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Trauma assessment

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Trauma is said to have occurred when the body tissues and/or organs sustain injuries caused by the transfer of some form of energy that is greater than they can tolerate (Emergency Nurses Association (ENA), 1995).

Using a systematic approach, the trauma assessment is broken down into two stages: primary and secondary assessment. The primary assessment is carried out using the ‘ABCD’ of the Advanced Trauma Life Support course run by the Royal College of Surgeons (See Box 1). The secondary assessment involves the exposure and examination of the patient for non life-threatening injury (E).

Primary assessment

At this stage the patient is assessed for any potentially life-threatening conditions, injuries are assessed and priorities of care are set. Information obtained from the ambulance crew can be especially useful in the prediction of underlying injuries that may not yet have impacted on the patient’s general condition, for example the type of impact sustained or the height fallen from.

Secondary assessment

Exposure and examination of the patient

Once the patient has been assessed for ABC and D factors, and any potential or actual life-threatening conditions have been addressed, the secondary assessment is undertaken. At this stage the patient is exposed completely and a thorough external examination is carried out. This will enable the trauma nurse to identify other injuries and to obtain a full set of vital signs. The assessment should be methodical and should involve inspection, auscultation and palpation (ENA, 1995).

The patient should be examined for any signs of the following:

- Soft tissue injuries, such as lacerations, abrasions, contusions, puncture wounds, impaled objects or avulsions. The skin surfaces should be palpated for signs of subcutaneous emphysema (crackling) and to identify tender areas

- Bony deformities such as angulation, depression, exposed bone or tenderness on bony prominences should be identified

- The abdomen should be palpated for signs of tenderness, rigidity, masses, and to identify guarding. Bowel sounds should be listened for and identified before palpation

- The pelvis should be examined for stability and tenderness over the symphysis pubis and the iliac crests

- The skin colour, temperature and pulses should be checked in all the extremities, as well as their motor function

- The patient should also be log-rolled by a team of people to enable a thorough examination of all the posterior surfaces. Throughout this procedure the cervical spine should remain stabilised. The individual performing the assessment palpates and inspects the cervical spine area for tenderness or deformity. The anal sphincter also needs to be palpated for the presence or absence of tone.

Severity indices

Throughout the trauma assessment process the patient’s condition should be documented clearly and concisely. Several severity indices have been developed, including the Glasgow Coma Scale (GCS) (ENA, 1995; Box 4) and the Revised Trauma Score (RTS) (ENA, 1995; Box 5). When recording the patient’s GCS the best response in each section is taken. However, a patient’s GCS is a gross measurement of his or her neurological status and not a measure of total neurological function. The RTS measures the patient’s physiological response to their injuries with coded values assigned for GCS, respiratory rate and systolic blood pressure.


Initial assessment of the patient’s airway is a priority. Stabilisation or immobilisation of the cervical spine is maintained throughout by either supporting the head in a neutral position or using devices such as cervical collars or bilateral sandbags secured with tape to the back board on which the patient is lying. Hypoxic patients often display symptoms including confusion and restlessness, so this state needs to be corrected in order to secure co-operation. In this initial stage 100% oxygen can be administered to ensure adequate tissue oxygenation (Jevon and Ewens, 2001). Arterial blood gas analysis should also be performed (Horne and Derrico, 1999).

The airway should be observed for the following:

- The presence of vomit or other secretions

- Any sign of excessive bleeding

- Obstruction caused by the tongue in an unresponsive patient

- The presence of loose teeth or other foreign objects

- Oedema.

If there is partial or complete obstruction, the following techniques can be used to clear the airway:

- Jaw thrust and/or chin lift

- The removal of debris and foreign objects using fingers or McGill forceps

- Suctioning using a large-bore yankeur suction device on high suction pressure.

In order to maintain a patent airway it may be necessary to intubate the patient via the oral or nasal route or by cricothyroidotomy.


Once the patency of the airway has been secured, the patient’s breathing should be assessed for signs of life-threatening respiratory conditions (Box 2). This can be done by carrying out the following observations:

- Rate, depth, symmetry of breathing

- Whether the breathing is spontaneous

- Whether the patient is using accessory muscles to breathe

- The patient’s skin colour

- The integrity of the skin and bony structures of the chest wall

- The position of the trachea

- Breath sounds can be assessed by auscultation of the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space anterior axillary line (ENA, 1995, Jevon and Ewens, 2001).


Assessment of the circulation is performed by observing the following:

- The patient’s pulse. This should be assessed for strength and rate

- Signs of external bleeding

- The colour of the skin, whether diaphoresis is present, and the temperature of the skin (Smith, 2000)

Inadequate circulation will result in the patient displaying the clinical signs of shock (Box 3), although these are generally not clearly present until the patient has lost 30% of their circulating blood volume (Metheny, 1996).

Uncontrolled external bleeding can be contolled by applying direct pressure to the site or to arterial pressure points (ENA, 1995). Elevation of a bleeding limb can help to control blood loss, with tourniquets only being used as a last resort (

The rule of thumb with trauma patients is to put large cannulae into large veins, for example the antecubital fossa, and to aim to restore the circulating volume to its original level by initially using 2 litres of warmed intravenous fluids and then titrating fluids to blood loss (Metheny, 1996). Rapid infusion devices can be used to maximise the fluid replacement rate and it may be necessary to perform a surgical cut-down in order to access a large vein. In the absence of a palpable carotid pulse, cardiopulmonary resuscitation is indicated (RCUK, 2000).


Assessing the patient’s neurological status is the next stage. This can be done using the Glasgow Coma Scale (Box 4). Once the baseline reading has been established, subsequent readings can be compared to establish whether there is any deterioration in the patient’s condition. Any such problem should initiate the re-evaluation of the patient’s airway, breathing and circulation status.

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