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Objective To determine the predictive value of the Mechanism of Injury step of the American College of Surgeon’s Field Triage Decision Scheme for determining trauma center need. Methods EMS providers caring for injured adult patients transported to the regional trauma center in 3 midsized communities over two years were interviewed upon ED arrival. Included was any injured patient, regardless of injury severity. The interview collected patient physiologic condition, apparent anatomic injury, and mechanism of injury. Using the 1999 Scheme, patients who met the physiologic or anatomic steps were excluded. Patients were considered to need a trauma center if they had non-orthopedic surgery within 24 hours, intensive care unit admission, or died prior to hospital discharge. Data were analyzed by calculating positive likelihood ratios (+LR) and 95% confidence intervals (CI) for each mechanism of injury criteria. Results 11,892 provider interviews were conducted. Of those, 1was excluded because outcome data were not available and 2,408 were excluded because they met the other steps of the Field Triage Decision Scheme. Of the remaining 9,483 cases, 2,363 met one of the mechanism of injury criteria, 204 (9%) of which needed the resources of a trauma center. Criteria with a +LR ≥5 were death of another occupant in the same vehicle (6.8; CI:2.7–16.7), fall >20 ft.(5.2; CI:2.4–11.3), and motor vehicle crash (MVC) extrication >20 minutes (5.0; CI:3.2–8.0). Criteria with a +LR between 2 and <5 were intrusion >12 inches (3.7; CI:2.6–5.3), ejection (3.2; CI:1.3–8.2), and deformity >20 inches (2.3; CI:1.7–3.0). The criteria with a +LR <2 were MVC speed >40 mph (1.9; CI:1.5–2.2), pedestrian/bicyclist struck >5mph (1.2; CI:1.0–1.5), bicyclist/pedestrian thrown or run over (1.2; CI:0.9–1.6), motorcycle crash >20mph (1.1; CI:0.96–1.3), rider separated from motorcycle (1.0; CI:0.9–1.2), and MVC rollover (1.0; CI:0.7–1.5). Conclusion Death of another occupant, fall distance, and extrication time were good predictors of trauma center need when a patient did not meet the anatomic or physiologic conditions. Intrusion, ejection, and vehicle deformity were moderate predictors.