1. ASSESSMENT OF THE TRAUMA PATIENT
April Morgenroth RN, MN

2. = better patient outcomes
Initial Assessment
Early recognition of injury + early intervention
= better patient outcomes

3. Primary Assessment
Airway
Breathing
Circulation
Disability

4. Remember … Airway History/Head to toe Disability Breathing Circulation
Is the patient stable?
Breathing
Circulation
Disability
Is the patient stable?
Full set Vital Signs/Five interventions
History/Head to toe

5. Airway
Inspect the patient’s airway while maintaining cervical spine stabilization.
Observe for speaking, tongue obstructing airway , bleeding , vomiting, and swelling.

6. Interventions for Ineffective Airway
Maintain Cervical Spine Stabilization and/or immobilization
Proper positioning for airway patency
Jaw thrust
Chin lift
Removal of or foreign objects or debris
Suctioning

7. Assess for rise and fall of chest, respiratory rate and pattern.
Breathing
Assess for rise and fall of chest, respiratory rate and pattern.

8. Signs of Ineffective Breathing
Restlesness, agitation, altered mental status
Cyanosis, especially around mouth
Asymetrical chest expansion
Use of Accessory and/or abdominal muscles
Sucking chest wounds
Jugular vein
distention
Tracheal shift deviation
Absent or diminished breath sounds

9. Interventions for Ineffective Breathing
Administer Oxygen via a mask or nasal cannula.
Ventilate the patient via a non-rebreather mask.
Insert Artificial Airway

10. Circulation Palpate Pulses: Are they normal, weak or strong?
Inspect skin: Is the color normal? Is it warm or cold? Clammy or dry?
Look for obvious bleeding.
Obtain blood pressure.

11. Signs of Ineffective Circulation
Uncontrolled External Bleeding
Altered Mental Status
Tachycardia
Excessive sweating
Pale, cool, skin
Low blood pressure

12. Interventions for Ineffective Circulation
Control any uncontrolled bleeding by:
Apply direct pressure to the wound and/or apply a pressure dressing
Use a tourniquet only when other methods to control bleeding have failed
Initiate IV access
Fluid resuscitation with Normal Saline or Lactated Ringer’s
Consider planning for a blood transfusion, if ordered and available

13. Disability – Neurologic Status
The patient’s level of consciousness can show immediate signs of brain injury.
A – Alert and responsive
V – Responds to verbal stimuli
P – Responds to only painful stimuli
U - Unresponsive
Pupils
Assess pupils for size, shape, equality, and reactivity to light

14. Secondary Assessment Obtain Vital Signs Head to Toe Assessment
Medical History

15. Full Set Vital Signs
Obtain vital signs: respirations, pulse, blood pressure, temperature, pulse oximetry, pain.
Obtain Laboratory studies if necessary.

16. History Mechanism of Injury and time it happened
Mechanism of Injury and time it happened
Description of Injuries and pain
Past medical history, previous hospitalizations
Age
Medications / Allergies
Immunization history
Use of drugs or alcohol, smoking history
Last menstrual period

17. 7. Head-to-Toe Assessment
Chest
Abdomen and flanks
Pelvis
Extremities
Back
Head and face

18. General Appearance:
Take note of the patient’s level of distress (mild, moderate, severe),
body position,
posture,
rigidity or flaccidity of muscles,
unusual odors (alcohol, gasoline, chemicals, body fluids).

19. Head and Face
Loose teeth or foreign objects which may compromise the airway
Soft tissue injuries
Deformities
Eyes
Ears
Nose
Neck
Soft Tissue Injuries:
Inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impales objects, eccymosis, and edema.
Palpate for crackling associated with subcutaneous emphysema
Palpate for areas of tenderness

20. Head and Face Assess for: Gross visual acuity
Bruising, bleeding, or swelling around the eyes
Pupils: equal sizes, shape, reactivity
Eyes

21. Head and Face (Battle’s Sign) Inspect for:
Bruising behind the ear (Battle’s sign)
Soft tissue injury
Unusual drainage from ears or nose, such as blood or clear fluid. DO NOT pack it to stop drainage as it may be cerebrospinal fluid (CSF).
Avoid inserting a nasogastric tube if such drainage is present.
Ears/Nose
(Battle’s Sign)

22. Neck Inspect for: Signs of trauma
Observe position of trachea and appearance of external jugular veins. n

23. Chest
Inspection
Observe breathing for rate, depth, effort, use of accessory muscles, asymmetrical chest rise
Auscultation
Note any abnormal lung sounds
Palpation
Palpate clavicles, sternum, and the ribs for bony crepitus or deformities

24. Abdomen/Flanks Inspection Auscultation Palpation Soft tissue injuries
Bowel sounds
Palpation
Rigidity, guarding, masses, areas of tenderness.

25. Pelvis/Perineum
Inspect for external soft tissue injuries, deformities, exposed bone, blood at the perineum
Palpate for stability of pelvic bones

26. Extremities Circulation Inspect color Palpate skin temperature
Palpate pulses
Soft tissue injuries
Bony injuries
Motor function:
Check motor function on both sides – does the patient move both sides of the body equally?
Hand grasp and foot strength

27. Inspect The Back Maintain cervical spine stabilization
Support extremities with suspected injuries
Logroll patient with at least 3 other team members
Palpate all posterior surfaces for deformity and areas of tenderness

28. A measure of the patient’s level of consciousness
Glasgow Coma Scale
Area of Response
Points
Best Eye Opening
Spontaneously
In response to voice
In response to pain
No eye opening 4 3 2 1
Best Verbal Response
Oriented
Confused
Inappropriate
Incomprehensible
none 5
Best Motor Response
Obeys commands
Localizes pain
Withdraws from pain
Flexion/decorticate posturing
Extension/decerebrate posturing
No movement 6
A measure of the patient’s level of consciousness
Score ranges from 3-15
Severe head injury
<8
Moderate head injury
9-12
Minor head injury
13-15