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Adopting ACS guidelines to guide transport decisions

Revamped triage criteria streamline decision making and relieve the burden on hospital systems


“We must take things into our own individual hands to make the best decisions for our patients. Keep the red stuff inside and the air going in and out of the right places,” writes Heggie.

Photo/Brandon Heggie

This article originally appeared in the EMS1 Digital Edition, “Prehospital trauma: Today’s tenets for triage, treatment and transport.” Download the free special report here.

Give me the definition, what is a Step 3 trauma? OK, better yet, where should you take a step 3 trauma? What about a Step 4? It’s not easy to keep it all straight and figure out where trauma patients should be transported. Today we are going to talk about how the trauma triage guidelines have affected us in the past and what has been done to remedy much of the confusion regarding transport decision making in reference to destination.


Historically, we have been relying on the American College of Surgeons’ 4-tiered trauma triage guidelines which are supposed to assist in our decision making on where to transport our patients. Those steps are broken down as such:

  • Step 1 – Vital sign changes (blood pressure, pulse, respiratory rate, mental status)
  • Step 2 – Anatomy of injuries (paralysis, flailed segments, penetrating trauma, bilateral long-bone fractures, etc.)
  • Step 3 – Mechanism of injury (MVC, car vs. pedestrian, falls, death of occupant in the same vehicle, intrusion of vehicle, etc.)
  • Step 4 – Everything else (History including anticoagulants; age extremes; medic gut feeling, etc.)

For bigger cities with Level 2 or higher trauma centers, this isn’t that big of an issue. For more rural agencies, like mine, we only have a level 4 trauma center in town, with a level 3 about 30-45 minutes. To get to a level 1 trauma center, Harborview Medical Center, it takes about a 1.5 hour drive or 30 minute flight from here.

Our decision making of where we are going must be made quickly, abruptly and with accuracy. Going through the triage guidelines didn’t make that decision easy, until now. Previous guidelines did not specify what level of hospital to take different triage levels to. Vague phrases like, “preferentially to the highest level of care within the trauma center,” and, “consider transport to a trauma center or specific resource hospital,” lead to confusion.

I had the unique opportunity to sit in a trauma lecture for my county, put on by a trauma surgeon from Harborview Medical Center that presented data of all the patients transported to Harborview via ground transportation for trauma in the Puget Sound region. The data that made us scratch our heads (and identify that change that was needed), is how many step 3 and 4 traumas went to Harborview, bypassing lower level trauma centers, purely because the guidelines led to the “trauma center.” This is an inappropriate transport decision, not only for the patient, but for the prehospital/hospital system in the region as a whole.

ACS National Guidelines for the Field Triage of Injured Patients

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In 2022, the American College of Surgeons met and finalized the updated version of the National Guideline for the Field Triage of Injured Patients, making some rather important changes. No longer are we utilizing a 4-tier system. Instead, the ACS has decreased to two tiers and made the guidelines read to make a little more sense.

We now have “Red Criteria – High Risk for Serious Injury” and “Yellow Criteria – Moderate Risk for Serious Injury.” These split the two categories down the middle. Red Criteria now contains the Step 1 and Step 2 traumas, meaning patients with vital sign changes or anatomic injuries are now high risk for serious injury, indicative they should go to the highest-level trauma center. Yellow Criteria patients (formerly Step 3 and 4) should be transported to a trauma center as available within the geographic constraints of the regional trauma system, which needs not be the highest-level trauma center.

The guidelines also added additional categories to Red Criteria. Active bleeding requiring a tourniquet or wound packing with continuous pressure, as well as a different shock index/blood pressure change for patients over 65 years old qualify as Red Criteria. Yellow Criteria changed to include all falls from heights over 10 feet (so it is not broken up by age).


By revamping these guidelines, we have been able to spread the load of trauma patients more appropriately through our overwhelmingly taxed hospital and prehospital systems. But just because we changed a guideline, doesn’t mean it is going to work.

Why am I being so pessimistic? Well, we as providers must study the guidelines, and we must know what every hospital in our region is capable of and how long it takes to get there via ground or air. It’s more than following a graph. It’s about being an experienced provider with an understanding of the system as a whole.

We must take things into our own individual hands to make the best decisions for our patients. Keep the red stuff inside and the air going in and out of the right places. In the world of trauma, EMS is purely a Band-Aid. The only thing that fixes trauma, is cold steel in an operating room. We just have the responsibility to get the patient to the right place in either the same or better condition. So let’s be serious about our decision making.

Brandon Heggie has been working in fire and EMS for over 15 years. He has numerous experiences ranging from being a tactical medic on a SWAT team, to a high angle rope rescue tech. He is currently a lieutenant firefighter/paramedic for a busy cross-staffed department. He obtained an Associate’s Degree in Emergency Medicine and Health Services.