The Major Trauma by-pass clinical practice guideline has been designed to identify trauma patients that would benefit primary transport direct to a Major Trauma Centre (MTC). Studies demonstrate that identification of major trauma in the patients ≥ 65 cohort is challenging. An older adult triage tool has been included with specific decision criteria that are expected to improve patient outcomes.


  1. All patients with major trauma should be taken directly to RPH where possible.
  2. Where the patient’s condition appears imminently life threatening, diversion to the nearest appropriate emergency department for stabilisation should be undertaken.
  3. Trauma patients with obvious spinal injuries, who are pregnant or have major pelvic injuries, should always be taken to RPH except in imminent life-threatening situations where stabilisation is required prior to transfer to RPH.
  4. Burns: Patients should be taken to FSH where possible. Should significant major trauma also be present, they should be taken to RPH.
  5. All country hospital transfers of major adult trauma should be taken to RPH. RFDS transfers will have a designated receiving hospital and crews should follow this.


All major paediatric (patients age less than 14 years) trauma (including burns) should be taken to PCH unless urgent stabilisation is required at the nearest appropriate emergency department prior to transfer to PCH.

Patients not suffering major trauma as defined in this guideline are to be transported to the hospital designated by the Ambulance Network Coordinator (ANC). Should the patient need specialised care as defined by the Clinical Distribution Matrix, the ANC should be contacted to inform them of the change of destination.

 Trauma & Major Trauma Criteria

In accordance with the trauma services plan developed by the Department of Health, patients suffering major trauma should be taken to hospitals designated as Major Trauma Centres. Major Trauma should be considered in any one of the following criteria

Physiological Criteria (any of the following):

  0 - 3 months 3 - 12 months 1 - 4 years 5 - 11 years 12-16 years Adult ≥ 65
HR <110 or >160 <100 or >160 <90 or >140 <80 or >140 <60 or >120 <50 or >120 <50 or >120
RR <30 or > 60 <25 or >55 <20 or >40 <15 or >35 <15 or >30 <8 or >25 <8 or >25
BP SYS <70 <75 <80 <80 <90 <90 <120
SpO2 <92% <92% <92% <92% <92% <94% <94%
GCS  <Baseline <Baseline <Baseline   <Baseline <Baseline  <Baseline <Baseline


Injury Criteria (any of the following):

All patient cohorts
  • Suspicion of multiple rib #’s, severe pain, restraint abrasion/contusion, evidence of blunt impact
  • Significant injuries involving more than one body region
  • 2 or more proximal long bone fractures
  • Amputation / crush Injury proximal to hand and foot
  • Crushed, de-gloved or mangled limb or extreme open fracture
  • Suspected spinal fracture and/or spinal cord injury
  • Suspected open and/or depressed skull fracture
  • Suspected fractured pelvis
  • Penetrating Injuries to the head, neck, chest, abdomen, pelvis, axilla, or groin

High Risk Criteria (any of the following):

Adult Older adult Paediatric
  • Fatality on scene whereby the patient was in the same vehicle
  • MBA > 30 km/h with injuries
  • MVA > 60 km/h with injuries
  • Partial or complete ejection
  • Fall > 3 meters
  • Pedestrian or cyclist with speed impact > 25km/h
  • Patient entrapment with compression
  • Cabin intrusion
    • >30 cm occupants side
    • >45 cm any side
  • Explosion

As for adult but inclusive of:

  • Heightened clinical consideration for significant mechanism, in presence of multiple comorbidities or anticoagulation therapy
  • Falls ≥ 2 times the patients height
Older adult (≥65 years old) Head Injury Criteria

Patients in this cohort can have a blunted response to trauma. Advocate for transport to hospital if there is history of a head strike (including fall from standing) and any of the following:

  • Unequal pupils
  • Blurred vision
  • Severe or persistent headache
  • Nausea or vomiting
  • Change in neurological status (from baseline)
  • On anticoagulant therapy

Major Trauma Decision Tool

An online quick reference tool to assist with the identification of major trauma, and to assist in destination choice for the patients presenting condition.

Major Trauma Decision Tree

 Additional Information
  • Patients’ pharmacology can influence clinical presentation and vital signs
  • Pregnant patients associated with trauma require assessment for both maternal and foetal wellbeing
  • This guideline is intended to guide crews who are within 45 minutes from a Major Trauma Hospital (Royal Perth Hospital)
  • Crews managing major trauma that are outside of the 45-minute radius and who have already been transported to a peripheral hospital are encouraged to contact CSP SOC for awareness and notification of RPH to facilitate long term patient oversight

Key Terms & Links

Immediate life-threat

Patients with immediate life-threat should address time-critical concerns prior to continuing with this guideline.

Major Trauma Quick Charts


Brown, E., Tohira, H., Bailey, P., Fatovich, D., Pereira, G. and Finn, J., 2019. Older age is associated with a reduced likelihood of ambulance transport to a trauma centre after major trauma in Perth. Emergency Medicine Australasia, 31(5), pp.763-771.

Crewdson K, Lockey D, Davies G. Outcome from paediatric cardiac arrest associated with trauma. Resuscitation 2007;75:29–34.

Director of Trauma Services Royal Perth Hospital / State Director of Trauma (WA).

European Resuscitation Council Guidelines for Resuscitation 2015, Section 4. Cardiac arrest in special circumstances.

Fiorelli, E., Bozzano, V., Bonzi, M., Rossi, S., Colombo, G., Radici, G., Canini, T., Kurihara, H., Casazza, G., Solbiati, M. and Costantino, G., 2020. Incremental Risk of Intracranial Hemorrhage After Mild Traumatic Brain Injury in Patients on Antiplatelet Therapy: Systematic Review and Meta-Analysis. The Journal of Emergency Medicine, 59(6), pp.843-855.

Ichwan, B., Darbha, S., Boulger, C. and Caterino, J., 2013. Evaluation for Ohio's Geriatric Specific Trauma Triage Criteria: Assessing Implementation and Improvement in Outcomes for Ohio's Elders. Annals of Emergency Medicine, 62(4), p.S115.

Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 2006;48:240–4.172.

Luna GK, Pavlin EG, Kirkman T, Copass MK, Rice CL. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma 1989;29:1430–3.170.

Newgard CD, Lin A, Eckstrom E, Caughey A, Malveau S, Griffiths D, Zive D, Bulger E. Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults. J Trauma Acute Care Surg. 2019 May;86(5):829-837. doi: 10.1097/TA.0000000000002195. PMID: 30629015; PMCID: PMC6370024.

Special focus report - Elderly major trauma patients. (n.d.). health.vic. Retrieved September 17, 2021, from https://www2.health.vic.gov.au/about/publications/researchandreports/Special%20Focus%20Report%20-%20Elderly%20Major%20Trauma%20Patients

Victorian Paediatric Clinical Network, Melbourne, Australia, The Victorian Children's Tool for Observation and Response (ViCTOR), available from www.victor.org.au

Willis CD, Cameron PA, Bernard SA, Fitzgerald M. Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury 2006;37:448–54.171.

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