Initial Trauma
Assessment
Trauma Room (Crisis Resource Management –
Brindley, Cardinal)
Background: Addressing traumatic injuries is a major
component of Emergency Medicine (EM) practice.
Providers are asked to quickly evaluate these patients,
address major life threats, and make a full inventory of
injuries. Having a systematic approach is essential to a
rapid assessment that minimizes the chance of missing
injuries. This post will outline a step-by-step approach to
evaluation.
Pre-Arrival
• All providers should don appropriate personal
protective equipment including gowns, gloves,
facemasks, and face-shields
• If patients are coming in by Emergency Medical
Services (EMS), the pre-hospital team will often call
ahead with vital signs and information about
mechanism of injury
◦ Mechanism of injury guides evaluation and raises
or lowers probability of certain injuries
▪ Majority of presentations categorized as blunt
versus penetrating trauma
▪ Specific mechanistic considerations include
speed of collisions, damage to vehicles,
presence of blood at the scene, and other
victims or fatalities
▪ Use this information to prepare for anticipated
interventions
◦ Field vital signs can be used to anticipate potential
injuries and prepare interventions
• Patients are usually triaged based on mechanism of
injury or physiologic criteria
◦ Specific criteria will trigger activation of a trauma
team and route patient to resuscitation area
◦ Most trauma centers have two tiers of activation
(eg. level I and level II)
◦ Multiple providers often respond, including nurses,
EM physicians, and trauma surgeons based on
level of activation
Trauma Resuscitation (http://www.lasvegasemr.com/)
Arrival
• Most important first step in major trauma (eg. Level I or
II) is completion of EMS hand-off
◦ Give the pre-hospital team silence in the room to
give report before beginning patient
assessment
◦ Immediate life threats (agonal respirations, risk of
exsanguination) will require immediate
management and are often identified by the
pre-hospital team
Primary Survey
• Goal is to find and address immediate life threats
• Typical approach is ABCDE mnemonic, standing for
airway, breathing, circulation, disability, and
exposure
• Although often taught as dictating priority or order of
assessment (eg. airway before circulation), all
components should be assessed in parallel
Airway
• Look externally for potential obstructions like facial
injuries, blood, or vomit
• Have the patient say their name, listening for any
gargling or noisy breathing
• Quickly assess mental status and determine whether
they are able to clear secretions and keep their
tongue from obstructing the airway
Breathing
• Inspect and palpate chest wall for injury. Look at the
position of the trachea and for JVD. Inspect work of
breathing
◦ Visualization of the neck will require temporary
removal of the C-collar
• Listen for breath sounds bilaterally
• Assess the patient’s O2 saturation as a marker of
oxygenation. Attach EtCO2 or observe respirations
to assess ventilation
EFAST in Trauma (Army.mil)
Circulation
• Look for any major sources of external bleeding.
Assess for internal bleeding with rapid physical
exam
◦ Often augmented by an Extended Focused
Assessment with Sonography in Trauma (E-
FAST)
◦ 5 major locations patients can exsanguinate
▪ Chest
▪ Abdomen/pelvis
▪ Retroperitoneum
▪ Long bone (eg. femur)
▪ Street (externally)
◦ Pediatric patients can bleed out from head injuries
due to lower blood volume (scalp lacerations
or, rarely, intracranial hemorrhage)
• In blunt trauma, the presence of any vital sign
abnormalities may prompt empiric placement of a
pelvic binder
• Check the patient’s blood pressure
• Palpate radial and dorsalis pedis pulses bilaterally
◦ Assess for presence, quality, and rate
◦ Presence of pulses in particular anatomic
locations were previously used as markers of a
certain BP, however this has found to be
inaccurate (Deakin 2000, Poulton 1988)
Disability
• Examine the pupils
• Calculate the Glasgow coma scale (GCS)
• Look for movement of all extremities
Exposure
• Remove all clothing from the patient
• Re-cover the patient with warm blankets
• Log roll to assess for injuries in the back
Secondary Survey
• Divided into focused AMPLE history and head to toe
physical exam
• May be abbreviated in unstable patients as they
progress to surgery, imaging, or interventional
radiology
AMPLE History
• If patient is unable to provide history, try to obtain
information from pre-hosptial team, family members
or witnesses
• AMPLE mnemonic is often used
◦ Allergies
◦ Medications
▪ Ask specifically about anticoagulants
◦ Past medical history
◦ Last meal
◦ Events/Environment
▪ Obtain a clear history of the events leading up
to and after the injury
▪ Ask in general about injuries sustained and
specifically about head injures
▪ If there is concern for a head injury, ask
about loss of consciousness and
vomiting
Physical Exam
• HEENT
◦ Examine the scalp for bleeding
◦ Palpate the scalp, face and jaw for tenderness
◦ Examine the pupils again for size and reactivity
◦ Examine the ears for hemotympanum
◦ Examine the nose for septal hematoma
◦ Examine the oral cavity for injuries or broken teeth
▪ Ask the patient to close their mouth and ask if
teeth alignment feels normal
• C-Spine
◦ If your patient is in a C-collar, have an assistant
maintain spinal precautions while you remove
the collar
▪ Note that patients with penetrating trauma
should not be placed in C-collars due to
increased mortality (Oteir 2015)
◦ Palpate the cervical spinous processes for
tenderness
▪ Midline tenderness is concerning for spine
injury and should prompt consideration of
cervical spine imaging
▪ Be specific with location tenderness
• Thorax
◦ Feel the shoulder girdle for instability or fractures
◦ Check the ribs for tenderness or instability
◦ Recheck lung sounds and perform a
cardiovascular exam
•
Seat Belt Sign
(regionstraumapro.com)
Abdomen/Pelvis
◦ Examine the abdomen for bruising
◦ Palpate for tenderness, guarding and rebound
◦ Avoid rocking pelvis
▪ If examining for stability, press inward to
avoid further injury
◦ Any suspicion for pelvic injury should dictate
placement of a pelvic binder and further
manipulation should be minimized
(manipulation can lead to worsening of injuries
and additional blood loss)
• Extremities
◦ Check all extremities for strength, sensation, and
presence of a pulse
◦ Range the joints
◦ Palpate for tenderness and deformity
• Back
◦ Roll the patient with assistance, maintaining spinal
precautions if necessary
◦ Palpate the spinous processes for tenderness or
step-offs
◦ Digital rectal exam
▪ Historically included as part of assessment
▪ Recent literature has questioned the
necessity of this practice (Esposito 2005)
▪ ATLS now recommends DRE as a selective
intervention before inserting a urinary
catheter (Kortbeek 2008)
▪ Motor function of L5-S2 can be assessed by
asking the patient to flex their gluteal
muscles (“squeeze your butt-cheeks”)
Take Home Points
• Development of a systematic approach is essential to
rapidly assessing the wide diversity of trauma
patients and minimizes missed injures
• Prepare with whatever information is available before
the patient arrives and remember to get a good
handoff from the pre-hospital team
• Complete the primary survey (ABCDEs) and address
immediate life threats
Obtain a good medical history and remember to
complete a comprehensive head-to-toe exam
