View source for 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:'''
* '''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.

[[Category:Primary Care|0203]]