2019 PROVINCIAL GUIDELINE

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in

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 3 Introduction

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 Columbia Adult 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 5 Step 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 Columbia Step 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 7 Step 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 – SBP <110 may represent shock after age 65 support services available at the LTH. Patients who • Children meet any of these criteria are recommended to be – Should be triaged preferentially to a transported to a LTH or to a hospital that is capable pediatric-capable trauma centre of a complete evaluation and timely treatment. 2) Anticoagulation and bleeding disorders Paramedic judgement and local destination or 3) Burns with trauma mechanism bypass protocols can be used to help determine transport destination. CliniCall or EPOS physician 4) Pregnancy ≥ 20 weeks consultation can be obtained for advice if required If these criteria have not been met, transport the in the decision making process. patient to the closest, most appropriate emergency department.

8 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Pre-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 YES on regional trauma guidelines), transport to nearest – GCS ≤13 emergency department • 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

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Winter Stump North Fort p Golden Kokish Cracroft Birken Spences Pass Harbour McNeill Port Roy Lake Vernon Kedleston Bonaparte Chu Nicholson Beaver Cove Pemberton Gramsons Bridge Chua Mahatta Neville 70 Banff Yreka Meadows Darfield River Hardwicke Thurlow Brem no Mile Seymour Creekside p Lavington no!? Port Island Blind River Clapperton VERNON House Arm Big Jesmond Albas Alice Hkusam Channel Owl JUBILEE Barriere Parson Vermilion Bay Creek Agate Coldstream Big p Chasm Crossing Stuart Cedar Castledale Rock Pemberton Fintry Bar Vidette Louis Nimpkish Owen Island p Douglas Grove Woods Big Harrogate Bay Homfray noLytton p Creek Clinton CreekExlouBlucher Elk Bay Lower Quilchena Lake Carrs Oyama Hall Landing Eddy Kootenay Creek Nicola Spillimacheen Bay Surge Nicola Nahun McLure Adams Crossing Granite Canford Woodsdale Magna Craigellachie no Revelstoke Narrows Coyle nop Kelly Lake p Bay Kanaka Winfield Bay Anglemont Malakwa Brisco Read ?! Lake ScotchCelista Bold Bar Black Pines Cahilty Island Squirrel Merritt Creek Point Tamarisk McKinley Cove no!? Whistler Solsqua Sicamous Heriot Refuge LandingEllisonp Cache Heffley Chase Squilax Balmoral Camborne Radium Bloedel Alta Edgewater Bay Whaletown Cove Sproatt Moha Pavilion KAMLOOPS Creek Chamiss Duncan Bay Seaford Lake Kelowna Gold Creek Annis Beaton Hot Fair Aspen GENERAL Brexton Boston Shuswap Bay Quathiaski Mansons !? CopperAIRPORTRayleigh Springs Harbour ?! Bliss Grove ?!no Bridge Flats Galena Ferguson Campbellton?!Cove Landing Chaumox Glenrosa Ogden Savona Creek Pinantan Dry Gulch Kyuquot ! Landing p Salmon Bay Trout no ? Westbank Myra Bralorne Fountain Walhachin Lake no Mara Wilmer Campbell Lund Garibaldi Skookumchuck Gellatly McCulloch Shalalth no Tranquille Lake Zeballos Braeloch Seton p MontePritchard p Powell North Bend Trépanier !? Arm no!?p River Boston Portage no?! Kamloops p?!no Creek Grindrod Hupel p River Brookmere Peachland p Ashcroft Silver Kingfisher Bar Lillooet ROYAL Holmwood Creek Invermere no Oyster Sliammon McGillivray Beresford EnderbyAshton Esperanza Wildwood Hells Chute INLAND Bestwick Ya nke e River Cranberry Greata Monte Creek Poplar Ceepeecee no!? Cheakamus Gate Bankeir Lake Spatsum Flats Williams Westviewp Port Roy D'Arcy Lac Brigade Lake Falkland Creek To by Black Creek Beach Myrtle Douglas Jellicoe Devine Westwold Glenemma p Nuchatlitz Blubber Lang Saltery p Chapmans Gates Le Lake Creek Merville Brew Brackendale Naramata Birken Armstrong Bay Point Bay Earls Spuzzum Thurlow Brem Jeune Trinity Grantham Van BayStillwaterBay Egmont no Blind Pemberton Gramsons Spences Howser Headquarters Summerland Big River Logan Stump Gold ?! Little Anda Cove Channel Meadows Bridge Valley Mabel Shoreholme Billings Doriston no!? Squamish Creekside Lake VERNON Marblehead River River Rock Bay Lake Courtenay p Gillies Bay Garden Woodfibre Church Owl Lake JUBILEE Lumby p Meadow Creek Owen Clapperton Shuswap no!? Cooper Creek Elkford pno!? Comox Bay Britannia Tulameen Jura PENTICTON Bay House Creek Cherryville Round Bevan Bay Madeira Alvin Silver no Elk Bay Homfray no Falls Argenta Canal REGIONAL Penticton Pemberton Vernon Lavington Summit Lardeau Prairie Park Beach River Coalmont p Bay Granite Creek p Agate p Cumberland no McNab Bear Dogwood Lytton Creighton Nakusp Lake Flats Bay Surge no Johnsons Union Bay Creek Porteau Creek Valley p Read Lower Valley Hills Ekins no Kaleden Narrows Nicola Douglas Fintry Coldstream Retallack Landing Premier HalfmoonTuwanek Port Anvil Choate Marron Island p Makinson Denman Okanagan Nicola Quilchena Lake Carrs Zincton Birchdale Buckley Bay MellonPoint Lions Valley Refuge ?! Oyama Carrolls Rosebery Lake Island BuccaneerBay Sechelt Island Princeton Bloedel Heriot Kanaka Canford Cody False Hedley Falls Whaletown Cove Nesters nop Nahun Landing New Shutty Bench Redroofs !? Haig no!?AltaWhistler Bar no!? Sandon Boat Bay Bay no Bay Duncan BayBay Seaford Elkp p Harrison Othello Burton Denver Basin Mud Bay Gibsons Floodsno ?! ?! Lake Merritt Winfield no Prairie Bowser Roberts LIONS p Willowbrook p Stewardson Qualicum Bowen Hot Olalla no ?! Wilson Landing Silverton Ta Ta Creek GATE Hope Mirror Lake Wasa no EstevanHesquiat Inlet Lund Aspen Ellisonp Kaslo Creek Hot DunsmuirBeach Island Springs Keremeos p Campbell Powell Garibaldi KELOWNA Fauquier Point Dashwood ! no Chaumox Springs ST? PAULS Cawston p Skookumchuck Grove GENERAL Kelowna Slocan Riondel Crowsnest Beaver no Harrison Cheam Oliver Camp Oyster River River North Bend !no!? Kimberley Cove Hilliers p Parksville Vancouver ?! RO YA L Miracle River Sliammon Boston ? Applegrove Brandon Coombs ?! no View McKinney Ainsworth Creekp ?! no Valley Mills Inkaneep Williams !? Myra Edgewood Fort Hosmer Kleecoot?! Errington Nanoose VANCOUVER no no!?no ?! COLUMBIAN no Brew Bar McCulloch Hot Springs Crawford Bay Marysville no!? no Beach Blubber p Cheakamus Brookmere Trépanier Lemon Creek Wycliffe p Steele Sproat French Bay GENERAL no!? no Myrtle Bay Saltery Hells Peachland Meachen Corbin no!? p Merville Bay Port Perrys Balfour !? Chetarpe Lake Creek no Grantham Van Point Stillwater Bay Earls p Gate Appledale Longbeach Gray Creek Fernie no p no!? p Egmont Douglas Bankeir Greata Chute !? !? no p Manning Anda Billings Cove Chapmans Winlaw Willow Harrop no!? Bull Cokato Opitsat Port no? no BC CHILDREN'S p no! Doriston Lake Lebahdo ? Park Chopaka Osoyoos Courtenay pComox Gillies !? Squamish Spuzzum Jellicoe Point River Clayoquot Gabriola ?! nop!? Bay no Summerland Vallican Cranbrook no Alberni VANCOUVER ?! nop Bevan Bay Passmore Wardner Morrissey Flathead Britannia no PENTICTON Christian Lumberton Galloway ?! no Cumberland Slocan Park Taghumnop Nelson Boswell INTERNATIONAL p p ABBOTSFORD !? no Beach Alvin REGIONAL Valley Jaffray no Denman Silver Blewett Caithness p Cassidy no p Fanny Tuwanek Tulameen Jura Elko p AIRPORT REGIONAL Island Lions River Carmi Sanca Bay Halfmoon Bear Coalmont no RenataDeer Thetis North False Creek Penticton Hall Moyie Baynes Kildonan no?! Bay Bay p Beaverdell Park Porto Galiano Bay !? Choate nop Castlegar Kuskonook Lake Island no Rico Port Ecoole Bowser Davisp LIONS Marron Kaleden Ladysmith BCEHS: Flying Times from Vancouver Airport (CYVR) and no Ymir Sirdar Albion Chemainusno Bay Gibsons HarrisonRuby Valley Okanagan p Dunsmuir Sechelt GATE no HopeOthello Princeton Hedley Blueberry Salmo Dashwood p Falls Wynndel Arrow Grasmere Caycuse Lake Crofton no!? Mayne Drive Times fromTrauma Receiving and Tertiary Trauma Facilities ST PAULS Hot Creek Creek Youbou no!? !? Kleecoot pParksville ?! ROYAL LaidlawFloods Genelle Erie Creek Ganges no p Hilliers HOSPITAL no Willowbrook Ya hk Cowichan Maple Island Sproat?! Errington Nanoose?! Springs Olalla Rhone Paulson Mesachie Saturna 30, 60 & 75 Minute Flying Time from Vancouver Airport (CYVR) & 30 Minute DriveTimes from Trauma Receiving no?! COLUMBIANno?! Miracle Harrison Cheam no Curzon Newgate ?!no!? Somenos Bay Pender !? Bay Vancouver no !? Eholt Trail Paldi Fulford Lake no Lantzville no!?nono?! Agassiz View Warfield Glenlily Gordon Lake no!? Island no !? Valley Mills Keremeos Cawston no Westbridge !? Lister Cowichan Harbour & Tertiary Trauma Facilities (Vancouver General, St Paul’s, Lions Gate, BC Children’s Hospital, Royal Columbian, VANCOUVER no pno Popkum p Zamora Greenwood Rossland no Creston p River p !? Rosedale Camp Niagara Huscroft Duncan Bay ?!no no!? GENERAL p no!? Inkaneep Deadwood Christina Fruitvale Abbotsford Regional, Royal Inland (Kamloops), Kelowna General, Penticton Regional, Vernon Jubilee & Victoria General) Prince ?! Nanaimo no p no Oliver McKinney Fife p Remac Cobble Hill Prince BC CHILDREN'S p Kettle Kerr Lake Silica Shawnigan Rupert ?! ABBOTSFORDno?! !? Montrose George p ?! Cultus Slesse Manning Bridesville Valley Creek no Gilpin Mill Sidney no nop p Whyac Lake no Hospital 60NM, 30 Minutes from p p REGIONAL Lake Park Park Chopaka Osoyoos Bay p p Airport Kamloops p !? Midway Grand Forks Clo-oose CYVR National Park Vancouver Kildonan no pno Bambertonno p Ladysmith ?!no Hospital\Health Facility Victoria Ecoole Port Malahat no ?! Helipad 120NM, 60 Minutes from White with Helipad Provincial Park no no Hospital 60NM, 30 Minutes from 30 Minute Drive Time To Renfrew CYVR Extent of Map p Airport 0 15 30 60 km Geographic 0 15 30 60 km ?! BCEHS: Flying Times from Kamloops AirportRock (CYKA) and CYKA Trauma Receiving\Tertiary National Park ?! Major Road no!? Prince no Wooded Area ?!!? no!? !? Hospital\Health Facility with Prince Data Sources: no!? no no Trauma Hospital 150NM, 75 Minutes from no Drive Times from Trauma Receivingno and Tertiary Trauma Facilities no ?! Helipad Trauma Facility Rupert no!? Geographic Data Sources: Helipad 120NM, 60 Minutes from Provincial Park George BCEHS & Province River no CYVR !? 0 10 20 40 NM 0 10 20 40 NM ?! no CYKA ´ Kamloops of British Columbia ´ First Nations Reserve BCEHS & Province of British Columbia Border Major Road Jordan Trauma Hospital with 30, 60 & 75 Minute Flying Time from Kamloops Airport (CYKA) & 30 Minute Drive Times from Trauma Receiving Wooded Area p VICTORIA Victoria no British Columbia no Trauma Hospital Vancouver Helipad 30 Minute Drive Time To 150NM, 75 Minutes from GENERAL British Columbia Border & Tertiary Trauma Facilities (Vancouver General, St Paul’s, Lions Gate, BC Children’s Hospital, Royal Columbian, First Nations Reserve 1:2,000,000 Victoria 1:1,600,000 Trauma Receiving\ Abbotsford Regional, Royal Inland (Kamloops), Kelowna General, Penticton Regional, Vernon Jubilee & Victoria General) CYKA no Trauma Hospital with Helipad Extent of Map Tertiary Trauma Facility Produced by F Shew Produced by F Shew

Helicopter Flight Range from Vancouver Map Credit: Frances Shew, Corporate Data Analyst (GIS), BCEHS

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 Columbia Lamming Mills no Blackwater Dunkley McBride Eddy Cinema

Dunster Ten Wells Croydon Moose Mile Mount Pinegrove Barkerville Shere Red HeightsLake Cottonwood Tête Robson Wingdam Stanley Pass Ulkatcho Nazko p Coldspring Jaune Quesnel no!? House Cache Rich ?! Lucerne Bar p Cedarside Kersley Valemount Keithley Creek Australian Quesnel Albreda Forks Alexandria Hydraulic Likely

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North Fort nop Golden Bonaparte Chu Pass Nicholson Chua Banff 70 Darfield Mile Seymour House Arm Jesmond Albas Barriere Parson Vermilion Big p Chasm Crossing Castledale Bar Vidette Louis Harrogate Creek Clinton CreekExlouBlucher Woods Big Hall Landing Eddy Kootenay Spillimacheen McLure Adams no Revelstoke Crossing Magna Craigellachie p Kelly Lake Bay Scotch Anglemont Malakwa Brisco Lake Black Pines Cahilty Celista Creek Solsqua Cache Squilax Sicamous Radium Heffley Chase Balmoral Camborne Edgewater Moha Pavilion KAMLOOPS Creek Gold Creek Annis Beaton Hot Brexton Boston CopperAIRPORTRayleigh Shuswap Bridge Galena Ferguson Springs Ogden Flats Savona Pinantan Dry Gulch p Creek Salmon Bay Trout Bralorne Fountain Walhachin Lake no Mara Wilmer Shalalth no Tranquille p Lake Seton p !? MontePritchard Arm no!?p Portage no?! Kamloops p?!no Creek Grindrod Hupel p Ashcroft Silver Kingfisher Lillooet ROYAL Holmwood Creek Invermere McGillivray Beresford EnderbyAshton INLAND Bestwick Ya nke e Monte Creek Poplar Spatsum Flats D'Arcy Brigade Lake Falkland Creek To by Roy Devine Lac Glenemma p Gates Le Lake Westwold Armstrong Creek Thurlow Brem Birken Jeune Blind Pemberton Gramsons Spences Trinity Howser Big River Logan Stump Channel Meadows Bridge VERNON Valley Mabel Shoreholme Bay Creekside Lake Marblehead Rock Lake Lake Meadow Creek Owen Church Owl JUBILEE Lumby Shuswap !?p Elkford Bay Clapperton no Cooper Creek Round Elk Bay House Homfray Creek no Falls Cherryville Argenta Canal Pemberton Vernon Lavington Summit Lardeau Prairie Bay Granite Creek p Agate p Lytton Creighton Nakusp Lake Flats Bay Surge no Johnsons Read Lower Valley Hills Narrows Nicola Douglas Fintry Coldstream Retallack Landing Premier Island Nicola Lakep Makinson Zincton Birchdale Refuge ?! Quilchena Carrs Oyama Carrolls Rosebery Lake Bloedel Heriot Kanaka Canford no Nahun Cody Whaletown Cove Nesters!? p Landing New !? Sandon Shutty Bench Bay noAltaWhistler Bar no p Duncan Bay Seaford Burton Elk ?! ?! Lake Merritt Winfield Denver no ?! p Prairie no Wilson Landing Silverton Mirror Lake Ta Ta Lund Ellisonp Kaslo Wasa no Aspen KELOWNA Fauquier Creek p Campbell Powell Garibaldi Chaumox Skookumchuck Grove GENERAL !? Kelowna Slocan Riondel Crowsnest OysterRiver River Sliammon River North Bend ?!no Kimberley Boston Applegrove Brandon Ainsworth Williams Edgewood Fort Hosmer no!? Bar Myra Hot Springs Marysville Beach Brew Brookmere Trépanier McCulloch Lemon Creek Crawford Bay Steele Blubber p Saltery Cheakamus Meachen Wycliffe p Corbin Merville Myrtle Bay Hells Peachland Perrys Bay Bay Port Balfour no!? Grantham Van Point Stillwater Earls Egmont p Gate Chute Appledale Longbeach Gray Creek Fernie Douglas Bankeir Greata Harrop Cokato Anda Billings Cove Chapmans Lake Winlaw Willow no!? Bull Courtenay pComox Gillies Doriston !? Jellicoe Lebahdo nop!? Bay no Squamish Spuzzum Summerland Vallican Point Cranbrook River Bevan Bay Passmore Wardner Morrissey Flathead Britannia no PENTICTON Christian Lumberton Galloway Cumberland Slocan Park Taghumnop Nelson Boswell no Beach Alvin REGIONAL Valley Jaffray Denman Silver Blewett Caithness Fanny Tuwanek River Tulameen Jura Carmi Sanca Elko Bay Island Halfmoon Lions Bear Coalmont RenataDeer False Creek Penticton no Hall Moyie Baynes Bay Bay p Beaverdell Park Porto Bay !? Choate nop Castlegar Kuskonook Lake no Rico Bowser Davisp LIONS Marron Kaleden no Ymir Sirdar Qualicum Beach Bay Harrison Okanagan p Dunsmuir Sechelt Gibsons GATE Ruby Othello Princeton Hedley Valley Blueberry Dashwood no Hope Salmo Arrow Grasmere ST PAULS Hot Creek p Falls Creek Wynndel Kleecoot pParksville ?! ROYAL LaidlawFloods Genelle Erie Creek p Hilliers HOSPITAL no Willowbrook Ya hk Sproat?! Errington Nanoose?! Springs Olalla Rhone Paulson no?! COLUMBIANno?! Miracle Harrison Cheam no Curzon Newgate Lake no!? Bay Lantzville Vancouver no no!?no Eholt Trail Warfield Glenlily Port Alberni no!? no?! Valley Mills Agassiz View Keremeos no Westbridge VANCOUVER no!? Cawston p Zamora Greenwood no!? Lister pno Popkum Camp Niagara Rossland Creston Huscroftp ?!no !? p !? Rosedale Deadwood Fruitvale ?! Nanaimo no GENERAL no no no Oliver Inkaneep McKinney ChristinaFife p Remac BC CHILDREN'S p p Kettle Kerr Silica ?!?! ABBOTSFORDno?! no!? Lake Montrose p nop Cultus Slesse Manning Bridesville Valley Creek pGilpin nop p REGIONAL Park Osoyoos p no!? Lake Park Chopaka Midway Grand Forks Kildonan Ladysmith no?! no p Ecoole White no Hospital 60NM, 30 Minutes from 30 Minute Drive Time To no p Airport 0 15 30 60 km Geographic BCEHS: Flying Times from Kamloops AirportRock (CYKA) and CYKA Trauma Receiving\Tertiary National Park !? no!? Prince Data Sources: ?!no!? no no!? Hospital\Health Facility with Trauma Facility Prince Drive Times from Trauma Receiving and Tertiary Trauma Facilities no ?! Helipad Rupert George !? Helipad 120NM, 60 Minutes from Provincial Park 0 10 20 40 NM BCEHS & Province no CYKA ´ Kamloops of British Columbia Major Road British Columbia Border 30, 60 & 75 Minute Flying Time from Kamloops Airport (CYKA) & 30 Minute Drive Times from Trauma Receiving Wooded Area p no Trauma Hospital Vancouver 150NM, 75 Minutes from & Tertiary Trauma Facilities (Vancouver General, St Paul’s, Lions Gate, BC Children’s Hospital, Royal Columbian, First Nations Reserve 1:2,000,000 Victoria Abbotsford Regional, Royal Inland (Kamloops), Kelowna General, Penticton Regional, Vernon Jubilee & Victoria General) CYKA no 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 59°0'0"N

! 58°0'0"N Fort Nelson 57°0'0"N 56°0'0"N

Fort !! St John ! Stewart !Dawson Chetwynd ! Creek 55°0'0"N

! Mackenzie ! Gitwinksihlkw ! ! Gingolx Fort ! St 54°0'0"N Smithers ! James ! BC Emergency Health Services !Prince Terrace Burns Rupert !Lake Flying Distances for Fixed Wing ! Aircraft (King Air 350) from Masset ! Kitimat ! Vancouver, Kelowna & o Queen 53°0'0"N Prince George Airports PRINCE Prince Charlotte GEORGE George ! ! AIRPORT McBride Flying Distances from Airports ! Quesnel Airport & Distance\Flight Time

52°0'0"N KELOWNA AIRPORT, Bella 300NM - 1 hour flight Bella ! Williams Coola Lake !Bella ! PRINCE GEORGE AIRPORT, 300NM - 1 hour flight 100 ! ! Mile Clearwater !Golden

51°0'0"N VANCOUVER House INTERNATIONAL AIRPORT,

300NM - 1 hour flight ! Salmon Revelstoke VANCOUVER Arm ! Ashcroft ! INTERNATIONAL AIRPORT, Port Alert ! ! Invermere ! ! 450NM - 1.5 hour flight Hardy Bay Lillooet Kamloops 50°0'0"N ! ! Nakusp KELOWNAVernon ! Port ! Port ! ! AIRPORT New ! Sparwood Airports ( Kelowna, Prince Alice McNeill Merritt ! ! o George & Vancouver) Campbell Lytton ! Denver Kaslo River Powell o! Kelowna !Fernie ! ! !Tahsis River ! ! Cranbrook VANCOUVER ! Squamish! BC Border Comox! Summerland Nelson ! ! ! INTERNATIONAL Princeton! 49°0'0"N Penticton ! ! !Hope Castlegar Port AIRPORT ! ! Creston ! ! Alberni ! !!! Oliver !Grand Trail ! ! ! ! 0 25 50 100 NM ! ! !! ! Chilliwack Forks ! Nanaimo o! ! ! ! Tofino Ladysmith! Vancouver ! ! 0 40 80 160 km ! Duncan ´ ! 48°0'0"N ! ! 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°0'0"W 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 ), 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 Columbia Helicopter 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 13 Conclusion

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 [email protected]

14 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Appendix A. Adult and Pediatric Lead Trauma Hospitals in British Columbia

Health Authority Location Name of Facility Level

FHA New Westminster 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 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 15