5 Regional Injury Assessment

Priorities in regional assessment

Regional assessment follows immediate correction of life threats. Continue the primary survey, control catastrophic external bleeding, and reassess circulation and breathing as injuries are identified.

Interpret physical findings alongside the mechanism of injury, vital-sign trends, mental status, and response to resuscitation. A normal early examination or a negative screening test does not reliably exclude serious injury.

Chest trauma

Inspect the chest for wounds, bruising, asymmetry, paradoxical movement, and increased work of breathing. Palpate for tenderness, instability, and subcutaneous air; compare breath sounds and assess oxygenation and perfusion. Chest-wall injury may coexist with injury to the lung, pleura, heart, or great vessels.

Match urgent action to the pattern of findings:

• Severe respiratory distress, markedly reduced breath sounds on one side, and worsening circulation raise concern for tension pneumothorax. Treat urgently on clinical suspicion when the patient is unstable or severely compromised; do not delay for imaging.

• Shock with reduced breath sounds and chest injury raises concern for major hemothorax or another bleeding source. Support oxygenation and circulation while urgently mobilizing trauma and hemorrhage-control resources.

• Chest-wall instability or paradoxical movement with significant pain and hypoxia raises concern for rib fractures, a flail segment, or pulmonary contusion. Reassess ventilation and oxygenation, provide timely analgesia and respiratory support, and account for the possibility that contusion-related breathing problems will evolve.

• Air movement through a penetrating chest wound raises concern for open pneumothorax, which may progress to tension. Apply an appropriate occlusive dressing and watch closely for deterioration.

• High-energy deceleration or major chest trauma raises concern for blunt aortic or other occult injury. If the patient is stable enough for imaging, obtain urgent appropriate imaging and specialist evaluation.

Clinical assessment guides urgent action. A negative eFAST does not exclude pneumothorax. For a stable patient or one responding to resuscitation, chest imaging—often CT when indicated—can define injuries that were not apparent on the initial examination.

Abdominal trauma

Inspect for penetrating wounds, bruising, distention, and seat-belt marks. Assess tenderness, guarding, and peritoneal signs. After blunt or penetrating mechanisms, consider injury to the liver, spleen, kidney, bowel, mesentery, or blood vessels.

A soft abdomen early after injury does not rule out internal bleeding or bowel injury. Pain may be obscured by altered consciousness, medication, or distracting injuries.

Unstable or deteriorating patients

Treat shock as hemorrhage until assessed otherwise. Use bedside ultrasound and only the minimum imaging needed to direct immediate intervention. A positive FAST in an unstable patient raises concern for intraperitoneal bleeding and requires urgent trauma or surgical decision-making. A negative FAST does not rule out intraperitoneal or retroperitoneal hemorrhage.

Stable patients or those responding to resuscitation

Contrast-enhanced CT is generally used to define injury and guide nonoperative management or intervention. If concern for bowel or mesenteric injury persists, reassess serially: CT can miss subtle injury, so interpret imaging alongside the mechanism and the evolving examination.

For a penetrating wound or evisceration, do not remove an impaled object or push exposed organs back into the abdomen. Protect the wound and promptly involve the trauma team.

Abdominal and pelvic injuries may cause substantial bleeding without obvious external blood loss. Reassess perfusion, mental status, pain, abdominal findings, and response to treatment while coordinating definitive hemorrhage control.

Pelvic trauma

Suspect pelvic-ring injury after high-energy blunt trauma, especially when there is pelvic or groin pain, deformity, perineal bruising, or unexplained shock. Pelvic hemorrhage may be concealed and may occur alongside abdominal, chest, or long-bone bleeding. Avoid repeatedly manipulating or “springing” the pelvis, and minimize unnecessary movement.

If pelvic bleeding is suspected, apply a purpose-made pelvic binder promptly, centered over the greater trochanters, and continue resuscitation and the search for other bleeding sources. In an unstable patient, do not delay hemorrhage control for CT. A stable patient can undergo CT to characterize the fracture and identify bleeding.

Persistent instability may require coordinated pelvic stabilization and hemorrhage control, such as preperitoneal packing, angioembolization, or both. The approach depends on the bleeding pattern, associated injuries, and local trauma capability.

Musculoskeletal and limb trauma

Expose and inspect the entire limb, including the joints above and below a suspected fracture. Note deformity, swelling, wounds, contamination, and active bleeding. Perform and repeat a specific distal neurovascular examination, comparing with the opposite limb when useful. Document findings before and after splinting, reduction, or another intervention; a palpable pulse alone does not exclude vascular injury.

Hard signs such as an absent pulse, ongoing blood loss, or an expanding hematoma require urgent vascular assessment.

Bleeding, stabilization, and open fractures

Apply direct pressure and a dressing to control bleeding. Use a tourniquet for life-threatening limb bleeding that is not controlled by direct pressure. Do not delay transport or definitive care to repeatedly reassess uncontrolled hemorrhage.

Splint suspected fractures to reduce movement, pain, and further tissue injury. Recheck and document distal neurovascular status after stabilization.

For an open fracture, cover the wound with a sterile dressing, avoid emergency-department irrigation before operative wound excision, and give prompt IV prophylactic antibiotics under local protocol. Arrange urgent orthopedic evaluation; severe open injuries may require coordinated orthopedic and plastic-surgical care.

Compartment syndrome

Escalating pain out of proportion to the injury, pain on passive stretch, and paresthesia are concerning early findings. Weakness, pallor, and absent pulses are late signs; their absence does not exclude the condition. Escalate urgently for surgical assessment. If the examination is unreliable or equivocal, compartment-pressure measurement may assist decision-making.

Long-bone and pelvic fractures can contribute to major blood loss. Treat the patient’s physiology, not just the visible deformity: a fracture must not distract from chest, abdominal, or pelvic sources of shock.

Coordination and reassessment

1. Identify and treat immediate threats. Severe respiratory compromise, uncontrolled external bleeding, and signs of internal hemorrhage take priority over a complete limb examination or nonessential imaging.

2. Match diagnostics to physiology. Use bedside assessment to guide urgent intervention in unstable patients. Use CT to define injuries when the patient is stable enough or responding to resuscitation. Do not treat a negative FAST as clearance of the abdomen or pelvis.

3. Coordinate early. Communicate the mechanism, vital-sign and mental-status trends, suspected bleeding sites, examination findings, interventions, and response. Involve trauma surgery and relevant chest, orthopedic, vascular, or interventional teams early when indicated.

4. Repeat the assessment. Deterioration, new pain, changing perfusion, or evolving respiratory findings may signal occult or progressive injury. Document serial findings and reassess after every intervention.

Regional assessment links findings to immediate threats: chest injury can compromise ventilation or circulation; abdominal and pelvic injury can cause concealed hemorrhage; and limb trauma can threaten life, perfusion, or tissue viability. Prioritize stabilization and hemorrhage control, choose imaging according to hemodynamic status, and coordinate definitive care without allowing a visible injury to obscure another source of shock.