For blunt head trauma with a positive head CT. Not a screening tool for who needs a CT in the first place — for pediatric imaging-decision screening (PECARN), see the imaging references cited on your department's pediatric trauma resources.
⚠ LOCAL ROUTING — LOCALIZE: mBIG-1 routes to the trauma attending, not neurosurgery; mBIG-2 and mBIG-3 are transferred to the receiving trauma center, not admitted locally — both per a workflow agreed with the receiving center's trauma medical director (see the "Local practice" notes below). The categories and imaging thresholds below are from the published mBIG literature.
mBIG-1 — LOWEST RISK
mBIG-2 — MODERATE RISK
mBIG-3 — HIGHEST RISK (any one qualifies)
WHY THIS MATTERS
Sources: Joseph JM, et al. "Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization." J Emerg Med. 2022;63(4):490–498 (mBIG-1/2/3 criteria and management, cross-verified via EMOttawa Blog clinical summary and WikEM). Original concept: Joseph B, et al. "The Brain Injury Guidelines (BIG) project: defining the management of traumatic brain injury by acute care surgeons." J Trauma Acute Care Surg. 2014;76(4):965–969. The "Local practice" call-routing and transfer notes above are local practice, agreed directly with the receiving center's trauma medical director — not part of the published mBIG literature. This card is also linked from Clinical Pathways.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
02Level 1 Trauma Activation
HIGHEST-TIER TEAM ACTIVATION CRITERIA
Who triggers a full trauma team response. Criteria adapted from the CDC/ACS-COT National Guideline for Field Triage — this card assumes a Level III trauma center without in-house neurosurgery, so this is the evidence base for its activation tier, not an ACS Level I standard, and anything needing neurosurgical care transfers.
⚠ LOCALIZE THIS CARD: a trauma-center level (ACS/state verification of a hospital's resources) and a Level 1 activation (this hospital's per-patient response tier) are different things — this card assumes a Level III trauma center with general surgery but no in-house neurosurgery. Confirm locally: who responds to a full activation (ED physician, general surgery, anesthesia, on-call roster), expected response time, and the transfer trigger/receiving center for anything beyond Level III capability (any neurosurgical need). The criteria below are the national evidence base to adapt, not your site's own protocol.
PHYSIOLOGIC CRITERIA
ANATOMIC CRITERIA
MECHANISM CRITERIA
ESCALATE DESPITE NORMAL VITALS
FIRST MINUTES
AFTER ACTIVATION — MECHANISM BRANCH
PRIMARY SURVEY · <C>ABCDE
ADJUNCTS TO THE PRIMARY SURVEY
SECONDARY SURVEY — HEAD TO TOE
CT GUIDANCE — BLUNT
CT GUIDANCE — PENETRATING
Sources: National Guideline for the Field Triage of Injured Patients, 2021 (CDC/ACS-COT National Expert Panel on Field Triage), J Trauma Acute Care Surg, DOI 10.1097/TA.0000000000003627. ACS Committee on Trauma, Resources for Optimal Care of the Injured Patient, 2022 Standards, Standards 5.3–5.4 (levels of activation / surgeon response). Illustrative hospital protocols citing these standards: UW Medicine and Froedtert Hospital trauma activation criteria (GCS<9 local convention). Nunez TC, et al. "Early prediction of massive transfusion in trauma: simple as ABC?" J Trauma 2009;66(2):346-352 (ABC score). Sierink JC, et al. (REACT-2), Lancet 2016;388(10045):673-83. Geriatric/anticoagulant overtriage: PubMed 31030991. Age-65 SBP threshold and low-level-fall escalation per the CDC/ACS field-triage algorithm above. Primary/secondary survey, adjuncts, and the <C>ABCDE sequence per ATLS Student Course Manual, 11th ed. (American College of Surgeons, 2024). C-spine imaging decision per the Canadian C-Spine Rule (Stiell, JAMA 2001) and NEXUS (Hoffman, NEJM 2000). Pediatric head-CT selection per PECARN (Kuppermann, Lancet 2009). BCVI screening → card 08.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
Multi-system blunt injury. For activation criteria see card 02; for isolated head injury see card 06.
PRIMARY SURVEY & RESUSCITATION TARGETS
IMAGING
MASSIVE TRANSFUSION & TXA
DON'T-MISS PATTERNS
Sources: ACS Committee on Trauma, ATLS 11th Edition (2025) — "xABCDE" primary survey change. Bickell WH, et al. N Engl J Med. 1994;331(17):1105-9 (permissive hypotension, penetrating trauma, extrapolated to blunt DCR teaching). Brain Trauma Foundation, Guidelines for the Management of Severe TBI, 4th ed., Neurosurgery 2017;80(1):6-15 (age-stratified SBP targets). Sierink JC, et al. (REACT-2), Lancet 2016;388(10045):673-83. Holcomb JB, et al. (PROPPR), JAMA 2015;313(5):471-82. CRASH-2 Collaborators, Lancet 2010;376(9734):23-32, and 2011 timing sub-analysis. EAST PMG, Blunt Aortic Injury (Fox N, et al., 2015). EAST PMG, Blunt Cardiac Injury Screening (Clancy K, et al., J Trauma Acute Care Surg 2012;73(5 Suppl 4):S301-6). Seatbelt-sign/hollow-viscus CT exclusion study, PMC9280606.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
04Penetrating Trauma
TORSO / ABDOMEN — GSW & STAB
Gunshot and stab wounds to the torso/abdomen. Penetrating neck trauma has its own card — see Penetrating Neck Trauma.
⚠ LOCALIZE THIS CARD: this card assumes a Level III trauma center — general surgery is available, but there is no in-house neurosurgery. A penetrating torso/proximal-extremity wound is high-acuity: resuscitate, involve the surgeon early, and start the transfer conversation early for anything beyond local capability (or any neurosurgical need). Confirm your receiving trauma center and the point at which that call goes out — early, in parallel with the workup, not after it.
BEFORE ANYTHING ELSE — IS THE DEPARTMENT SAFE?
HEMORRHAGE-FIRST PRIMARY SURVEY
CHEST — IMMEDIATE LIFE THREATS
ABDOMEN
GUNSHOT WOUND DOCUMENTATION
MTP, TXA & TRANSFER
Sources: Bickell WH, et al. N Engl J Med. 1994;331(17):1105-9. Tactical Combat Casualty Care (TCCC) Guidelines, current edition, Committee on TCCC — MARCH framework, open-pneumothorax dressing change (2013). Mowery NT, et al. (EAST), J Trauma 2011;70(2):510-8 (hemothorax thresholds). Como JJ, et al. (EAST), J Trauma 2010;68(3):721-33 (selective non-operative management, penetrating abdominal trauma). Western Trauma Association, Critical Decisions — Resuscitative Thoracotomy algorithm, 2024. Nunez TC, et al., J Trauma 2009;66(2):346-52 (ABC score). CRASH-2 Collaborators, Lancet 2010/2011. ACEP Now, "The Clinical Forensic Evaluation of Gunshot Wounds in the ED." CDC/ACS-COT National Guideline for Field Triage, 2021 (transfer trigger).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
05Burn
INITIAL MANAGEMENT & TRANSFER
Burn triage and resuscitation. For circumferential-burn compartment release, see Escharotomy.
⚠ LOCALIZE THIS CARD: confirm your regional burn center and its transfer contact — burn-center transfer criteria below are American Burn Association national criteria, not a guarantee any specific facility accepts every category.
BURN CENTER TRANSFER CRITERIA (ABA)
TBSA ESTIMATION
FLUID RESUSCITATION
AIRWAY & INHALATION INJURY
PAIN, WOUND CARE & PRE-TRANSFER DON'TS
Sources: American Burn Association, "Guidelines for Burn Patient Referral," 2022, ameriburn.org; ACS Resources for Optimal Care of the Injured Patient (2006) burn-center guidelines. Cartotto R, et al. "American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation," J Burn Care Res 2024;45(3):565-89. Orlando Regional Medical Center, "Burn Inhalation Injury Treatment" EBM guideline, 2025 rev. Romanowski KS, et al. (ABA pain guideline), J Burn Care Res 2020;41(6):1152-64. Lanham JS, et al. (wound care), Am Fam Physician 2020. StatPearls, "Escharotomy" (Wang & Hughes, updated 2026). Full research notes with additional citations saved to the project.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
06Isolated Head Trauma
BEFORE / INDEPENDENT OF CT RESULT
Initial triage and secondary-injury prevention. Once a head CT is positive for minor TBI, hand off to Brain Injury Guidelines (BIG) for disposition. PECARN pediatric imaging criteria are out of scope here.
SEVERITY & AIRWAY
CT DECISION
PREVENT SECONDARY INJURY — AVOID THE "H-BOMBS"
HERNIATION — TREATMENT LADDER
ANTICOAGULATION & SEIZURE PROPHYLAXIS
Sources: ACS TQIP Best Practices Guidelines for TBI, 2024 rev. Stiell IG, et al. (Canadian CT Head Rule), Lancet 2001;357(9266):1391-6, and JAMA 2005;294(12):1511-8 (head-to-head vs. New Orleans Criteria). ACEP Clinical Policy, mild TBI, Feb 2023, Ann Emerg Med. Brain Trauma Foundation, Guidelines for the Management of Severe TBI, 4th ed., Neurosurgery 2017;80(1):6-15. Emergency Neurological Life Support (ENLS) TBI and ICP/Herniation Protocols, Neurocritical Care Society, current editions. Murphy L, "Hypertonic saline is just as good as (and probably better than) mannitol," CJEM 2020;22(2):142-3. Kowal D, Ross D, "Emergency Department Trephination for Epidural Hematoma," ACEP Now, Oct 2022. Frontera JA, et al., Neurocritical Care 2016;24(1):6-46 (anticoagulant reversal).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
07Mangled / Amputated Extremity
SALVAGE, PRESERVATION & TRANSFER
This card assumes a hospital that is not a replant center — the goal here is hemorrhage control, correct part preservation, and getting the patient and part to a replant/hand center fast.
HEMORRHAGE CONTROL
MESS SCORE — LIMITATIONS
AMPUTATED PART PRESERVATION
VASCULAR ASSESSMENT
COMPARTMENT SYNDROME & PROPHYLAXIS
ANTIBIOTICS & TETANUS
Sources: TCCC Guidelines, current edition, Committee on TCCC (tourniquet-first hemorrhage control). Johansen K, et al. (MESS), J Trauma 1990;30(5):568-72; Aldabagh et al., systematic review, Open Access Maced J Med Sci 2023; Abdo et al., Vasc Endovascular Surg 2023 (MESS reliability, upper- vs. lower-extremity). StatPearls, "Digit Amputation" (preservation/replantation). ILCOR scoping review, "Preservation of Traumatic Amputated Body Parts," Oct 2024. EAST PMG, Penetrating Lower Extremity Arterial Trauma (2002, hard/soft signs, 6h window). Romagnoli AN, et al., "Hard Signs Gone Soft," J Trauma Acute Care Surg 2021. StatPearls, "Acute Compartment Syndrome." EAST PMG, Prophylactic Antibiotics in Open Fractures (2011).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
08BCVI Screening
BLUNT CEREBROVASCULAR INJURY — WHO GETS A CTA NECK
Screening for blunt carotid or vertebral artery injury. The point is to catch it before it strokes — most BCVI strokes happen hours to days later and are largely preventable with early antithrombotic therapy. CTA neck is the screening test.
⚠ LOCALIZE THIS CARD: this card assumes a Level III trauma center without in-house neurosurgery — a positive screen or a confirmed BCVI is a transfer + neurosurgery/vascular/stroke conversation. Confirm local CTA availability and the receiving center's antithrombotic preference. The three criteria sets below are published screening tools to adopt, not a site protocol; pick one deliberately.
SIGNS / SYMPTOMS — IMAGE NOW, ANY CRITERIA
DENVER CRITERIA — RISK FACTORS (SCREEN IF PRESENT)
EXPANDED DENVER CRITERIA (ADDS)
UNIVERSAL SCREENING
IF THE SCREEN IS POSITIVE
Sources: Biffl WL, et al. "Blunt carotid arterial injuries: implications of a new grading scale," J Trauma 1999;47(5):845-53 (Denver grading); Biffl WL, et al., Ann Surg 1998 (Denver screening criteria). Burlew CC, et al. "Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis," J Trauma Acute Care Surg 2012;72(2):330-7 (Expanded Denver criteria). Kim DY, et al. EAST Practice Management Guideline, "Evaluation and management of blunt cerebrovascular injury," J Trauma Acute Care Surg 2020;88(6):875-887. Western Trauma Association BCVI algorithm. Universal-screening discussion: e.g. Black JA, et al., J Trauma Acute Care Surg 2021 and related single-center series. Criteria and grades vary between published tools — verify against your local trauma-center protocol before adopting one.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
09Mass-Casualty Incident — First 15 Minutes
DECLARE · ROLES · TRIAGE · SPACE
More patients than the department can treat normally — a bus, a fire, a lightning strike on a summit. The first 15 minutes decide whether the ED runs the event or the event runs the ED.
⚠ DRAFT — NOT CLINICALLY REVIEWED: written from the published guidance cited below to fill coverage gap #93. Verify against local plans before this card is trusted.
1 · DECLARE & CLAIM ROLES (MINUTES 0–5)
2 · TRIAGE & SPACE (MINUTES 5–10)
3 · SUPPLY, COMMS & THE NEXT HOUR (MINUTES 10–15)
Sources: START/SALT triage per CHEMM (chemm.hhs.gov); ACS Committee on Trauma disaster resources. This card needs site-specific facts filled in: the actual call-tree names/numbers and the designated zones.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
10Electrical & Lightning Injury
THE BURN IS THE TIP · THE RHYTHM IS THE RISK
High-voltage current cooks from the inside; lightning is a different disease again. The skin often lies about both.
⚠ DRAFT — NOT CLINICALLY REVIEWED: written from the published guidance cited below to fill coverage gap #96. Verify against local plans before this card is trusted.
1 · SCENE, TRIAGE & THE ARREST EXCEPTION
2 · WORKUP & WHO GETS A MONITOR
3 · BURNS, RHABDO & THE QUIET INJURIES
Sources: Wilderness Medical Society lightning injury guidelines (WEM 2014); ACS/ABA burn referral criteria; Zafren et al., electrical injuries review. See also the Burn card for fluid math.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.
11Hazmat / Contaminated Patient
STOP AT THE DOOR · UNDRESS · WASH · ANTIDOTE
A chemical, radiological or unknown-exposure patient. The first decision is not clinical — it is whether this patient comes inside. Removing clothing alone removes most of the contaminant.
⚠ DRAFT — NOT CLINICALLY REVIEWED: written from the published guidance cited below to fill coverage gap #124. Verify every dose and every local detail (decon location, PPE stock, hazmat team) before this card is trusted.
1 · STOP THE PATIENT OUTSIDE — PROTECT THE DEPARTMENT
2 · DECONTAMINATE — UNDRESS FIRST
3 · TREAT THE TOXIDROME
Identify by the syndrome in front of you, not by waiting for the agent to be named.
4 · CALL FOR HELP & SUPPLY
Sources: HHS/ASPR Chemical Hazards Emergency Medical Management (CHEMM, chemm.hhs.gov) — toxidrome recognition, decontamination sequence, and the nerve-agent antidote figures (atropine titrated to drying secretions; pralidoxime; benzodiazepine for seizures). ATSDR Medical Management Guidelines for the individual agents. Radiation guidance per HHS Radiation Emergency Medical Management (REMM). Hydroxocobalamin dosing consistent with the smoke-inhalation line on card 05. This card needs site-specific facts filled in: where decontamination actually happens at this site, what PPE is stocked and where, which hazmat team responds, and whether any antidote autoinjectors are held in the department.
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.