Systematic Trauma Assessment
Trauma assessment follows a systematic approach that prioritizes life-threatening conditions. The NREMT expects EMTs to demonstrate a logical, organized assessment process that identifies and manages threats to life in order of priority. Understanding this process is essential for both the psychomotor skills exam and the cognitive exam.
Scene Size-Up
Before approaching any patient, assess the scene for safety hazards, determine the mechanism of injury (MOI), estimate the number of patients, and request additional resources as needed. Scene safety is always the first priority. Identify hazards such as traffic, downed power lines, hazardous materials, fire, structural instability, and potential for violence.
The mechanism of injury guides your assessment. Significant mechanisms include vehicle collisions with intrusion, ejection, or rollover; falls greater than 20 feet for adults or 10 feet for children; motorcycle crashes above 20 mph; and penetrating injuries to the head, chest, or abdomen.
Primary Assessment (XABCDE)
X - Exsanguinating Hemorrhage
Control life-threatening external bleeding immediately. Apply direct pressure, pack wounds, or apply a tourniquet for extremity hemorrhage that cannot be controlled with direct pressure. This step takes priority even before airway management because a patient can exsanguinate in minutes.
A - Airway with Cervical Spine
Assess and manage the airway while maintaining cervical spine stabilization. Use jaw-thrust for trauma patients. Suction blood and debris. Insert an appropriate airway adjunct if needed. A patient who is talking has a patent airway, but continue to reassess.
B - Breathing
Assess breathing rate, depth, and quality. Look for asymmetric chest rise, paradoxical motion (flail chest), open chest wounds, and signs of tension pneumothorax (absent breath sounds, tracheal deviation, JVD, hypotension). Seal open chest wounds with an occlusive dressing. Assist ventilation with BVM if breathing is inadequate.
C - Circulation
Assess pulse rate, quality, and regularity. Check skin color, temperature, and moisture. Pale, cool, diaphoretic skin suggests shock. Assess capillary refill (normal is less than 2 seconds). Control any remaining bleeding and initiate shock management.
D - Disability
Perform a rapid neurological assessment. Determine the patient's level of consciousness using AVPU (Alert, Verbal, Pain, Unresponsive). Check pupil size, equality, and reactivity. Assess motor function in all four extremities.
E - Expose and Environment
Expose the patient enough to identify injuries, but protect from hypothermia. Remove clothing as needed to assess, then cover with blankets. Hypothermia worsens outcomes in trauma patients.
Transport Decision
Based on the primary assessment, mechanism of injury, and patient condition, decide whether to perform a rapid secondary assessment on scene or package and transport immediately. Patients with significant MOI, altered mental status, or signs of shock should be transported rapidly to a trauma center with only critical interventions performed en route.