GUIDELINE

National guideline for the field triage of injured patients:

Recommendations of the National Expert Panel on Field
Triage, 2021

Craig D. Newgard, MD, MPH, FACEP, Peter E. Fischer, MD, Mark Gestring, MD, Holly N. Michaels, MPH,
Gregory J. Jurkovich, MD, FACS, E. Brooke Lerner, PhD, FAEMS, Mary E. Fallat, MD,
Theodore R. Delbridge, MD, MPH, Joshua B. Brown, MD, MSc, FACS, Eileen M. Bulger, MD,
and the Writing Group for the 2021 National Expert Panel on Field Triage, Portland, Oregon

I n the United States, unintentional injury remains the leading

cause of death and years of potential life lost among children
and young adults, and the third most common cause of death
of tertiary trauma centers is less clear, with some studies showing
reduced mortality17,18 and others no effect.7,19 Until the evidence
becomes clearer, the prevailing view is that seriously injured older
overall.1,2 Injury is the most common reason for use of 9-1-1 adults should be managed in trauma centers.
emergency medical services (EMS) in the United States,3 with The effectiveness of field triage is measured at the system
EMS playing a critical role in the early evaluation and care of in- level using metrics termed undertriage and overtriage. Undertriage
jured patients.4 An important aspect of EMS care is field triage is the percentage of seriously injured patients missed by field tri-
—the process of identifying seriously injured patients in need of age processes and transported to nontrauma hospitals, which is
care in specialized trauma centers from among the larger number associated with increased mortality in adults and children.20–23
of patients with minor to moderate injuries who can be cared for Overtriage is the percentage of patients with minor to moderate
in nontrauma hospitals. To accomplish this task quickly and ef- injuries identified by field triage criteria as having serious inju-
ficiently, EMS clinicians use specific prehospital criteria known ries and transported to trauma centers unnecessarily, represent-
as the field triage guideline. The triage guideline was originally ing overuse of limited resources and inefficiency in the system.
developed in 1976, with periodic revisions every 5 to 10 years.5 Undertriage and overtriage are inversely related.24 Trauma sys-
The most recent evidence-based revisions to the field triage tems have prioritized the goal of minimizing undertriage and
guideline were completed in 2011.6 accepting a higher level of overtriage to avoid increased mortality,
Concentrating the most seriously injured patients in with targets set at ≤5% and ≤35%, respectively.4 A systematic re-
trauma centers through field triage is predicated on the principle view of field triage performance across all ages showed 14% to
that patients have better outcomes in these hospitals. A landmark 34% undertriage and 12% to 31% overtriage.25 Undertriage of
study demonstrated 20% lower in-hospital mortality and 25% children is up to 51%26 and has increased with recent triage
lower 1-year mortality among seriously injured adults treated guidelines.27 Undertriage is highest among older adults,28–30 with
in Level I trauma centers compared with nontrauma hospitals.7 half of seriously injured older adults treated in nontrauma centers
Other studies have shown that regionalized trauma systems are nationally.31 Reducing undertriage was an important goal of the
associated with reductions in mortality,8–11 with the benefit panel for the current guideline revision.
driven primarily by Level I trauma centers.8,9 The benefits are The purpose of this report is to present the final 2021 field
similar for children, particularly when treated in pediatric trauma triage guideline and to describe the process of guideline develop-
centers12–14 and in trauma centers with high emergency depart- ment and the supporting evidence. The guideline is intended for
ment (ED) pediatric readiness.15,16 For older adults, the benefit use in civilian 9-1-1 EMS systems and is not intended to guide

Submitted: February 25, 2022, Revised: March 9, 2022, Accepted: March 15, 2022, Supplemental digital content is available for this article. Direct URL citations appear in
Published online: April 27, 2022. the printed text, and links to the digital files are provided in the HTML text of this
From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Re- article on the journal’s Web site (www.jtrauma.com).
search in Emergency Medicine, Oregon Health and Science University, Portland, Address for reprints: Craig D. Newgard, MD, MPH, Department of Emergency Medicine,
Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Cen- Center for Policy and Research in Emergency Medicine, Oregon Health and Science
ter, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, University, 3181 SW Sam Jackson Park Rd, mail code CR-114, Portland, OR 97239-
Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American 3098; email: newgardc@ohsu.edu.
College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf
Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), Univer- of the American Association for the Surgery of Trauma. This is an open-access ar-
sity at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of ticle distributed under the terms of the Creative Commons Attribution-Non
Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible
Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, to download and share the work provided it is properly cited. The work cannot be changed
Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), in any way or used commercially without permission from the journal.
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of
Surgery (E.M.B.), University of Washington, Seattle, Washington. DOI: 10.1097/TA.0000000000003627

J Trauma Acute Care Surg

Volume 93, Number 2 e49
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Newgard et al. Volume 93, Number 2

mass casualty events or in-hospital trauma team responses. The sensitivity and specificity, are not influenced by disease preva-
evidence to support the current guideline is based on civilian lence, and provide more balanced metrics (Table 1). We used
trauma systems. The guideline is intended for patients in whom +LRs because individual triage criteria generally favor specific-
maximal resuscitative care is appropriate and does not apply to ity over sensitivity. When all triage criteria are combined, the
patients with limited goals of care. collective sensitivity of the guideline is raised. We also consid-
ered ease of use in the field and quality of the evidence.
METHODS
Process for Generating the Updated Guidelines
Study Design We assembled a steering committee years in advance to
We conducted an evidence-based revision of the field tri- develop key questions for the systematic reviews, organize, plan,
age guideline using an interdisciplinary national expert panel and orchestrate the revision process. The expert panel met for
and systematic reviews of the field triage literature. We used 2 days in April 2021 to review the evidence base and discuss po-
the Reporting Tool for Practice Guidelines in Health Care32 to re- tential revisions to the guideline. Following the meeting, the
port the 2021 revision to the field triage guideline. A complete steering committee drafted proposed revisions to the guideline
Reporting Tool for Practice Guidelines in Health Care checklist and compiled additional data to address questions from the
is included as supplemental online content (Supplemental Digital panel. A second meeting with the panel was held 2 months later
Content, Supplementary Data 1, http://links.lww.com/TA/C515). to discuss the draft revisions, present additional data, and reach
consensus on recommendations for the new guideline. Follow-
Panel Participant Recruitment ing the second meeting, the steering committee integrated the
The expert panel included EMS clinicians, EMS physi- additional revisions and sent the draft guideline to stakeholder
cians, emergency physicians, trauma surgeons, pediatric surgeons, organizations for feedback. The steering committee integrated
nurses, EMS medical directors, experts in EMS training and edu- feedback from each of these organizations and again returned
cation, EMS and trauma system administrators, researchers, and the updated guideline to the expert panel for review. This pro-
representatives from stakeholder organizations. The function of cess was repeated until all comments, suggestions, and feedback
the panel was to review the evidence base, provide stakeholder had been addressed.
feedback, assess usability and feasibility, and make informed de- In parallel with preparations for revisions to the guideline,
cisions about revisions to the triage guideline. the EMS Subcommittee of the American College of Surgeons
Committee on Trauma developed and piloted a 40-question
Systematic Reviews and Evidence Base
electronic end-user feedback tool in the fall of 2020. The tool
We organized multiple systematic reviews in advance of
was distributed to 29 national organizations to gather information
the guideline revision. The reviews were targeted to controver-
about use of the field triage guideline directly from EMS clini-
sial aspects of the guideline, opportunities for new or modified
cians. Responses from 3,958 EMS clinicians37 were shared with
criteria, and to identify relevant literature published since the
the expert panel and integrated into the guideline revision process.
2011 guideline, including assessment of the quality of evidence
and risk of bias. The systematic reviews included the predictive
utility of out-of-hospital motor Glasgow Coma Scale (GCS) score RESULTS
versus total GCS,33 circulatory measures,34 respiratory mea- Overview
sures,35 mechanism of injury and special considerations criteria,36 The 2021 field triage guideline includes important clarifi-
and the overall performance of the triage guideline.25 cations regarding nomenclature and terminology. The name has
An inherent challenge in field triage is defining a “seri- been revised to “National Guideline for the Field Triage of In-
ously injured” patient, which has varied widely across studies. jured Patients,” reflecting the goal and intended function of the
Most triage research has used one of the following categories to document. The name can be shortened to “Field Triage Guide-
define “serious injury”: (1) anatomic injury severity (e.g., Injury line,” as needed.
Severity Score ≥16), (2) critical resource use (e.g., blood transfu-
sion requirements, certain operative interventions, and specific Format and Structure
“life-saving” procedures), (3) in-hospital mortality, or (4) a com- There are substantive changes to the format and structure
bination of categories.25,33–36 We considered any of these defini- of the guideline. Because stakeholder feedback and research indi-
tions to represent “serious injury.” cated that the step-wise algorithmic format of prior versions was
Criteria for addition and removal of triage criteria
For the 2011 guideline, the threshold to add new triage TABLE 1. Statistical Criteria Used to Add and Remove Individual
criteria was a positive predictive value of 20% or greater, with re- Triage Criteria
moval of criteria when predictive evidence was lacking.6 Be-
cause the positive predictive value is dependent on the preva- • To add a new field triage criterion: +LR ≥2 or AUROC ≥ 0.60
Magnitude of predictive utility:
lence of disease (e.g., serious injury) and therefore not readily ○ Large effect: +LR ≥10, AUROC ≥0.80
comparable across studies, we worked with experts in predictive ○ Moderate effect: +LR 5–9, AUROC 0.7–0.79
analytics to identify rigorous statistical criteria to guide the addi- ○ Small effect: +LR 2–4, AUROC 0.6–0.69
tion and removal of triage criteria. Ultimately, we opted to use • To remove a field triage criterion: no evidence or +LR 1.0–1.5 or AUROC 0.50–
positive likelihood ratios (+LRs) and area under the receiver op- 0.55 across multiple studies (triage criteria were not removed based on a single
study)
erating characteristic curves (AUROCs) because they combine

e50 © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.
J Trauma Acute Care Surg
Volume 93, Number 2 Newgard et al.

overly complex for field use, the expert panel modified the struc- • Criterion clarified: Chest wall instability, deformity, or
ture to align with the flow of information to EMS and actual use suspected flail chest
of the guideline.37–39 The redesigned structure consolidates tri- Rationale: This criterion was revised from “Chest wall instability
age criteria into two main categories based on risk of serious in- or deformity (e.g., flail chest)” based on EMS feedback.
jury: (1) high-risk criteria (red box), including Injury Patterns
(previously “Anatomic Criteria”) and Mental Status and Vital • Criterion clarified: Suspected pelvic fracture
Signs (previously “Physiologic Criteria”), and (2) moderate-risk Rationale: This criterion was revised from “Pelvic fractures”
criteria (yellow box), including Mechanism of Injury and EMS based on EMS feedback. While field use of this criterion has
Judgment (previously “Special Considerations”). Each risk cate- shown lower predictive utility than other anatomic criteria, hav-
gory is aligned with recommendations for a destination hospital. ing a pelvic fracture by International Classification of Diseases,
The guideline is intended to be read from top-to-bottom (risk) Ninth Revision, diagnosis codes increased the +LR to 6.2.40 The
and left-to-right (flow of information to EMS). panel felt that this criterion should be retained, noting an oppor-
tunity for EMS training.
Specific Field Triage Guideline Recommendations
The 2021 guideline is detailed in Figure 1. Changes from
• Criterion clarified: Suspected fracture of two or more proxi-
the 2011 field triage guideline are summarized in Table 2. The
mal long bones
2011 guideline is included in the online supplement for reference
Rationale: This criterion was revised from “Two or more proxi-
(Supplemental Digital Content, Supplementary Data 2, http:// mal long-bone fractures” based on EMS feedback.
links.lww.com/TA/C516).
Retained Criteria (No Changes)
Injury Patterns (Previously Step 2 Anatomic Criteria) • Retained criterion: Crushed, degloved, mangled, or pulseless
Injury patterns are highly specific, yet insensitive for iden- extremity
tifying seriously injured patients.40 We added one new criterion • Retained criterion: Amputation proximal to wrist or ankle
and revised six criteria for clarity. Two criteria remain un- Rationale: While the panel debated changes to the level of am-
changed. We also revised the order of criteria to align with a putation (e.g., hand, digit) based on the limited availability of
head-to-toe field-based rapid physical assessment. hand surgeons in many regions, they ultimately decided to retain
the criterion without changes.
New and Modified Criteria
• New criterion: Active bleeding requiring a tourniquet or
wound packing with continuous pressure Mental Status and Vital Signs (Previously Step 1
Rationale: Research in military settings has shown that early Physiologic Criteria)
field application of tourniquets is associated with improved sur-
vival and few complications.41–43 Tourniquet use was not in- These criteria are highly specific, but insensitive for identify-
cluded in the 2011 guideline because of insufficient evidence ing seriously injured patients. The panel focused on expanding this
in the civilian setting. Multiple civilian studies have since been category based on new evidence, with attention to feasibility of use
published on the appropriate application of field tourniquets, in the field. There are five new criteria, three retained criteria, and
safety, effectiveness, and specificity for serious injury. Among three criteria removed.
306 civilian trauma patients with tourniquet application, 92% re- New and Modified Criteria
quired surgical intervention within 8 hours and field application • New criterion: “Unable to follow commands (motor GCS <6)”
was associated with lower transfusion requirements and higher replaces total “GCS ≤13.”
survival.44 Additional studies showed similar results.45–47 The Rationale: Twelve head-to-head studies compared total GCS to
panel added “wound packing with continuous pressure” to motor GCS, with high AUROCs for both measures (0.8–0.9).33
capture external bleeding requiring operative intervention in The AUROC difference in predictive performance between the
anatomic locations not amenable to tourniquet placement. two measures was small and unlikely to have clinical impact,33
particularly considering ease of use and the dichotomized
• Criterion clarified: Penetrating injuries to the head, neck, cut point used for field triage. Feedback from EMS and the
torso, and proximal extremities expert panel indicated strong preference for simplifying the
Rationale: This criterion was revised from “proximal to elbow or criterion for feasibility and EMS training. This measure also
knee”6 to “proximal extremities” to simplify the criterion based applies to young children,48,49 as lacking spontaneous or pur-
on EMS feedback. This criterion includes impalement. poseful movements. Patients with language barriers who are
unable to understand commands is a potential limitation of
• Criterion clarified: Skull deformity, suspected skull fracture this criterion.
Rationale: This criterion was revised from “Open or depressed
skull fracture” based on EMS feedback. • New criterion: heart rate (HR) > systolic blood pressure
(SBP) (adults and older adults)
• Criterion clarified: Suspected spinal injury with new motor Rationale: The systematic review of circulatory predictors iden-
or sensory loss tified 29 studies evaluating shock index (HR/SBP), most of
Rationale: This criterion was revised from “Paralysis” based on which used a value of 1.0.34 Among out-of-hospital studies,
EMS feedback. pooled estimates showed a sensitivity of 37%, a specificity of

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 J Trauma Acute Care Surg
Newgard et al. Volume 93, Number 2

Figure 1. 2021 National Guideline for the Field Triage of Injured Patients. *For the red criteria transport recommendations, patients in
extremis (e.g., unstable airway, severe shock, or traumatic arrest) may require transport to the closest hospital for initial stabilization,
before transport to a Level I or II trauma center for definitive care. Pediatric patients meeting the red criteria should be preferentially
triaged to pediatric-capable trauma centers. The EMS Judgment criteria should be considered in the context of resources available in
the regional trauma system, including consideration of online medical control for further direction. Examples of patients with special,
high-resource health care needs include tracheostomy with ventilator dependence and cardiac assist devices, among others. Patients
with combined burns and trauma should be preferentially transported to a trauma center with burn care capability. If not available,
then a trauma center takes precedence over a burn center. Specific age used to define “children” is based on local system resources
and practice patterns.

85%, and an AUROC of 0.72 for identifying seriously injured achieves the goal of identifying patients with a shock index
patients.34 Among five head-to-head studies comparing shock of >1.0 and facilitates EMS training. Pediatric studies have
index to SBP, all favored shock index, although the quality of used an age-adjusted shock index to predict serious injury,50,51
evidence was low.34 Assessing if HR is greater than SBP but the panel felt that calculating an age-adjusted shock index

e52 © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.
J Trauma Acute Care Surg
Volume 93, Number 2 Newgard et al.

TABLE 2. Summary of Changes to the Field Triage Guidelines

Type of Change Changes in 2021 Field Triage Guidelines Age Range 2011 Field Triage Guidelines
Format and structure Two categories of triage criteria, based on risk of serious All ages 4 Categories of triage criteria, classified as “steps”
injury — high risk versus moderate risk (from top to
bottom organization)
Within each risk category, the groups of criteria are listed No alignment with flow of information to EMS
from left to right to follow the flow of information
to EMS
Injury patterns criteria are organized from head-to-toe No specific order
to align with rapid field assessment

Injury Patterns All ages Anatomic criteria (step 2)

New criterion Active bleeding requiring a tourniquet or wound All ages None
packing with continuous pressure
Clarified criteria Skull deformity, suspected skull fracture All ages Open or depressed skull fracture
Suspected spinal injury with new motor or sensory loss All ages Paralysis
Chest wall instability, deformity or suspected flail chest All ages Chest wall instability or deformity (e.g., flail chest)
Suspected pelvic fracture All ages Pelvic fractures
Suspected fracture of two or more proximal long bones All ages Two or more proximal long-bone fractures

Mental Status and Vital Signs All ages Physiologic criteria (step 1)
New criteria Motor GCS <6 (unable to follow commands) All ages GCS ≤13
Heart rate >SBP ≥10 y None
SBP <70 mm Hg + (2  age in years) 0–9 y None
Respiratory distress or need for respiratory support All ages Respiratory rate <20 in infant aged <1 y;
ventilatory support
Room air pulse oximetry <90% All ages None
Relocated criteria SBP <110 mm Hg for older adults ≥65 y SBP <110 might represent shock after age 65 y
(Special Considerations section)

Mechanism of Injury Criteria All ages Mechanism criteria (step 3)

New criterion Child (age 0–9 y) unrestrained or in unsecured child 0–9 y None
safety seat
Modified criteria Rider separated from transport vehicle with significant All ages Motor cycle crash >20 mph
impact (e.g., motorcycle, ATV, horse, etc.)
Fall from height >10 ft (all ages) All ages Adults: >20 ft (one story is equal to 10 ft)
Children: >10 ft or two to three times the height
of the child
Modified criterion Pedestrian/bicycle rider thrown, run over, or with Auto vs. pedestrian/bicyclist thrown, run over, or
significant impact with significant (>20 mph) impact

EMS Judgment All ages Special considerations criteria (step 4)

New criteria Low level falls in young children (≤ 5 y) or older 0–5 y, ≥65 y Older adults — low impact mechanisms (e.g.,
adults (≥ 65 y) with significant head impact ground level falls) might result in severe injury
Suspicion of child abuse Any child, with None
focus on ≤5 y
Special, high resource health care needs All ages None
Modified criteria Anticoagulation use All ages Anticoagulants and bleeding disorders — patients
with head injury are at high risk for rapid
deterioration

Transport Patients meeting any of the high risk criteria (Injury Patients meeting any of the Step 1 (physiologic) or
recommendations Patterns and Mental Status and Vital Signs) Step 2 (anatomic) criteria “should be transported
“should be preferentially transported to the highest preferentially to the highest level of care within
level trauma center available within the geographic the defined trauma system”
constraints of the regional trauma system”

Continued next page

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TABLE 2. (Continued)

Type of Change Changes in 2021 Field Triage Guidelines Age Range 2011 Field Triage Guidelines
Patients not meeting high risk criteria, but meeting Patients not meeting Step 1 or 2 criteria but meeting
any of the moderate risk criteria “should be Step 3 criteria, “transport to a trauma center, which,
preferentially transported to a trauma center, as depending upon the defined trauma system, need
available within the geographic constraints of the not be the highest level trauma center”
regional trauma system (need not be the highest Patients not meeting Steps 1, 2, or 3, but meeting
level trauma center)”. Step 4 criteria, “transport to a trauma center or
hospital capable of timely and thorough evaluation
and initial management of potentially serious
injuries. Consider consultation with medical control.”

would be cumbersome and nonfeasible for field use. Therefore, this Retained Criteria (No Changes)
criterion only applies to adults and older adults. • Retained criterion: SBP <90 mm Hg
Rationale: The predictive utility of hypotension is supported by
• New criterion: SBP < 70 mm Hg + (2  age in years) 49 studies, most of which evaluated a cut point of
(children 0–9 years) SBP <90 mm Hg.34 A meta-analysis of 17 studies showed that
Rationale: Two studies showed that age-adjusted hypotension prehospital SBP <90 mm Hg had a pooled sensitivity of 19%, a
(calculated using this formula) in the ED is an independent pre- specificity of 95%, and an AUROC of 0.67 for patients with se-
dictor of mortality among injured children.12,16 Inclusion of this rious injuries.34 Higher thresholds for SBP modestly raised
criterion aligns the triage guideline with Advanced Trauma Life sensitivity, but lowered specificity,34 and the panel sought to
Support training52 and was viewed by the panel as a pediatric- preserve the specificity of this measure. This criterion applies
specific training opportunity for EMS. Children older than 9 years to patients 10 years and older, with use of a higher threshold
reach the adult threshold of SBP <90 mm Hg using the formula. for older adults.
Because hypotension is a late finding of pediatric shock (decom-
pensated shock), EMS training on the use of visual cues (e.g.,
pallor, mottling, cyanosis) is encouraged, as represented in the • Retained criterion: SBP <110 mm Hg for older adults
Pediatric Assessment Triangle.53–55 Rationale: The criterion “SBP <110 mm Hg might represent
shock after age 65 years” was added to the “Special Consider-
• New criterion: “Respiratory distress or need for respiratory ations” section in 2011 to address the issue of undertriage
support” replaces “need for ventilatory support” and “respi- among older adults.6 Because SBP <90 mm Hg has a sensitivity
ratory rate <20 in infant aged <1 year.” of 4% to 5% for identifying seriously injured older adults, a
Rationale: The criterion “need for ventilatory support” was higher SBP threshold improves sensitivity (13–29%) while pre-
added in 20116 based on three studies showing that need for airway serving specificity (83–93%) in this population.34 This criterion
management and assisted ventilation was highly predictive of seri- was moved from the Special Considerations section to Mental
ous injury and death.56–58 There have since been four studies eval- Status and Vital Signs for clarity and consistency.
uating the need for respiratory support (variably defined as assisted
ventilation, intubation, or need for mechanical ventilation), which • Retained criterion: Respiratory rate of <10 or >29 breaths
showed a sensitivity of 8% to 53% and a specificity of 61% to per minute
100% for identifying patients with serious injury.35 The panel re- Rationale: Respiratory rate is the most commonly studied respi-
vised the wording to “need for respiratory support” based on ratory triage criterion (25 studies), with respiratory rate of <10 or
EMS feedback. Because there is not a specific respiratory rate >29 breaths per minute being the most studied parameters.35
threshold for injured infants,58 the “respiratory rate <20 in infants” This criterion had a pooled sensitivity of 13% and a specificity
criterion was removed. The panel included “respiratory distress” to of 96% for identifying seriously injured patients, with an
facilitate EMS training on important examination findings that pre- AUROC of 0.70.35 While most studies were conducted in adults,
cede the need for respiratory support, particularly in children.53–55 a respiratory rate <10 or >29 breaths/minute demonstrated good
predictive utility in children and older adults, yet with more var-
• New criterion: Room-air pulse oximetry <90% iability in the accuracy estimates.35 This criterion applies to pa-
tients of all ages.
Rationale: Pulse oximetry is widely available on portable moni-
tors used by EMS and has been evaluated in five studies, with
most using a cut point of <90%.35 Pulse oximetry had AUROC Mechanism of Injury Criteria
values of 0.59 to 0.76 for identifying patients with serious injury, Because anatomic and physiologic criteria identify less
similar to the respiratory rate criterion.35 While most studies than half of patients with serious injuries,28,60,61 the mechanism
were conducted in adults, one study demonstrated the predic- criteria are important in the triage process. However, the mecha-
tive utility of pulse oximetry in injured children57 and another nism criteria are less specific for serious injuries (lower +LR)
study showed the benefit of respiratory support and correction and therefore are included in the “moderate risk” category.
of hypoxia among young children with traumatic brain injury.59 Based on high undertriage associated with previous versions
Therefore, this criterion applies to patients of all ages. of the guideline,25–27,29 the panel considered changes to reduce

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J Trauma Acute Care Surg
Volume 93, Number 2 Newgard et al.

undertriage, particularly in children. There is one new criterion, for children and adults and to remove the age-based height for
three modified criteria, and four unchanged criteria. children.

• Modified criterion: Pedestrian/bicycle rider thrown, run over,

New and Modified Criteria
or with significant impact
• New criterion: Child (age 0–9 years) unrestrained or in unse-
Rationale: This triage criterion was included in the 1987 guide-
cured child safety seat
line, with slight modifications over time.5,6 Six studies pub-
Rationale: Motor vehicle crashes are a common cause of pediat-
lished since 2011 showed mixed results (+LR, 0.4–2.8).36 In a
ric injury. Lack of appropriate restraints is a consistent factor
study of children not meeting physiologic or anatomic criteria,
among seriously injured children.62–66 Unrestrained children the pedestrian criterion was predictive for patients run over and
have higher injury severity, greater trauma resource needs and
with significant impact (>20 mph).60 Among adults, this crite-
are more likely to die than restrained children.62–64 Lack of re-
rion demonstrated predictive utility with higher speed of impact
straint use also has been shown to predict seriously injured chil- (+LR ≥2.2).61 Because this criterion has long existed in the tri-
dren involved in motor vehicle crashes.66 The panel felt that this
age guideline with reasonable predictive utility for children, the
criterion was most pertinent for children 0 to 9 years, which pro-
panel retained the criterion and simplified the wording.
vided consistency with the age range for pediatric blood pres-
sure to simplify EMS training. Retained Criteria (No Changes)
• Retained criterion: Ejection (partial or complete) from auto-
• Modified criterion: Significant intrusion (including roof) >12 in mobile
occupant site or >18 in any site or need for extrication of the Rationale: Among multiple studies published since 2011, most
entrapped patient showed that ejection remains a significant predictor of serious
Rationale: As criteria already present in the guideline,6,67 addi- injury and death in adults and children.36,60,61
tional studies have confirmed the predictive utility of these
criteria in adults and children.36,60,61,68 Extrication >20 minutes • Retained criterion: Death in passenger compartment
was removed from the 2006 guideline based on varying defini- Rationale: In several studies published since 2011, death of an-
tions of “prolonged extrication” in the literature and the belief other passenger in the same vehicle predicted serious injury in
that the intrusion criteria would capture patients requiring extri- adults and children.36,60,61
cation.6,67 However, a systematic review showed that extrication
of any duration was a significant predictor of serious injury in • Retained criterion: Vehicle telemetry data consistent with se-
adults and children36 and that predictive utility was retained vere injury
down to ≥5 minutes.61 Based on these studies, the panel added Rationale: This criterion was added to the 2006 guideline based
the extrication criterion back to the guideline, without a specific on promising developments in automated collision notification
time requirement. Because different studies used “extrication” systems and retained in 2011 based on six studies demonstrating
and “entrapment” interchangeably, the panel integrated these predictive utility and the potential for transmission to 9-1-1 dis-
terms for the criterion. patch centers.6 In five recent studies, crash algorithms had good
predictive utility (+LR, 4.7–22.2),36 yet studies evaluating real-
time use of vehicle telemetry for field triage are lacking.
• Modified criterion: Rider separated from transport vehicle
with significant impact (e.g., motorcycle, ATV, horse, etc.) Emergency Medical Services Judgment (Previously
Rationale: Different versions of the motorcycle crash criterion
have been present since the 1990 guideline,5 despite limited
Step 4 Special Considerations)
data. A study of adults not meeting physiologic or anatomic The “Special Considerations” step has changed over time
criteria showed that motorcycle crash >20 mph or with rider sep- to include special populations, unique triage factors, and EMS
aration had poor overall predictive utility (+LR, 1.0–1.2).61 With provider judgment.6 While some studies of EMS provider judg-
only a single study evaluating the motorcycle criterion in the ment have had mixed results,70,71 others have shown judgment
past 10 years36 and the speed component offering little pre- to be independently associated with serious injury.72 The panel
dictive yield,61 the panel removed the speed requirement and felt that EMS judgment plays an important role in field triage,
broadened the type of transport vehicle for greater application but is dependent on training and experience. For the current
to children.60 guideline, the panel created a category for “EMS Judgment” to
replace “Special Considerations” and provided structured guid-
ance on factors to consider in the decision-making process.
• Modified criterion: fall from height >10 ft (all ages) The criteria in this section generally have less evidence and
Rationale: The 2011 guideline specified falls >20 ft in adults lower predictive utility, but remain important considerations in
and >10 ft in children (or two to three times the height of the field triage. There are three new criteria, one modified criterion,
child).6 However, the >10 ft criterion has good predictive utility and three unchanged criteria.
for children60 and adults.61 The criterion specifying two to three
times the height of the child was based on research in young New and Modified Criteria
children falling from bunk beds69 but has not demonstrated im- • New criterion: Suspicion of child abuse
proved prediction compared with a >10 ft criterion.60 For consis- Rationale: Child abuse can be difficult to diagnose and have sub-
tency and simplicity, the panel opted to use the same fall height tle presentations, yet with potentially devastating consequences.

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Mortality is elevated among abused children, especially with re- Rationale: The pregnancy criterion was added to the 1999 guide-
current episodes of abuse.73 Abused children frequently require line5 and refined to “pregnancy >20 weeks” in 2006.67 While
specialty care to address their injuries and the complex legal, pregnancy does not necessarily increase the likelihood of serious
logistical, social, and investigative aspects of these incidents. injury, simultaneous management of the mother and unborn
Trauma centers are required to have protocols in place to provide child can create complex clinical scenarios requiring trauma
comprehensive evaluation of such children, with guidelines and centers with obstetrics capabilities. Therefore, the panel felt that
best practices published by several national trauma organiza- this factor should be part of EMS Judgment.
tions.74–76 Training EMS clinicians to recognize the signs of
child abuse and integration of prehospital information into ED- • Retained criterion: Burns in conjunction with trauma
based clinical decision support systems77,78 are supported by Rationale: Consistent with Advanced Trauma Life Support
multiple national organizations. Based on these considerations, teaching, when a burn patient has other injuries, the injuries
the panel added suspicion of child abuse. should be evaluated and potentially prioritized over the burn.
Trauma centers have the capability to quickly evaluate these pa-
• New criterion: Special, high-resource health care needs tients to expedite care for both clinical conditions.
Rationale: Various comorbid conditions were in the triage guide-
lines from 1987 to 2006, but were removed in 2011 because of • Retained criterion: Children should be triaged preferentially
lack of evidence.5,6 Among five recent studies evaluating the to pediatric capable trauma centers
use of comorbidities for field triage,36 some showed that comor- Rationale: For injured children, research has demonstrated
bidities were independently associated with death and could re- higher survival in pediatric trauma centers compared with adult
duce undertriage among older adults.36 However, the predictive or mixed trauma centers.12 However, many regions do not have
utility of comorbidities varied across studies (+LR, 0.8–3.1).36 access to pediatric trauma centers.86 While transport to a pediat-
The panel recognized that injured patients with special health ric trauma center is preferable, the panel felt that transport to pe-
care needs related to comorbidities (e.g., ventilator dependence diatric versus adult trauma centers should be determined by local
or ventricular assist devices) may require the resources and ex- protocols and proximity. Based on stakeholder and expert feed-
pertise of trauma centers. back, the panel chose not to use a specific age to define children,
as there is insufficient evidence for a specific age limit and sys-
• Modified criterion: Low level falls in young children (age tems have established varying age limits based on local re-
≤5 years) or older adults (age ≥65 years) with significant sources and practice patterns. Because high ED pediatric readi-
head impact. ness has been associated with improved short- and long-term
Rationale: The panel moved these criteria from the Mechanism survival of children in US trauma centers,15,16 all trauma centers
and Special Considerations sections to EMS Judgment. Re- are strongly encouraged to meet such criteria.
search has shown that some children incur serious injuries from
low-height falls, including falls from standing,60 and that such
TRANSPORT RECOMMENDATIONS
falls are a common cause of traumatic brain injury in young chil-
dren.79 For older adults, ground-level falls can cause serious in- Emergency medical services systems vary by geography,
jury and death,19,80–82 which were the reasons for inclusion in organization, resources, service levels, staffing, training, ac-
the 2011 guideline.6 However, ground-level falls are common cess to air medical services, travel times, oversight, and gov-
among older persons and therefore are relatively nonspecific ernance. Trauma centers are hospitals that are prepared to
for serious injury (+LR, 1.2–1.9).25 Based on concerns that these provide emergent care for seriously injured patients through
criteria could result in overtriage, the panel included these factors resources, personnel, expertise, education, and quality im-
under EMS Judgment and added “with significant head impact.” provement programs. There are national standards for adult
and pediatric trauma centers, with trauma center designation
• Modified criterion: Anticoagulation use (Levels I to V) typically made at the state level (Table 3). State
Rationale: “Coagulopathy” was added to the triage guideline in trauma systems may be inclusive or exclusive, with inclusive
19905 and included in the 2011 guideline as “Anticoagulants systems categorizing most hospitals and demonstrating lower
and bleeding disorders — patients with head injury are at high injury-related mortality.87
risk for rapid deterioration.”6 Five recent studies evaluating anti- Recognizing the variability in EMS and trauma systems,
coagulant use for triage showed relatively low predictive utility transport recommendations in the guideline allow local flexibility.
(+LR, 0.73–1.8).36 Some research suggests that such a criterion There is not a “one size fits all” that will work for all systems.
could help identify older adults with intracranial hemorrhage,83 While the survival benefit of regionalized trauma care is driven
but other studies show otherwise.84 In a prospective study of primarily by Level I hospitals,7–9 there are large regions across
older adults transported by EMS, the incidence of brain hemor- the United States that do not have immediate access to such
rhage was similar between patients taking versus not taking an- trauma centers. Although 84% to 88% of US residents have ac-
ticoagulants.85 Based on these data, the panel felt that use of an- cess to a Level I or II trauma center within 60 minutes, these pro-
ticoagulants (including antiplatelet agents) was best considered portions are substantially lower when limited to ground travel and
in the context of EMS Judgment. shorter time windows.88,89 Access to pediatric trauma centers is
even lower,86 with widely variable proximity by state.90 Rural re-
Retained Criteria (No Changes) gions have the most limited access to Levels I and II trauma cen-
• Retained criterion: Pregnancy >20 weeks ters,86,88,89 resulting in higher undertriage, more interhospital

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TABLE 3. Characteristics of Trauma Centers

Level Criteria
I • Regional resource center expected to manage large numbers of seriously injured patients
• Admit ≥1,200 trauma patients or have ≥240 admissions with ISS ≥16 per year
• Attending trauma surgeon participates in major resuscitations in ED, present at operative procedures, and actively involved in critical
care of all seriously injured patients (24-h in-house availability)
• Immediate availability of board-certified emergency physicians, general surgeons, anesthesiologists, neurosurgeons, and orthopedic surgeons
• Maintain a surgically directed critical care service
• Participate in resident training
• Be a leader in education and outreach activities
• Conduct trauma research
II • Regional resource center expected to manage large numbers of seriously injured patients
• Same standards for provision of clinical care without the volume requirements
• No requirement for resident training, education, outreach, trauma research, or surgically directed critical care service
III • Capability to initially manage the majority of injured patients
• Transfer agreements with Level I or II trauma centers for seriously injured patients
• Continuous general surgical coverage
IV • Often serve rural regions and supplement care within a larger trauma system
• Initial evaluation and assessment of injured patients, with expected transfer of many patients to higher-level trauma centers
• Transfer agreements with higher-level trauma centers
• 24-h emergency coverage by a physician or midlevel provider
• Frequently lack continuous surgical coverage
From Resources for the Optimal Care of the Injured Patient, Committee on Trauma, American College of Surgeons, 2014. There is variation in state-to-state definitions and designations of
trauma centers. There are separate processes and criteria for pediatric trauma centers.
ISS, Injury Severity Score.

transfers, and longer transfer distances compared with urban set- guideline varies widely, with lowest adherence for the physiologic
tings.91 The triage guideline is intended to provide a template that criteria.97 Strict adherence would reduce undertriage.98 While
can be adapted for use in all systems. there are many hurdles to implementing an updated guideline,
When feasible, patients meeting the “high risk” criteria translating the science into practice is arguably the most important
should be triaged to the highest-level trauma center within the step of realizing effective field triage practices. The 2021 guideline
region, including consideration of air medical services. Injured is organized to facilitate ease of use, increase speed of decision-
patients meeting the physiologic criteria have lower mortality making, and promote adherence. We recommend adoption at the
when cared for in Level I trauma centers.92 Air medical ser- state level (similar to the trauma center designation process),
vices may offer advanced care clinicians, access to additional allowing regional and local EMS and trauma systems to determine
interventions, and more rapid transport. Emergency medical system-specific adaptations for hospital selection.
services medical directors and trauma system managers are
encouraged to evaluate the resources relevant to their systems
to guide implementation of the field triage guideline. Because FUTURE RESEARCH
time is known to be crucial for certain trauma patients,93 field
There is substantial need for future research to inform the
triage favors short time intervals. However, the current evi-
triage guideline. Noninvasive monitor technology and point-of-
dence is insufficient to make specific recommendations re-
care testing hold promise for field triage, particularly for seri-
garding transport times and when air medical services should
ously injured patients not meeting the high-risk criteria. System-
be activated.94 Some EMS systems may opt to implement a
atic reviews of circulatory and respiratory criteria identified sev-
closest hospital approach for patients with an unstable airway,
eral promising measures (e.g., point-of-care lactate, end-tidal
severe shock, traumatic arrest, or other “extremis” conditions
CO2, and heart rate variability), but more research and technology
for initial stabilization, before higher level transport for defin-
are needed to facilitate field use.34,35 Research on new criteria
itive care.
added to the 2021 guideline will be particularly important, as well
as studies on the real-time use of automated collision notification
IMPLEMENTATION AND ADHERENCE TO THE systems for field triage.
FIELD TRIAGE GUIDELINE The 2021 guideline includes changes in format, structure,
and content. Research is needed to evaluate the usability, perfor-
The triage guideline is not useful if not fully implemented mance, adherence, and application of the new guideline (including
into trauma systems and adopted by EMS clinicians. Following the impact on health outcomes), particularly compared with the
the 2006 triage guideline, only 17% of states had full adoption of 2011 guideline. Research on efficient and effective training
the new guideline, with 61% using an older version or a different methods, including training frequency, is also needed. Under-
protocol altogether.95 In a study of six metropolitan regions, only standing how and why EMS clinicians make triage decisions, in-
one region had adopted the most recent triage guideline within cluding concordance versus discordance with the guideline, will
2 years and 36% of triage criteria in use had been previously be important in optimizing triage performance. Based on the
removed or never included.96 Compliance with the field triage slow and variable uptake of previous triage guidelines,95,96

© 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma. e57
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creating new ways of disseminating, implementing, and moni- Expert Panel

Eileen Bulger, ACS Steering Committee; Craig Newgard, ACS Steering
toring adherence will be important to realizing the true potential Committee + expertise based; Mark Gestring, ACS Steering Committee;
of the guideline. Finally, there is a need for more system-based Greg Jurkovich, ACS Steering Committee; Joshua Brown, ACS Steering
research to inform transport times, when air medical services Committee + expertise based; Peter Fischer, ACS Steering Committee; E.
should be activated, and the role of different provider levels. Brooke Lerner, ACS Steering Committee; Mary Fallat, ACS Steering Com-
mittee + American Academy of Pediatrics; Clay Mann, ACS Steering Com-
mittee + expertise based; Brian Eastridge , ACS Steering Committee; Bellal
CONCLUSION Joseph, expertise based; Laura Godat, expertise based; John Armstrong,
The 2021 field triage guideline is based on the most current past guidelines; Jorie Klein, past guidelines; Scott Sasser, past guidelines;
Stewart C. Wang , past guidelines; Jeff Goodloe, American College of
science, a national panel of interdisciplinary experts, direct feed- Emergency Physicians; Lisa Gray, Emergency Medical Services for Children;
back from EMS clinicians, and input from many stakeholders. This Jeffrey Gilchrist, Emergency Nurses Association; Ron Lawler , National Asso-
guideline presents an opportunity to improve the prehospital care of ciation of EMS Educators; Dennis Rowe, National Association of Emergency
injured patients across the United States. Effective field triage is Medical Technicians; Theodore Delbridge, National Association of State
EMS Officials; Jon Krohmer, National Highway Traffic Safety Administration;
foundational to trauma systems, concentrating the most seriously Robert Russell, Pediatric Trauma Society; Nathan Christopherson, Society of
injured patients in trauma centers to improve survival after injury. Trauma Nurses; Jeffrey Salomone, National Registry of EMTs; and John M.
AUTHORSHIP Gallagher, National Association of EMS Physicians.
List of Organizations and Federal Agencies Endorsing the Field
E.M.B., C.D.N., P.E.F., M.G., and H.N.M. contributed in the study concep- Triage Guidelines
tion and design. R.C. and J.R.L. contributed in the systematic reviews. R.C., American College of Emergency Physicians, Emergency Medical Services
J.R.L., E.M.B., and C.D.N. contributed to the literature search (systematic for Children, Emergency Nurses Association, National Association of
reviews and other). P.E.F., M.G., H.N.M., and E.M.B. contributed to the EMS Educators, National Association of Emergency Medical Technicians,
EMS feedback. E.M.B., C.D.N., P.E.F., M.G., and H.N.M. participated as National Association of State EMS Officials, Pediatric Trauma Society, Soci-
the steering committee. H.N.M., M.D., M.N., and J.D. participated as ad- ety of Trauma Nurses, National Registry of EMTs, National Association of
ministrative support. All authors participated as panel members. E.M.B. EMS Physicians, American Academy of Pediatrics, and American College
was the panel leader. All authors contributed to the interpretation of re- of Surgeons Committee on Trauma.
sults. E.M.B. obtained funding. C.D.N. performed the drafting of manu-
script. All authors contributed in the critical revision. DISCLOSURE

ACKNOWLEDGMENTS The authors declare no conflicts of interest.

The American College of Surgeons was funded to perform an evidence-
We thank the Office of Emergency Medical Services at the National High- based revision of the Field Triage Guidelines as part of Cooperative Agree-
way Traffic Safety Administration for their support, guidance, and involve- ment number 693JJ91950007 between the American College of Surgeons
ment in this project. and the National Highway Traffic Safety Administration, Office of Emer-
Additional Authors Included in the Writing Group: gency Medical Services funded in part by the Health Resources and Services
Jeffrey M. Goodloe, MD, FACEP, FAEMS, Department of Emergency Med- Administration, Maternal and Child Health Bureau, and Emergency Medical
icine, University of Oklahoma School of Community Medicine Tulsa, Oklahoma; Services for Children Program. The contents are those of the authors and do
John H. Armstrong, MD, University of South Florida Morsani College of not necessarily represent the official views of, nor an endorsement, by the
Medicine, Tampa, Florida; John M Gallagher, MD, FAEMS, FACEP, Board US Government. For more information, please visit EMS.gov and HRSA.gov.
of Directors, National Association of EMS Physicians, Overland Park, Kan-
sas; Stewart C Wang, MD PhD FACS, Department of Surgery, University of
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