Trauma Assessment (Trauma Primary and Secondary Survey)

Trauma Assessment Template

This emergency trauma assessment template is designed for emergency medicine specialists and EMTs to thoroughly document critical trauma cases. Equipped with ambient AI, the template intelligently transcribes the entire trauma assessment (including primary and secondary trauma surveys), eliminating the need for self-scribing or allocating a dedicated scribe.

• Suitable for clinicians of all backgrounds
• Includes prompts for ancillary information, such as pre-arrival info, patient history, and assessment & plan 
• Additional non-verbal information (eg., test results and handover) can be added as context

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See Sample PDF 

What is a Trauma Assessment?

Initial evaluation of trauma patients aims to stabilize the patient while identifying and treating life-threatening conditions. The term trauma assessment describes an organized and systematic approach to this initial evaluation, designed to reduce the risk of preventable death and improve outcomes for trauma victims.

Any clinician with emergency medicine experience knows early-stage trauma care is a high-pressure, high-stakes environment. Having a structured trauma assessment process—which is usually defined in a trauma assessment template—takes some of the uncertainty and stress out of delivering care in this challenging practice area.

In this article, we’ll explore the purpose of standardized trauma assessment and the benefits of using purpose-built templates. We also provide free downloadable trauma assessment templates that include the trauma primary and secondary survey. Finally, we cover how AI-assisted templates can improve the efficiency and accuracy of trauma assessment.

The Purpose of Standardized Trauma Assessments

Trauma is the leading cause of death for people under 45 years of age. And for every person who dies as a result of trauma, thousands more are seriously injured or permanently disabled.

With the aim of reducing preventable deaths and improving outcomes for trauma victims, hospitals and healthcare authorities throughout the world have implemented standardized approaches to trauma management—often referred to as trauma systems.

What is a Trauma System?

There are four key components of a trauma system:

1. Pre-hospital care
2. Acute hospital care
3. Post-hospital care
4. Injury prevention

In a well-functioning trauma system, multidisciplinary teams from these four areas work in a collaborative and coordinated way to reduce the overall mortality and morbidity burden from trauma within a given region.

The Importance of Trauma Assessment

Trauma assessment primarily relates to pre-hospital and acute hospital care (points 1 and 2 from the list above).

When undertaking trauma assessment, first responders and emergency medicine clinicians rapidly evaluate injury victims with the goal of stabilizing the patient and triaging them to the most appropriate setting. 

Research shows there is a significantly lower risk of death when trauma victims with moderate to severe injuries are triaged appropriately and transferred to a trauma center. Accurate trauma assessment also prevents the unnecessary use of high-cost trauma care when not warranted.

Why Trauma Assessment Standardization Matters

Several unique challenges make a standardized approach particularly useful when assessing trauma patients. Below is an overview of how and why a coordinated approach and shared understanding matters in trauma assessment:

• Time pressure - Decisions must be made quickly in trauma care. The “golden hour” principle suggests that appropriate intervention within 60 minutes after traumatic injury significantly improves outcomes. 
• Multiple injuries - Trauma patients often present with multiple injuries across different bodily systems. A systematic approach reduces the risk of overlooking a life-threatening injury. 
• Variable team composition - Trauma teams usually comprise members from different disciplines and backgrounds. A common assessment framework promotes effective collaboration in high-pressure situations.
• Universal language - Shared language enables EMTs, hospital-based emergency medicine teams, and post-hospital care providers to effectively handover and communicate with each other.

Benefits of Using Trauma Assessment Templates

Trauma assessment templates are a crucial step in the process of establishing the principles of evidence-based trauma care in real-world practice settings. 

Most of the benefits that apply to standardization of trauma assessment also relate to using templates. However, templates offer some advantages beyond a shared understanding of how trauma assessment should take place.

Reduced Cognitive Load

Compared to manually remembering each step of a trauma assessment, using a template can dramatically reduce the cognitive burden clinicians face when evaluating trauma victims.

Rather than having to recall every part of the process during high-stress situations, a good trauma assessment template guides the clinician through each step of the trauma primary survey and trauma secondary survey. 

This guided approach allows the clinician to dedicate more mental resources to clinical reasoning, critical interventions, and treatment planning. It can also reduce the cognitive fatigue accumulated from working in emergency settings for extended periods.  

Improved Documentation

During the pressure of managing a trauma patient, clinical documentation can easily become a secondary concern. By prompting clinicians to document specific findings for each bodily system, trauma assessment templates help maintain documentation quality even in demanding clinical situations.

The effectiveness of structured trauma assessment templates improving documentation quality is backed by research, with a 2024 study finding an 18.95% improvement in record completeness after implementing templates in an emergency medicine setting. 

Defensible Decision-Making

Trauma assessment is often scrutinized in a medicolegal context, especially in cases with poor outcomes.

Templates create a clear record of the trauma assessment process, showing that the clinician systematically evaluated each body system, identified relevant injuries, and followed established protocols. This high-quality documentation and associated admission notes and medical reports can help defend clinical decision-making if questions about the standard of care provided arise.

Improved Efficiency with AI

Contemporaneous notes are ideal for trauma assessment. However, clinicians in trauma settings often have to make the difficult decision between:

• Allocating a dedicated scribe (resource intensive)
• Leaving notes until after the assessment (not as thorough or accurate)
• Trying to juggle documentation with performing the assessment and interventions (stressful and may compromise care)

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AI-enabled trauma assessment templates solve all of these problems.

When using a template with an AI medical scribe like Heidi, clinicians simply press ‘Start Transcribing’ and the AI captures all details from the assessment. Upon pressing ‘Stop,’ Heidi generates a complete, editable, and properly formatted trauma assessment ready to be reviewed and placed on the medical record.

Consultant Neurosurgeon and Spinal Surgeon Mr. Gordan Grahovac uses templates within Heidi for both clinic appointments and operation notes for complex procedures. “I save one hour not doing dictations after appointments in busy clinic mornings just from Heidi alone,” he states. 

Describing the impact on his wellbeing, Mr. Grahovac explains, “I’m more relaxed because of Heidi. It means I can see more patients and don’t need to rush between consultations or worry I will forget something the patient said. At the end of the day, I don’t get tired. You can’t really quantify it, but it reduces psychological burden for the clinician.”

How to Conduct a Trauma Assessment

Trauma assessments are most commonly undertaken by EMTs and emergency medicine staff in hospitals. The trauma assessment should continue through two distinct phases: the trauma primary survey and trauma secondary survey.

Below is a summary of each step of a trauma assessment. Please be aware that this is a shortened, generalized overview, which may require expansion and/or customization for your practice setting.

Preparation and Triage

Proper preparation is crucial for effective trauma assessment and begins before the patient arrives. The process varies slightly depending on whether you work in a pre-hospital or hospital setting.

EMT trauma assessment preparation includes:

• Assessing the safety of the scene
• Determining the need for additional resources (e.g., fire services or police)
• Planning transport to the most suitable receiving facility
• Gathering information about the circumstances of injury and the patient’s medical history

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Preparing for trauma assessment in hospital involves:

• Assembling a team based on pre-arrival information
• Clearly defining each team member’s role (including team leader)
• Gathering equipment (monitoring devices, airway equipment, IV access supplies, etc)
• Reviewing pre-arrival information

Trauma Primary Survey

The first step of trauma patient assessment is called the trauma primary survey. This initial rapid trauma assessment aims to rapidly identify and address life-threatening conditions. Each step follows an "assess-identify-intervene" sequence, where problems are addressed as they are found before moving to the next step. The acronym ABCDE may be used to remember the steps of the primary survey. 

Throughout the trauma primary survey, the patient's condition is continually reassessed, particularly after any intervention. If deterioration occurs at any point, immediately return to the beginning of the ABCDE trauma assessment to identify new or worsening problems.

Airway and Cervical Spine

Assessment

Evaluate for airway patency while maintaining c-spine precautions.

• Ask the patient a question to assess their ability to speak clearly
• Look for signs of airway obstruction (stridor, gurgling, or excessive secretions)
• Inspect for facial fractures, oral trauma, or foreign bodies
• Listen for abnormal breathing sounds

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Potential interventions

Throughout airway management, maintain cervical spine immobilization in patients with suspected head or neck trauma.

• Chin lift or jaw thrust
• Suction to clear secretions or blood
• Application of high-flow oxygen
• Intubation

Breathing and ventilation

Assessment

Evaluate the adequacy of breathing and identify immediate life-threats (such as pneumothorax and haemothorax).

• Expose the chest and observe respiratory rate, depth, and pattern
• Look for open chest wounds or asymmetrical chest wall movement
• Assess for tracheal deviation, jugular vein distention, or subcutaneous emphysema
• Auscultate all lung fields
• Monitor oxygen saturation

Potential interventions

Assess the need for intervention(s) to establish adequate ventilation.

• Chest decompression for a tension pneumothorax
• Chest drain insertion for haemothorax
• Apply occlusive dressing for open pneumothorax
• Assist ventilation with bag-valve-mask or mechanical ventilation as needed

Circulation with hemorrhage control

Assessment

Evaluate for shock and identify sources of blood loss.

• Check central and peripheral pulses for rate, quality, and regularity
• Assess skin color, temperature, and capillary refill
• Identify any obvious external bleeding
• Measure blood pressure when possible
• Evaluate responsiveness as an indicator of perfusion

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Potential interventions

Identify and stop source(s) of bleeding while concurrently resuscitating the patient.

• Control external hemorrhage with direct pressure, wound packing, or tourniquets
• Establish IV access and initiate fluid resuscitation and blood products
• Consult with surgeon and/or interventional radiologist if surgical control of bleeding is required

Disability (neurological state)

Assessment

Perform a rapid neurological evaluation to identify presence of traumatic brain injury.

• Assess level of consciousness using the Glasgow Coma Scale (GCS)
• Check pupil size, symmetry, and reactivity
• Evaluate gross motor and sensory function in all four extremities

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Potential interventions

Minimize secondary brain injury via neuroprotective strategies.

• Maintain adequate oxygenation and circulation to prevent hypoxia
• Consider intubation for patients with GCS ≤8
• Document baseline neurological status to track improvement or deterioration
• Expedite CT imaging if indicated

Exposure and Environmental Control

Assessment

Completely expose the patient to identify all injuries.

• Remove all clothing to fully expose the patient
• Inspect for signs of any obvious injury

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Potential interventions

Minimize the risk of hypothermia.

• Cover patient with warm blankets after examination
• Use warmed IV fluids and external warming devices
• Maintain a warm room temperature

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After the trauma primary survey is completed the trauma secondary survey can commence. 

Trauma Secondary Survey

The trauma secondary survey is a systematic head-to-toe examination that begins after the primary survey is complete and life-threatening conditions have been addressed. 

The purpose of the secondary trauma survey is to gather relevant history and identify all injuries that weren't detected during the primary survey. This information helps to prioritize the continued management of the patient.

History and background

Gather as much medical and personal history as is available, such as:

• Allergies and medications
• Medical conditions and diagnoses (verified from discharge summaries or progress notes where possible) 
• Summary of events related to the injury

Head and face

• Conduct a head trauma assessment by examining the scalp thoroughly, palpating for hematomas, depressions, or lacerations
• Inspect and palpate facial bones for asymmetry, step-offs, and instability
• Check eyes for pupillary size and reactivity, extraocular movements, and periorbital ecchymosis ("raccoon eyes")
• Examine ears for hemotympanum and retro-auricular ecchymosis (Battle's sign)
• Look for clear fluid from ears or nose that may indicate CSF leakage
• Inspect the nose for septal hematoma

Neck

• Maintain cervical spine immobilization throughout the examination
• Inspect for deformity, hematomas, and vascular injury
• Palpate for tenderness, crepitus, and tracheal position
• Check for subcutaneous emphysema which may indicate tracheal or laryngeal injury
• Assess for jugular vein distention

Chest

• Inspect for asymmetry, bruising, and open wounds
• Palpate the entire chest wall including sternum and clavicles for tenderness, crepitus, or instability
• Thoroughly auscultate all lung fields and heart sounds 

Abdomen

• Inspect for distension, contusions, and abrasions
• Look specifically for seat belt signs which strongly correlate with internal injuries
• Auscultate for bowel sounds in all four quadrants
• Palpate for tenderness, guarding, or rigidity
• Perform a focused abdominal sonography examination (FAST)

Pelvis

• Inspect the pelvis for bruising or signs of instability
• Inspect the perineum and external genitalia for ecchymosis
• Consider rectal or vaginal examination if indicated

Limbs

• Inspect all limbs for deformities, swelling, and bruising
• Palpate each bone and joint for tenderness and abnormal movement
• Assess pulses, perfusion, and capillary refill in all limbs
• Evaluate motor and sensory function in each extremity

Back

• Log roll the patient while maintaining spinal alignment
• Inspect for contusions, abrasions, and penetrating injuries
• Palpate the entire spine for step-offs, gaps, or tenderness

Neurological

• Repeat GCS and compare to initial assessment
• Examine pupils and response to light
• Test motor strength in all extremities

There are a lot of steps to remember in a trauma assessment. So for ease of reference, we’ve collated everything into a free downloadable template.

Trauma Assessment Template Example

Using a template makes it easier to recall each step of a trauma assessment and to complete adequate medical and nursing notes. However, it doesn’t overcome the fact that right when you need all hands on deck, one clinician on the team is partially or completely occupied with documentation.

The solution to this challenge is to use an AI-enabled trauma assessment template, such as those available in Heidi’s Template Community.

AI-Supported Trauma Assessment Documentation with Heidi

With Heidi’s ambient AI technology, completing documentation for a trauma assessment is as simple as pressing Start at the beginning of the assessment and letting Heidi process everything that’s said. At the end of the assessment, simply add any non-verbal contextual information (like medical charts, test results, or intake forms), choose a template, and Heidi produces a perfectly formatted document in seconds.

Advantages of using Heidi for trauma assessment include:

• No need to allocate valuable clinical resources to scribing
• Background information is easily added via copy & paste or document upload
• Automating notes reduces cognitive load on clinicians and can enhance the accuracy of clinical documentation

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Trusted for over one million patient interactions each week, Heidi’s advanced AI scribing technology processes encounters between clinicians and patients to automatically produce notes and follow-up documents. Heidi adheres to global security standards such as HIPAA, GDPR, and Australian Privacy Principles, and has obtained enterprise-grade certifications such as SOC2 and ISO27001.

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Free Trauma Assessment Templates

Trauma Primary Survey Template

This template covers the entire trauma primary survey in the ABCDE trauma assessment format, with detailed prompts for airway, breathing, circulation, disability, and environment. It includes a section to list pre-arrival preparation and handover upon arrival. The trauma primary survey template is suitable for any clinicians involved in trauma assessment. 

View template

Trauma Secondary Survey Template

This trauma secondary survey template guides clinicians through the second component of a trauma assessment. It begins with a prompt to prepare and reassure the patient, then covers examining the patient’s head, face & neck, chest, abdomen, pelvis, limbs, back, and neurological state. 

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Pediatric Trauma Assessment Template

Based on guidance by the Royal Children’s Hospital in Australia, this template is tailored to the specific needs of clinicians completing a trauma assessment in pediatric settings. The template begins with sections for pre-arrival and preparation before covering every step of the trauma primary survey and trauma secondary survey.

View template

FAQs about Trauma Assessments

How many staff should be present for a trauma assessment?

In emergency services, at least two EMTs would usually be present for a trauma assessment. In hospital settings with a full complement of staff, four doctors (team leader, airway, circulation, and procedure), five nurses (scribe, airway, circulation, procedure, and runner/medications), and an orderly would ideally be present. 

Do trauma assessments always follow the same sequence?

A properly conducted trauma assessment should always follow the sequence set out in the trauma primary and secondary survey. This structure follows evidence-based guidelines that are proven to improve outcomes for trauma victims.

Can I create my own trauma assessment template?

Heidi makes it easy to create a personalized template for trauma assessment. You can: 1) Choose an existing trauma assessment template from the community and modify it; 2) Provide a reference trauma assessment and ask Heidi to transform it into a template; 3) Create your own template from scratch using our guide to creating templates in Heidi.