In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.

In the United States, injury is the leading cause of death for persons aged 1--44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health. At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called "field triage." Although basic emergency services generally are consistent across hospital emergency departments (EDs), certain hospitals have additional expertise, resources, and equipment for treating severely injured patients. Such facilities, called "trauma centers," are classified from Level I (centers providing the highest level of trauma care) to Level IV (centers providing initial trauma care and transfer to a higher level of trauma care if necessary) depending on the scope of resources and services available. The risk for death of a severely injured person is 25% lower if the patient receives care at a Level I trauma center. However, not all patients require the services of a Level I trauma center; patients who are injured less severely might be served better by being transported to a closer ED capable of managing milder injuries. Transferring all injured patients to Level I trauma centers might overburden the centers, have a negative impact on patient outcomes, and decrease cost effectiveness. In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is an algorithm that guides EMS providers through four decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to determine the most appropriate destination facility within the local trauma care system. Since its initial publication in 1986, the Decision Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began facilitating revision of the Decision Scheme by hosting a series of meetings of the National Expert Panel on Field Triage, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies. The Panel reviewed relevant literature, presented its findings, and reached consensus on necessary revisions. The revised Decision Scheme was published in 2006. This report describes the process and rationale used by the Expert Panel to revise the Decision Scheme.

BACKGROUND: Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. METHODS: Using data from the National Emergency Medical Services Information System, we examined data from 2012-5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. RESULTS: Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20-29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13-1.22) and for men (aOR = 1.13, 95% CI = 1.10-1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72-0.80 and aOR = 0.85, 95% CI = 0.80-0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68-0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45-3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09-1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). CONCLUSION: This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs.

OBJECTIVE: To determine the situational circumstances associated with bystander interventions to render aid during a medical emergency. METHODS: This study examined 16.2 million Emergency Medical Service (EMS) events contained within the National Emergency Medical Services Information System. The records of patients following a 9-1-1 call for emergency medical assistance were analyzed using logistic regression to determine what factors influenced bystander interventions. The dependent variable of the model was whether or not a bystander intervened. RESULTS: EMS providers recorded bystander assistance 11% of the time. The logistic regression model correctly predicted bystander intervention occurrence 71.4% of the time. Bystanders were more likely to intervene when the patient was male (aOR = 1.12, 95% CI = 1.12-1.3) and if the patient was older (progressive aOR = 1.10, 1.46 age group 20-29 through age group 60-99). Bystanders were less likely to intervene in rural areas compared to urban areas (aOR = 0.58, 95% CI = 0.58-0.59). The highest likelihood of bystander intervention occurred in a residential institution (aOR = 1.86, 95% CI = 1.85-1.86) and the lowest occurred on a street or a highway (aOR = 0.96, 95% CI = 0.95-0.96). Using death as a reference group, bystanders were most likely to intervene when the patient had cardiac distress/chest pain (aOR = 11.38, 95% CI = 10.93-11.86), followed by allergic reaction (aOR = 7.63, 95% CI = 7.30-7.99), smoke inhalation (aOR = 6.65, 95% CI = 5.98-7.39), and respiration arrest/distress (aOR = 6.43, 95% CI = 6.17-6.70). A traumatic injury was the most commonly recorded known event, and it was also associated with a relatively high level of bystander intervention (aOR = 5.81, 95% CI = 5.58-6.05). The type of injury/illness that prompted the lowest likelihood of bystander assistance was Sexual Assault/Rape (aOR = 1.57, 95% CI = 1.32-1.84) followed by behavioral/psychiatric disorder (aOR = 1.64, 95% CI = 1.57-1.71). CONCLUSION: Bystander intervention varies greatly on situational factors and the type of medical emergency. A higher risk of patient death is likely to prompt bystander action. These novel study results can lead to more effective first aid training programs. KEY WORDS: bystander; EMS; rural; cardiac distress; trauma.

OBJECTIVE: Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. METHODS: Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. RESULTS: Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. CONCLUSION: Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI.

INTRODUCTION: Among people aged ≥65 years, falling is the leading cause of emergency department visits. Emergency medical services (EMS) are often called to help older adults who have fallen, with some requiring hospital transport. Chief aims were to determine where falls occurred and the circumstances under which patients were transported by EMS, and to identify future fall prevention opportunities. METHODS: In 2012, a total of 42 states contributed ambulatory data to the National EMS Information System, which were analyzed in 2014 and 2015. Using EMS records from 911 call events, logistic regression examined patient and environmental factors associated with older adult transport. RESULTS: Among people aged ≥65 years, falls accounted for 17% of all EMS calls. More than one in five (21%) of these emergency 911 calls did not result in a transport. Most falls occurred at home (60.2%) and residential institutions such as nursing homes (21.7%). Logistic regression showed AORs for transport were greatest among people aged ≥85 years (AOR=1.14, 95% CI=1.13, 1.16) and women (AOR=1.30, 95% CI=1.29, 1.32); for falls at residential institutions or nursing homes (AOR=3.52, 95% CI=3.46, 3.58) and in rural environments (AOR=1.15, 95% CI=1.13, 1.17); and where the EMS impression was a stroke (AOR=2.96, 95% CI=2.11, 4.10), followed by hypothermia (AOR=2.36, 95% CI=1.33, 4.43). CONCLUSIONS: This study provides unique insight into fall circumstances and EMS transport activity. EMS personnel are in a prime position to provide interventions that can prevent future falls, or referrals to community-based fall prevention programs and services.

OBJECTIVES: We determined the factors that affect naloxone (Narcan) administration in drug overdoses, including the certification level of emergency medical technicians (EMTs). METHODS: In 2012, 42 states contributed all or a portion of their ambulatory data to the National Emergency Medical Services Information System. We used a logistic regression model to measure the association between naloxone administration and emergency medical services certification level, age, gender, geographic location, and patient primary symptom. RESULTS: The odds of naloxone administration were much higher among EMT-intermediates than among EMT-basics (adjusted odds ratio [AOR] = 5.4; 95% confidence interval [CI] = 4.5, 6.5). Naloxone use was higher in suburban areas than in urban areas (AOR = 1.41; 95% CI = 1.3, 1.5), followed by rural areas (AOR = 1.23; 95% CI = 1.1, 1.3). Although the odds of naloxone administration were 23% higher in rural areas than in urban areas, the opioid drug overdose rate is 45% higher in rural communities. CONCLUSIONS: Naloxone is less often administered by EMT-basics, who are more common in rural areas. In most states, the scope-of-practice model prohibits naloxone administration by basic EMTs. Reducing this barrier could help prevent drug overdose death.

INTRODUCTION: The most effective use of trauma center resources helps reduce morbidity and mortality, while saving costs. Identifying critical infrastructure characteristics, patient characteristics and staffing components of a trauma center associated with the proportion of patients needing major trauma care will help planners create better systems for patient care. METHODS: We used the 2009 National Trauma Data Bank-Research Dataset to determine the proportion of critically injured patients requiring the resources of a trauma center within each Level I-IV trauma center (n=443). The outcome variable was defined as the portion of treated patients who were critically injured. We defined the need for critical trauma resources and interventions ("trauma center need") as death prior to hospital discharge, admission to the intensive care unit, or admission to the operating room from the emergency department as a result of acute traumatic injury. Generalized Linear Modeling (GLM) was used to determine how hospital infrastructure, staffing Levels, and patient characteristics contributed to trauma center need. RESULTS: Nonprofit Level I and II trauma centers were significantly associated with higher levels of trauma center need. Trauma centers that had a higher percentage of transferred patients or a lower percentage of insured patients were associated with a higher proportion of trauma center need. Hospital infrastructure characteristics, such as bed capacity and intensive care unit capacity, were not associated with trauma center need. A GLM for Level III and IV trauma centers showed that the number of trauma surgeons on staff was associated with trauma center need. CONCLUSION: Because the proportion of trauma center need is predominantly influenced by hospital type, transfer frequency, and insurance status, it is important for administrators to consider patient population characteristics of the catchment area when planning the construction of new trauma centers or when coordinating care within state or regional trauma systems.

BACKGROUND: Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient. OBJECTIVES: This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population. METHODS: The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling. RESULTS: The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7-28.3). Other physiologic criteria also demonstrated significant odds of death. CONCLUSIONS: These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.

BACKGROUND: Ambulance transport of injured patients to the most appropriate medical care facility is an important decision. Trauma centers are designed and staffed to treat severely injured patients and are increasingly burdened by cases involving less-serious injury. Yet, a cost evaluation of the Field Triage national guideline has never been performed. OBJECTIVES: To examine the potential cost savings associated with overtriage for the 1999 and 2006 versions of the Field Triage Guideline. METHODS: Data from the National Hospital Ambulatory Medical Care Survey and the National Trauma Databank (NTDB) produced estimates of injury-related ambulatory transports and exposure to the Field Triage guideline. Case costs were approximated using a cost distribution curve of all cases found in the NTDB. A two-way sensitivity analysis was also used to determine the impact of data uncertainty on medical costs and the reduction in trauma center visits (12%) after implementation of the 2006 Field Triage guideline compared with the 1999 Field Triage guideline. RESULTS: At a 40% overtriage rate, the average case cost was $16,434. The cost average of 44.2% reduction in case costs if patients were treated in a non-trauma center compared with a trauma center was found in the literature. Implementation of the 2006 Field Triage guideline produced a $7,264 cost savings per case, or an estimated annual national savings of $568,000,000. CONCLUSION: Application of the 2006 Field Triage guideline helps emergency medical services personnel manage overtriage in trauma centers, which could result in a significant national cost savings.

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

Why should specialists in craniofacial and maxillofacial surgery care about blast injury from bombings, and what is important to know about blast injuries? The recently revised bombings curriculum Bombings: Injury Patterns and Care, Version 2.0, released through the Centers for Disease Control and Prevention National Center for Injury Prevention and Control, provides answers by addressing the global context of bombings, reviewing the 4 mechanisms of blast injury, and describing the management and care of blast casualties.

Explosions and bombings are the most common deliberate cause of disasters with large numbers of casualties. Despite this fact, disaster medical response training has traditionally focused on the management of injuries following natural disasters and terrorist attacks with biological, chemical, and nuclear agents. The following article is a clinical primer for physicians regarding traumatic brain injury (TBI) caused by explosions and bombings. The history, physics, and treatment of TBI are outlined.