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Trauma Assessment

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Author:    Pamela Dugle (RN, MSN)


Trauma is the leading cause of death for all individuals under the age of 35 (Madigan, 2007). Trauma can be described as any type of injury caused by an outside source (Merriam-Webster OnLine, n.d.). The term major trauma is used for events that involve sudden overwhelming injury and shock to multiple body systems. However, major trauma has no consistently accepted definition. In common usage, it is a means to convey the extreme of seriousness and extent of complex injury caused by an external force.

In an effort to standardize trauma care and promote consistent data collection the Trauma Care Systems Planning and Development Act of 2007 was passed as Public Law 110-23, 121 Stat. 90-99. The beauty of this bill provides increased trauma care nationally and therefore, improves survival rates for victims of traumatic injuries. Seventy five percent of the nation's population is served by a local trauma center. The $12 million funding from this bill will be disseminated throughout the 50 states to provide funding and access to improved care (Nations' Emergency Physicians Herald Passage of Trauma Care Act of 2007, n.d.).

One generally considers trauma to be the result of an accident, but according to the Emergency Nurses Association the term accident has become an obsolete term. Accidents can be considered avoidable and therefore, preventable. Trauma, on the other hand, is most likely unintended. Understanding that trauma can occur at any time, the responsibility of the medical field is to ensure there are adequate resources available to those in need.

Essential to treating trauma patients is the knowledge of the mechanism of injury. The force and impact of the body in relation to the energy imposed by the trauma plays an important role in the extent and nature of the injury to the internal and external organs of the body.

Mortality rates are the easiest result of traumatic injury to track. Information on the numbers of disabling injuries and loss of productive time is much more difficult to measure, yet has an enormous impact.

When working with major trauma rapid, accurate assessments are an integral part of recognizing and dealing with the injury. From the instant the first trained responder arrives on the injury scene, event victims should be evaluated in a systematic progression of assessments speeding them to the most appropriate and beneficial care for their wounds. There are injury assessment scales and tools that can be used to make determinations of severity of injury. The type and quality of assessments used greatly impacts the effectiveness of the trauma care offered.

Sudden, life-threatening injury is a threat to life

Emergency service personnel and healthcare professionals need to be constantly alert to the speed at which terrible things occur and the rapid deterioration that can occur with trauma victims.

Sequential Assessment begins when the first trained personnel arrive at the scene of a major trauma and continues through until injury-specific treatment can occur.


Assessment using an injury rating scale provides an objective measure of the degree of injuries present as well as a statistical prediction of recoverability from the trauma. Consistent use of a recognized injury rating scale facilitates speedy and appropriate decisions regarding, which of the area facilities individual victims should be transported to, which greatly aids the decision process at the scene of an accident or disaster.

Development of injury rating scales is an on-going process, one principle player for which is the Center for Disease Control's – International Collaborative Effort (ICE) on Injury Statistics. ICE on Injuries promotes and coordinates efforts to develop effective, efficient measurements of traumatic injury that can give consistent prediction of care needs and outcomes (ICE, 2006).

Of the rating scales in current use, versions of the system known as the Injury Severity Scale (ISS) are common. The base ISS scoring system uses a zero to 24 scale to represent degree of injury severity. For example, the victim of a motor vehicle accident with an injury score of less than 10 on the ISS scale would be appropriate for transport to a local community hospital emergency room after a brief initial stabilization at the scene of the accident. However, the passenger from the same vehicle would be rapidly transported to the nearest certified Level I Trauma Center if they had an ISS score of greater than 15.

Injury Severity Score (ISS) - Ranges

Minor Injury 0-8

Moderate Injuries 9-14

Serious Injury 15-24

Critical Injury > 24

Another injury rating scale advocated by the state of New York Department of Health uses the classifications of critical, unstable, potentially unstable, and stable (CUPS) system. This scale uses the initial assessment as well as information about the cause of injury to determine a trauma level and gauge appropriate aftercare placement.

Critical patients


Unstable patients


Immediate airway management, rapid transport with further assessment and resuscitation during transport

Potentially unstable


Stable patients


Initial management of the patient may be done on the Scene, transport after initial stabilization


When using the CUPS system the presence of any one of the following criteria signifies the presence of Major Trauma:

Mechanism of Injury

  1. Fall more than 20 feet
  2. Survivor of motor vehicle crash in which there was a death of an occupant of the same vehicle
  3. Struck by a vehicle moving faster than 20 mph
  4. Ejected from a moving vehicle
  5. High speed crash with resulting severe deformity of the vehicle
  6. Vehicle rollover

Physical Findings

  1. Pulse less than 50/minute or greater than 120/minute
  2. Systolic blood pressure of 90 mm Hg or less
  3. Respiratory rate less than 10/minute or greater than 28/minute
  4. Glasgow coma scale less than 13
  5. Penetrating injuries of the trunk, head, neck, chest, abdomen or groin
  6. Two or more proximal long bone fractures
  7. Flail chest
  8. Burns involving 15% or more of the body surface or the presence of facial/airway burns
  9. Combined system trauma that involves two or more body systems
  10. Spinal cord injury or limb paralysis
  11. Amputation (except digits)

Level I Trauma Centers typically serve a large city or a population dense area and are expected to be capable of handling large numbers of injured patients. Facilities of this nature are expected to admit a minimum of 1200 trauma patients yearly. Such centers have a dedicated trauma program, trauma service, trauma team, and a medical director. Centers accorded a Level I rating possess departments or divisions of surgery, neurosurgery, orthopedic surgery, emergency medicine, and anesthesia. General surgeons, anesthesiologists, and emergency medicine specialists are immediately available, 24 hours a day, with immediate operative capacity available at all times.

Level II Trauma Centers are able to provide support in the event of mass casualties to a Level I center. This is especially crucial in population dense areas, though frequently Level II Centers serve on their own in less populated areas. When there is no Level I Trauma center readily available, the expectation is present that transfer agreements are in place to provide prearranged transport to a Level I center. Level II centers are expected to have similar clinical capabilities as a Level I; however some specialty services such as cardiac surgery, microvascular surgery, and acute in-house hemodialysis (for example) are not required. Emergency department personnel and equipment should mirror those of a Level I center, yet operating room availability and personnel are not expected to be on duty at all times, merely readily available. A Level II center however must be able to provide CT or MRI testing at all times.

Level III Trauma Centers must have the capability to manage the initial care of the majority of injured patients that might be generated in a major event or natural disaster, and also have 24-hour general surgical coverage. These facilities must also have ready transport available for patients that exceed in-house abilities.

Level IV Trauma Centers should be able to provide initial evaluation, assessment and resuscitation of injured patients, and have 24-hour coverage by a physician. Ready transport again must be available on need to larger facilities with more resources.

Trauma Teams

Victims of major trauma require a well-organized and trained team made up of staff competent in assessing and treating the wide range of life threatening injuries commonly seen in trauma. Most Level I and Level II Trauma Centers have accepted the trauma team approach, designating specific staff members and service specialties to roles in the care of major trauma victims. When the scene-of-event triage and injury rating assessments are received, the designated trauma leader makes decisions as to who should be on hand for that patient's arrival and initiates preparations. Often the trauma leader is a dedicated emergency services coordinator but sometimes the emergency room physician or a senior emergency room nurse function in the role trauma leader.

The composition of a trauma team will differ somewhat between institutions; however, some elements remain consistent. A designated team leader to coordinate and supervise the joint effort must be present, the emergency room physician, a trauma specialist when available, a general surgeon, an anesthesiologist, radiologist, and an orthopedic surgeon are all essential. Other specialty surgeons such as a cardiovascular surgeon or neurosurgeon should be available on call as needed. Specialized nursing services and personnel include emergency room nurses, intensive care, operating room personnel, and post operative recovery nurses. Team members from both laboratory and radiology must be present at the time of arrival of major traumas. Respiratory therapists are essential members of the trauma team since managing an effective airway is the number one concern during the initial hospital phase of trauma assessment and treatment. Pastoral care and social work personnel may also be on the trauma team to support family and friends.

Every trauma victim must have two assessments; a primary assessment and a secondary assessment. During the primary assessment a patient may be determined to require resuscitation. These priorities follow the Advanced Cardiac Life Support protocols simultaneously with the primary assessment. The secondary assessment comes after the primary and more time can be spent completing this phase of the assessment. During the secondary assessment is when the medical team will determine if the patient will require transfer to a different facility.

Primary Assessment

With arrival to the trauma center we assess, assess, then assess again. This is a word memory device denoting the three levels of assessment utilized with victims of major trauma.

Immediately on arrival the first assessment, the Primary Assessment begins. Primary assessment must focus exclusively on immediate life threatening conditions. When found, they must be treated immediately and aggressively. If you know your alphabet you can easily follow the assessment plan. One very useful plan of assessment is the ABCDE formula:

          Airway control with cervical spine protection
          Circulation and control of hemorrhage
          Disorders of the central nervous system
          Exposure of the whole body

Do not be distracted! Immediate life-threatening injuries are the focus of the primary assessment; injuries not imminently lethal must wait. Any loss of airway for example, is crucial to the survivability of the patient, and the airway takes precedence throughout initial assessment.

A - Airway loss demands initiation of Advanced Cardiac Life Support and immediate intubation to recapture the airway. Cricotomy or tracheotomy should be used if intubation fails.

Stabilization of the cervical spine is always an issue during these initial maneuvers, and measures should be taken to protect the spine from additional trauma. With practice, trauma team members can continue their initial assessments of both breathing and circulation while stabilization of the cervical spine is occurring. A second person may be needed to maintain cervical neck immobilization at this stage.

B - Breathing is the next priority because the absence of breath effort can cause death in five to eight minutes whether an open airway is present or not. Assess the appropriate oxygen delivery method here because you may need to use a face shield or prepare for intubation.

C - Circulation demands assessment in any form of trauma. It does not take a visible arterial bleed to lead to loss of effective blood volume. Internal bleeding from blunt trauma is just as effective way to die as visible exsanguinations. Listen to what your patient is saying. Is he or she complaining about severe back pain that could be a dissecting AAA?

D – Deficits found in the primary assessment indicate the search for neurological injury, and includes level of consciousness and pupil responses. Remember to use the AVPU level of consciousness assessment during this phase.

          A-Alert and awake
          V-Verbal response

E – Exposure is the rapid search for hidden injury. Assessment cannot be thorough when the body is hidden by concealing clothing or objects. As you move down the body during your primary assessment begin removing concealing garments in order to assess for emergently life-threatening damage hidden beneath. Practiced trauma teams often pre-designate one or more staff to the essential task of exposure. Cut the clothing off to get a better view. That is why they call them trauma shears. Cut the clothes off to prevent extraneous movements of the body parts.

Case Study

A patient was transported by ambulance to the nearest hospital and upon arrival the primary assessment revealed the patient was complaining of dyspnea and left chest wall pain. During the exposure phase of the primary assessment the nurses noted the patient had a distinct paradoxical movement. As the patient inspired the left chest wall moved with the inspiration as well as with the expiration. X-rays revealed the ribs were fractured and the patient's sternum was separated from the ribs creating a flail chest. During the initial stages after the trauma, the muscles generally hold the chest in place and are not as noticeable at the scene due to spasms of those muscles.

Secondary Assessment

Immediately after the conclusion of the primary assessment, the second assessment prompts staff to begin again. This time your emphasis is more thorough, and designed to provide the information needed to establish a baseline by which progress or systems decay is measured. The following FGHI formula can be used for the secondary assessment:

          Full vital signs and Five interventions
          Give comfort
          Head to toe examination for injury
          Inspect the back and any areas otherwise hidden

F - Full vital signs are needed to provide tracking information as to your patient's systemic response to the grievous injury. F- Five important medical interventions should now take place, with a designated trauma team member handling each aspect.

  1. Place a pulse oximeter in an area with sufficient blood flow to give an accurate reading.
  2. Place monitors for real-time heart evaluation.
  3. Insert an indwelling urinary catheter to monitor output levels.
  4. Insert a nasogastric tube and actually look at the aspirate for frank bleeding before placing it to low suction.
  5. Initial labs should be drawn.

If indicated and possible, add an arterial line as part of the place monitors intervention. This allows for real time blood pressure monitoring and the many frequent laboratory draws that are inevitable following major trauma.

G - Give comfort. During the task of assessment and initial stabilization, it is so very easy to overlook comfort. Your patient will be very frightened and disoriented by what is going on. Speak in a slow, steady tone, giving brief, reassuring updates as to what is happening. With fading consciousness comes increased confusion. Keep extraneous noises to a minimum and detail one specific team member to speak to the patient.

H - Head to toe examination is the methodical, detailed inventory of wounds. Each area must be examined for injury and the damage graded and categorized. This is also the point in the examination when one must obtain a full history of the prehospital event and the patient's medical history.

I - I is the memory aid letter to remind the team to Inspect the back and any other hidden areas. It is amazing how in the flurry of activity such a simple thing as looking at the patients back for injury can be missed; but… it happens.

Focused Assessment

Remember the saying - assess, assess, and then assess again?

The primary assessment deals with acute, immediately life-threatening injury. The secondary assessment is a gathering of the rough data that will sketch the patient's status into an overall framework. Once these two assessments are completed, assessment turns toward a detailed evaluation of each injury that was noted during secondary assessment.

During these Focused Assessments special attention should be given to the pulmonary, cardiovascular and neurologic systems. Even when no visible injury is evident, a full and detailed focused examination of these systems is mandatory. One formula to use as a component of the focused assessment phase is to remember that you have AMPLE time:

      Medications, including tetanus status
      Previous medical history
      Last meal
      Events leading to the injury

Focused assessment examines each injury starting with those identified as the most life-threatening during the secondary assessment. Penetrating injuries can result in massive blood loss as well as damage organs in areas distant from the entry point. They require manual exploration to determine the extent of injury as well as to clean any debris before repair.

Case Study

A 24 year old male is admitted with a gunshot wound to the abdomen. Gunshot wounds are especially troublesome as they are high-energy injuries, causing extensive damage as the bullet tunnels through the body. Added to that, negative pressure follows the bullet, pulling in contaminated materials from the outside. The patient may experience extensive blood loss due to damage to the veins and arteries. This can send the patient into hypovolemic shock. Although the patients initial was stable, reassessment of the vital signs and Glasgow Coma Scale identify problems. As the patient loses more blood his mentation decreases and he becomes increasingly confused and anxious. Due to the decreased amount of circulating blood volume the oxygen level decreases as well. Physiologic signs will show the heart rate increasing, the respiratory rate increasing, and the blood pressure decreasing in an effort to normalize the body.

Blunt traumas may fail to break the skin and therefore warrant another form of exploration in the form of radiology or ultrasound exams to discern whether tissue damage has been spread from the point of impact by crush and tearing pressures. Whenever internal bleeding is suspected, especially in abdominal injuries, exploratory surgery should be utilized in these cases when there is a need to contain the spread of continuing trauma from internal bleeding or organ rupture.

Closed head injuries are especially tricky since any bleeding that results from tissue tear or contusion has no place to spread. Instead, the increased pressure continues to injure the brain and tissues around it. CT or MRI studies are important, as are assessment tools such as the following Glasgow Coma Scale.




Eye Opening




To Pain



To Verbal Stimuli





Best Verbal

No Response



Incomprehensible Words



Inappropriate Words



Disoriented and Converses



Oriented and Converses


Best Motor

No Response



Extension Abnormal (decerebrate rigidity)



Flexion Abnormal (decorticate rigidity)



Flexion Withdrawal



Localizes Pain



Obeys Commands



Total Score

 3 – 15

The GCS score is a familiar tool used in the emergency work. It is based on observation of eye opening, best motor responses, and best verbal abilities. In the absence of confusing factors, such as alcohol or drug use, a low GCS score is a strong predictor of a poor prognosis. A GCS score of 3-8 indicates a severe central nervous injury, while a score of 14-15 correlates with mild CNS injury (the GCS score of 15 is accepted as normal).

(Galler & Skinner, 2006)

 Traumatic injuries can occur to any area of the body and require immediate attention to prevent loss of that body part. Traumatic injuries can be from penetrating injuries or from blunt force injuries. Burns attribute for 51,000 hospital admissions annually (Wraa, 2007). Regardless of the cause of the trauma, the significance is the stabilization of the injury and the patient.


Events that produce Major Trauma often occur suddenly and without warning. From the time of trauma until injury-specific medical interventions can take place, a series of vital assessments must occur. On arrival, primary assessment by an organized trauma team can ascertain the presence of immediately life threatening dangers. Secondary assessments can establish a framework of information about that persons injuries and condition that allows formation of a plan of treatment using the objective information obtained by initial vital sign measurements and lab values. Focused assessments following that plan allow caregivers to explore and begin treatment of each injury in detail starting with the most crucial.

The implementation of sequential assessments beginning from the time the first trained personnel arrive at the scene of a traumatic injury and continuing to where injury-specific treatments can begin greatly increases favorable outcomes to tragic events of major trauma.


Madigan, Kyle (2007). Mechanism of Injury. In C. Tryniszewski (Ed.), Emergency Nursing: Core Curriculum (6th ed., p. 761). St. Louis: Elsevier.

Merriam-Webster OnLine. (n.d.). Retrieved March 10, 2010, from

Nations' Emergency Physicians Herald Passage of Trauma Care Act of 2007. (n.d.). Retrieved March 2, 2010, from

Wraa, C. (2007). Burn Trauma. In C. Tryniszewski (Ed.), Emergency Nursing: Core Curriculum (6th ed., p. 803). St. Louis: Elsevier.

Galler, D. and Skinner, A. January 25, 2006. “Critical Care Considerations in Trauma”. eMedicine. Accessed March 1, 2007.

International Collaborative Effort on Injury Statistics. October 18, 2006. “What is ICE on Injury Statistics?” Centers for Disease Control. Accessed March 30, 2007.