services.
• Protocol SB214 can help EMS providers decide who needs direct transport to a trauma center, based on Ohio's trauma triage criteria.

Adult Trauma Patient Evaluation Criteria (Age 16-64)

• Physiological Criteria:
  • Significant signs of shock or poor perfusion: cold, clammy skin, decreased mental status, weak pulse, pallor.
  • Pulse > 120 or < 50.
  • Systolic blood pressure (SBP) < 90 (Geriatric patients may be in shock with SBP < 110).
  • Absence of radial pulse when carotid pulse is present or change in pulse character.
  • Airway or Breathing Difficulties: Respiratory rate < 10 or > 29, need for ventilator support.
  • Neurologic Considerations: Evidence of Head Injury, GCS scale < 13, AVPU scale not responding to Pain, Unresponsive, alteration in LOC, loss of consciousness > 5 min, failure to localize pain.
  • Suspected spinal cord injury (paralysis, sensory loss).
  • Anatomic Criteria:
• Penetrating trauma to head, chest, abdomen, neck, or extremities proximal to knee or elbow.
• Extremity injuries with: Amputations proximal to wrist or ankle, visible crush injury, fractures of two or more proximal long bones, neurovascular compromise.
• Tension pneumothorax that is relieved.
• Injuries to the head, neck, or torso with: Visible crush injury, abdominal tenderness/distention/seat belt sign, suspected pelvic fracture, flail chest, open skull fracture.
• Signs or symptoms of spinal cord injury.
• Submersion Injuries, Strangulation & Asphyxia
• Burns: Second or third-degree burns > 10% TBSA, or significant burns to face, feet, hands, genitalia, or airway.
• Other Considerations (High suspicion warranted):
  • Significant Mechanisms of Injury: ATV/Motorcycle crashes, significant falls (20’), high-risk auto crash, MVC ejection, death in same compartment, auto vs. pedestrian/bicycle (thrown, ran over, > 20mph), vehicle telemetry data consistent with high risk of injury.
  • Age > 65.
  • Anticoagulation and evidence of traumatic brain injury.
  • Pregnancy:
    • Optimal resuscitation of the mother is the best initial treatment for the fetus.
    • Pregnant patients can lose significant blood before showing typical signs of hypovolemia.
    • Severe maternal shock is associated with a high fetal mortality rate (80%).
    • The fetus may be in distress even if the mother's vital signs appear stable.
    • Maintain maternal oxygen saturation >95%.
    • Use vasopressors cautiously due to their effect on utero-placental perfusion, only for intractable hypotension unresponsive to fluids.
    • After mid-pregnancy, displace the gravid uterus off the inferior vena cava (manual displacement or left lateral tilt 30°).
    • Fetal loss can occur even with no abdominal injuries to the mother.
    • While severe injuries are more likely to cause fetal loss on a case basis, most fetal losses due to trauma result from minor maternal injury mechanisms because of the higher frequency of minor trauma during pregnancy.
    • Intubation is more difficult; a smaller ET Tube is recommended.
    • Insert 2 large bore IVs for rapid crystalloid infusion and possible blood transfusion.
    • Avoid focusing solely on the fetus.
    • Question trauma patients specifically about domestic or intimate partner violence.
    • Call medical control with any questions and notify the receiving hospital.

Transportation of the Adult Trauma Patient

• Ground Transportation:
  • 30 minutes or less to a Trauma Center (excluding uncontrolled airway or traumatic CPR).
  • Greater than 30 minutes: consider the nearest appropriate facility.
• Ground Transportation Guidelines: transport to the nearest appropriate facility if:
  • Airway is unstable and cannot be controlled/managed.
  • Potential for unstable airway (facial/upper torso burn).
  • Blunt trauma arrest (no pulses or respirations) if indicated per C308.
  • Patient does NOT meet trauma patient criteria.
• *** PRE-ARRIVAL NOTIFICATION OF THE RECEIVING FACILITY IS ESSENTIAL!!!****
• Air Medical Transportation:
  • Avoid prolonged delays at the scene waiting for air medical transport.
  • If air transport is unavailable (e.g., weather), transport by ground guidelines.
  • If air transport is dispatched and the patient is being taken to the nearest non-trauma center, divert the helicopter to the hospital.
  • Air Medical Programs share the responsibility to educate EMS units and facilities on appropriate triage and should institute a utilization and quality review program.
  • Patients with uncontrolled ABCs should be taken to the closest appropriate facility (24-hour emergency department) if faster than waiting for air medical transport.
  • Traumatic cardiac arrest due to blunt trauma is not appropriate for air transport.
• Reasons to Consider Air Transport:
• Prolonged extrication.
• Multiple victims/trauma patients.
• Time/distance factors: If ground transport to a trauma center is >30 minutes AND ground transport to the nearest trauma center is longer than the total transport time to a trauma center by helicopter.
• Total transport time includes scene time and transport time.
• In rural environments, immediate air medical transport may be appropriate for severely traumatized patients if it doesn't significantly delay treatment for life-threatening injuries.

Geriatric Trauma Patients (≥ 65 Years)

• Geriatric trauma patients should be triaged for evaluation at a trauma center for:
  • Glasgow Coma Score ≤ 14 with known or suspected traumatic brain injury.
  • Systolic blood pressure < 110 mmHg or pulse > 90.
  • Falls from any height, including standing falls, with evidence of traumatic brain injury.
  • Pedestrian struck by a motor vehicle.
  • Known or suspected proximal long bone fracture sustained in a motor vehicle crash.
  • Injury sustained in two or more body regions.
  • Anticoagulation and evidence of traumatic brain injury.
  • GCS scale < 13 or AVPU scale that does not respond to Pain or Unresponsive.
  • Alteration in LOC during examination or thereafter; loss of conscious > 5 min.
  • Failure to localize pain.
• Special consideration for trauma center evaluation should be given to geriatric patients with: diabetes, cardiac disease, congestive heart failure, CVA, pulmonary disease (COPD), clotting disorder (including anticoagulants), immunosuppressive disorder (HIV/AIDS, organ transplant, chemotherapy, long-term use of corticosteroids), or those requiring dialysis.

Anatomy of Injury (All ages)

• Penetrating injury to head, neck, or torso
• Crush injury of head, neck or torso
• Open skull fracture
• Flail chest
• Abdominal tenderness, distention, or seatbelt sign
• Pelvic fracture
• Spinal cord injury
• Penetrating injury proximal to knee or elbow w/neurovascular compromise
• Amputation proximal to wrist or ankle
• Crush of arm or leg
• 2 humerus and/or femur fractures
• Arm or leg injury with neurovascular compromise
• 2° and 3° burn injury > than 10% TBSA
• Significant burns of face/hands/feet/genitals/airway
• Drowning, near-drowning, strangulation, and asphyxia

Trauma patient assessment and transportation guidelines prioritize rapid assessment, treatment, and transport to appropriate facilities. The goal is to minimize on-scene time, ensure pre-arrival notification, and utilize trauma triage criteria for facility selection. Medical direction is encouraged in difficult cases.