Prehospital Trauma Triage Decision Guidelines. "The following pediatric trauma triage guidelines are provided to assist in determining the disposition of children 12 years of age or younger. Use the adult trauma triage guidelines for children older than 12 years of age. It is understood that these are guidelines only and are to be used, whenever possible, in communication with a base station physician. These guidelines are intended to be utilized in conjunction with clinical judgment." Reference: New Jersey Department of Health & Senior Services. Trauma triage & transport. Trenton: New Jersey Department of Health & Senior Services; 1992. See also:

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Copyright Holder:
State of New Jersey, Department of Health
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April 25, 2018

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New Jersey Standard Pediatric Trauma Triage Guidelines

New Jersey Standard Pediatric Trauma Triage Guidelines

Step 1: Physiology (any one of the parameters listed below)
AVPU = responsive to voice, pain, or unresponsive
Evidence of poor perfusion (skin pallor, cool extremities, weak distal pulses, cyanosis/mottling, etc.)
Heart rate: child ≤ 5 yr old: < 80/min or > 180/min; child ≥ 6 yr old: < 60/min or > 160/min
Respiratory rate > 60, or respiratory distress, or apnea
Capillary refill > 2 seconds (evaluated on warm body part)
Step II: Anatomy (any one present)
Penetrating injuries (ex. gunshot/stab wounds) to the head, neck, torso or extremities (above the elbow and knee)
Flail chest
Fractures - more than one involving humerus and/or femur
Pelvic fractures
Paralysis or evidence of spinal cord injury
Amputation above the wrist or ankle
Burns when combined with other major injuries
Seat belt mark on the torso
Step III: Mechanism of injury (any one present)
Ejection from motor vehicle
Falls > 3x patient's height
Extrication time > 20 minutes with an injury
High voltage electrical injury
Unrestrained passenger in vehicle roll over
Pedestrian, motorcyclist, or pedalcyclist thrown or run over

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