Reference — Emergency Nursing
Trauma Assessment Reference
Quick reference for systematic trauma assessment — ABCDE primary survey with key findings, life threats, and interventions, plus secondary survey head-to-toe and AMPLE history.
Educational use only. This content is intended for nursing students and exam preparation. Always follow your institution's trauma protocols and ATLS guidelines. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Primary Survey — ABCDE Quick Reference
AAirway (with C-Spine Protection)
Normal: Patient speaks in full sentences; no stridor, gurgling, or snoring
Abnormal Findings
- !Stridor — partial upper airway obstruction
- !Gurgling — blood, secretions, vomitus
- !Snoring — tongue obstruction (unconscious patient)
- !Aphonia (inability to speak) — complete obstruction or cord injury
Life Threats
- !Complete airway obstruction — immediate death without intervention
- !Inhalation injury with upper airway burns — progressive edema and closure
Interventions
- ✦Jaw thrust (NOT head-tilt in trauma)
- ✦Suction
- ✦Oropharyngeal airway (OPA — unconscious) or Nasopharyngeal airway (NPA — conscious)
- ✦Rapid sequence intubation (RSI)
- ✦Surgical cricothyrotomy if cannot intubate
Maintain manual in-line stabilization (MILS) until rigid cervical collar applied. Jaw thrust maintains c-spine neutrality.
BBreathing and Ventilation
Normal: RR 12–20/min, symmetric chest rise, SpO₂ ≥95%, bilateral breath sounds equal
Abnormal Findings
- !Absent unilateral breath sounds — pneumothorax or hemothorax
- !Tracheal deviation — tension pneumothorax
- !Paradoxical chest wall movement — flail chest
- !Sucking chest wound — open pneumothorax
Life Threats
- !Tension pneumothorax — absent sounds + tracheal deviation (AWAY from affected side) + JVD + hypotension
- !Open pneumothorax (sucking chest wound) — air enters chest through wound
- !Massive hemothorax — >1500 mL blood in pleural space
- !Flail chest — paradoxical movement from ≥3 ribs fractured in ≥2 places
Interventions
- ✦High-flow O₂ (15 L/min NRB mask)
- ✦Needle decompression: 2nd ICS MCL (tension PTX)
- ✦Chest seal: 3-sided occlusive dressing (open PTX)
- ✦Chest tube thoracostomy: 5th ICS AAL (hemothorax, pneumothorax)
- ✦Intubation for respiratory failure
CCirculation and Hemorrhage Control
Normal: HR 60–100, BP ≥90/60, cap refill <2 sec, warm skin, no major external bleeding
Abnormal Findings
- !Tachycardia — earliest sign of hemorrhagic shock
- !Hypotension — indicates ≥30% blood volume loss (late sign)
- !Cool, pale, diaphoretic skin — peripheral vasoconstriction
- !Prolonged cap refill — poor perfusion
- !Distended neck veins — obstructive shock (tamponade, tension PTX)
Life Threats
- !Exsanguination — any uncontrolled major hemorrhage
- !Cardiac tamponade — Beck's triad: JVD + hypotension + muffled heart sounds
- !Aortic disruption — widened mediastinum on CXR
- !Intra-abdominal hemorrhage — distended abdomen, FAST positive
Interventions
- ✦Control external hemorrhage: direct pressure, tourniquet (extremity), wound packing
- ✦Two large-bore peripheral IVs (16G or 18G — arms preferred)
- ✦FAST exam (ultrasound) for intra-abdominal hemorrhage
- ✦Pelvic binder for open book pelvic fracture
- ✦Massive transfusion protocol (MTP): 1:1:1 pRBC:FFP:platelets
- ✦Permissive hypotension (SBP 80–90) in penetrating trauma until surgical control
DDisability (Neurological Status)
Normal: GCS 15, pupils equal and reactive (PERRL), alert and oriented
Abnormal Findings
- !GCS ≤8 — severe TBI, requires airway protection
- !Unequal pupils — uncal herniation (pupil ipsilateral to bleed dilates first)
- !Cushing's triad: bradycardia + hypertension + irregular respirations — elevated ICP emergency
- !One-sided motor weakness — lateral cortical injury
Life Threats
- !Epidural hematoma — lucid interval then rapid deterioration (arterial bleed — middle meningeal artery)
- !Subdural hematoma — slower presentation (venous bleed; often elderly)
- !Diffuse axonal injury (DAI) — immediate coma from high-speed rotational forces
Interventions
- ✦GCS scoring: E (1–4) + V (1–5) + M (1–6) = 3–15. GCS ≤8 = intubate.
- ✦AVPU rapid assessment: Alert / Voice / Pain / Unresponsive
- ✦Check blood glucose (hypoglycemia mimics TBI)
- ✦Pupils: check size, symmetry, direct and consensual response
- ✦CT head for GCS <15, LOC, or focal deficit
- ✦Neurosurgery consult for significant intracranial injury
EExposure and Environment
Normal: No additional injuries found on posterior or extremity examination
Abnormal Findings
- !Hidden wounds on back or buttocks — missed if not log-rolled
- !Hypothermia — core temp <35°C; part of lethal triad
- !Burns — extent and depth documentation
- !Deformity, swelling, crepitus — fractures
Life Threats
- !Lethal triad of trauma: hypothermia + coagulopathy + metabolic acidosis — mortality >90% if all three present
- !Open fractures with vascular injury — limb-threatening
- !Compartment syndrome — pressure within a fascial compartment exceeds perfusion pressure
Interventions
- ✦Remove all clothing (cut off) — inspect entire body surface
- ✦Log-roll with 3-person technique — inspect posterior
- ✦Warm IV fluids, warm blankets, warm environment — prevent and treat hypothermia
- ✦Photograph all injuries
- ✦Document extremity neurovascular status: pulse, movement, sensation distal to injury
AMPLE History (Secondary Survey)
| Letter | Component | Key Information |
|---|---|---|
| A | Allergies | Drug allergies (especially latex, contrast, antibiotics), food allergies, environmental allergies |
| M | Medications | Anticoagulants (warfarin, NOACs → bleeding risk), beta-blockers (mask tachycardia), insulin, steroids (impair wound healing), immunosuppressants |
| P | Past Medical/Surgical History | Prior surgeries, medical conditions relevant to current injury, tetanus immunization status, pregnancy (females of childbearing age) |
| L | Last Oral Intake | Timing of last food/fluid — critical for anesthesia (aspiration risk), rapid sequence intubation (RSI) planning |
| E | Events/Mechanism | How did the injury occur? MVC speed, seatbelt, airbag deployment, ejection, height of fall, weapon type, contamination (farm injury, bite wound) |
Secondary Survey — Head-to-Toe Quick Reference
| Region | Key Findings to Assess | Red Flag Signs |
|---|---|---|
| Head/Scalp | Lacerations, contusions, hematomas, step-off deformity | Depressed skull fracture, Battle's sign (mastoid), Raccoon eyes (periorbital) = basilar skull fracture |
| Face | Midface instability, dental occlusion, mandible stability | CSF rhinorrhea (clear fluid from nose), orbital fracture, Le Fort fracture |
| Eyes | Visual acuity, pupil response, extraocular movement | Hyphema (blood in anterior chamber), globe rupture, lens dislocation |
| Ears | TM integrity, external canal | CSF otorrhea = basilar skull fracture, hemotympanum |
| Neck | Tracheal position, JVD, subcutaneous emphysema, carotid | Tracheal deviation (tension PTX), expanding hematoma (vascular injury), crepitus (pneumomediastinum) |
| Chest | Chest wall symmetry, breath sounds, heart sounds, rib palpation | Flail segment, sucking wound, absent sounds, Beck's triad (tamponade) |
| Abdomen | Tenderness, guarding, rigidity, distension, FAST | Grey Turner's sign (flank ecchymosis = retroperitoneal), Cullen's sign (umbilical = intraperitoneal hemorrhage) |
| Pelvis | Single gentle AP compression | Instability = pelvic fracture → apply pelvic binder immediately; repeat compression is DANGEROUS |
| Genitourinary | External injuries, urethral meatus, scrotal hematoma | Blood at urethral meatus = urethral injury — do NOT insert Foley until urology cleared |
| Extremities | Deformity, swelling, neurovascular status distal | Pulse deficit = vascular injury; pain out of proportion = compartment syndrome |
| Posterior | Log-roll: inspect back, flanks, spine | Spinal step-off, penetrating wounds, flank ecchymosis |
Related Resources
Trauma Assessment GuideFull ABCDE guide with c-spine precautions and NCLEX pearls
Open →Primary vs Secondary Survey ChartSide-by-side survey comparison table
Open →Emergency Department TriageTrauma triage — ESI 1 and 2 priority assignments
Open →Glasgow Coma Scale ReferenceGCS eye, verbal, motor scoring components
Open →Increased Intracranial PressureCushing's triad, ICP monitoring in TBI
Open →Shock States OverviewHypovolemic shock — most common cause of traumatic death
Open →Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Emergency Nurses Association (ENA) · AHA ACLS / PALS Guidelines · Advanced Trauma Life Support (ATLS). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →