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 Criteria for Early Fixed Wing Launch (EFWL) ...... 16 Appendices ...... 18 Appendix A. Lead Trauma Hospitals in British Columbia ...... 18 Appendix B. BCEHS Traumatic Arrest Guidelines ...... 19 Appendix C. Pediatric Assessment Triangle, Pediatric Vital Signs and GCS ...... 21 Appendix D. Regional Specifics for Auto-Launch...... 22 Appendix E. BCEHS & Trauma Program Key Contacts ...... 23 Appendix F. Pre-hospital Triage and Inter-Facility Transfer Guideline by Health Authority ...... 24 Appendix G. Pre-hospital Trauma Triage Standard & Air Ambulance Utilization Review Process ...... 33 Appendix H. Communication & Education for Provincial Pre-hospital Triage Guideline ...... 34

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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Silver Deep Lake Mine Fountain Creek Ashton Big Housep Buffalo Clearwater Sound Holmwood Creek Creek Tatton Echo no?! Valley RO YA L Creek Tatlayoko Creek Creek Port no Seton Lake ?!no no!? Bay p INLAND Beresford Ya nke e 100 Mile House Birch Health Portage Bestwick Monte Enderby nop Blackpool Hardy Fort Lillooet Flats Hullcar Island Vavenby Donald Bay Falkland Dog Forde Holberg p Sointula McGillivray Lake 93 Lone Rupert Spatsum Brigade Glenemma Blaeberry Field Lac Westwold Gang Creek Mile East Lake Butte Roe Coal Alert Minstrel Logan Ranch Bridge Gate D'Arcy Le Nemaiah Lake Harbour no Bay Island Armstrong Edelweiss no!? p Devine Lake Jeune Valley Lake Little p Port p Telegraph Cove Matilpi Gates Rogers ?!no!? Winter Quatsino 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 Sayward 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 Woss 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 KELOWNA 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 Tahsis 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 Yuquot 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 Fanny Bay 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 Ahousat 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 Marktosis Lantzville 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 Tofino Gabriola ?! nop!? Bay no Summerland Vallican Cranbrook no Alberni Nanaimo 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 Ucluelet Chemainusno Qualicum Beach 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 Bamfield Paldi Fulford Lake no Lantzville no!?nono?! Agassiz View Warfield Glenlily Gordon Lake no!? Island Port Alberni 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 Sooke 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

Castle Rock Anahim Marguerite Lakep Macalister Big McLeese Chezacut Lake Lake Ranch Nimpo Horsefly Lake Towdystan Miocene Williams Pine Blue Lake Valleyp 150 Mile p Chilcotin River Chilanko Redstone Meldrum no House pForks Alexis Forest Creek Mica Sugarcane Creek Creek 141 Mile House Riske Enterprise Kleena Springhouse Lees Creek Kleene Ta tla Corner Becher Lake Eagle House Wright Mahood Creek Lac la Falls Avola Alkali Hache Forest Canim Lake 105 Mile Grove Lake Big p Buffalo Clearwater Tatton House Tatlayoko Creek Creek Lake 100 Mile House ?!no nop Blackpool Birch Island Vavenby Donald Dog Forde 93 Lone Gang Blaeberry Field Creek Mile Butte Roe East Ranch Bridge Gate Nemaiah Lake Edelweiss Valley Lake Little p Rogers ?!!? 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 ! Chemainus ! 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 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 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 Criteria #1: MPDS Auto-Launch Criteria

Patients with the following dispatch MPDS coding and criteria are eligible for Auto-Launch:

Event Description Additional Type Code Criteria 07C03 Burns – Burns=>18% body area with or without Explosion or Fire Present 07C04 Burns – SIGNIFICANT FACIAL burns 07D02 Burns – Unconscious? Arrest with or without Explosion or Fire Present 07D03 Burns – Not alert 08D01 HAZMAT / CBRN – Unconscious or Arrest – CBRN, Smell of gas, CO, Suicide attempt or unknown 08D02 HAZMAT / CBRN – not alert – CBRN, Smell of gas, CO, Suicide attempt or unknown 14D01 Drowning – Unconscious or Arrest 14D03 Drowning – Diving or suspected neck injury 14D04 Drowning – SCUBA accident 15D01 Electrocution – Unconscious 15D04 Electrocution – EXTREME FALL 15D05 Electrocution – LONG FALL Not Alert 15E01 Electrocution – NOT BREATHING / INEFFECTIVE BREATHING 17D01 Falls – EXTREME FALL 17D05 LONG FALL Not Alert 22D01 Inaccessible Incident / Other Entrapments – Mechanical /Machinery ENTRAPMENT 22D02 Inaccessible Incident / Other Entrapments – Trench collapse 22D03 Inaccessible Incident / Other Entrapments – Structure collapse 22D04 Inaccessible Incident / Other Entrapments – Confined space ENTRAPMENT 22D06 Inaccessible Incident / Other Entrapments – Mudslide / Avalanche 27D01 Stab / GSW – unconscious or Arrest – Gunshot, Penetrating, Stab or Self inflicted 27D03 Stab / GSW – CENTRAL wounds – gunshot, Penetrating, Stab or Self-inflicted (all sub-determinants) 29D01 MVA - MAJOR INCIDENT 29D02 MVA – HIGH MECHANISM 29D04 MVA – Pinned (trapped victim) 30D01 Traumatic Injuries – Unconscious or Arrest 30D03 Traumatic Injuries – Chest or Neck injury

14 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Criteria #2: Auto-Launch Continuation Criteria

In order for the helicopter to continue to scene after 2) Mechanism Considerations (in absence of ground ambulance crew arrival and assessment, above criteria): one of the following criteria must be confirmed: a. Fall: Adult > 6 m (20 feet), Pediatrics 1) Physiological and Anatomical: > 3m (10 feet) or 2-3 times height of the child a. GCS now less than or equal to 13 b). Intrusion, entrapment, prolonged extrication b. Patient was unconscious but not yet returned > 20 minutes to GCS 15 c. Severe deceleration event, ejection from c. Respiratory rates less than 10 or greater than 30 vehicle, death in same vehicle d. SBP less than 90 and/or clinical signs of shock d. Pedestrian or bicyclist struck > 30 km/hr, thrown or run over e. SBP less than 110 in age > 65 e. Motorcycle collision > 30 km/hr f. Open or depressed skull fracture g. New paralysis or neurological deficits 3) Access h. Major penetrating injury (defined as all a. Obvious severe injury but unable to fully penetrating injuries to head, neck, torso and assess, or treat the patient extremities proximal to elbow or knee) b. Patient is not accessible in a reasonable i. Facial injury with potential airway compromise treatment time window (i.e. located in isolated community or area) j. Two or more proximal long-bone fractures k. Crushed, de-gloved, mangled or pulseless extremity l. Amputation proximal to wrist or ankle m. Chest wall instability or deformity (e.g. flail chest) n. Major burns: i. Partial thickness burns > 20% or full thickness burns > 10% (≥2% for pediatrics) ii. Facial or airway burns with or without inhalation injury iii. Full thickness burns involve the eyes, neck, hands, feet or groin iv. High voltage electrical burns o. Mechanically unstable pelvic fractures

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 15 Criteria for Early Fixed Wing Launch (EFWL)

Launching an early fixed-wing response is dependent on the patient meeting physiological, anatomical, or mechanism of injury indicators (see below). Activation of the EFWL is not dependent upon the proximity to the nearest non-trauma hospital.

An EFWL can only be initiated by paramedics at the trauma scene and CliniCall / EPOS physician consultation to confirm the activation. Once this occurs, dispatch will send the aircraft and will advise the sending and receiving hospitals, and PTN about the EFWL.

The Lead Trauma Hospital destination selection for the EFWL program follows the trauma referral patterns established by the respective health authorities.

Early Fixed Wing Launch Criteria

Physiologic Indicators Anatomic Indicators Mechanism Indicators • GCS ≤ 13 • Open or depressed skull • Falls: Adult > 20 feet (6 metres) fractures OR Pediatrics > 10 feet (3 metres) or more 2-3 times height of the child • SBP < 90 • New paralysis or • Motor vehicle accident • SBP < 110 in Age > 65 neurological deficits (ejection, intrusion, rollover, death of occupant) • RR < 10 or > 30 • Major penetrating injury • Pedestrian or bicyclist struck at > 30 km/h, thrown, run over • Respiratory compromise or • Facial injury with potential • Motorcycle collision > 30 km/hr need for ventilatory support airway compromise • Abnormal SBP, HR, RR for • Two or more proximal long age in pediatrics bone fractures • Crushed, de-gloved, mangled, or pulseless extremity • Amputation proximal to wrist or ankle • Chest wall instability or deformity (e.g. Flail Chest) • Major burns • Unstable pelvic fracture

16 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 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]

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 17 Appendix 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

18 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Appendix B. BCEHS Traumatic Arrest Guidelines

The BCEHS Traumatic Arrest Guidelines are found on the BCEHS handbook and online at https://handbook.bcehs.ca/treatment-guidelines/adult-guidelines/major-trauma/traumatic-arrest/ traumatic-arrest-medical-principles/.

Traumatic Arrest Principles

Discontinue in Obvious Death: • Transsection • Decapitation • Incineration • Open skull fracture with exposed brain matter

Identify Treatable Causes: • Tension pneumothorax • Hypovolemia due to blood loss • Suspected cardiac tamponade

Blunt Traumatic Arrest: Review the history of the event carefully. It is sometimes difficult to determine if a medical event preceded the trauma or if the severe trauma resulted in the arrest.

With signs of major trauma and loss of pulse and respiration (either after the initial assessment and rapid trauma survey or during transport), you are likely dealing with a non-survivable situation.

EPOS consultation should be obtained for likely discontinuation orders.

With lower force trauma, consider medical diagnosis for the event.

Penetrating Traumatic Arrest: This is a special situation where there may be a surgically correctable bleeding site if direct control is quickly possible.

If you are within 15 minutes anticipated time from loss of pulse and respiration to a Level 1 or 2 trauma centre, then rapid transport and pre-notification is indicated. Otherwise, EPOS consultation should be obtained to determine decision to transport or discontinuation of resuscitation.

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 19 Traumatic Arrest Intervention Guidelines

Paramedic Practice Level Interventions

EMR Discontinue in obvious death Assess degree of injury and mechanism Ensure open airway and provide ventilations

Low energy blunt trauma: • CPR according to medical guidelines

High energy blunt trauma: • CPR • Obtain EPOS consultation for decision to discontinue resuscitation

Penetrating trauma: • CPR • If time from loss of pulse to arrival at Level 1 or 2 trauma centre is less than 15 minutes  immediately prepare for rapid transport –Otherwise, obtain EPOS consultation for decision to transport or discontinue resuscitation • Control life threatening bleeding while facilitating transport • Direct pressure to sites of obvious ongoing blood loss • Application of tight tourniquet for catastrophic extremity injury with ongoing large volume blood loss

PCP All the above, plus: IV therapy (NS fluid challenge up to 2L)

ACP / CCP All the above, plus: Assess for pneumothorax • Decompress chest with needle thoracentesis Consider advanced airway management en-route to hospital

20 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Appendix C. Pediatric Assessment Triangle, Pediatric Vital Signs and GCS

Normal Pediatric Vital Signs (from BCEHS Handbook)

Age Heart Rate Resp Rate Systolic BP 0-1 month 100-160 40-60 50-90 3 months 100-180 30-45 65-100 6 months 100-180 25-35 70-110 12 months 100-180 25-35 70-110 2 years 80-160 20-30 70-110 3 years 80-130 20-30 75-110 4 years 70-110 18-24 80-110 6 years 70-110 18-24 80-110 8 years 70-110 18-22 80-110 10 years 70-110 18-22 80-110 12 years and older 70-110 16-20 90-120

Pediatric Glasgow Coma Scale (GCS)

Eye Opening Verbal Motor 4 Spontaneous 5 Coos and babbles / Oriented 6 Spontaneous / Obeys 3 To Speech 4 Irritable Cry / Confused 5 Withdraws to touch / Localizes to Pain 2 To Pain 3 Cries to Pain / Inappropriate Words 4 Withdraws to Pain 1 No Response 2 Non-specific sounds / Moans to Pain 3 Flexion / Decorticate 1 No Response 2 Extension / Decerebrate 1 No Response

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 21 Appendix D. Regional Specifics for Auto Launch

Region Lead Trauma Hospital Response Area

Kamloops Royal Inland Hospital • Interior Health Authority area excluding East Kootenay Dispatch Kelowna General Hospital • First call for responses west of Golden • “No Fly Zone” in Okanagan corridor between Vernon and Penticton (area served by trauma centres in Penticton and Vernon)

Easy Kootenay Foothills Medical Centre • East Kootenay Health Service Area Auto-Launch Alberta Children’s Hospital

Vancouver Vancouver General Hospital • Sea-to-Sky corridor to Pemberton Dispatch Royal Columbian Hospital • East up to Coquihalla toll booth BC Children’s Hospital • South down to USA Border • Sunshine coast

Vancouver Island Victoria General Hospital • All areas of Vancouver Island from south of Sayward Dispatch

The East Kootenay Auto-Launch is a version of When BCEHS ground paramedics determine the Auto-Launch modified for the East Kootenay Health patient can be transported to the nearest hospital Service Area. It involves BCEHS and Alberta Air prior to helicopter arriving on scene, the helicopter Ambulance resources, and includes both rotor-wing can be diverted to that hospital in anticipation of a and fixed wing transport. subsequent transport to the trauma centre.

STARS (Shock Trauma Air Rescue Society via If STARS is not available or unable to fly due to Alberta Air Ambulance) helicopter response is the weather, dispatch will decide on assigning a BCEHS primary choice for East Kootenay Auto-Launch or STARS fixed-wing transport for the call. activations (availability and weather permitting). STARS is launched at the same time as the BCEHS The Lead Trauma Hospital assigned to the East ground unit. Kootenay Auto-Launch are Foothills Medical Centre for adult trauma and Alberta Children’s Hospital for pediatric trauma.

22 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Appendix E. BCEHS & Trauma Program Key Contacts

Provincial Contacts Name Title

Trauma Services Dr. David Evans Medical Director, Trauma Services BC Micheline Wiebe Provincial Clinical Director, Trauma Services BC Beide Bekele Program and Project Lead, Trauma Services BC Jaimini Thakore Provincial Lead, Data Evaluation & Analytics, Trauma Services BC

Regional Contacts

Fraser Health Dr. Ian MacPhail Regional Medical Director, FH / RCH Trauma Dr. Wilson Wan BCEHS Regional Medical Director Chris Windle Director Clinical Operations, RCH Emergency, Medicine and FH Trauma

Interior Health Dr. Heather Wilson Medical Director, Trauma Program Dr. Anders Ganstal BCEHS Regional Medical Director Crystal White IHA Operations Director

Island Health Dr. Hans Cunningham Medical Director, Trauma Program Dr. Jim Goulding BCEHS Regional Medical Director John Marc Priest Regional Manager, Trauma Services Anna Hill Director for Trauma Services

Northern Health Dr. Patrick Rowe Medical Director, Trauma Program Dr. Devin Spooner BCEHS Regional Medical Director Jordan Oliver Executive Lead, Emergency and Trauma Program

Vancouver Dr. Hazel Park Medical Director, Trauma Program Coastal Health Dr. Jan Trojanowski BCEHS Regional Medical Director Michelle de Moor Regional Director, Emergency and Trauma Programs Ruby Syropiatko Regional Program Lead – Emergency and Trauma

PHSA, Dr. Gen Ernst Co-Medical Director, Trauma Program Pediatric Trauma Dr. Robert Baird Co-Medical Director, Trauma Program Michelle Dodds Trauma Manager, BC Children’s

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 23 Appendix F. Pre-hospital Triage and Inter Facility Transfer Guideline by Health Authority

• Fraser Health –East – West • Interior Health • Island Health • Northern Health • Vancouver Coastal Health –Urban Adult –Pediatric –Rural / Remote

24 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia Fraser EAST (East of 264th Street) Pre-hospital Trauma Triage Guidelines

Failed airway1 YES • Transport to the nearest emergency department NO Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to consider YES discontinuation of resuscitation vs. transport NO Penetrating traumatic arrest • Transport to ARHCC if time from loss of pulse and (due to penetrating injury to head, neck and/or torso) respiration to arrival at hospital is < 15 min. YES • Otherwise, obtain CliniCall / EPOS Consultation to determine decision to transport or discontinuation of resuscitation NO Step 1: Physiological Physiological criteria (any of the following): • Transport to RCH if transport time < 60 min. • Adult: • Otherwise, transport to ARHCC – SBP < 90 (Consider helicopter if transport time to RCH > 30 min.) –RR < 10 or > 30 or need for ventilatory support YES –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 RCH if transport time < 60 min. • Open or depressed skull fracture* • Otherwise, transport to ARHCC • New paralysis or neurological deficits* (Consider helicopter if transport time to RCH > 30 min.) • Major penetrating injury • Facial injury with potential airway compromise * For patients with suspected neurosurgical injury: Transport • Two or more proximal long bone fractures YES to RCH if < 60 min., otherwise transport to ARHCC • 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 RCH or ARHCC if transport time • Falls Adult: > 6m (20 feet) <60 min. • Falls Pediatrics: > 3m (10 feet) or 2-3 times the height of the child (Consider helicopter if transport time to RCH >30 min.) • MVA: intrusion/ejection/death in vehicle YES • Otherwise, transport to nearest emergency department • 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 to determine if transport to • Elderly RCH or ARHCC is appropriate • SBP < 110 in age > 65 • Consider CliniCall / 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 by ANY means. If you can oxygenate/ventilate, then it is not a failed airway. Fraser WEST (West of 264th Street) Pre-hospital Trauma Triage Guidelines

Failed airway1 YES • Transport to the nearest emergency department NO Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to consider YES discontinuation of resuscitation vs. transport NO Penetrating traumatic arrest • Transport to RCH if time from loss of pulse and respiration (due to penetrating injury to head, neck and/or torso) to arrival at hospital is < 15 min. YES • Otherwise, obtain CliniCall / EPOS Consultation to determine decision to transport or discontinuation of resuscitation NO Step 1: Physiological Physiological criteria (any of the following): • Transport to RCH • Adult: (Consider helicopter if transport time to RCH > 30 min.) – SBP < 90 –RR < 10 or > 30 or need for ventilatory support YES –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 RCH • Open or depressed skull fracture (Consider helicopter if transport time to RCH > 30 min.) • New paralysis or neurological deficits • Major penetrating injury • Facial injury with potential airway compromise • 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 RCH if transport time <60 min. • Falls Adult: > 6m (20 feet) (Consider helicopter if transport time to RCH >30 min.) • 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 • 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 to determine if transport to • Elderly RCH is appropriate • SBP < 110 in age > 65 • Consider CliniCall / 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 by ANY means. If you can oxygenate/ventilate, then it is not a failed airway. Interior Health Pre-hospital Trauma Triage Guidelines

KEY TRIAGE POINTS Regional Trauma Receiving Centres (Level 3) Consider Transport Resources if transport times > 90 min • BC Helicopter / STARS / Fixed wing / HART Tertiary Trauma Centres (Level 2) • Penticton for transport times < 90min EPOS/CliniCall if: • Vernon • Kelowna • Cranbrook • Unsure, Physiologic, Anatomical, Mechanism criterion • Kamloops • Trail AUTOLAUNCH Cancelling? • Williams Lake • MUST Consult CliniCall or EPOS

Failed airway or suspected Tension Pneumothorax • Transport to the nearest emergency department (Failed airway = failure to maintain patency by ANY means. YES If you can oxygenate/ventilate, then it is not a failed airway.) NO Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to determine decision YES to likely discontinue resuscitation vs. transport NO Penetrating traumatic arrest Transport time < 15 min from loss of pulse/respirations to hospital: (due to penetrating injury to head, neck and/or torso) • Transport to nearest LEVEL 2 Trauma Receiving Centre YES Transport time > 15 min from loss of pulse/respirations to hospital: • Obtain EPOS Consultation to determine decision discontinue resuscitation vs. transport NO Step 1: Physiological Physiological criteria (any of the following): 1. Transport time < 90 min • Adult: • Transport to Tertiary (Level 2) Trauma Centre – SBP < 90 Transport time > 90 min • Transport to Regional (Level 3) Trauma Centre –RR < 10 or > 30 or need for ventilatory support YES –GCS ≤13 • Consider BC Helicopter / STARS / Fixed wing intercept • Pediatrics: 2. Call EPOS/Clinicall: –Abnormal SBP, HR, RR for age or need for ventilatory support • Destination/Treatment Uncertainty –GCS ≤ 13 • Patient has Physiologic, Anatomic or Mechanism Criterion NO • Change in Patient Condition Step 2: Anatomical • Multi Casualty • Pregnant > 20 weeks Anatomical criteria (any of the following): • Elderly • Open or depressed skull fracture • Pediatrics – Consider: • New paralysis or neurological deficits 1. Possible transport to: KGH, RIH, BC Children’s Hospital, • Major penetrating injury Alberta Children’s Hospital • Facial injury with potential airway compromise 2. Transport Intercept • Two or more proximal long bone fractures YES If Communication Unavailable: • Crush, degloved, mangled, or pulseless extremity • Initiate Auto-Launch • Amputation proximal to wrist or ankle • Pre-notify Destination • Chest wall instability or deformity (i.e. flail chest) • Consider ALS intercept if available • Major burns • **NOTE - Ensure ED / D&T / Health Centre is NOT on • Unstable pelvis diversion or closed NO Step 3: Mechanism Mechanism criteria (any of the following): • Consider Clinicall or EPOS consultation for further guidance. • Falls Adult: > 6m (20 feet) • Falls Pediatrics: > 3m (10 feet) or 2-3 times the height of the child • MVA: intrusion/ejection/death in vehicle YES • 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): • Elderly • SBP < 110 in age > 65 • Anticoagulation YES • Pregnancy > 20 weeks • Pediatric patients should be preferentially transported to Pediatric Lead Trauma Hospitals NO Transport to nearest emergency department Northern Health Pre-hospital Trauma Triage Guidelines

KEY TRIAGE POINTS Call EPOS/CliniCall if: UHNBC Trauma Activation Number: (250) 563-0935 • Uncertain about destination • Patient’s condition changes Additional resources and assistance when transporting a patient • Multi-casualty incident (MCI) with major trauma: • Paramedic disagreement about destination • Initiate Early Fixed Wing Launch or Rotary Wing Auto-launch (if available in area) **Ensure ER/D&T (Diagnostic and Treatment Centre)/Health • Pre-notify destination for Trauma Team Activation at 20 min Centre is not on diversion or closed. Individual D&T/Health Island Health pre-hospital triage guidelines prior to arrival (or at scene if transport time < 20 min) Centre resources and staffing may be limited and may not be • Consider ALS intercept if transporting to UHNBC appropriate destinations to transport trauma patients. The regional pre-hospital triage guidelines are currently under review and will be published shortly. Failed airway • Transport to the nearest emergency department or (Failed airway = failure to maintain patency by ANY means. YES D&T/Health Centre If you can oxygenate/ventilate, then it is not a failed airway.) NO Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to consider YES discontinuation of resuscitation NO Penetrating traumatic arrest • Transport to nearest ER or D&T Centre if time from loss of (due to penetrating injury to head, neck and/or torso) pulse and respiration to arrival is < 15 min YES • Otherwise, obtain EPOS Consultation to determine decision to transport or discontinuation of resuscitation NO Step 1: Physiological Physiological criteria (any of the following): Transport Destination Decision: • Adult: Call EPOS/Clinicall if one of the following apply: – SBP < 90 – RR < 10 or > 30 or need for ventilatory support YES • If Transport time to Lead Trauma Hospital (LTH) > 60 min and – GCS ≤13 > 15 min to nearest ER/D&T/Health Centre • Pediatrics: • If Transport time to LTH < 60 min and < 15 min to nearest – Abnormal features on Pediatric Assessment Triangle assessment ER/D&T/Health Centre – Abnormal SBP, HR, RR for age or need for ventilatory support • If uncertain about best hospital destination, including – GCS ≤ 13Penetrating neighbouring province or territory hospital NO Step 2: Anatomical OR Anatomical criteria (any of the following): • Transport to Lead Trauma Hospital (LTH) within area • Open or depressed skull fracture – if transport time > 15 min to nearest ER/D&T/Health Centre • New paralysis or neurological deficits and < 60 min to LTH • Major penetrating injury • Facial injury with potential airway compromise OR • Two or more proximal long bone fractures YES • Transport to Nearest ER/D&T/Health Centre* • Crush, degloved, mangled, or pulseless extremity – If Transport time < 15 min to nearest ER/D&T/Health Centre • Amputation proximal to wrist or ankle – Consider physician check on stretcher to facilitate timely • Chest wall instability or deformity (i.e. flail chest) – transfer to LTH with same ground crew and/or more than • Major burns – 60 min out of hospital time expected • Unstable pelvis NO Step 3: Mechanism LTH = Lead Trauma Hospital within regional catchment areas include the following hospitals: Mechanism criteria (any of the following): • Northern Interior • Falls Adult: > 6m (20 feet) – UHNBC (Prince George) – both adults and pediatrics • Falls Pediatrics: > 3m (10 feet) or 2-3 times the height of the child YES – Quesnel • MVA: intrusion/ejection/death in vehicle • North East • Pedestrian or bicyclist struck > 30 km/hr, thrown or run over – Fort St John • Motorcycle collision at > 30 km/hr – Dawson Creek NO • North West – Mills Memorial (Terrace) Step 4: Special considerations – Prince Rupert Special considerations(any of the following): • Elderly • SBP < 110 in age > 65 • Anticoagulation YES • Pregnancy > 20 weeks 28 Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia • Pediatric patients should be preferentially transported to Pediatric Lead Trauma Hospitals NO

Transport to Nearest Emergency Department or Diagnostic & Treatment/Health Centre** Call EPOS/Clinicall if uncertain about destination Northern Health Pre-hospital Trauma Triage Guidelines

KEY TRIAGE POINTS Call EPOS/CliniCall if: UHNBC Trauma Activation Number: (250) 563-0935 • Uncertain about destination • Patient’s condition changes Additional resources and assistance when transporting a patient • Multi-casualty incident (MCI) with major trauma: • Paramedic disagreement about destination • Initiate Early Fixed Wing Launch or Rotary Wing Auto-launch (if available in area) **Ensure ER/D&T (Diagnostic and Treatment Centre)/Health • Pre-notify destination for Trauma Team Activation at 20 min Centre is not on diversion or closed. Individual D&T/Health prior to arrival (or at scene if transport time < 20 min) Centre resources and staffing may be limited and may not be • Consider ALS intercept if transporting to UHNBC appropriate destinations to transport trauma patients.

Failed airway • Transport to the nearest emergency department or (Failed airway = failure to maintain patency by ANY means. YES D&T/Health Centre If you can oxygenate/ventilate, then it is not a failed airway.) NO Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to consider YES discontinuation of resuscitation NO Penetrating traumatic arrest • Transport to nearest ER or D&T Centre if time from loss of (due to penetrating injury to head, neck and/or torso) pulse and respiration to arrival is < 15 min YES • Otherwise, obtain EPOS Consultation to determine decision to transport or discontinuation of resuscitation NO Step 1: Physiological Physiological criteria (any of the following): Transport Destination Decision: • Adult: Call EPOS/Clinicall if one of the following apply: – SBP < 90 – RR < 10 or > 30 or need for ventilatory support YES • If Transport time to Lead Trauma Hospital (LTH) > 60 min and – GCS ≤13 > 15 min to nearest ER/D&T/Health Centre • Pediatrics: • If Transport time to LTH < 60 min and < 15 min to nearest – Abnormal features on Pediatric Assessment Triangle assessment ER/D&T/Health Centre – Abnormal SBP, HR, RR for age or need for ventilatory support • If uncertain about best hospital destination, including – GCS ≤ 13Penetrating neighbouring province or territory hospital NO Step 2: Anatomical OR Anatomical criteria (any of the following): • Transport to Lead Trauma Hospital (LTH) within area • Open or depressed skull fracture – if transport time > 15 min to nearest ER/D&T/Health Centre • New paralysis or neurological deficits and < 60 min to LTH • Major penetrating injury • Facial injury with potential airway compromise OR • Two or more proximal long bone fractures YES • Transport to Nearest ER/D&T/Health Centre* • Crush, degloved, mangled, or pulseless extremity – If Transport time < 15 min to nearest ER/D&T/Health Centre • Amputation proximal to wrist or ankle – Consider physician check on stretcher to facilitate timely • Chest wall instability or deformity (i.e. flail chest) – transfer to LTH with same ground crew and/or more than • Major burns – 60 min out of hospital time expected • Unstable pelvis NO Step 3: Mechanism LTH = Lead Trauma Hospital within regional catchment areas include the following hospitals: Mechanism criteria (any of the following): • Northern Interior • Falls Adult: > 6m (20 feet) – UHNBC (Prince George) – both adults and pediatrics • Falls Pediatrics: > 3m (10 feet) or 2-3 times the height of the child YES – Quesnel • MVA: intrusion/ejection/death in vehicle • North East • Pedestrian or bicyclist struck > 30 km/hr, thrown or run over – Fort St John • Motorcycle collision at > 30 km/hr – Dawson Creek NO • North West – Mills Memorial (Terrace) Step 4: Special considerations – Prince Rupert Special considerations(any of the following): • Elderly • SBP < 110 in age > 65 • Anticoagulation YES • Pregnancy > 20 weeks • Pediatric patients should be preferentially transported to Pediatric Lead Trauma Hospitals NO

Transport to Nearest Emergency Department or Diagnostic & Treatment/Health Centre** Call EPOS/Clinicall if uncertain about destination VCH Urban – Adult ≥16 years Pre-hospital Trauma Triage Guidelines

Failed airway1 YES • Transport to the nearest emergency department NO

Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to consider YES discontinuation of resuscitation vs. transport NO

Penetrating traumatic arrest • Transport to VGH if time from loss of pulse and respiration (due to penetrating injury to head, neck and/or torso) to arrival at hospital is <20 min, otherwise transport to the YES nearest Emergency Department • Otherwise, obtain EPOS Consultation to determine decision to transport or discontinuation of resuscitation NO Step 1: Physiological Physiological criteria (any of the following): • If transport <30 min, go to VGH, otherwise transport • Adult: to the nearest emergency department – SBP < 90 YES • North Shore – can go to LGH – RR < 10 or > 30 or need for ventilatory support • If transport distance >40 min, consider helicopter – GCS ≤13 NO Step 2: Anatomical Anatomical criteria (any of the following): • If transport <40 min, go to VGH • Open or depressed skull fracture • North Shore – can go to LGH • New paralysis or neurological deficits • If transport > 40 min, consider helicopter • Major penetrating injury • Otherwise, transport to nearest emergency department • Facial injury with potential airway compromise • 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): • If transport <30 min, go to VGH • Falls Adult: > 6m (20 feet) • North Shore – go to LGH • MVA: intrusion/ejection/death in vehicle YES • Otherwise, transport to nearest emergency department • 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): • Consider transport to VGH if <30 min transport • Elderly • North Shore – go to LGH • SBP < 110 in age > 65 YES • Otherwise, transport to nearest emergency department • Anticoagulation • Pregnancy > 20 weeks NO

Transport to nearest emergency department

1. Failed Airway = failure to maintain patency by ANY means. If you can oxygenate/ventilate, then it is not a failed airway. 2. Patients with suspected neurosurgical injuries should be transported to either VGH or LGH. VCH-PHC Pediatric ≤16 years Pre-hospital Trauma Triage Guidelines

Failed airway1 YES • Transport to the nearest emergency department NO

Blunt traumatic arrest • Obtain Pediatric Coordinator consultation to determine YES decision to discontinue resuscitation vs. transport NO

Penetrating traumatic arrest • If transport < 15 min, go to BC Children’s Hospital otherwise (due to penetrating injury to head, neck and/or torso) transport to nearest hospital. YES • Consider obtaining EPOS Consultation to determine decision to transport or discontinuation of resuscitation NO Step 1: Physiological Physiological criteria (any of the following): • If transport < 30 min, go to BC Children’s Hospital. • Pediatrics: • If transport > 15 min to BCCH, consider helicopter. – Abnormal SBP, HR, RR for age or need for ventilatory support YES • Otherwise transport to nearest emergency department – GCS ≤ 13 NO Step 2: Anatomical Anatomical criteria (any of the following): • Transport < 30 min, go to BC Children’s Hospital. • Open or depressed skull fracture • If transport > 15 min, consider helicopter. • New paralysis or neurological deficits • Otherwise transport to nearest emergency department • Major penetrating injury • Facial injury with potential airway compromise • 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): • Transport < 30 min, go to BC Children’s Hospital. • Falls > 3m (10 feet) or 2-3 times the height of the child If transport > 15 min, consider helicopter. • MVA: intrusion/ejection/death in vehicle YES • Paramedic judgement can be used to decide which other • Pedestrian or bicyclist struck > 30 km/hr, thrown or run over pediatric patients should be transported to BCCH • Motorcycle collision at > 30 km/hr NO

Step 4: Special considerations Special considerations(any of the following): • If transport < 30 min, Go to BC Children’s Hospital • Infant < 1 year • Paramedic judgement can be used to decide which other • Suspect non-accidental trauma YES pediatric patients should be transported to BCCH • Pediatric patients should be preferentially transported to Pediatric • Consider CliniCall or EPOS consultation for further guidance Lead Trauma Hospitals NO

Transport to nearest emergency department

1. Failed Airway = failure to maintain patency by ANY means. If you can oxygenate/ventilate, then it is not a failed airway. Pediatric Trauma Centres • BCCH – Level 1 • LGH – Level 3 VCH Rural / Remote Pre-hospital Trauma Triage Guidelines

Failed airway1 YES • Transport to the nearest emergency department NO Blunt traumatic arrest • Obtain CliniCall / EPOS Consultation to determine decision to YES discontinue resuscitation vs. transport to nearest emergency department NO Penetrating traumatic arrest • Transport to Nearest Emergency Department if loss of (due to penetrating injury to head, neck and/or torso) pulse and respiration to arrival at hospital is < 15 min. YES • Otherwise, obtain EPOS Consultation to determine decision to transport or discontinuation of resuscitation Step 1: Physiological NO Physiological criteria (any of the following): • Transport to nearest Emergency Department. • Adult: • Consider transport via helicopter – SBP < 90 – RR < 10 or > 30 or need for ventilatory support YES – GCS ≤13 • Pediatrics: – Abnormal SBP, HR, RR for age or need for ventilatory support – GCS ≤ 13 Step 2: Anatomical NO Anatomical criteria (any of the following): • Transport to nearest Emergency Department. • Open or depressed skull fracture • Consider transport via helicopter. • New paralysis or neurological deficits • Adult-If transport time < 60 min, transport to VGH or LGH • Major penetrating injury • Pediatric-If transport time < 60 min, transport to BCCH or LGH • Facial injury with potential airway compromise • 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 Step 3: Mechanism NO Mechanism criteria (any of the following): • Transport to nearest Emergency Department. • Falls Adult: > 6m (20 feet) • Adult-If transport time < 60 min, transport to VGH or LGH • Falls Pediatrics: > 3m (10 feet) or 2-3 times the height of the child • Pediatric-If transport time < 60 min, transport to BCCH or LGH • MVA: intrusion/ejection/death in vehicle YES • 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 to guide transport destination • Elderly • Consider CliniCall or EPOS consultation for further guidance • SBP < 110 in age > 65 • Consider: • Anticoagulation YES – Adult-If transport time < 60 min, transport to VGH or LGH • Pregnancy > 20 weeks – Pediatric-If transport time < 60 min, transport to BCCH • Pediatric patients should be preferentially transported to Pediatric – or LGH Lead Trauma Hospitals • Infant <1 yr or child with suspected nonaccidental injury NO

Transport to nearest emergency department

1. Failed airway = failure to maintain patency by ANY means. If you can oxygenate/ventilate, then it is not a failed airway. Appendix G. Pre-hospital Trauma Triage Standard & Air Ambulance Utilization Review Process

Given the evolving nature of clinical trauma care, and the operational demands within each health authority, it is important that each regional trauma program hosts an annual review of its regional trauma pre-hospital triage and inter-facility guideline. The review should be hosted in collaboration with Trauma Services BC and regional medical directors of BCEHS. A collaborative performance based review will ensure both pre-hospital and in-hospital considerations are taken in to account in determining region-specific primary (field) and secondary (transfer) triage protocols to definitive care for trauma patients.

Regional Review Process Trauma Pre-hospital Triage and Inter Facility Guidelines

What is reviewed? Regional Trauma Pre-hospital Triage and Inter-Facility Guidelines

How often is it reviewed? Annually

Who should participate in the review? BCEHS Regional Medical Director (Mandatory Review Members) BCEHS Paramedic Practice Leader Regional Trauma Medical Director (Chair) Regional Trauma Operational Director TSBC – Provincial Clinical Director TSBC – Provincial Lead, Data, Evaluation and Analytics

Provincial Repository BCEHS APP ( BCEHS Handbook) (Source of truth) https://handbook.bcehs.ca/clinical/trauma/

Performance Reports A high level report on trauma transport metrics and compliance to pre-hospital triage and inter-facility guidelines will be pre- circulated by TSBC to facilitate discussion.

Version Control / Change communication Change in practice or destination guideline: A ‘MEMO’ should be drafted highlighting ‘what’ is changing and the ‘Change Rationale & Impact’ to all review members listed above. BCEHS and TSBC will collaborate to ensure: 1. All source documents are updated 2. Memo is circulated to key stakeholders

Pre-hospital Triage and Transport Guidelines for Adult and Pediatric Major Trauma in British Columbia 33 Appendix H. Communication & Education for Provincial Pre-hospital Trauma Triage Guideline

BCEHS TSBC

BCEHS Learning, Practice & Clinical Initiatives is Each of the regional guidelines have been vetted responsible for supporting paramedics by providing and endorsed by regional trauma program consistent, relevant, and timely practice support. operations and medical leadership. Trauma Services Practice updates such as the Provincial Pre-hospital BC will support regional health authorities as they Triage Guidelines will be communicated through implement this guidelines. Each regional trauma two main approaches: online communication and program will disseminate the Pre-hospital Trauma face-to-face field learning support. Triage Guidelines via their regional trauma advisory committees, medical advisory committees, and key The Provincial Pre-hospital Triage Guidelines and trauma stakeholders for information purposes only. the regional destination guidelines will be made As changes need to be made to these guidelines, available to all paramedics through the BCEHS TSBC will work with BCEHS and regional programs Handbook. The BCEHS handbook is an online to provide data for reviews and ensure updated resource that can be accessed via web browser versions are published on the BCEHS handbook. or iOS app that houses all the BCEHS treatment guidelines and clinical reference materials. The Pre-hospital Trauma Triage Guidelines for all guidelines will also be featured on the BCEHS regional health authorities will be easily accessible service-wide monthly practice update e-mail, through the BCEHS handbook which will serve as SnapComms communications, and the BCEHS the source of truth for the most up-to-date version. Facebook Operations page. They will also be Clinicians may also download the BCEHS Handbook presented at the monthly BCEHS educational clinical App (as described above) for instant access to rounds with a dedicated discussion and question trauma transport information. period, which is broadcasted to 10 locations in province and accessible anywhere via the internet.

BCEHS Paramedic Practice Educators, Paramedic Practice Leaders, and Medical Directors provide field learning support on a regular basis. The guidelines will be reviewed with individual paramedics during station and field visits, with an opportunity to discuss or address any questions that may arise.

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