2019 PROVINCIAL GUIDELINE - Trauma Services BC
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2019 PROVINCIAL GUIDELINE
Pre-hospital Triage and Transport Guidelines
for Adult and Pediatric Major Trauma in British Columbia
Trauma Services BC
A service of the Provincial Health Services Authority
Contents
Foreword ...........................................................................................................................................................................................3
Introduction .....................................................................................................................................................................................4
Adult and Pediatric Pre-hospital Trauma Triage Guidelines – Principles ..........................................................................5
Step One – Physiological .................................................................................................................................................... 6
Step Two – Anatomical .........................................................................................................................................................7
Step Three – Mechanism .................................................................................................................................................... 8
Step Four – Special Considerations ................................................................................................................................... 8
Pre-hospital Trauma Triage Standard – British Columbia ......................................................................................................9
Air Ambulance Utilization Guideline – Introduction ......................................................................................................... 10
Helicopter Flight Range from Vancouver ........................................................................................................................ 10
Helicopter Flight Range from Kamloops .......................................................................................................................... 11
Fixed Wing Flying Times and Distances ...........................................................................................................................12
Helicopter On-Scene Response for Trauma Patients (Auto-Launch Protocol) .........................................................13
Appendices ................................................................................................................................................................................15
Appendix A. Lead Trauma Hospitals in British Columbia .............................................................................................15
2 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia
Foreword
From:
Dr. John M. Tallon, Vice President Clinical and Medical Programs, BC Emergency Health Services
Dr. David C. Evans, Medical Director, Trauma Services BC
To:
Regional Health Authority Trauma Medical Directors
Regional Health Authority Trauma Program Operations
Regional Medical Directors, BC Emergency Health Services
Paramedics, BC Emergency Health Services
Developed as a collaboration between BC Emergency Health Service (BCEHS) and Trauma Services BC
(TSBC), this guideline describes the decision making framework for pre-hospital triage and transport
of acute major trauma from the scene of injury to initial hospital assessment and stabilization in British
Columbia.
This guideline was produced by the Joint BCEHS-TSBC Trauma Working Group and references best
evidence including the consensus derived Guidelines for Pre-hospital Triage of Injured Patients produced
by the U.S. Department of Health and Human Services and Centers for Disease Control and Prevention in
2011, as current best practice. The guideline is endorsed by both BCEHS and TSBC on behalf of BC’s five
Regional Trauma Programs representing their respective health authorities.
Special acolades to the exceptional work done by Dr. Wilson Wan, Dr. Sandra Jenneson and Beide Bekele
in completing this guideline.
Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 3Introduction
British Columbia has an inclusive trauma system This document defines a provincial pre-hospital
within which all acute care hospitals play a trauma triage and transport guideline to be utilized
designated role in the care of the injured patient. by BCEHS paramedics and dispatchers. It is intended
Because of B.C.’s expansive and challenging that the Regional Trauma Programs will adapt
geography, all acute care facilities must be prepared this guideline to particular geographic and access
to receive, assess and stabilize major trauma from challenges, resource availability, and other regionally
the field. Level 5 trauma hospitals are generally specific needs. Each Regional Trauma Program will
located in rural and remote regions and provide specify appropriate referral hospitals, bypass criteria,
basic stabilization with the expectation that major and no-refusal policies for reception of the major
trauma will be transferred forward expeditiously trauma patient from the field.
from these centres to a higher level of care at an
appropriate Lead Trauma Hospital (LTH). Lead Given the evolving nature of clinical trauma care and
Trauma Hospitals are designated trauma centres inherent changes within individual health authorities,
that serve defined regional catchment areas. By this document will be reviewed and updated
definition, LTH’s are capable of and expected to regularly as outlined in the Management of EMS
provide definitive care for the vast majority of Guidelines and Procedures for Major Trauma.
appropriately referred major trauma patients.
4 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British ColumbiaAdult and Pediatric Pre-hospital Trauma Triage Guidelines – Principles
Pre-hospital triage guidelines offer a framework to Steps 1 and 2 are designed to identify the most
ensure that acutely injured patients sustaining major seriously injured patients. These patients should be
trauma are directed to a medical facility capable transported to LTHs.
of providing appropriate care within an acceptable
timeframe. Lead Trauma Hospitals are designated The criteria used for bypass to a LTH in Steps 3
trauma centres that serve defined regional and 4 are not absolute; but rather indicators of
catchment areas (Appendix A). the potential for significant injury or need for the
specific support services at the LTHs. Not all patients
The criteria cited below reasonably identify the in these two categories require transport to a LTH
major trauma patients and should be applied by and paramedics should use clinical judgement to
paramedics responding at the scene of injury. determine the need for direct transport to a LTH.
Adult and pediatric patients meeting these criteria
should be directed to the most appropriate trauma Patients in traumatic arrest should be treated
receiving hospital as indicated by regionally adapted according to the BCEHS traumatic arrest protocol
pre-hospital triage guidelines. The pre-hospital (Appendix B).
trauma triage standard includes a four (4) step
decision process:
• Step One: Physiological
• Step Two: Anatomical
• Step Three: Mechanism of Injury
• Step Four: Special Considerations
Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 5Step One – Physiological
Step 1 is to allow for measurement of a critically Adult Trauma Patient:
injured trauma patient’s level of consciousness and • GCS ≤ 13
vital signs. These indicators directly demonstrate
• Systolic blood pressure < 90 mmHg
with high predictive value the severity of injury and
the need to be preferentially transported to a LTH • Respiratory rate < 10 or > 30 breaths per minute
for a higher level of care. or need for ventilatory support
If a paramedic is unable to successfully manage the Pediatric Trauma Patient (Appendix C):
airway in the trauma patient, the patient should be • GCS ≤ 13
transported to the nearest Emergency Department.
• Abnormal vital signs (HR, RR, SBP) for age or need
Adult and pediatric patients who meet any of for ventilatory support
the following physiological criteria should be
If these criteria have not been met, proceed to Step 2.
transported directly to the nearest LTH.
In certain cases, the distance or transport time
from scene to LTH may be too great given the
geographical challenges within the province. As
such, regional destination guidelines (Appendix
F) may dictate that patients who meet physio-
logical criteria be initially transported to the nearest
emergency department. CliniCall or EPOS physician
consultation can be obtained for further advice in
these situations as necessary.
6 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British ColumbiaStep Two – Anatomical
In Step 2, patients do not have abnormal physiologic ** Patients with a major penetrating injury in
criteria present but may have obvious major injuries traumatic arrest with vital signs absent (VSA) are
that indicate a moderate risk for clinical deterioration to be managed by the BCEHS traumatic arrest
or probable need for definitive surgical management protocol, and should immediately be transported
at a LTH. directly to LTH (preferentially) or closest
emergency department, if the time from loss of
Adult and pediatric patients who meet any of the pulse and respiration to hospital is LESS THAN 15
following anatomical criteria should be transported minutes. Otherwise, EPOS consultation should be
directly to the nearest LTH. obtained for decision to transport or discontin-
• Open or depressed skull fracture uation of resuscitation.
• New paralysis or neurological deficits
Similar to Step 1, regional destination guidelines
• Major penetrating injury (defined as all penetrating (Appendix F) may dictate that patients who meet
injuries to head, neck, torso and extremities anatomical criteria be initially transported to the
proximal to elbow or knee) ** nearest emergency department due to great
• Facial injury with potential airway compromise distances or transport time to LTH. CliniCall or EPOS
physician consultation can be obtained for further
• Two or more proximal long-bone fractures
advice in these situations as necessary.
• Crushed, de-gloved, mangled or pulseless
extremity If these criteria have not been met, proceed to Step 3.
• Amputation proximal to wrist or ankle
• Chest wall instability or deformity (e.g. flail chest)
• Major burns (defined as partial thickness burns
> 20%, full thickness burns > 10% (> 2% for
pediatrics), facial or airway burns with or without
inhalation injury, 3rd degree burns involving the
eyes, neck, hands, feet or groin, high voltage
electrical burns)
• Mechanically unstable pelvic fractures
Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 7Step Three – Mechanism
The mechanism of injury (MOI) should be evaluated 2) High Risk Automobile Crash
as some injuries may be occult or in pathophys- a) Intrusion ≥ 0.3 metres occupant site; ≥ 0.5
iological evolution and are more severe. The metres any site, including the roof
evaluation of the MOI will assist in determining if the b) Ejection (partial or complete) from automobile
patient should be transported to a LTH. This factor
c) Death in the same passenger compartment
helps to reduce the possibility of under triage.
d) Vehicle telemetry data consistent with high risk
for injury (if available)
Adult and pediatric patients with any of the following
criteria should be preferentially transported to a LTH 3) Auto vs. pedestrian/bicyclist thrown, run over or
if any of the following are present: with significant (≥ 30 km/h) impact
1) Falls 4) Motorcycle crash ≥ 30 km/h
a) Adults ≥ 6 metres (one story is equal to 3
metres) CliniCall or EPOS physician consultation can be
obtained for advice if required in the decision
b) Children ≥ 3 metres or two to three times the
making process.
height of the child
If these criteria have not been met, proceed to Step 4.
Step Four – Special Considerations
Patients may have underlying conditions that could 1) Age
put them at a greater risk for severe injury. These • Older adults
criteria are indicators of the potential for significant – Risk of injury/death increases after age 55
injury or indicate that the patient may require other
– SBPPre-hospital Trauma Triage Guidelines – British Columbia
Failed airway1 YES • Transport to the nearest emergency department
NO
Blunt traumatic arrest • Obtain EPOS Consultation to consider discontinuation
YES of resuscitation
NO
Penetrating traumatic arrest • Transport to Lead Trauma Hospital (preferentially) or
(due to penetrating injury to head, neck and/or torso) Nearest Emergency Department if time from loss of pulse
YES and respiration to arrival at hospital is < 15 minutes
• Otherwise, obtain EPOS Consultation to determine
decision to transport or discontinuation of resuscitation
NO
Step 1: Physiological
Physiological criteria (any of the following): • Transport to nearest Lead Trauma Hospital OR Pediatric
• Adult: Lead Trauma Hospital
– SBP < 90 • If transport distance or time to LTH too great (based
– RR < 10 or > 30 or need for ventilatory support on regional trauma guidelines), transport to nearest
YES emergency department
– GCS ≤13
• Pediatrics:
– Abnormal SBP, HR, RR for age or need for ventilatory support
– GCS ≤ 13
NO
Step 2: Anatomical
Anatomical criteria (any of the following): • Transport to nearest Lead Trauma Hospital OR Pediatric
• Open or depressed skull fracture Lead Trauma Hospital
• New paralysis or neurological deficits • If transport distance or time to LTH too great (based
• Major penetrating injury on regional trauma guidelines), transport to nearest
• Facial injury with potential airway compromise emergency department
• Two or more proximal long bone fractures YES
• Crush, degloved, mangled, or pulseless extremity
• Amputation proximal to wrist or ankle
• Chest wall instability or deformity (i.e. flail chest)
• Major burns
• Unstable pelvis
NO
Step 3: Mechanism
Mechanism criteria (any of the following): • Consider transport to Lead Trauma Hospital OR Pediatric
• Falls Adult: > 6m (20 feet) Lead Trauma Hospital
• Falls Pediatrics: > 3m (10 feet) or 2-3 times the height of the child • Otherwise, transport to nearest emergency department
• MVA: intrusion/ejection/death in vehicle YES as per regional trauma guidelines
• Pedestrian or bicyclist struck > 30 km/hr, thrown or run over
• Motorcycle collision at > 30 km/hr
NO
Step 4: Special considerations
Special considerations (any of the following): • Paramedic judgement and local destination protocols to
• Elderly guide transport destination
• SBP < 110 in age > 65 • Consider CliniCall or EPOS consultation for further guidance
• Anticoagulation YES
• Pregnancy > 20 weeks
• Pediatric patients should be preferentially transported to Pediatric
Lead Trauma Hospitals
NO
Transport to nearest emergency department
1.
Failed airway = failure to maintain patency Triage
Pre-hospital by ANYand
means. If youGuidelines
Transport can oxygenate/ventilate, then it isMajor
for Adult and Pediatric not a failed
Trauma airway.
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Air Ambulance Utilization Guideline – Introduction
The BCEHS Critical Care Transport Program provides The Auto-Launch program is available within the
specialized, emergency patient care and transport flight ranges of dedicated helicopters located in
for the critically injured trauma patient across the Vancouver and Kamloops. The helicopter has a flight
province. “Auto-Launch” is an innovative, life-saving range of approximately 300 nautical miles without
protocol that helps ensure that patients with refueling at a speed of 115 nautical miles per hour.
life-threating injuries are transported to a trauma As such, the deployment area is considered to be
centre as quickly as possible. The Auto-Launch within 60-75 flight minutes for Auto-Launch calls.
protocol simultaneously dispatches both a ground
ambulance and a helicopter with a critical care
transport crew based on information provided from
the scene by 911 callers.
10 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British ColumbiaLamming
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Passmore
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Lumberton
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p
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Denman
Fanny Tuwanek Lions River Tulameen Jura Carmi Elko
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Renata
Hall Baynes
Bay Creek Moyie
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Bay Beaverdell Park
p
Bay ?
! Choate Lake
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p
Davis
Qualicum Beach Gibsons HarrisonRuby Princeton Ymir Sirdar
Sechelt Bay GATE Hope o
n Valley Okanagan Salmo
p
Dunsmuir Othello Hedley Blueberry
Dashwood ST PAULS Hot Creek Floods Falls Wynndel Arrow Grasmere
!
p
Parksville ? Creek
Kleecoot
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p
HOSPITAL
!
? Hilliers Springs
p
Willowbrook
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?
Errington Nanoose
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n n!
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n? COLUMBIAN Olalla Rhone Paulson
Trail Warfield o
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Bay Lantzville Miracle Harrison
VANCOUVER n o ?n
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! GENERAL ?
! Rosedale
Oliver Deadwood
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Inkaneep McKinney Christina
ABBOTSFORD n
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n
o
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Kettle Silica Montrose
!
? !
? Kerr
p
Lake
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o from Kamloops Airport
n
BCEHS: Flying Times Rock (CYKA) and n
o Hospital Airport 60NM, 30 Minutes from 30 Minute Drive Time To
0 15 30 60 km Geographic
´
p
? n o CYKA Trauma Receiving\Tertiary National Park
o
n
!
?
?
! Drive Times from Trauma n
o
! ?!
!
o
n
Receiving
? and Tertiary Trauma Facilities o
n Hospital\Health Facility with
!
? Helipad 120NM, 60 Minutes from
Trauma Facility
Provincial Park
Prince Prince
Rupert George
Data Sources:
BCEHS & Province
Helipad
30, 60 & 75 Minute Flying Time from Kamloops Airportn
o 0 10 20 40 NM
?(CYKA) & 30 Minute Drive Times from Trauma Receiving
! Major Road CYKA British Columbia Border Kamloops of British Columbia
o
n Trauma Hospital Wooded Area
p
Vancouver
& Tertiary Trauma Facilities (Vancouver General, St Paul’s, Lions Gate, BC Children’s Hospital, Royal Columbian, 150NM, 75 Minutes from First Nations Reserve 1:2,000,000 Victoria
Abbotsford Regional, Royal Inland (Kamloops), Kelowna General, Penticton Regional, Vernon Jubilee & Victoria General) CYKA
o
n Trauma Hospital with Helipad Extent of Map
Produced by F Shew
Helicopter Flight Range from Kamloops
Map Credit: Frances Shew, Corporate Data Analyst (GIS), BCEHS
The East Kootenay Auto-Launch is a version
of Auto-Launch program modified for the East
Kootenay Health service area that utilizes both
BCEHS and STARS (Shock Trauma Air Rescue
Society via Alberta Air Ambulance) resources
and consists of both helicopter and fixed-wing
responses. Region specific details on the
Auto-Launch protocol can be found in Appendix D.
Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 11!
Fort
Nelson
Fort
St !!
John
!
Stewart !
Dawson
Chetwynd ! Creek
! Mackenzie
!
Gitwinksihlkw
! !
Gingolx Fort
!
Smithers St
James
BC Emergency Health Services Prince
!
Terrace Burns !
Flying Distances for Fixed Wing
!
Rupert Lake
!
Aircraft (King Air 350) from
!
Masset !
Vancouver, Kelowna &
Prince George Airports Queen
Kitimat
PRINCE
oPrince
!
Charlotte
GEORGE George !
!
AIRPORT McBride
Flying Distances from Airports
!
Quesnel
Airport & Distance\Flight Time
KELOWNA AIRPORT,
300NM - 1 hour flight Bella Bella Williams
!
Bella Coola Lake
!
PRINCE GEORGE AIRPORT, !
300NM - 1 hour flight 100
Mile !
Clearwater Golden
VANCOUVER
!
House !
INTERNATIONAL AIRPORT,
300NM - 1 hour flight !
Salmon Revelstoke
VANCOUVER Arm
Port Ashcroft !
Invermere
INTERNATIONAL AIRPORT, Alert !
!
450NM - 1.5 hour flight Hardy! Bay !
Lillooet Kamloops
!
KELOWNA Nakusp
Port !
!!
Vernon !
Port
AIRPORT New !
!
o Airports ( Kelowna, Prince
George & Vancouver)
Alice McNeill Campbell
River Powell
!
Lytton !
Merritt
o Kelowna
!
Denver !
Kaslo
Sparwood
!
!
Fernie
Tahsis !
River !
!
VANCOUVER Cranbrook
!
Squamish Summerland
!
Nelson
BC Border Comox
! INTERNATIONAL
!
Princeton
!
!
!
Hope ! Penticton !
Castlegar
Port ! AIRPORT !
!
Creston
Alberni ! Oliver Grand !
Trail
oVancouver
!
!! !! !
!! Chilliwack
Nanaimo
! !
Forks
´
0 25 50 100 NM !
!
! ! !
!
!
!
Tofino Ladysmith!
!
! !
Chemainus! !
0 40 80 160 km !
Duncan
!
1:7,000,000
Victoria!!!!!
Produced by F Shew
138°0'0"W 137°0'0"W 136°0'0"W 135°0'0"W 134°0'0"W 133°0'0"W 132°0'0"W 131°0'0"W 130°0'0"W 129°0'0"W 128°0'0"W 127°0'0"W 126°0'0"W 125°0'0"W 124°0'0"W 123°0'0"W 122°0'0"W 121°0'0"W 120°0'0"W 119°0'0"W 118°0'0"W 117°0'0"W 116°0'0"W 115°0'0"W 114°0
Fixed Wing Flying Times and Distances
Map Credit: Frances Shew, Corporate Data Analyst (GIS), BCEHS
Requests for air ambulance trauma responses The EWFL program includes geographic areas
outside the Auto-Launch prescribed operating serviced by the Northern Health Authority, Island
areas should be considered for an Early Fixed Health Authority (northern Vancouver Island),
Wing Launch (EFWL). EFWL provides a primary Interior Health Authority (communities outside
fixed-wing resource for areas of BC that are Station 370 and STARS ranges), and Vancouver
not accessible by the Auto-Launch program Coastal Health Authority (communities of Bella
to improve transfer times for trauma patients. Bella and Bella Coola). Additionally, EFWL provides a
The EWFL program relies on aircraft that are secondary air resource, when appropriate, for areas
based in Vancouver, Kelowna and Prince George. covered by Auto-Launch but where the dedicated
helicopter is unavailable for patient transfer.
12 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British ColumbiaHelicopter On-Scene Response for Trauma Patients (Auto-Launch Protocol)
Auto-Launch is a dispatch protocol and is the In addition to the MPDS and continuation criteria,
automatic dispatching of dedicated helicopters with the transport time from accident scene to the
a critical care transport (CCT) crew to a specific set LTH by ground ambulance must be greater than
of MPDS criteria. 30 minutes.
The following two criteria must be met by a patient Once the CCT crew arrive at the scene and assess
to qualify for an air ambulance on scene response: the patient, they may decide to:
• Transport the patient by air to the LTH
Criteria #1: MPDS Auto-Launch criteria AND
• Accompany the patient by ground with the
Criteria #2: Meeting the continuation criteria BCEHS ground crew to the LTH
AND / OR The patient is not accessible
• Direct the BCEHS ground paramedics to the
within a reasonable treatment window.
appropriate local hospital without the support
of the CCT crew
When Criteria #1 is met, based on the 911 call
information and MPDS coding, the helicopter will
BCEHS ground paramedics on scene may decide
be launched directly to the scene. Once the ground
to cancel the Auto-Launch if:
ambulance crew arrives at scene, they will assess
for continuation criteria (Criteria #2). If the patient • The patient does not meet the Auto-Launch
meets the continuation criteria, the helicopter will continuation criteria
continue to the scene. If the patient is not accessible • The response time of the aircraft and CCT crew
by ground ambulance within a reasonable treatment is longer than the drive time to the LTH
window, the helicopter will continue to scene
without confirmation of continuation criteria.
If the call’s circumstances and patient fail to meet
the continuation criteria and an air ambulance is
known to be responding based on the merits of the
initial request (i.e. 911 call), the ground paramedic
will obtain CliniCall consultation to confirm that an
on-scene response is not required.
Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 13Conclusion
The introduction of the Pre-hospital Trauma Triage Guidelines and Air Ambulance Utilization Standard for
Trauma in British Columbia is based on expert medical opinion guided by established existing evidence.
The goal is to improve the outcomes of severely injured trauma patients by providing paramedics with the
necessary criteria to apply when assessing trauma patients in the pre-hospital environment and determining
the most appropriate receiving facility.
For any questions, comments or change requests, please email Trauma Services BC at tsbc@phsa.ca
14 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British ColumbiaAppendix A. Adult and Pediatric Lead Trauma Hospitals
in British Columbia
Health
Authority Location Name of Facility Level
FHA New Westminster Royal Columbian Hospital Level 1
Abbotsford Abbotsford Regional Hospital and Cancer Centre Level 3
IHA Kamloops Royal Inland Hospital Level 2
Kelowna Kelowna General Hospital Level 2
Cranbrook East Kootenay Regional Hospital Level 3
Penticton Penticton Regional Hospital Level 3
Trail Kootenay Boundary Regional Hospital Level 3
Vernon Vernon Jubilee Hospital Level 3
Williams Lake Cariboo Memorial Hospital Level 3
NHA Prince George University Hospital of Northern British Columbia Level 3
Fort St. John Fort St. John Hospital Level 4
Quesnel GR Baker Hospital Level 4
Terrace Mills Memorial Hospital Level 4
PHC Vancouver St. Paul’s Hospital Level 3
PHSA Vancouver British Columbia Children’s Hospital (Pediatric LTH only) Level 1
VCH Vancouver Vancouver General Hospital (Adult LTH only) Level 1
North Vancouver Lions Gate Hospital Level 3
VIHA Victoria Royal Jubilee Hospital Level 2
Victoria Victoria General Hospital Level 2
Nanaimo Nanaimo Regional General Hospital Level 3
Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 15You can also read
