Managing Trauma Assessments

Managing Trauma Assessments

Conducts structured primary and secondary trauma surveys following Advanced Trauma Life Support (ATLS) methodology to systematically identify and treat life-threatening injuries.

Why This Skill Exists

Trauma is the leading cause of death in individuals aged 1-44 and the fourth leading cause of death overall in the United States. The "golden hour" concept — that mortality increases significantly with delays in definitive care — underpins the ATLS framework developed by the American College of Surgeons (ACS). Missed injuries occur in 2-12% of trauma patients, with delayed diagnosis contributing to preventable deaths in up to 30% of trauma fatalities reviewed at morbidity and mortality conferences.

ACS-verified trauma centers are required to demonstrate adherence to ATLS protocols during verification surveys. Documentation of primary and secondary surveys, trauma team activation criteria, and disposition decisions is subject to performance improvement and patient safety (PIPS) review. Incomplete trauma documentation is the single most common deficiency cited during trauma center verification visits. This skill ensures systematic, complete trauma assessment documentation that meets ACS standards.

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the mechanism of injury (MOI)? (Default: document as reported by EMS or patient)
2. What were the prehospital vitals and interventions? (Default: extract from EMS PCR)
3. What level of trauma activation was triggered (Level I, Level II, trauma consult)? (Default: apply institutional field triage criteria)
4. What is the patient's GCS on arrival? (Default: calculate and document E+V+M components)
5. Is the patient intubated, on backboard, or in cervical collar? (Default: document prehospital immobilization status)
6. What is the estimated blood loss if applicable? (Default: document based on mechanism and prehospital report)
7. Are there known comorbidities, anticoagulant use, or pregnancy? (Default: query and document)
8. What is the patient's tetanus immunization status? (Default: query and update)

Documents to Request

• EMS prehospital care report with vitals, interventions, and mechanism detail
• Trauma activation notification record
• Field triage criteria assessment (CDC Field Triage Decision Scheme)
• Previous imaging or surgical records if transfer patient
• Current medication list (critical for anticoagulant identification)
• Blood bank specimen labels and crossmatch orders

Step 1: Primary Survey (ABCDE)

The primary survey must be completed within the first 5-10 minutes and documented in ABCDE order. Each element requires a positive or negative finding.

A — Airway with Cervical Spine Protection

B — Breathing and Ventilation

• Inspect: chest wall movement, symmetry, open wounds, flail segments
• Auscultate: bilateral breath sounds (present, diminished, absent)
• Palpate: crepitus, tenderness, subcutaneous emphysema
• Immediate threats to treat: tension pneumothorax (needle decompression 2nd ICS MCL), open pneumothorax (3-sided occlusive dressing), massive hemothorax (chest tube 36-40Fr), flail chest (intubation if respiratory failure)

C — Circulation with Hemorrhage Control

• Assess: heart rate, blood pressure, pulse quality, skin color/temp/moisture, capillary refill
• Direct pressure on external hemorrhage; tourniquet for extremity hemorrhage not controlled by pressure
• Establish two large-bore (16G or larger) IV lines
• Initiate massive transfusion protocol (MTP) if Class III or IV hemorrhagic shock:

• Activate MTP: target 1:1:1 ratio (pRBC:FFP:platelets)
• Permissive hypotension (target SBP 80-90) in penetrating torso trauma until surgical control

D — Disability (Neurologic Status)

• GCS score with individual components (E__ V__ M__)
• Pupil size and reactivity (PERRL or asymmetry)
• Lateralizing signs (unilateral weakness, posturing)
• GCS ≤8 = secure airway; unilateral dilated pupil = emergent neurosurgery consult

E — Exposure and Environmental Control

• Fully undress patient (cut clothing)
• Log-roll with spinal precautions to examine posterior surfaces
• Assess perineum, axillae, and skin folds
• Prevent hypothermia: warm blankets, warmed IV fluids, Bair Hugger
• Document all wounds, abrasions, contusions, and deformities found

Step 2: Adjuncts to Primary Survey

Complete these during or immediately after the primary survey:

• FAST exam (Focused Assessment with Sonography for Trauma): RUQ, LUQ, subxiphoid, suprapubic — document positive or negative in each window
• Chest and pelvis X-rays (portable AP in resuscitation bay)
• Foley catheter (contraindicated if blood at meatus, scrotal hematoma, or high-riding prostate)
• Gastric tube (orogastric if midface fracture suspected)
• Labs: CBC, BMP, coags (PT/INR, fibrinogen), type and screen/crossmatch, lactate, ABG, ethanol, urine drug screen, urinalysis, beta-hCG (all females of childbearing age)
• Tetanus prophylaxis assessment

Step 3: Secondary Survey (Head-to-Toe)

The secondary survey is a systematic head-to-toe examination performed only after the primary survey is complete and resuscitation is underway. Document each body region.

AMPLE History

• Allergies
• Medications (especially anticoagulants, antiplatelets, beta-blockers, insulin)
• Past medical/surgical history
• Last meal
• Events/environment surrounding injury

Step 4: Imaging and Disposition Decision

CT Imaging Indications in Trauma

Disposition Decision Framework

• Operating Room: Hemodynamically unstable with positive FAST, peritonitis, evisceration, vascular injury with hard signs
• Interventional Radiology: Pelvic fracture with ongoing hemorrhage after binder, solid organ injury with active extravasation on CT
• ICU Admission: GCS ≤12, intubated, MTP activated, significant multi-system injury, hemodynamic instability requiring vasopressors
• Floor Admission: Isolated injuries requiring observation (e.g., rib fractures with adequate pain control, stable solid organ injuries)
• Discharge: Minor injuries, negative workup, reliable follow-up, no red flags

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the primary survey (ABCDE) documented completely with positive and negative findings for each element?
2. Are FAST results documented for all four windows (RUQ, LUQ, subxiphoid, suprapubic)?
3. Is the GCS documented with individual component scores (E+V+M)?
4. Does the disposition rationale reference the clinical findings that drove the decision?
5. Are all injuries identified in the secondary survey accounted for in the treatment plan?

Quality Audit

• Mechanism of injury clearly documented with specific details
• Trauma activation level documented with time of activation
• Primary survey (ABCDE) fully documented with findings for each element
• GCS documented with component breakdown (Eye + Verbal + Motor)
• FAST exam documented with results for each window
• Hemorrhage class estimated and documented if significant bleeding
• Secondary survey (head-to-toe) completed and documented for each body region
• AMPLE history obtained and documented
• Imaging results documented with interpretation
• Disposition decision documented with clinical rationale
• Tetanus status assessed and prophylaxis given if indicated
• Beta-hCG obtained for all females of childbearing age
• Blood products documented if administered (units, timing, reaction monitoring)
• Trauma surgery and subspecialty consults documented with recommendations

Guidelines

1. Never skip the primary survey to perform the secondary survey — the ABCDE sequence is inviolable and must be completed first even if specific injuries are visually obvious.
2. Document GCS at arrival, after resuscitation, and at disposition — the trend matters more than any single value for neurosurgical decision-making.
3. A negative FAST does not exclude intra-abdominal injury — sensitivity is approximately 73-88%; if clinical suspicion remains, proceed to CT.
4. Assess pelvic stability only once — repeated rocking can dislodge clots and worsen hemorrhage in unstable pelvic fractures.
5. All trauma patients on anticoagulants with head injury require CT Head regardless of GCS — intracranial hemorrhage can be delayed and initially occult.
6. Hypothermia, acidosis, and coagulopathy form the "lethal triad" of trauma — actively prevent and treat all three simultaneously.
7. Document all prehospital interventions and their effectiveness, including tourniquet application times, fluid volumes, and medications administered.
8. Time-stamp every major event in the trauma resuscitation: arrival, intubation, imaging, blood products, OR departure — these timestamps are required for PIPS review and registry reporting.