Rapid Trauma Assessment, Focused History and Physical Exam
Section 2 - PRIMARY CARE
2.03 RAPID TRAUMA ASSESSMENT
FOCUSED HISTORY AND PHYSICAL EXAM
RAPID ASSESSMENT, HISTORY, PHYSICAL EXAM, AND INTERVENTIONS:
Assess mental status. Check for presence of symmetrical sensory and motor function.
Inspect and palpate the head and face. Note any drainage from the ears or nose. Check for symmetry.
Re-inspect pupils for size, shape, equality and reactivity. Note extraoccular motion vs. deviations. Note any trauma to eye, lids or orbits.
Total spinal immobilization as indicated. Check for point tenderness. Note presence of carotid pulses, JVD, subcutaneous emphysema and tracheal deviation prior to applying collar.
Inspect, auscultate, and palpate for signs of injury. For suspected rib fracture, ask the pt. to cough.
Inspect and palpate for signs of injury. If evisceration, cover with sterile moist saline dressings. Do not remove penetrating objects.
- SOFT-TISSUE / MUSCULOSKELETAL:
Inspect and palpate for signs of injury. Assess vascular, motor and sensory function distal to injuries. Immobilize limbs and / or joints as indicated.
Document detailed list of patient medications. If patients are currently on blood thinners, strong consideration should be made for transport to nearest trauma center.
- REASSESS AND RECORD VITAL SIGNS every 5-10 minutes.