NREMT Trauma Assessment: The Station, the Sequence and the Practice

The NREMT trauma assessment is the psychomotor skill where a candidate assesses and manages an injured patient, where your level's psychomotor exam includes one (formats have changed and differ by level; check nremt.org for yours). It has the same backbone as the medical assessment, scene size-up, primary survey, history, secondary exam and reassessment, but the emphasis shifts: mechanism of injury, hemorrhage control and a systematic head-to-toe exam carry more of the weight.

What the assessment is testing

A trauma assessment evaluates whether you can keep yourself safe, identify and control threats to life quickly, decide early how urgently the patient needs a hospital, and then find every other injury without missing a region. It rewards a disciplined sequence. A common way to go wrong is not failing to recognize an injury but finding it late, or never looking.

The sequence, phase by phase

The current official sheet sets the exact items and their order. The shape of a trauma assessment is consistent across EMS education:

1. Scene size-up

• Personal protective equipment and scene safety, stated and done. Older sheets called the first of these body substance isolation, or BSI.
• Mechanism of injury, and what it suggests about hidden injuries.
• Number of patients and whether you need more help.
• Spinal motion restriction considered based on mechanism and findings, according to your protocol.

2. Primary survey

• General impression and level of responsiveness.
• Catastrophic external bleeding, controlled as soon as it is found. Current trauma teaching puts this at the start of the primary survey; follow the order on your current sheet.
• Airway, with spinal considerations.
• Breathing, including exposing and assessing the chest and managing what you find.
• Circulation: pulse, skin, and any remaining bleeding.
• The priority of the patient and the transport decision, made early.

3. History

A SAMPLE history, from the patient if they can give it and from bystanders if they cannot, with the events leading up to the injury carrying extra weight.

4. Secondary assessment

A head-to-toe secondary assessment using DCAP-BTLS at each region, quicker or slower depending on the patient. Older textbooks called these the rapid trauma assessment and the detailed assessment. Expose to assess, and do not forget the back.

Score a level of consciousness for the trauma patient

5. Vital signs, interventions and reassessment

Obtain and state a full set of vital signs. Manage the injuries you found in an order that makes sense for the patient, splinting, wound care and burn care included. Then reassess: repeat the primary survey and vital signs, recheck your interventions, and change the plan if the patient changes.

Estimate burn surface area during the secondary assessment

What fails a candidate, in general terms

The exact critical criteria are on the official sheet, and you should learn them from it. Described in our own words rather than the Registry's, the classes of failure in a trauma assessment look like this:

• Leaving yourself unprotected or the scene unchecked.
• Overlooking what the mechanism says about the spine.
• Letting serious bleeding, or a problem with the airway, breathing or circulation, go unfound or unmanaged.
• Spending time on the head-to-toe exam while a life threat waits.
• Staying on scene too long with a patient who needs a hospital now.
• Doing something to the patient that could harm them.
• Leaving the patient without a second look.

How to practice

• Drill the sequence until it is automatic, then practice it on patients with different injuries so it bends to the patient rather than the other way round.
• Say what you are doing as you do it. The evaluator credits what they see and hear, and on many sheets stating an action is not the same as doing it.
• Practice with a moulaged or briefed patient who has a hidden injury you only find by actually looking, especially on the back.
• Practice the early transport decision. Many candidates know the sequence and still spend too long on scene with a critical patient.
• Run multiple-patient drills now and then, because sizing up a scene with three patients is a different skill.
• Time yourself against the limit on the current official sheet.

When there is more than one patient, practice triage too

The short version

• Same backbone as the medical assessment, with mechanism, bleeding control and a head-to-toe exam carrying more weight.
• Scene size-up with mechanism, primary survey with hemorrhage control and an early transport decision, SAMPLE, DCAP-BTLS head to toe, vitals, interventions, reassessment.
• Manage life threats as you find them.
• Expose to assess, and do not forget the back.
• Learn the critical criteria from the current official sheet.
• Check nremt.org for the current exam format for your level.