Guide — Emergency Nursing
Trauma Assessment: Primary & Secondary Survey
The trauma assessment follows a structured two-phase approach. The primary survey (ABCDE) rapidly identifies and treats life-threatening injuries. The secondary survey performs a thorough head-to-toe evaluation once the patient is stabilized.
12 min read · Emergency Nursing
Educational use only. This content is intended for nursing students and exam preparation. Clinical decisions require licensed professional judgment and institutional protocols. 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.
Trauma Assessment Overview
Trauma is the leading cause of death in persons aged 1–44 years. Systematic assessment using the ATLS (Advanced Trauma Life Support) framework ensures no life-threatening injury is missed.
| Phase | Focus | Priority |
|---|---|---|
| Primary Survey (ABCDE) | Identify and treat immediately life-threatening injuries | Performed simultaneously by trauma team; each finding treated before moving to next |
| Resuscitation | Restore hemodynamic stability during or after primary survey | IV access, fluids, blood products, interventions as indicated |
| Secondary Survey | Head-to-toe examination for all injuries (after stabilization) | History (AMPLE), systematic physical exam, diagnostic workup |
| Tertiary Survey | Repeat full examination 24 hours later to catch missed injuries | Re-examine after swelling resolves, patient more cooperative, imaging reviewed |
The primary survey is never complete until all five components (A through E) are addressed and life threats are treated. Do NOT proceed to secondary survey until the patient is hemodynamically stable.
Primary Survey — ABCDE
Airway (with C-Spine Protection)
Is the airway patent? Can the patient speak (speaking = airway open)? Look for: blood, vomitus, secretions, foreign body, facial/jaw fractures, burns to airway, stridor, snoring, gurgling. Interventions: jaw thrust (not head-tilt in trauma), suction, OPA/NPA, RSI and intubation, surgical airway (cricothyrotomy) if unable to intubate.
Breathing and Ventilation
Is the patient breathing adequately? Inspect chest wall symmetry, rise/fall, respiratory rate. Auscultate breath sounds. Identify: tension pneumothorax (absent sounds + tracheal deviation + JVD + hypotension), open pneumothorax (sucking chest wound), hemothorax, flail chest (paradoxical movement). Interventions: high-flow O₂, needle decompression (tension PTX), chest seal (open PTX), bag-valve-mask, intubation.
Circulation with Hemorrhage Control
Assess perfusion: HR, BP, cap refill, skin color/temperature/moisture. Identify source of hemorrhage. External bleeding: direct pressure, tourniquet (extremity), wound packing. Internal bleeding: pelvis (pelvic binder), abdomen (FAST exam), chest (chest tube for hemothorax). Two large-bore IVs. Massive hemorrhage: activate massive transfusion protocol (MTP) — 1:1:1 ratio of pRBC:FFP:platelets. Permissive hypotension (SBP 80–90) in penetrating trauma until hemorrhage controlled.
Disability (Neurological Status)
Rapid neuro assessment: GCS score (E+V+M, range 3–15), AVPU (Alert/Voice/Pain/Unresponsive), pupillary response (size, symmetry, reactivity). Identify: altered mental status, lateralizing signs (one-sided weakness), Cushing's triad (bradycardia + hypertension + irregular respirations = increased ICP — emergency). Check glucose (hypoglycemia mimics head injury).
Exposure / Environment
Completely undress the patient (cut off clothing). Log-roll to inspect posterior for wounds, deformities, hematomas. Prevent hypothermia: warm blankets, warm IV fluids. Trauma hypothermia = death (lethal triad: hypothermia + coagulopathy + acidosis). Document and photograph all injuries. Protect patient dignity — cover after inspection.
Cervical Spine Precautions
C-spine injury must be assumed in all trauma patients until ruled out by imaging and clinical assessment. Improper movement of an unstable c-spine fracture can cause permanent paralysis.
Indication for C-Spine Precautions
- ✦High-speed MVC
- ✦Fall from height >3 feet or 5 stairs
- ✦Diving injury
- ✦Axial loading injury
- ✦Any trauma with altered mental status
- ✦Focal neurological deficit
- ✦Midline cervical spine tenderness
C-Spine Protection Measures
- ✦Manual in-line stabilization (MILS) during airway management
- ✦Rigid cervical collar (correct size — improper fit increases ICP)
- ✦Backboard with head blocks (for transport, not prolonged immobilization)
- ✦Log-roll technique for position changes — 3-person minimum
- ✦Airway: jaw thrust only (no head-tilt chin-lift)
Clearance Criteria (NEXUS)
- ✦No midline cervical tenderness
- ✦No focal neurological deficit
- ✦Normal level of alertness
- ✦No evidence of intoxication
- ✦No distracting painful injury — all 5 required to clear clinically without imaging
Nursing Role
- ✦Maintain MILS until collar placed
- ✦Size collar correctly
- ✦Reassess neurovascular status (movement, sensation) every 1–2 hours
- ✦Monitor for pressure injury under collar
- ✦Document any c-spine precaution deviations
Secondary Survey — Head-to-Toe
Begin the secondary survey only after the primary survey is complete and life-threatening injuries are addressed. The goal is a complete, systematic evaluation to identify all injuries.
AMPLE History:
| A | Allergies — medications, food, contrast, latex |
| M | Medications — including anticoagulants, beta-blockers, insulin, steroids |
| P | Past medical and surgical history |
| L | Last meal — timing important for airway management (aspiration risk) |
| E | Events leading to injury — mechanism, position, airbag deployment, ejection |
Head-to-Toe Assessment Sequence:
| Region | Key Assessment Points |
|---|---|
| Head/Scalp | Lacerations, hematomas, depressed skull fractures. Raccoon eyes (periorbital ecchymosis) or Battle's sign (mastoid ecchymosis) = basilar skull fracture. |
| Eyes | Pupil size, symmetry, reactivity. Vision, hyphema, subconjunctival hemorrhage, globe rupture. |
| Face/Nose/Ears | Midface instability (Le Fort fractures). Epistaxis, CSF rhinorrhea/otorrhea (clear fluid from nose/ear = basilar skull fracture). TM rupture. |
| Neck | Tracheal position (midline?), JVD (tension pneumo, cardiac tamponade), subcutaneous emphysema, carotid bruit, hematoma. |
| Chest | Paradoxical movement (flail chest), rib tenderness, breath sounds, heart sounds (muffled = tamponade — Beck's triad: JVD + hypotension + muffled sounds). |
| Abdomen | Inspection (distension, ecchymosis — Grey Turner's sign = flank = retroperitoneal; Cullen's sign = umbilical), FAST exam for free fluid. |
| Pelvis | Pelvic stability (single gentle AP compression — repeat compression is dangerous if fracture found). High pelvic fracture mortality from retroperitoneal hemorrhage. |
| Extremities | Deformity, swelling, crepitus, neurovascular status (pulse, sensation, movement) distal to injury. Compartment syndrome: pain out of proportion, pain with passive stretch, paresthesias. |
| Posterior | Log-roll: inspect back, flanks, gluteal area. Rectal exam if spinal cord injury suspected (sphincter tone). |
NCLEX Pearls
- ✦Primary survey order is always ABCDE — Airway before Breathing before Circulation. Never skip ahead to circulation if airway is not secured.
- ✦C-spine protection begins immediately with manual in-line stabilization (MILS). Jaw thrust (not head-tilt chin-lift) to open airway in trauma.
- ✦Tension pneumothorax = absent breath sounds (unilateral) + tracheal deviation AWAY from affected side + JVD + hemodynamic instability. Needle decompression 2nd ICS midclavicular line.
- ✦Cardiac tamponade (Beck's triad) = JVD + hypotension + muffled heart sounds. Pericardiocentesis is definitive treatment.
- ✦Flail chest = paradoxical chest wall movement — segment moves IN during inspiration (opposite of normal). Cause: ≥3 consecutive ribs fractured in ≥2 places.
- ✦Lethal triad of trauma: hypothermia + coagulopathy + acidosis. Treat with warm fluids, blood products, and damage control resuscitation.
- ✦FAST exam (Focused Assessment with Sonography in Trauma): ultrasound looking for free fluid in pericardium, Morrison's pouch (hepatorenal), splenorenal, and pelvis.
- ✦GCS of 8 or less = intubate. Mnemonic: GCS ≤8, intubate.
- ✦Raccoon eyes + Battle's sign = basilar skull fracture. CSF rhinorrhea/otorrhea = halo sign (blood ring on gauze with clear halo).
- ✦Secondary survey ONLY after primary survey complete and patient stabilized — do not perform head-to-toe exam on actively dying patient.
Related Resources
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 →