Secondary Assesment
Secondary assessment is a systematic process used to identify injuries or conditions that may not have been found during the primary assessment.
It typically follows the primary assessment and is performed after immediate life threats have been addressed.
The process involves a thorough physical examination and obtaining a patient history to gather more detailed information about the patient's condition.
Secondary assessment is closely related to other key areas such as scene size-up, primary assessment, vital signs monitoring, and effective communication and documentation.
Standards
Secondary assessment involves a more detailed and thorough evaluation of a patient after the primary assessment, focusing on identifying additional injuries or medical issues.
Reassessment is the ongoing process of monitoring a patient's condition, checking for changes, and adjusting care as needed.
Clinical behavior and judgment refer to the decision-making process used by healthcare providers to interpret assessment findings and determine appropriate interventions.
Competencies
You use scene information and patient assessment findings—including scene size-up, primary and secondary assessments, patient history, and reassessment—to guide your emergency management decisions.
You initiate basic interventions based on your assessment findings, aiming to reduce the severity of the emergency and provide limited symptom relief.
Your actions focus on providing access to definitive care, ensuring the patient receives further necessary treatment beyond your initial interventions.
Core Concepts
Secondary assessment involves evaluating patients after the primary assessment to identify additional injuries or medical issues.
For a responsive medical patient, the secondary assessment focuses on obtaining a thorough history and performing a focused physical exam based on the patient's chief complaint.
For an unresponsive medical patient, the assessment relies more heavily on a comprehensive physical exam and gathering information from bystanders or family, since the patient cannot provide a history.
Trauma patients with minor injuries receive a focused secondary assessment targeting the area of injury and related body systems.
Trauma patients with serious injury or multisystem trauma require a detailed physical exam covering all body systems to identify potentially life-threatening conditions.
The detailed physical exam is a systematic, head-to-toe evaluation used especially for patients with significant trauma or when the initial assessment suggests possible hidden injuries.
Learning Objectives
The secondary assessment is a systematic process integrated into overall patient care to identify injuries or conditions not found during the primary assessment. Its main purpose is to gather additional information through physical examination, patient history, and vital signs.
Key components of the secondary assessment include a focused history, physical examination, and reassessment of vital signs. The approach may be modified based on patient factors such as responsiveness, type of complaint, and environment.
For medical patients, the secondary assessment differs based on responsiveness: responsive patients typically provide a history first, while unresponsive patients require a rapid physical exam and vital sign assessment.
For trauma patients with serious or multisystem injuries, the secondary assessment involves a rapid head-to-toe exam and ongoing monitoring, with techniques adapted to the suspected body systems involved.
Decision making in EMS scenarios requires analyzing the situation and choosing the appropriate secondary assessment approach, which varies between trauma patients with minor injuries (focused exam) and those with serious or multisystem injuries (comprehensive exam).
Key Terms
The secondary assessment is a thorough evaluation performed after the primary assessment to identify problems not addressed initially, confirm findings, and determine the root cause of signs and symptoms.
Patient care decisions in EMS often require both rapid action and informed, structured thinking; the secondary assessment provides critical information for diagnosis and treatment within your scope of practice.
A structured patient assessment sequence—identifying immediate needs, gathering additional information, and reassessing—helps manage stress, ensures clarity, and supports effective patient care planning, even in chaotic situations.
The process of assessment and reassessment (think–act–reassess) is essential for closing the loop in patient evaluation and achieving successful outcomes.
The Secondary Assessment
The primary assessment focuses on quickly identifying and reacting to immediate life threats, requiring rapid observation and intervention.
The secondary assessment involves detailed history taking and physical examination to gather information, diagnose, and plan targeted interventions based on underlying pathophysiology.
The secondary assessment is performed only after the scene size-up and primary assessment to ensure scene safety, resource availability, and that no immediate life threats are present.
For critical patients, the secondary assessment may be abbreviated or delayed until after transport has begun, with life-saving interventions taking priority.
For stable patients, the secondary assessment can be conducted more thoroughly on scene without the need to rush.
Following the correct order of assessments is essential, as starting the secondary assessment before completing the scene size-up or primary assessment can be dangerous and is penalized in practical skills evaluations to reinforce its importance.
Components of the Secondary Assessment
Patients are categorized as medical, trauma, or unknown based on their complaint, which guides the approach to secondary assessment.
Secondary assessment consists of three main components: physical examination, patient history, and vital signs, which can be performed in any order or simultaneously, depending on the situation and team coordination.
Physical examination uses your senses to detect injuries or abnormalities, such as feeling for injuries, listening for abnormal breathing, and observing swelling or skin changes.
Patient history is gathered by asking questions about the current complaint (history of present illness/injury, HPI) and past medical history (PMH), including prior conditions and medications, with information possibly coming from the patient, family, or bystanders.
Vital signs include pulse, respirations, blood pressure, pulse oximetry, skin assessment, and pupil evaluation, providing immediate information about patient stability and a baseline for future comparison.
The order of assessment varies: for medical patients, history is often prioritized; for trauma patients, hands-on physical examination is usually first; unresponsive patients require information from others and rely heavily on physical examination.
Assessment methods are adapted to patient condition and urgency, such as rapid physical exams for seriously ill or injured patients who need prompt transport.
Signs are objective findings you can observe (e.g., deformed limb, swollen ankles), while symptoms are subjective experiences reported by the patient (e.g., pain, difficulty breathing).
Patient assessment is dynamic and individualized, changing based on patient type, stability, and available personnel, with tasks often divided among team members.
Assessment is an ongoing process, continuing beyond the secondary assessment through regular reassessment.
Secondary Assessment of the Medical Patient
The goals of patient assessment are consistent for all illnesses and injuries: to create a clinical picture, recognize patterns, and identify immediate medical needs, but the approach varies based on the patient's condition and communication ability.
For medical patients, history-taking is prioritized over physical examination, while for trauma patients, immediate physical examination takes precedence over history.
Secondary assessment consists of three main components: patient history, physical exam, and baseline vital signs, but the sequence and emphasis differ for responsive and unresponsive medical patients.
Responsive medical patient assessment:
Gather the chief complaint and history of present illness using a body system approach and the OPQRST mnemonic (Onset, Provocation, Quality, Radiation, Severity, Time).
Obtain a comprehensive past medical history using the SAMPLE mnemonic (Signs and symptoms, Allergies, Medications, Pertinent past history, Last oral intake, Events leading to the illness).
Conduct a focused physical exam on the area of complaint and related body systems.
Obtain baseline vital signs: respirations, pulse, skin, pupils, blood pressure, and oxygen saturation.
Unresponsive medical patient assessment:
Begin with a rapid physical exam, focusing on body systems and areas related to the suspected condition (head, neck, chest, abdomen, pelvis, extremities, posterior).
Obtain baseline vital signs as above.
Gather history of present illness (OPQRST) and past medical history (SAMPLE) from family or bystanders.
The order of assessment steps may be adjusted based on the situation, available personnel, and the urgency of the patient's condition.
Additional assessment techniques, such as blood glucose measurement, may be necessary for unresponsive patients depending on the clinical scenario.
Chapter 15 Visual Guide
Begin assessment by developing a general impression of the patient through observation and approach.
Primary assessment focuses on determining responsiveness: check if the patient is responsive or unresponsive; if lifeless and not breathing, immediately assess circulation and pulse (C-A-B sequence).
Supplemental oxygen is indicated for certain patients, especially those with respiratory compromise.
Determine patient priority for care and transport based on initial findings.
Secondary assessment includes evaluating vital signs and performing interventions, especially for serious or unstable patients, while en route to the hospital.
Transport decisions (timing, priority, destination) are based on the patient’s condition.
Reassessment intervals: every 5 minutes for unstable patients, every 15 minutes for stable patients; repeat primary assessment, reassess chief complaint, check interventions, and repeat vital signs.
Notify the hospital with a concise report and alert specialized teams (e.g., cardiac or stroke) as needed.
Throughout patient care, provide comfort, reassurance, and remain vigilant for changes in the patient’s condition.
Responsive Medical Patient
The patient's responsiveness significantly affects the assessment process, especially for medical patients.
Medical patients often lack visible external signs of illness, making their verbal history the most crucial source of information.
When a patient is awake and responsive, obtaining their medical history should be the first step in the assessment.
SCAN 15-1
Secondary assessment for responsive medical patients involves obtaining a detailed patient history and performing a focused physical exam based on the chief complaint. The patient is the primary source of information unless they are unresponsive or unable to communicate.
Use open-ended questions to gather information and avoid leading the patient to specific answers. Tailor your questions to the patient's chief complaint and use the SAMPLE mnemonic to ensure a comprehensive history.
Physical exams for responsive medical patients are typically brief and focused on the area of complaint. Most important information comes from the history and vital signs, but specific complaints require targeted assessments (e.g., listening to lung sounds for shortness of breath, inspecting and palpating the abdomen for abdominal pain).
For certain complaints, additional history and specific physical exam steps are necessary:
Shortness of breath: Ask about cough, fever, orthopnea, and bronchodilator use; assess lung sounds, work of breathing, oxygen saturation, and look for edema or jugular venous distention.
Chest pain: Ask about nitroglycerin or aspirin use, palpitations, dizziness, nausea; assess skin, blood pressure, pulse, lung sounds, jugular vein distention, ankle edema, and oxygen saturation.
Mental status changes/neurologic complaints: Ask about headache or seizures; use the BE-FAST assessment (Balance, Eyes, Face, Arms, Speech, Time) to identify possible stroke.
Allergic reactions: Ask about time of exposure, symptom onset, throat symptoms, GI symptoms; look for stinger, rash, lung sounds, face/neck swelling, and check oxygen saturation.
Abdominal pain: Ask about fever, GI symptoms, blood in vomit or stool, menstrual history; inspect and palpate all four abdominal quadrants.
Altered mental status with diabetic history: Ask about oral intake, medications, recent illness, excessive hunger/thirst/urination; check blood glucose, skin, mental status, and breath odor.
Obtain a complete set of baseline vital signs during the secondary assessment. These are essential for monitoring trends and changes in the patient's condition. Always verify automatic blood pressure readings with a manual measurement, especially if there are significant changes.
Prompt transport decisions are part of the treatment plan for critical patients or those with specific complaints (e.g., chest pain, suspected stroke). Oxygen administration may be appropriate for responsive patients as an initial intervention.
Think Like an EMT
History gathering can be challenging due to patient-specific factors such as communication style, mental status, and social context.
When a patient provides excessive unrelated information (e.g., an elderly patient who talks off-topic), you need to gently redirect the conversation to focus on relevant medical issues.
Sensitive topics (such as possible pregnancy in a teenager) require privacy and tact; consider asking family members to step out to ensure confidentiality and encourage honest responses.
Altered mental status (as seen in a diabetic patient who is combative, quiet, or unresponsive) may limit history reliability; gather information from family or bystanders and consider underlying medical causes affecting communication.
Patients exhibiting unusual behavior or possible psychiatric symptoms (such as a college student who is withdrawn, rocking, and incoherent) may not provide a coherent history; collateral information from others and careful observation are essential.
Unresponsive Medical Patient
Assessment sequence differs for responsive and unresponsive medical patients: For responsive patients, you first obtain the history of present illness and past medical history, then perform a physical exam and take baseline vital signs.
For unresponsive patients, the process is reversed: You begin with a rapid physical examination based on scene information, then take baseline vital signs, and finally attempt to gather the patient's history from relatives or bystanders.
History gathering for unresponsive patients relies on others: Since the patient cannot communicate, you should seek relevant information from people nearby to understand the events leading up to the emergency.
SCAN 15-2
For responsive patients, your physical exam is focused on the area related to the patient's complaint, as they can communicate their symptoms.
For unresponsive patients, you must perform a rapid assessment of the entire body because they cannot indicate where the problem is, and bystanders may have limited information.
The approach to physical examination differs significantly based on the patient's ability to communicate, requiring broader assessment for those who are unresponsive.
Pediatric Note
Communicate at the child's level by physically positioning yourself at their eye level to make them feel more comfortable.
Use simple, age-appropriate language when asking questions to ensure the child understands.
Obtain most or all historical information from parents or adult caretakers, especially for infants, as they cannot provide their own history.
Point of View: Patient
Rapid assessment of unresponsive patients is essential, focusing on head, neck, chest, abdomen, pelvis, extremities, and posterior to identify injuries or medical issues.
Key signs to check include jugular vein distention (JVD) and medical ID devices on the neck, breath sounds and abnormalities in the chest, abdominal distention or rigidity, incontinence in the pelvis, and pulse, motor function, sensation, oxygen saturation, and medical ID devices on extremities.
Medical identification devices (necklaces, bracelets, wallet cards, or tattoos) can provide critical information about underlying medical conditions; always check for these and inform emergency department staff.
Pupil assessment is crucial in unresponsive patients, especially when their eyes are closed, as changes can indicate neurological or systemic issues.
Obtain baseline vital signs—pulse, respirations, skin condition, pupils, blood pressure, and oxygen saturation—recording these for comparison during ongoing care.
Consider requesting advanced life support (ALS) personnel if available and beneficial, or determine if stopping at a closer facility for advanced care is warranted, especially in rural or remote settings.
Gather patient history from bystanders by asking about the patient’s name, what happened, observed symptoms before the event, known illnesses, and current medications, prioritizing information from relatives or friends.
Multiple crew members can simultaneously gather history and perform exams to maximize efficiency and information collection.
Be alert for signs of trauma or mechanisms of injury that may require spinal motion restriction.
All gathered information and assessments are vital for emergency department teams to continue appropriate care upon patient arrival.
Mid-Chapter Review
Secondary assessment differs based on patient responsiveness: For responsive patients, you first obtain a patient history, then perform a focused physical exam on affected areas, followed by baseline vital signs.
For unresponsive patients, begin with a rapid physical exam: Since they cannot provide history, you start with a quick head-to-toe exam, then take baseline vital signs, and finally gather history from family, friends, or bystanders.
Information from the secondary assessment may not alter immediate field treatment but is crucial for emergency department staff.
Key Decisions
Assess the patient's responsiveness to determine if they can provide their medical history.
If the patient is unresponsive or unable to communicate, seek information from bystanders or others present at the scene.
Tailor the secondary assessment based on the patient's chief complaint to focus on the most relevant systems or issues.
Preparation for Your Examination and Practice
The secondary assessment for a medical patient focuses on identifying underlying medical conditions through a detailed history and physical exam, while for a trauma patient, it emphasizes searching for hidden injuries due to physical forces. This difference exists because trauma patients are at risk for multiple injuries that may not be immediately obvious, requiring a systematic head-to-toe exam, whereas medical patients often benefit more from targeted assessments based on their symptoms and medical history.
For a responsive medical patient, the secondary assessment relies heavily on obtaining a thorough history (using SAMPLE and OPQRST) and performing a focused physical exam based on the patient’s chief complaint. In contrast, for an unresponsive medical patient, you cannot obtain a history directly, so the assessment shifts to a rapid head-to-toe exam and gathering information from bystanders or family, as well as searching for medical alert tags or medications.
When faced with multiple patients, such as an elderly man with chest pain and his wife with shortness of breath, you should immediately call for additional resources and prioritize care based on the severity of each patient’s condition. Scene size-up principles apply: ensure scene safety, determine the number of patients, and request backup if needed, then begin assessment and care for the most critical patient first while monitoring the other.
Critical Thinking Exercises
Effective communication skills are essential when obtaining a medical history, especially in emotionally charged situations. For an upset family member, use calm, empathetic communication, acknowledge their distress, and gently guide them to focus on providing essential information.
Redirecting and focusing the conversation is important when a patient is easily distracted or lonely. Politely and respectfully steer the discussion back to relevant medical questions while maintaining rapport, ensuring you gather necessary information efficiently.
A history of heavy smoking (such as three packs a day) is likely to increase a patient’s blood pressure. Smoking causes vasoconstriction and stimulates the sympathetic nervous system, both of which contribute to hypertension.
Street Scenes
Initial assessment identifies a middle-aged woman with moderate respiratory distress due to an asthma attack, but with an open airway, rapid and moderately labored breathing, normal skin, and a strong, regular, slightly rapid pulse.
Patient is alert, able to speak in complete sentences, and does not need to pause for breath, indicating her condition is not immediately life-threatening but has the potential to worsen.
Oxygen is administered via nasal cannula while further assessment continues, including history-taking and physical examination.
Patient has a history of mild, exercise-induced asthma for about 10 years, triggered during treadmill exercise, and usually uses albuterol inhaler (left at home during this episode).
Vital signs: pulse 120 (regular), respirations 24 (slightly labored), blood pressure 130/70, skin warm and dry, oxygen saturation 96%. Lung sounds reveal equal wheezes throughout.
Albuterol is administered by small volume nebulizer according to protocols, as the patient has a known asthma history and her own prescribed medication.
Patient is transported in a position of comfort (sitting up), with ongoing monitoring and communication with the emergency department.
Improvement is noted after nebulizer treatment: reduced wheezing, easier breathing, and absence of worsening signs such as retractions, inability to speak full sentences, or cyanosis.
Key signs of deterioration to monitor include increased work of breathing (retractions), inability to speak in full sentences, and cyanosis of lips or nail beds.
Secondary Assessment of the Trauma Patient
Use the eSCAPe framework to support injured patients: This involves providing care to every patient, offering social support, giving choices, helping patients anticipate what will happen next, and assisting with planning and organization every time.
Injuries vary in severity and visibility: You may encounter injuries ranging from minor (like a cut finger) to severe (such as a massive wound), and some injuries, especially internal ones, may not be immediately visible.
Decision-making is crucial even when injuries are not visible: You must determine the urgency of leaving the scene (expedited vs. routine) and decide how much care to provide on scene versus during transport in the ambulance.
Chapter 15 Visual Guide
Rapid identification and correction of life threats is essential, starting with scene size-up and providing cervical spine stabilization if indicated by injury mechanism or patient complaint.
Primary assessment follows the order: Massive hemorrhage, Airway, Breathing, Circulation (MABC) to address the most immediate threats to life.
Priority determination is based on injury severity: patients with serious injuries require rapid transport, while those with minor or isolated injuries can receive more thorough on-scene care.
On-scene examination differs by injury severity: serious or multiple injuries require a rapid head-to-toe exam (including head, neck, chest, abdomen, pelvis, extremities, and posterior), while minor injuries allow for a slower, focused exam.
Key factors in assessing patient severity include: injury location, mental status, airway status, vital signs, mechanism of injury, age, and preexisting conditions.
Patients are categorized as high-priority (serious/critical) or low-priority (minor injuries): high-priority patients are transported rapidly with minimal on-scene time; low-priority patients receive more on-scene care.
Assessment procedures for not seriously injured patients: determine chief complaint and history of present illness, perform a focused physical exam, assess baseline vital signs, and obtain past medical history.
Assessment procedures for more seriously injured patients: rapidly determine chief complaint and mechanism of injury, maintain spinal precautions (except in penetrating trauma), consider advanced life support, perform a rapid trauma assessment, assess baseline vital signs, and obtain patient history.
Patient priority can be adjusted as more information becomes available; when in doubt, treat as high priority.
Notify the receiving hospital and continue detailed assessment and reassessments during transport.
Trauma Patient with Minor Injury/Low Priority
Secondary assessment for minor trauma focuses on the specific injured areas rather than a full head-to-toe exam, guided by the patient's complaints, visible injuries, and suspected injuries based on the mechanism of injury.
Key components of the assessment include determining the chief complaint, obtaining a focused history of the present illness/injury, performing a targeted physical exam, recording baseline vital signs, and reviewing past medical history, medications, allergies, and last oral intake.
Understanding the mechanism of injury is crucial—gather details about how the injury occurred, the nature and direction of the force, protective equipment used, and actions taken to minimize injury. For example, knowing if a patient fell due to a medical issue or accident, or if protective gear was worn during a collision, can influence your assessment.
Physical examination uses three main techniques: observation, palpation, and auscultation. Observation looks for abnormalities in symmetry, color, shape, and movement; palpation assesses shape, temperature, texture, and sensation; auscultation involves listening for abnormal breath sounds.
The DCAP-BTLS mnemonic helps you remember types of injuries to look for: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling. These categories cover a wide range of trauma signs and symptoms.
Wounds, tenderness, and deformities are simpler categories that also guide trauma assessment, emphasizing the need to expose and compare injured areas to normal ones while maintaining patient privacy and comfort.
Patient history is especially important for identifying risk factors that may complicate minor injuries, such as anticoagulant use increasing the risk of serious bleeding from a small head bruise.
Point of View: Patient
Baseline vital signs are essential for initial assessment, providing a quick overview of a patient's stability and serving as a reference for future evaluations.
Early measurement of vital signs helps guide care decisions, especially in trauma situations where pain and injury may mask underlying issues.
Pain and movement can significantly affect a patient's experience and vital signs, highlighting the importance of gentle handling and prompt stabilization (such as splinting) during emergency care.
Spinal Motion Restriction—Applying a Cervical Collar
Cervical collars are used for spinal precautions in patients with potential spine injuries, and should be applied early in the assessment if indicated by mechanism of injury, responsiveness, injury location, or spinal protocols.
Rigid collars are preferred for immobilization, but soft collars may be used for low-risk patients to reduce discomfort; their main function is to remind patients not to move their neck.
Selecting the correct collar size is crucial—the collar should fit between the chin and the suprasternal notch, rest on the clavicles, and support the lower jaw without stretching, constricting, or being too short; neck length is more important than patient width.
Improperly sized collars can obstruct the airway or make breathing difficult, so if a proper collar is unavailable, a rolled towel may be used as a reminder not to move the head.
Before applying a collar, complete the primary assessment and address life-threatening issues, assess the patient’s neck, and explain the procedure to reassure the patient.
Remove jewelry and keep hair clear before collar application, and maintain the patient’s head in a neutral, in-line anatomical position during manual stabilization and collar placement.
SCAN 15-3
Proper sizing of a cervical collar is essential to ensure effective immobilization and prevent further injury to the cervical spine.
Application of a cervical collar requires maintaining manual stabilization of the patient's head and neck in a neutral, in-line position throughout the procedure, whether the patient is seated or supine.
For a supine patient, one provider stabilizes the head and neck while another slides the collar under the neck and secures it around the patient's neck, ensuring continued spinal alignment.
Even after the collar is applied, manual stabilization must be maintained until the patient is fully secured to prevent any movement that could exacerbate spinal injury.
Trauma Patient with Serious Injury or Multisystem Trauma/High Priority
For patients who are unstable or potentially unstable due to findings from the primary assessment or a significant mechanism of injury, you must take immediate action.
Instruct the patient not to move their head and neck to prevent further injury; manual stabilization is often maintained until a cervical collar is applied.
Consider requesting advanced life support (ALS) personnel for additional medical support.
Perform a rapid trauma assessment to quickly identify life-threatening injuries.
The mechanism of injury, such as a fall from height, helps predict possible injuries and guides decisions about patient stability and transport.
SCAN 15-4
If the mechanism of injury (MOI) is not significant, focus your physical exam only on the injured area.
If the MOI is significant, maintain spinal motion restriction, consider requesting advanced life support (ALS), reconsider transport decisions, reassess mental status, and perform a rapid trauma assessment.
Rapid trauma assessment involves quickly evaluating each part of the body and exposing the patient as needed to ensure a thorough check for injuries.
Assess baseline vital signs, including respiration, pulse, skin color/temperature/condition (and capillary refill in infants/children), pupils, blood pressure, and oxygen saturation.
Obtain a patient history using the SAMPLE method: Signs and symptoms, Allergies, Medications, Pertinent past history, Last oral intake, and Events leading to the problem.
Interventions and transport should be guided by contacting medical direction, performing necessary interventions, and packaging/transporting the patient appropriately.
Patients with significant MOI require additional steps compared to those with minor injuries, including a complete head-to-toe assessment rather than a focused exam.
BOX 15-1
Significant mechanisms of injury (MOI) require transport to a trauma care hospital if any of the following are present: falls greater than 10 feet (for all ages), high-risk auto crashes, or specific vehicle-related incidents.
High-risk auto crash criteria include: intrusion greater than 12 inches (30 cm) at the occupant site or greater than 18 inches (46 cm) at any site, partial or complete ejection from the automobile, death in the same passenger compartment, or vehicle telemetry data indicating high risk of injury.
Other significant MOI include: pedestrian or bicyclist being thrown, run over, or experiencing significant impact, and riders (of motorcycles, horses, ATVs) being separated from their vehicle with significant impact.
MOI is an important part of the assessment process, but it does not guarantee injury; patient injuries, presentation, and vital signs are also critical in determining condition.
Pediatric Note
Infants and children are more susceptible to injury from less force than adults, and their smaller size means that injuries may affect different body regions compared to adults (e.g., an impact that hits an adult’s thigh may strike a child’s abdomen or chest).
Children’s skeletons are less developed, so trauma can injure internal organs without obvious external signs like broken ribs.
Hidden injuries are possible even without initial symptoms, especially in children and after mechanisms such as seat belt use or airbag deployment; these injuries may become apparent only hours or days later.
Seat belts and airbags save lives but can also cause injuries: seat belts may cause abdominal or neck trauma, and airbags can injure small occupants or those improperly positioned. Always inspect for concealed damage, such as a bent steering wheel, by “lifting and looking” under deployed airbags.
Side-impact (side-curtain) airbags provide protection but can also cause injuries similar to those from front airbags and seat belts.
Mechanism of injury (MOI) should not be the sole factor in determining patient priority; rapid trauma assessment is necessary for patients with significant injuries, regardless of MOI.
Key signs indicating significant trauma include: unresponsiveness or altered mental status, penetrating wounds to the head/neck/chest/abdomen, compromised airway, respiratory distress, and signs of shock (e.g., pallor, tachycardia).
Spinal precautions should be maintained during primary assessment, including manual stabilization of the head until a cervical collar is applied, following local protocols.
Advanced Life Support (ALS) personnel may be requested based on local protocols, especially in urban/suburban areas; rural areas may have alternative arrangements, but trauma patients should ultimately be transported to a trauma center.
Rapid trauma assessment involves a quick, systematic head-to-toe evaluation using inspection, palpation, hearing, and smell to detect life-threatening injuries and gather information for hospital staff.
Physical exam focuses on wounds, tenderness, and deformities in each body region:
Head: check for crepitation, ear drainage, skull depression.
Neck: assess for jugular vein distention (JVD), crepitation.
Chest: look for paradoxical motion, crepitation, and breath sounds.
Abdomen: check for firmness, softness, distention.
Pelvis: assess for pain, tenderness, abnormal motion.
Extremities: evaluate distal circulation, sensation, and motor function.
Posterior: inspect for wounds, tenderness, and deformities.
Assessment of the head includes palpating for wounds and crepitation, inspecting the face, ears, eyes, nose, and mouth for injuries, drainage, bruising (e.g., Battle’s sign), and foreign bodies that could obstruct the airway.
Blood or clear fluid from the ears or nose may indicate skull or brain injury and provides a route for infection; these findings should be reported to hospital staff.
Neck assessment includes checking for wounds, tenderness, deformities, and JVD; abnormal findings (bulging veins when upright or flat veins when supine) may indicate cardiac or respiratory compromise or blood loss.
Be alert for surgical openings (stoma, tracheostomy) in the neck, which may require special airway management.* Paradoxical motion of the chest is a key sign of serious injury, often indicating a flail chest, where multiple ribs are broken in two places and move in the opposite direction from the rest of the chest during breathing.
Paradoxical motion suggests a significant mechanism of injury and likely damage to underlying structures such as the lungs.
Assessment of the chest should include checking for wounds, tenderness, deformities, crepitation (a crackling sensation), and paradoxical motion.
Palpation steps: Start at the clavicles, move to the sternum, then check the sides of the chest for equal expansion and feel for broken bones or floating segments.
Subcutaneous emphysema is detected as a crackling or crunching sensation under the skin, caused by air escaping from its normal passageways.
Breath sounds should be checked under the clavicles (mid-clavicular line) and at the bases of the lungs (mid-axillary line); absence or inequality of breath sounds may indicate a pneumothorax or other serious respiratory injury.
In trauma patients, the presence and equality of breath sounds are the most important characteristics to assess.
SCAN 15-5
Assess breath sounds at the mid-clavicular and mid-axillary lines on both sides of the chest, checking for air entry, absence, and equality between sides; always expose the chest for examination while considering patient privacy and environmental conditions.
Abdominal assessment includes checking for wounds, tenderness, deformities, firmness, softness, and distention; distention may indicate internal bleeding and can be difficult to judge quickly.
Inspect for colostomy or ileostomy bags and avoid removing or damaging them during clothing removal.
Palpate the abdomen gently in all four quadrants, pressing about 1 inch (2.5 cm) with warm hands; palpate painful areas last. Firmness may signal organ injury or internal bleeding, and a pulsating mass could indicate an enlarged aorta—do not press further if pulsations are felt.
Pelvic assessment involves checking for wounds, tenderness, deformities, bleeding, and priapism. In conscious patients, palpate gently and stop if pain is reported; treat pain as evidence of injury. In unconscious patients, gently compress the pelvis to detect tenderness or bone instability.
Extremity assessment includes checking all four limbs for wounds, tenderness, deformities, and evaluating distal circulation, sensation, and motor function. Test sensation by touching and asking for feedback, and test movement by asking the patient to squeeze fingers or move feet, but avoid this if a fracture is suspected.
SCAN 15-6
Assess distal circulation, sensation, and motor function in all four extremities to detect possible injuries affecting blood flow, nerves, or movement; check before and after interventions like splinting or bandaging, and during transport.
Monitor for changes in distal function after interventions; if function worsens, adjust your care to prevent further compromise.
Avoid asking patients with suspected musculoskeletal injuries or fractures to squeeze or apply pressure with the affected extremity to prevent further harm.
If a patient is a high transport priority and has extremity injuries, delay splinting until en route rather than at the scene.
Perform a rapid assessment of the posterior body by log-rolling the patient as a unit to inspect and palpate the spine, buttocks, and posterior extremities for wounds, tenderness, or deformities.
Use this opportunity to insert a transportation device (e.g., backboard or soft sleeve) if needed, following local protocols.
Stabilize an injured pelvis with a pelvic wrap or sling as directed by local medical protocols.
Quickly obtain baseline vital signs and, if possible, a past medical history; if the patient is unresponsive, seek information from bystanders or family.
Some General Principles
Communicate clearly with the patient by explaining each step of the examination, especially when pain or discomfort may occur, and ensure the patient understands your actions.
Emphasize the importance of the examination and work to build the patient’s confidence throughout the process.
Expose injured areas before examination to identify visible injuries such as bruises or puncture wounds, while maintaining the patient’s privacy and informing them before moving or removing clothing.
Maintain eye contact during interactions and avoid turning away while speaking or listening to the patient’s responses.
Follow spinal protocols: Apply spinal motion restriction for serious trauma patients or those with altered mental status, and know when it is or isn’t required based on injury type and patient assessment.
Use a rigid spine board for critically injured patients with multiple fractures (as a full body splint) or when CPR may be needed during transport (to provide a firm surface for compressions).
Most patients are transported with spinal motion restriction procedures rather than on a backboard, unless specific critical conditions apply.
Adapt the physical exam as needed: Pause or modify the assessment to provide necessary care based on the patient’s priority, such as bandaging or splinting non-life-threatening injuries for stable patients.
Apply a cervical collar during rapid trauma assessment if a spinal injury is suspected.
For high-priority patients requiring rapid transport, perform treatments like controlling non-life-threatening bleeding or splinting en route if the patient’s condition and time allow.
Think Like an EMT
Perform a rapid head-to-toe trauma assessment for patients with significant mechanisms of injury, altered mental status, or possible multiple injuries, such as an unresponsive patient ejected from a vehicle or a patient who fell from a height and briefly lost consciousness.
Conduct a focused physical exam for patients with isolated, minor injuries and no evidence of significant trauma, such as someone who tripped and suspects a broken wrist with no other complaints.
Even with minor complaints (e.g., neck pain after a severe car accident with airbag deployment), consider a rapid trauma assessment due to the potential for hidden injuries from significant force.
In pediatric assessments, do not apply pressure to an infant’s fontanelles; a bulging fontanelle may indicate increased intracranial pressure from trauma or meningitis, while a sunken fontanelle may suggest dehydration.
Head injuries are common in infants and children due to their proportionally larger heads; always check for signs such as bulging fontanelles, blood or clear fluids from the nose or ears (possible skull fracture), and airway obstruction in the mouth.
Assess the neck for cervical spine injuries in children, as their heavy heads make them more susceptible.
Examine the chest for even expansion, the abdomen for rigidity, tenderness, or distention, and listen for abnormal breathing sounds (e.g., wheezing).
Check the pelvis for instability in cases of trauma, especially in pediatric patients.
SCAN 15-7
The larynx, esophagus, diaphragm, lungs, and heart are key anatomical structures in the upper body: The larynx is located in the upper neck and leads to the trachea; the esophagus is a tube descending toward the abdomen; the diaphragm separates the chest from the abdomen; the lungs and heart are within the ribcage, with the heart positioned between the lungs.
Major blood vessels connected to the heart include the pulmonary artery, pulmonary vein, aorta, superior vena cava, and inferior vena cava: The pulmonary artery, pulmonary vein, and aorta arise from the heart, while the superior and inferior vena cava return blood from the upper and lower body, respectively.
Key anatomical landmarks for assessment include the apical (left chest center), axillary (left chest near armpit), and posterior (left back center) points.
Abdominal quadrants contain specific organs: The upper right quadrant has the liver, kidneys, duodenum, and gallbladder; the upper left has the diaphragm, stomach, spleen, and pancreas; the lower right has the ureters, bladder, femoral artery, and vein; the lower left has the large and small intestines, femoral artery, and vein.
Children’s anatomy and physiology differ from adults, affecting assessment and injury risk: Children are nose breathers, so nasal obstructions can cause significant breathing difficulty. Their heads are proportionally larger and heavier, making them more prone to spinal cord injuries, even without bone fractures, due to less developed neck support and incompletely calcified bones.
Airway management in children requires specific positioning: Keep an infant’s head neutral and a child’s head in a neutral-plus or sniffing position to maintain an open airway. Avoid hyperextension or hyperflexion, as children’s airways are smaller and more pliable, increasing the risk of airway closure.
Chest assessment should focus on breath sounds, symmetry, and signs of trauma: Listen for even air entry and abnormal sounds, and check for bruising, paradoxical movement, and retractions. Children’s ribs are softer and may not break easily, but internal injuries can still occur.
Abdominal assessment is critical due to organ vulnerability: Children’s abdominal organs are larger relative to their cavity size and less protected, making them more susceptible to trauma. Injuries affecting the diaphragm can compromise breathing, especially in children who are abdominal breathers.
Pelvic and extremity assessments should include stability, capillary refill, distal pulse, and neurologic checks: Children’s bones are more pliable, tending to bend or buckle rather than fracture. Capillary refill can be checked by squeezing a hand, foot, forearm, or lower leg, and injury sites should be evaluated for pain, swelling, and deformity.
Detailed Physical Exam
The detailed physical exam is a more thorough assessment performed after the primary and rapid trauma assessments, typically when there is more time available, such as en route to the hospital or while waiting for transport.
The main purpose of the detailed physical exam is to collect additional information about the patient's injuries and conditions, which can guide further treatment and assist emergency department staff.
This exam is most commonly performed on trauma patients with significant injuries or mechanisms of injury, less frequently on trauma patients without significant injuries, and rarely on medical patients.
Trauma Patient with a Significant Injury
The detailed physical exam is performed only after all critical interventions and a repeat of the primary assessment have been completed. Addressing life-threatening problems always takes priority over a detailed exam.
The sequence of trauma assessment prioritizes scene safety, primary assessment with critical interventions, rapid physical exam, repeat primary assessment, detailed physical exam (if time and patient condition allow), and ongoing reassessment.
The detailed physical exam is similar to the rapid trauma assessment but is more thorough and typically performed in the ambulance. It may be affected by environmental factors such as noise and motion, and by treatments already provided (e.g., cervical collars, splints).
When spinal precautions or splinting devices are in place, you must work around them, examining accessible areas and using collar openings to assess the neck for wounds, tenderness, deformities, jugular vein distention (JVD), and crepitation. JVD is normal in supine patients but abnormal in seated patients.
Reassessing the chest in a moving ambulance can be challenging due to noise, making breath sounds difficult to hear. Focus on palpation for crepitation or flail chest, and prioritize transport over stopping unless immediate intervention is possible.
Reassess the abdomen, pelvis, and extremities as in the rapid assessment. Injuries found earlier are likely immobilized; splinting can be done en route if time and patient condition permit.
Reassessment of the posterior body should be limited to what is accessible without moving the patient, especially while the ambulance is in motion. Focus on the flanks and reachable spinal areas.
You have more time during transport to be thorough, especially on long or rural transports. Use this opportunity to complete a comprehensive exam if the patient’s condition allows.
Notify the receiving hospital of the patient’s condition as soon as possible, following local protocols, to ensure they are prepared for arrival.
Trauma Patient Who Is Not Seriously Injured
Assessment for responsive trauma patients without significant injury focuses on areas of reported pain and suspected injury based on the mechanism of injury; a detailed physical exam is usually unnecessary unless there is doubt.
A high index of suspicion should be maintained, and a detailed physical exam should be performed if the mechanism of injury is significant, unclear, or unknown.
The approach to detailed physical exams differs between trauma and medical patients; for medical patients, history and vital signs are typically more informative than physical exam findings.
In cases where it is unclear whether the patient’s condition is medical or trauma-related, such as an unconscious patient found in a car with no damage, treat as a trauma patient with rapid assessment and seek history from witnesses when possible.
Responsive trauma patients may experience fear and require emotional support during assessment and care.