The importance of the initial trauma assessment cannot be overstated as it sets the tone and conduct for the successive steps in the patient’s overall care. Missed or delayed identification of injuries during the initial assessment can lead to adverse outcomes and complications later in a patient’s hospitalization. Although, there have been multiple studies demonstrating the effectiveness of trauma center care on outcome, in reality, the optimal approach to a trauma patient should be universal regardless of the center. Prompt evaluation and treatment are cornerstones of modern trauma systems, which all starts with the initial assessment.

The initial assessment begins with an understanding of which patients need an evaluation by a trauma team. After successful field triage (see Chapter 7), the injured patient should be seen in a setting that can accommodate both the patient and the full trauma team. The basic principles of Advanced Trauma Life Support (ATLS) are then utilized with the primary goal of identifying and treating life-threatening injury. Adjunctive tools of evaluation are often employed to help with the assessment. Finally, ongoing evaluation and training of the trauma team should be utilized to maintain readiness.

While the definition of trauma can be easily defined as injury, the patient with an injury requiring the resources and expertise of a trauma team is less clear. The ability to triage or “sort” trauma patients to the appropriate level care can be examined from several different aspects. These include (1) prehospital triage (ie, does this patient require a trauma center?), (2) trauma center designation (ie, in a region where there are several levels of trauma centers which one is most appropriate?), and finally (3) in-hospital triage tiered response (who is going to see and treat the patient upon arrival?). The best outcomes will be generated by a system that is seamlessly connected.

The most recent Resources for Optimal Care of the Injured Patient recognizes that inclusive regional trauma systems should optimally place the right patient in the right place at the right time.¹ Ideally the only difference between hospitals should be related to their resources and not their commitment to provide the best care for the injured patient (see Chapter 4). Trauma patients should be taken directly to the most appropriately equipped center to handle their needs. As such, there are many factors that have been examined to provide field triage to the injured patient which include anatomy, physiology, mechanism, comorbidities, and field triage scores. Of these indices, physiologic parameters provide the most accurate single criteria for triage but ideally a combination of physiologic, anatomic, mechanism, and comorbidities provide better triage than any criteria taken in isolation.^2,3 Levels of trauma center designation range from I to IV, with level I centers providing the most comprehensive trauma care and level IVs the least (see Chapter 4). Decisions to transport an injured patient to a specific trauma center will be based on multiple factors that are regionally dependent and ultimately on the severity of the patients injuries. Finally, utilizing a tiered response system in the hospital has been shown to be safe, cost effective, and can even potentially reduce over triage.^4,5,6,7

Although, there is no “official” standard for the amount of space needed for the optimal evaluation of the trauma patient, an understanding of the needs and composition of the team will help to dictate the space required. The room and equipment should be designed to optimize trauma team performance. A space large enough to accommodate the trauma team (see below) and ancillary staff is absolutely necessary. When considering size, one must also take into account the need for monitoring and resuscitation equipment, bedside radiographic studies and ultrasound as well as crowd control. In ideal situations, the room or rooms should be solely dedicated to the evaluation and initial management of the trauma patient. This dedicated room will allow the staff to become acquainted with the dynamics of the space. Having a readily available resuscitation room allows for rapid assessment and the ability to keep the appropriate equipment stocked in one easily accessible space. The room should also have telephone access for communication with the operating room, blood bank, and other important locations.

The room should have a standard set of equipment that can be utilized by the trauma team for all trauma patients. Personal protective equipment (PPE) in the form of fluid resistant gowns, head covering, face shield, and gloves (both sterile and nonsterile) should be made available to the entire trauma team. Depending on how x-rays will be performed, protective lead shielding should be provided. A radiographically compatible stretcher so as to obtain x-rays without having to move the patient would be ideal. Cardiac and vital sign monitoring equipment that includes dynamic ECG, oxygen saturation, and blood pressure should be permanently available in the room. Quantitative end tidal CO₂ monitoring is a nice adjunct to have as part of the monitoring system. A manual blood pressure cuff should also be immediately available.⁸ Flat panel monitors placed within the resuscitation room, which can display radiographic images and laboratory data, is an excellent adjunct which can allow the team to remain at the bedside of critically injured patients. Other basic equipment should include dressings/bandages, IV and phlebotomy equipment, thermometer, scalpels, suture material, and a needle driver. It does help to create a “universal” instrument set that would include standard equipment that can be utilized a broad spectrum of needs. The “other” equipment available in the trauma bay can be divided into categories based on injury need (Table 10-1).

Although, many iterations and variations are found as it relates to the optimal makeup of the trauma team, there are no hard recommendations as to the proper number and formulation of the team involved in the initial assessment. The key to formulating the makeup of the team lies in understanding the goals that need to be achieved. Quite simply, the goal of the initial assessment of the trauma patient is to identify significant injuries and initiate lifesaving measures. This can be further divided into the immediate evaluation and management of life-threatening injuries and subsequent identification and management of non–life-threatening issues. These concepts are commonly referred to as the primary and secondary surveys. As such, the ideal team to evaluate the trauma patient should include the personnel necessary to perform these tasks. Based on industrial and psychological research, team efficiency has been divided into horizontal and vertical organizations, which can be translated into horizontal and vertical resuscitations for trauma patients. A horizontal approach is preferred and is one in which each team member is carrying out their individual tasks simultaneously. Studies have demonstrated the effectiveness of this approach in improving resuscitation times.⁹ Conversely, the less efficient approach would be a vertical resuscitation where each task is performed sequentially.

Frequently seen as the “ideal” environment, the level I trauma center has a dedicated team for the initial evaluation of the trauma patient. This will often include a senior surgeon, residents and/or advanced practice providers, nursing staff, medical students, EM and anesthesia staff, respiratory and radiology staff. This team is clearly not attainable in all institutions and should only be used as a template. Trauma center designation should not factor into the proper evaluation of the trauma patient. With the goal to efficiently perform evaluation and management simultaneously, the minimum team numbers should include personnel to perform the primary and secondary survey (1 or 2 team members), procedures (1 or 2 members), and a team leader (1 member, usually the most experienced surgeon). The nursing staff will be working to help with intravenous access, providing medications, transfusions, and monitoring. Although not well studied, the importance of a well-experienced nursing staff as part of the trauma team cannot be stressed enough.

Trauma team leader: The leader of the trauma team should be the most experienced provider in the room with an understanding of the priorities in the evaluation and care of the injured patient. In a trauma center, this should be the trauma surgeon.¹ The team leader should provide direction and assign tasks to individual team members prior to arrival of the patient. With the goal of conducting the “trauma team orchestra,” they should situate themselves with a view of the entire proceedings. While this is often best accomplished at the foot of the bed, the geography of the resuscitation room will dictate the optimal position which affords the team leader the “big view.” Once the patient arrives, the team leader should keep the team on track and offer prompts as needed to bring the initial evaluation and management to an appropriate conclusion. Decisions as to the next steps in care should be made by the team leader. If trainees are present, opportunities should be made for them to be team leader under the close supervision of the attending.

Primary surveyor: This individual is responsible for the actual evaluation of the trauma patient. Based on ATLS algorithms, this individual will work through the ABCD/primary survey of the evaluation and report these findings to the team. Depending on available personnel, this individual can perform the secondary survey as well.

Procedures: Depending on the severity of the trauma, the patient may require many procedures or none. It is however imperative to pre-identify who is going to perform that procedure should it be needed. At the very minimum, someone should be designated to provide airway care. While in some institutions this has been traditionally performed by anesthesia personnel, no difference exists in endotracheal intubation success rates between emergency medicine and anesthesia in level I trauma centers.^10,11 Local protocols with appropriate quality assurance should dictate control of the trauma patient’s airway. All other procedures can be addressed using the most appropriate member of the team.

Ancillary team members: Because the extent and severity of a patient’s injuries are often not clear at the beginning of the initial assessment, a mechanism needs to be in place for bringing ancillary staff into the team. These may include extra nursing personnel, respiratory therapists, and x-ray technologists. Additionally, there needs to be a method for activating operating room or interventional radiology personnel if you are in a center that will be providing operative intervention or angiography. Appropriate and up-to-date contact information for relevant consultants (ie, neurosurgeons, orthopedic surgeons) will also need to be readily available.

EMS Handoff

The communication between prehospital providers and the trauma team provides the initial information that helps to paint the picture of the real and potential injuries the patient has sustained. Because communication errors have been shown to be a common cause of preventable disability or death, transmission of information between emergency medical services (EMS) and the trauma team should be afforded dedicated time. The EMS report ideally begins in the prehospital environment. Mature EMS systems will have a mechanism through which the prehospital providers can notify receiving teams about the incoming patient using radio, cell phone, or landlines. Creating a centralized center for dissemination of this information is an ideal way to minimize the need for multiple steps in communication, which could otherwise lead to misinformation. The report need only be brief, containing information as it relates to age, mechanism, hemodynamics, injuries, and estimated time of arrival (ETA). Prenotification then allows the trauma team to make the appropriate preparations prior to patient arrival. This can include mobilizing the appropriate personnel and obtaining the equipment necessary for the particular type of injuries that may be presenting.

Once in the hospital, EMS providers should be afforded dedicated time for their report. There have been multiple studies demonstrating difficulties in the handoff between prehospital providers and a receiving team.^12,13 The reasons for this have been shown to be multifactorial but include difficulties in communicating between teams with different views, the need to perform multiple simultaneous tasks, and relaying fragmented bits of information.¹⁴

Additionally, there does not seem to be a focus on educating EMS providers as to the information deemed important to the trauma team. Because of this disconnect, trauma teams often do not demonstrate a willingness to listen and EMS providers continue to provide information that may not be beneficial for the hospital providers. Several studies demonstrate the effectiveness of educating all the involved parties in a more “formal” handover using specific data points. At the current time there are several of these with one of the most common being MIST (mechanism, injuries suspected, signs [vitals] and symptoms, treatments). MIST has been adopted by many EMS systems internationally and is also being utilized by the military for their handovers.^13,15 Other studies have shown that better data and more timely handovers occur when a more formal handover is performed.¹⁶ From a practical standpoint and unless the patient is in extremis, the prehospital handover should ideally take place prior to the patient being transferred to the hospital stretcher. This allows the entire team to focus on the EMS provider without jumping into an assessment that precludes listening. The report should be prompted to start and finish by the team leader who should be cognizant of the information being given and limit extraneous stories. Ultimately, the prehospital report should not take more than 45 seconds to 1 minute. The team leader, who can utilize a tool such as MIST to ensure that the appropriate information has been conveyed, would then direct the transfer of the patient and beginning of the assessment.

With the overarching goal of trauma care to minimize mortality and improve outcomes, the primary assessment is designed to systematically allow the team to achieve this objective (Fig. 10-1). In fact, the term “primary assessment” or “survey” is somewhat a misnomer in that the goal is not only to identify (using the ABCDE moniker) potentially life-threatening injuries but also to intervene and correct these problems as soon as they are diagnosed. With the exception of those patients with external or compressible life-threatening hemorrhage where the circulation evaluation and treatment will come before airway, the provider should follow the airway, breathing, circulation, disability, and exposure/environment approach. One can rapidly obtain a general picture of the patient’s condition by merely asking them one or two questions. Appropriate answers to “What is your name?” and “Can you tell me what happened?” will provide the team with information regarding the first four (ie, ABCD) elements of the primary survey. If the patient is not awake and alert, tactile stimulation (ie, painful stimuli) in addition to questioning may result in the patient verbalizing answers to questions. A more complete description of assessing disability and altered metal status is outlined below.