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.
- REASSESS AND RECORD VITAL SIGNS every 5-10 minutes.