Trauma Room (Crisis Resource Management – Brindley, Cardinal)

Background: Addressing traumatic injuries is a major component of Emergency Medicine (EM) practice. Providers are asked to quickly evaluate these patients, address major life threats, and make a full inventory of injuries. Having a systematic approach is essential to a rapid assessment that minimizes the chance of missing injuries. This post will outline a step-by-step approach to evaluation.


  • All providers should don appropriate personal protective equipment including gowns, gloves, facemasks, and face-shields
  • If patients are coming in by Emergency Medical Services (EMS), the pre-hospital team will often call ahead with vital signs and information about mechanism of injury
    • Mechanism of injury guides evaluation and raises or lowers probability of certain injuries
      • Majority of presentations categorized as blunt versus penetrating trauma
      • Specific mechanistic considerations include speed of collisions, damage to vehicles, presence of blood at the scene, and other victims or fatalities
      • Use this information to prepare for anticipated interventions
    • Field vital signs can be used to anticipate potential injuries and prepare interventions
  • Patients are usually triaged based on mechanism of injury or physiologic criteria
    • Specific criteria will trigger activation of a trauma team and route patient to resuscitation area
    • Most trauma centers have two tiers of activation (eg. level I and level II)
    • Multiple providers often respond, including nurses, EM physicians, and trauma surgeons based on level of activation

Trauma Resuscitation (


  • Most important first step in major trauma (eg. Level I or II) is completion of EMS hand-off
    • Give the pre-hospital team silence in the room to give report before beginning patient assessment
    • Immediate life threats (agonal respirations, risk of exsanguination) will require immediate management and are often identified by the pre-hospital team

Primary Survey

  • Goal is to find and address immediate life threats
  • Typical approach is ABCDE mnemonic, standing for airway, breathing, circulation, disability, and exposure
  • Although often taught as dictating priority or order of assessment (eg. airway before circulation), all components should be assessed in parallel


  • Look externally for potential obstructions like facial injuries, blood, or vomit
  • Have the patient say their name, listening for any gargling or noisy breathing
  • Quickly assess mental status and determine whether they are able to clear secretions and keep their tongue from obstructing the airway


  • Inspect and palpate chest wall for injury. Look at the position of the trachea and for JVD. Inspect work of breathing
    • Visualization of the neck will require temporary removal of the C-collar
  • Listen for breath sounds bilaterally
  • Assess the patient’s O2 saturation as a marker of oxygenation. Attach EtCO2 or observe respirations to assess ventilation

EFAST in Trauma (


  • Look for any major sources of external bleeding. Assess for internal bleeding with rapid physical exam
    • Often augmented by an Extended Focused Assessment with Sonography in Trauma (E-FAST)
    • 5 major locations patients can exsanguinate
      • Chest
      • Abdomen/pelvis
      • Retroperitoneum
      • Long bone (eg. femur)
      • Street (externally)
    • Pediatric patients can bleed out from head injuries due to lower blood volume (scalp lacerations or, rarely, intracranial hemorrhage)
  • In blunt trauma, the presence of any vital sign abnormalities may prompt empiric placement of a pelvic binder
  • Check the patient’s blood pressure
  • Palpate radial and dorsalis pedis pulses bilaterally
    • Assess for presence, quality, and rate
    • Presence of pulses in particular anatomic locations were previously used as markers of a certain BP, however this has found to be inaccurate (Deakin 2000, Poulton 1988)


  • Examine the pupils
  • Calculate the Glasgow coma scale (GCS)
  • Look for movement of all extremities


  • Remove all clothing from the patient
  • Re-cover the patient with warm blankets
  • Log roll to assess for injuries in the back

Secondary Survey

  • Divided into focused AMPLE history and head to toe physical exam
  • May be abbreviated in unstable patients as they progress to surgery, imaging, or interventional radiology

AMPLE History

  • If patient is unable to provide history, try to obtain information from pre-hosptial team, family members or witnesses
  • AMPLE mnemonic is often used
    • Allergies
    • Medications
      • Ask specifically about anticoagulants
    • Past medical history
    • Last meal
    • Events/Environment
      • Obtain a clear history of the events leading up to and after the injury
      • Ask in general about injuries sustained and specifically about head injures
        • If there is concern for a head injury, ask about loss of consciousness and vomiting

Physical Exam

    • Examine the scalp for bleeding
    • Palpate the scalp, face and jaw for tenderness
    • Examine the pupils again for size and reactivity
    • Examine the ears for hemotympanum
    • Examine the nose for septal hematoma
    • Examine the oral cavity for injuries or broken teeth
      • Ask the patient to close their mouth and ask if teeth alignment feels normal
  • C-Spine
    • If your patient is in a C-collar, have an assistant maintain spinal precautions while you remove the collar
      • Note that patients with penetrating trauma should not be placed in C-collars due to increased mortality (Oteir 2015)
    • Palpate the cervical spinous processes for tenderness
      • Midline tenderness is concerning for spine injury and should prompt consideration of cervical spine imaging
      • Be specific with location tenderness
  • Thorax
    • Feel the shoulder girdle for instability or fractures
    • Check the ribs for tenderness or instability
    • Recheck lung sounds and perform a cardiovascular exam
  • Seat Belt Sign (


    • Examine the abdomen for bruising
    • Palpate for tenderness, guarding and rebound
    • Avoid rocking pelvis
      • If examining for stability, press inward to avoid further injury
    • Any suspicion for pelvic injury should dictate placement of a pelvic binder and further manipulation should be minimized (manipulation can lead to worsening of injuries and additional blood loss)
  • Extremities
    • Check all extremities for strength, sensation, and presence of a pulse
    • Range the joints
    • Palpate for tenderness and deformity
  • Back
    • Roll the patient with assistance, maintaining spinal precautions if necessary
    • Palpate the spinous processes for tenderness or step-offs
    • Digital rectal exam
      • Historically included as part of assessment
      • Recent literature has questioned the necessity of this practice (Esposito 2005)
      • ATLS now recommends DRE as a selective intervention before inserting a urinary catheter (Kortbeek 2008)
      • Motor function of L5-S2 can be assessed by asking the patient to flex their gluteal muscles (“squeeze your butt-cheeks”)

Take Home Points

  • Development of a systematic approach is essential to rapidly assessing the wide diversity of trauma patients and minimizes missed injures
  • Prepare with whatever information is available before the patient arrives and remember to get a good handoff from the pre-hospital team
  • Complete the primary survey (ABCDEs) and address immediate life threats
  • Obtain a good medical history and remember to complete a comprehensive head-to-toe exam


Deakin CD, Low JL. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ. 2000;321(7262):673-4. PMID: 10987771

Poulton TJ. ATLS paradigm fails. Ann Emerg Med. 1988;17(1):107. PMID: 3337405

Oteir AO, et al. Should suspected cervical spinal cord injury be immobilised?: a systematic review. Injury. 2015;46(4):528-35. PMID: 25624270

Esposito TJ, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59(6):1314-9. PMID: 16394903

Kortbeek JB, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma. 2008 Jun;64(6):1638-50. PMID: 18545134