The document provides guidance on performing an initial assessment of a trauma patient using the ABCDE approach and mnemonics to evaluate the patient's airway, breathing, circulation, disability, exposure, vital signs, comfort, history, and injuries. It emphasizes stabilizing life-threatening problems, providing ongoing monitoring, and evaluating multiple body systems.

1. Your patient is arriving in 5 minutes....
do you know where to start?

2. INITIAL ASSESSMENT
• Initial Assessment Divided into two
assessment phases:
• Primary
• Secondary
• Adherence to standard and
transmission-based precautions

3. Primary Assessment
• A Airway (with simultaneous cervical spine
stabilization and/or immobilization)
• B Breathing
• C Circulation
• D Disability
(neurologic status)
The key: Find immediate
life-threatening problems
really quickly

4. Secondary Assessment
• E Expose/Environmental control
• F Full set of vital signs / Family presence
• G Give comfort measures
• H History and Head-to-toe assessment
• I Inspect posterior surfaces
Now you have time to look
again (secondary)
At the rest of the issues

5. Airway Precautions
• Maintain cervical spine stabilization and/or
immobilization
Any patient whose findings
suggest spinal injury should
be stabilized or remain
immobilized
Never remove a cervical immobilisation
collar until the c-spine has been cleared
By the MD

6. Airway Assessment
Also think about potential
• Vocalization obstructions...Conditions
• Tongue obstruction could change quickly
• Loose teeth or foreign objects
• Bleeding
• Vomitus or secretions
• Edema
• Airway Obstructed?

7. Obstructed Airway
• Position the patient You don’t go on to “B” until
you have taken care of “A”
• Stabilize the cervical spine
• Open and clear the airway
• Insert airway
• Consider endotracheal
intubation
• Stop and intervene
before proceeding

8. Breathing
• History (medical and trauma)
• Blunt or penetrating trauma
• Steering wheel
• Other forces
What might cause this
Patient some breathing
Problems?

9. Breathing Assessment
What do you look for when
assessing breathing?
• Spontaneous breathing
• Chest rise and fall
• Skin color
• Pediatric: see handout with pictures of
infant chest for comparison

10. Breathing Assessment (cont)
• Respiratory rate
• Chest wall integrity
• Accessory and/or abdominal muscle use
• Bilateral breath sounds
• Jugular veins/trachea
What might compromise
this patient’s breathing?

11. Breathing: Effective
• Administer oxygen via a nonrebreather
mask at a flow rate sufficient to keep the
reservoir bag inflated (12 to 15 L/min or
more)
All trauma patients need
extra oxygen, even if
They do not have
respiratory system
Compromise.....Why?

13. Breathing: Ineffective
What are some other ways
that I can tell breathing is
• Altered mental status compromised?
• Cyanosis
• Asymmetrical chest wall expansion
• Accessory and/or abdominal
muscle use
• Sucking chest wounds
• Paradoxical movement of chest wall
• Tracheal shift from midline

14. Breathing: Ineffective
• Inspect for distended external jugular
veins
• Auscultate breath sounds to determine
if absent or diminished
• Administer oxygen via
nonrebreather mask or
with a bag-valve-mask
or assist with intubation
What are the nurse’s responsibilities
When the MD is intubating the patient?

15. Breathing Absent
• Ventilate patient with bag-valve-mask with
attached oxygen reservoir
• Assist with endotracheal intubation
• Stop and intervene if there are any life-
threatening injuries
• Pediatric: see handout
“pathways leading to
cardiopulmonary arrest”

16. Circulation
• Palpate What do I look for to
assess circulation?
• Pulse for quality and rate
• Central pulse (carotid or femoral)
• Skin for temperature and
moisture
• Inspect
• Skin for color
• Any obvious signs of bleeding

17. Circulation
• Auscultate blood pressure if other team
members are available
• If not, proceed with primary assessment
and auscultate blood pressure at
beginning of secondary assessment
Why is it OK to do the blood pressure
a little later in the assessment?
Why is one blood pressure reading
Not very helpful?

18. Circulation: Effective
• If the circulation is effective,
proceed with assessment

19. Circulation: Ineffective
• Tachycardia
• Altered level of consciousness
• Uncontrolled external bleeding
• Distended or abnormally flat external
jugular veins
• Pale, cool, diaphoretic skin
• Distant heart sounds
What do these signs and symptoms
tell you is happening to the patient?

20. Hypovolemic
Shock
This is the most
common type of
Shock....Don’t look
For another type of
Shock until you have
ruled out low volume

21. Circulation: Effective or
Ineffective
• Control any uncontrolled external bleeding
• Cannulate 2 veins with large bore (14- or
16-gauge) catheters and initiate infusions of
Normal Saline
• Obtain blood sample for typing
• Administer blood as prescribed
Normal Saline will replace fluids, but
what can’t it provide that red blood cells can?

22. Circulation: Absent
• Begin cardiopulmonary resuscitation
(CPR)
• Initiate advanced life support (ALS)
• Administer blood as prescribed
• Prepare for and assist with emergency
thoracotomy
• Prepare for definitive
operative care
What is definitive care?

23. Disability
• Determine level of consciousness using
the AVPU mnemonic
–A Alert
–V Verbal stimuli
–P Painful stimuli
–U Unresponsive
This is a simplified way
of measuring brain activity.
Does it provide complete
information?

24. Brief Neurologic
Assessment
• Extremity movement
• Pupil reaction
• Level of consciousness/orientation
This assessment will give you
some more information about
brain activity

25. Disability
• If decreased level of consciousness is
present, conduct further investigation in
secondary assessment
• Monitor ABCs for the patient who is not
alert or verbal
• If the patient demonstrates signs of
herniation or neurologic deterioration,
consider hyperventilation
What is the nurse’s responsibility
when the patient has decreased
brain activity?

26. Secondary Assessment
• Identify ALL injuries
• E Expose patient What about
hypothermia?
Environmental control
• F Full set of vital signs
Family presence
Why is the nurse
• G Give comfort measures the best person
for this task?

27. Secondary Assessment
• History
Prehospital information
M Mechanism of injury
I Injuries
V Vital signs
T Treatment
Patient-generated information
Past medical history (PMH) What impact could a
trauma patient’s
medical history have
on today’s injuries?

28. Secondary Assessment
• Head-To-Toe • Pediatric: see
Assessment handout, “Injury
– Head and face patterns in a child” for
– Neck comparison
– Chest
– Abdomen and flanks
– Pelvis and perineum
– Extremities
– Posterior surfaces
– General appearance

29. Secondary Assessment
• Focused Survey
• Pain Management
• Tetanus Prophylaxis
Why is initial pain control
In a trauma patient
always given I.V.?
Focused means
you can now
pay close
attention to
extremity
injuries, etc.

30. Glasgow Coma Scale
• Areas of Response Why is the GCS
more helpful than AVPU?
– Eye opening
– Best verbal response
– Best motor response
• Pediatric: see handout “pediatric
GCS” Why is the measurement
of children’s brain activity
different from adult?

31. Revised Trauma Score
• Area of Measurement
– Systolic blood pressure (mm Hg)
– Respiratory rate (spontaneous
inspirations/ minute)
– Glasgow coma scale score
• Pediatric: see handout “pediatric trauma
service triage criteria” Why is pediatric triage
criteria different from adult?

32. Nursing Diagnoses
(not medical diagnoses)
• Ineffective airway clearance
• Aspiration risk
• Impaired gas exchange
• Fluid volume deficit
• Decreased cardiac output
What is the nurse’s responsibility
in each of these situations?

33. Nursing Diagnoses
(not medical diagnoses)
• Altered tissue perfusion
• Hypothermia
• Pain
• Anxiety and fear
• Powerlessness
What is the nurse’s responsibility
in each of these situations?

34. Evaluation and Ongoing Assessment
• Airway patency
• Breathing effectiveness
• Arterial pH, PaO2, PaCO2
• Oxygen saturation (SpO2 or SaO2)
• Level of consciousness
• Skin color, temperature, moisture
• Pulse rate and quality The initial emergency
is over, but the patient
• Blood pressure still has needs. What
Is the nurse’s responsibility
• Urinary output Now?

35. Summary
• A Airway (with simultaneous cervical spine
stabilization and/or immobilization)
• B Breathing
• C Circulation
• D Disability (neurologic status)
• E Expose/Environmental control
• F Full set of vital signs/ Family presence
• G Give comfort measures
• H History and Head-to-Toe Assessment
• I Inspect posterior surfaces