Patient Arrival Time:_____ Alert Called :______ Level (Circle One): I II III Consult

Date______Patient arrival time:______Level (circle one): A B consult Patient Discharge Time: ______

Check all criteria met by patient. Method of arrival: EMS  Air Med ______ POV

Trauma Alert A – Stabilize and Initiate Transfer to Hillcrest Regional Trauma Center (Cat. 1 - ED time < 1 hrs.)
□ All penetrating injury to head, neck, torso or extremity
□ Respiratory compromise/obstruction
□ GCS < 14 with traumatic mechanism
□ O2 sat < 92%
□ Adult SBP < 100 or heart rate more than 130
□ Greater than sixty-four (64) years of age with SBP 120
□ Child < 1 year with SBP < 70 or HR < 100 or > 190
□ Child 1-9 years with SBP < 70 + 2X age (in years), HR < 80
or > 150
□ Traumatic paralysis
□ Pulseless extremity with traumatic mechanism
□ Greater than sixty-four (64) years with multi-system trauma / □ Amputation proximal to wrist or ankle
□ Two or more proximal long bone FX
□ Pelvic FX
□ Trauma transfer receiving blood or blood products
□ Any open FX (humerus, tibia, femur)
□ Core Temperature 95o F
□ Burns 10% BSA
□ Suspected or confirmed inhalation injury
□ Crush injuries
□ ED MD discretion
□ Sexual Assault (SANE)
Trauma Alert B (Cat. 2) / Trauma Alert B - Transfer Track (Cat. 2) (ED time 2 hours)
ED NURSE / MVC
□ with ejection (partial or complete)
□ speed > 30 mph
□ intrusion: > 12 inches occupant side or
> 18 inches any side
□ death in same passenger compartment
□ FALLS
□ ASSAULT/CHILD ABUSE
□ AUTO PEDESTRIAN
MOTORCYCYLE/ATV/BIKE/LARGE
ANIMAL
□ separation of rider
□ crash speed > 20 mph
□ run over
□ BURN (partial or full thickness)
□ HANGING/IMMERSION / ED PHYSICIAN / ED Physician:______Exam Time:______
CHECK ANY POSITIVE FINDINGS
□ Greater than sixty-four (64) years of age with SBP 120
□ Pregnant over 20 weeks gestation
HEAD NEUROLOGIC
□ any skull fracture □ focal deficit
□ abnormal brain CT □ traumatic paresis
MUSCULOSKELETAL ABDOMEN
□ femur FX (not isolated hip) □ gross hematuria
□ spine FX □ abnormal abdominal/pelvic CT
□ solid organ injury
BURNS
□ less than 10% BSA (face, hands, feet, genitalia, perineum, and/or major joints)
CHEST
□ multiple (> 2) rib fractures □ ED PHYSICIAN DISCRETION
□ sub Q air
□ pneumothorax □ SPECIALIST PHYSICIAN
□ hemothorax DISCRETION
Signatures / Time
MD
RN
RN / Patient Label
Rad.
Lab
PCP

Disposition: □ Home □ Floor □ ICU □ OR □ Morgue □ Acute transfer to ______EMS called: ______ETA: ______EMS Arrival: ______

Rev.12.3.14