Beyond the Basics: Trauma Assessment

CEU Review Form Trauma Assessment (PDF)Valid until October 6, 2006

The ABCs of trauma assessment-airway, breathing/oxygenation and circulation-represent the first steps in determining the extent of injury and patient care priorities; however, other factors must also be considered to provide effective and timely care. Identification of immediate life threats is of paramount importance to the EMS provider. The ability to accurately identify life threats may be the difference not only between life and death, but also between a patient leading a normal life and one with long-term disabilities. Aggressive assessment and management of trauma patients may aid in preventing death or disability.

General Impression
Form a general impression as you enter the scene, typically prior to any physical contact with the patient. Seasoned EMS providers are often able to identify "sick" patients and gauge the severity of their conditions or injuries during the general impression, which may also set the pace of emergency care and determine the need for rapid transport.

Age is an important consideration when assessing a trauma patient. The elderly and young children are more prone to suffering severe consequences from certain types of trauma. Comorbid factors in the elderly, such as significant atherosclerotic heart and vessel disease, congestive trauma and certain medications, can play a major role in helping providers understand the presentation of unusual signs and symptoms and progression of the condition, and in determining the severity. For example, an elderly patient who is taking a beta-blocker or calcium channel blocker may not develop tachycardia in response to severe blood loss. If not clearly understood, this may lead to a missed field impression and delay in treatment and transport. Another example is the patient taking Coumadin for chronic atrial fibrillation, who may bleed heavily from wounds that you would expect to clot easily with limited direct pressure.

Gender may be a significant consideration with trauma to the pelvis and abdomen in the pregnant patient. Physiologic changes may alter her presentation when in hypovolemic shock. The pregnant patient has a tendency to become more severely hypovolemic before showing the typical signs and symptoms of hemorrhage.

Patients are usually categorized as either medical or trauma during the scene size-up and general impression. Until the condition is identified or the possibility of spine injury is ruled out, manual in-line spinal stabilization must be established and maintained.

Mechanism of Injury
Trauma results from the transfer of energy in a quantity sufficient to cause damage at the cellular level. Kinetic, thermal, electrical and radiation are examples of sources of energy that may cause injury. Kinetic energy is the most frequent source of injury seen by EMS.

Mechanism of injury describes the process of assessment related to how kinetic energy was transmitted through the body and which organ systems were most likely affected. The most important basic concepts to keep in mind when assessing mechanism of injury are: 1) the anatomy of the area affected by trauma; and 2) Newton's first law of motion, which states that "An object at rest will remain at rest, and an object in motion will remain in motion until acted upon by an external force."

Newton's first law of physics explains the physiology of acceleration/deceleration injuries as follows: If a patient is traveling in a car at 60 mph and suddenly stops when the car impacts a tree, the victim's body will remain moving at 60 mph until it is acted upon by an "external force," such as the steering wheel, windshield, seat belt or air bag. The patient's brain, heart, liver, lungs and other internal organs will do the same, continuing at the same speed as the vehicle until they strike the inside of the skull, or thoracic and abdominal wall. As evidence of this concept, the frontal and temporal lobes of the brain are most often injured in this type of impact. The brain is injured as it rides over the bony ridges found on the inner surface of the moving skull. This acceleration/deceleration injury pattern is commonly referred to as the three-collision concept.