CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
TRAUMA ASSESSMENT (SIGNIFICANT TRAUMA)
Scene Size-Up
BSI Gloves, goggles, mask, gown, prn
Scene safety Is the scene safe for you, your partner, & the patient?
MOI/NOI Determine mechanism of injury
Number of patients MCI ? Is one crew enough to handle the job?
Need for additional resources PD ? FD ? Additional BLS ? ALS ? Etc.
Primary Assessment:
Life threats/chief complaint: Correct any obvious life threats
Impression (general) Age, sex, position, apparent level of consciousness
Stabilize C-spine PRN
AVPU Assess mental status
Airway: Open PRN Manual jaw thrust or head-tilt/ chin-lift
Suction PRN any audible noises, FBAO maneuvers
OPA secure airway
Breathing: Oxygen: Adequate or inadequate respirations (NRB/BVM)
Inspect The chest visually for any abnormalities, equal chest rise/fall
Palpate Chest for abnormalities (flail segments, swelling, deformities)
Auscultate Mid-axillary for presence of lung sounds
Seal Sucking chest wounds (occlusive dressings x3 sides)
Circulation: Voids Control serious bleeding
Carotid pulse If unresponsive
Radial pulse Compare with central pulse
Skin Color, temperature & Condition
Shock Elevate legs, maintain body temperature
Decision/dispatch: Identify priority patients, update EMS, obtains ETA
Secondary Assessment (History)
History: Sample history
S- Signs and Symptoms Is there anything else bothering you?
A- Allergies Do you have any allergies?
M- Medications Prescription/over-the-counter
P- Past/pertinent history Do you have any medical problems?
L- Last oral intake When was the last time you ate/drank?
E- Events What happened prior to the problem?
Assess: Assess for D.O.T.S. (Deformities, Open wounds, Tenderness, Swelling)
Head: Palpate scalp, inspect-eyes, ears, nose, mouth
Neck: Palpate trachea/cervical spine, check for jugular vein distention
Chest: Inspect, palpate & auscultate right/left lung mid-axillary
Abdomen/Pelvic: Inspect/palpate abdomen and Assess pelvis
Lower Extremities: Inspect, palpate, and check pulse, motor and sensory
Upper Extremities: Inspect, palpate and check pulse, motor and sensory
Posterior: Log-roll patient-inspect/palpate thorax, lumbar & buttocks
Vital signs: Blood pressure: Systolic/diastolic
Pulse: Rate & quality
Respirations: Rate & quality
Skin: Color, temperature and condition
Secondary injuries: Manage secondary injuries if time permits
Reassessment:
Repeat-
Primary Assessment
Secondary Assessment
Vital signs
Interventions Every 5 minutes for critical patients & Every 15 minutes for stable patients
Hand-off: Verbalize report to arriving ambulance crew