Rapid Trauma Assessment, Focused History and Physical Exam

Section 2 - PRIMARY CARE

FOCUSED HISTORY AND PHYSICAL EXAM

RAPID ASSESSMENT, HISTORY, PHYSICAL EXAM, AND INTERVENTIONS:

• NEURO:

Assess mental status. Check for presence of symmetrical sensory and motor function.

• HEAD:

Inspect and palpate the head and face. Note any drainage from the ears or nose. Check for symmetry.

• EYES:

Re-inspect pupils for size, shape, equality and reactivity. Note extraoccular motion vs. deviations. Note any trauma to eye, lids or orbits.

• NECK:

Total spinal immobilization as indicated. Check for point tenderness. Note presence of carotid pulses, JVD, subcutaneous emphysema and tracheal deviation prior to applying collar.

• CHEST:

Inspect, auscultate, and palpate for signs of injury. For suspected rib fracture, ask the pt. to cough.

• ABDOMEN:

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.

• MEDICATIONS:

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.