5 Trauma Assessment and Management

Priorities in trauma care

Trauma care prioritizes immediate threats to life, limits further injury, and moves the patient promptly to appropriate care. EMTs connect scene size-up, primary and secondary assessment, treatment, and transport decisions. Follow local protocols and stay within scope; a mechanism alone neither diagnoses an injury nor determines the destination.

Mechanism and injury risk

The Mechanism of injury (MOI) helps predict what may be injured, guides examination, and informs transport decisions. However, serious injury can occur without an impressive mechanism, and a high-energy mechanism does not prove a particular injury.

• Blunt trauma: Impact, rapid deceleration, compression, or shearing can injure organs without breaking the skin. In a vehicle crash, consider the whole vehicle, occupant position, restraints, intrusion, ejection, and injuries to other occupants.

• Penetrating trauma: The wound’s location, direction, and apparent depth can suggest structures at risk. Do not probe a wound or remove an impaled object.

• Falls and crush injuries: Consider height or force, landing surface, the body part struck, entrapment time, and possible internal injury. Older adults may sustain serious injury after a low-energy fall.

• Other mechanisms: Blast, thermal, and electrical injuries can cause multiple or initially subtle injuries.

Field-triage guidance distinguishes high-risk injury patterns and abnormal mental status or vital signs from mechanism and other considerations. Active bleeding requiring a tourniquet or wound packing with continuous pressure is one high-risk injury pattern. Use the current regional triage plan; a mechanism clue is not a substitute for assessment.

Scene size-up

Check scene safety, use appropriate personal protective equipment, identify the number of patients, and determine whether additional resources are needed. Consider hazards such as traffic, fire, weapons, electricity, and unstable structures. Form an initial impression of the mechanism and plan access, extrication, and transport. Do not enter an unsafe scene.

Primary assessment

The primary assessment finds and treats immediate threats. Use a systematic approach; XABCDE is commonly used when catastrophic external bleeding is present.

• X — Exsanguinating hemorrhage: Find and control life-threatening external bleeding immediately.

• A — Airway, with attention to the cervical spine: Check whether the patient can speak and maintain an open airway. Clear visible obstructions as appropriate and use basic airway maneuvers and adjuncts within scope. Consider spinal motion restriction when indicated, but do not let it delay essential airway care.

• B — Breathing: Assess rate, effort, chest rise, and breath sounds as trained. Expose enough of the chest to find injury while preventing heat loss. Support ventilation and oxygenation according to findings and protocol.

• C — Circulation: Assess pulses, skin, perfusion, and major bleeding. Look for shock and control hemorrhage; do not wait for low blood pressure before acting.

• D — Disability: Briefly assess mental status, responsiveness, and neurologic function. A change from normal may signal brain injury, shock, or another threat.

• E — Exposure and environment: Look for hidden injuries while preserving dignity and preventing hypothermia.

Treat threats as they are found and reassess after interventions. Arrange rapid transport for critical patients; a long examination or extrication process should not unnecessarily delay it.

Secondary assessment and history

When the patient is stable enough, perform a focused or rapid head-to-toe examination based on the mechanism and presentation. Inspect and palpate systematically for wounds, tenderness, deformity, swelling, instability, and abnormal movement. After extremity injuries or splinting, assess distal circulation, sensation, and movement. Do not repeatedly manipulate a suspected fracture or pelvic injury.

Obtain a SAMPLE history and use OPQRST to characterize pain when appropriate. Record vital signs and repeat them to identify trends. An unstable patient needs ongoing primary assessment and transport, not a prolonged secondary examination.

Spinal motion restriction

Consider spinal motion restriction after blunt trauma when the patient has altered mental status or intoxication, midline neck or back pain or tenderness, a focal neurologic finding, spinal deformity, or an unreliable examination because of a distracting injury or circumstance. Use the least movement and appropriate equipment consistent with protocol.

A backboard is primarily an extrication or transfer tool, not a requirement for every trauma patient. Consensus guidance finds no role for spinal motion restriction in penetrating trauma without a separate indication.

Hemorrhage control

Expose the bleeding site enough to treat it, using standard precautions. Reassess bleeding control and the patient’s perfusion after interventions.

1. Apply firm, direct pressure to the source; use a pressure dressing if effective.

2. For life-threatening extremity bleeding, apply a commercial tourniquet if indicated and within protocol. Place it above the wound, not over a joint; tighten until bleeding stops and note the application time. If bleeding continues, tighten or add another tourniquet as trained and directed by protocol. Do not loosen or remove it in the field unless specifically directed by an authorized clinician or protocol.

3. Pack a wound when appropriate, especially a deep junctional wound or one where a tourniquet cannot control bleeding, and maintain firm pressure. Use hemostatic gauze only as trained and authorized.

4. For an impaled object, control bleeding around it and stabilize it in place; do not remove it in the field.

Wound care must not delay urgent transport when the patient is unstable.

Recognizing and treating shock

Hemorrhagic shock occurs when blood loss impairs delivery of oxygen to tissues. Early signs may include anxiety or confusion, rapid pulse, pale or cool clammy skin, and weakness. Falling blood pressure can be a late sign, so a normal reading does not rule out early shock. Children may maintain blood pressure until they deteriorate rapidly; older adults may have important injury after seemingly minor trauma.

Control bleeding, maintain the airway and adequate breathing, keep the patient warm, position for comfort and breathing, and transport promptly. Give oxygen or assist ventilation as indicated by assessment and protocol. Reassess mental status, pulse, skin, breathing, and blood pressure frequently. Avoid food and drink. Do not routinely elevate a trauma patient’s legs or use a position that worsens breathing or a suspected injury.

Injuries by body region

Injuries to different regions can threaten the airway, breathing, circulation, or neurologic function. Examine systematically and continue to reassess for deterioration.

• Head and face: Watch for altered mental status, worsening headache, repeated vomiting, seizure, unequal pupils, or neurologic deficits. Protect the airway and monitor for deterioration. Facial blood, swelling, or damaged structures may threaten the airway. Do not press on an injured eye or an open or depressed skull injury.

• Neck and spine: Look for pain, tenderness, deformity, weakness, numbness, or loss of sensation. Minimize unnecessary movement and apply spinal motion restriction when indicated by assessment and protocol. Maintain airway and breathing priorities.

• Chest: Assess for pain, abnormal chest movement, penetrating wounds, respiratory distress, and signs of shock. Expose and reassess the chest. Manage open chest wounds and support breathing according to training and local protocol; monitor closely for worsening respiratory status.

• Abdomen: Pain, tenderness, bruising, rigidity, or penetrating injury may indicate internal bleeding. External appearance can underestimate severity. Do not press deeply on the abdomen or replace protruding organs. As trained, cover exposed organs with a clean, moist dressing and protect them loosely.

• Pelvis and hip: Pain, instability, or shock after significant trauma may indicate pelvic injury and substantial internal blood loss. Avoid rocking or repeatedly compressing the pelvis. Use a pelvic binder only if trained, equipped, and directed by protocol; prioritize careful movement and rapid transport.

• Extremities: Control bleeding first. Assess and document distal pulse, skin color and temperature, sensation, and movement before and after splinting. Immobilize as trained, include the joints above and below when appropriate, and avoid unnecessary attempts to straighten a deformity. Reassess for worsening pain, numbness, or loss of circulation.

• Burns: Stop the burning process and assess airway, breathing, circulation, and associated trauma. Cool a thermal burn with cool water when appropriate, but avoid ice and prevent hypothermia. Cover the injury with a clean, dry dressing and follow local guidance for burn-center transport.

Applying the priorities

A patient after a crash is awake but confused, breathing rapidly, and has severe bleeding from a thigh wound. Control the bleeding immediately, assess and support airway and breathing, treat for shock, reassess, and arrange prompt transport to an appropriate trauma destination. Do not let a detailed history or full head-to-toe examination postpone those priorities.

Coordinating assessment and transport

Use the mechanism to anticipate injuries, not to replace examination. Make the scene safe, control catastrophic bleeding, and perform a systematic primary assessment to identify immediate threats. Treat hemorrhage and shock early, assess injuries methodically when the patient’s condition allows, repeat vital signs and interventions, and transport promptly when serious injury is suspected. Destination and procedures should follow current field-triage guidance, local protocols, and EMT scope.

• Spinal motion restriction (SMR)