Trauma Patient Assessment (xABCDE and Field Triage)

Use these objective thresholds to decide urgency and destination. Life threats come first: control bleeding, secure the airway, then survey.

Trauma assessment finds the life threats and treats them in a fixed order. Every other injury comes after. Start the survey over after every intervention, every move and every change in the patient.

How It Works

• Primary survey (xABCDE): x is exsanguinating hemorrhage. Next comes the airway, with cervical spine protection, then breathing, circulation, disability (Glasgow Coma Scale [GCS], pupils, glucose) and exposure. Treat each threat the moment you find it.
• Secondary survey: a head-to-toe exam with DCAP-BTLS. You do it once the primary survey is done and the patient can take a fuller exam.
• Reassessment: vitals, GCS and bleeding get checked again after every intervention, move and change.
• Scene size-up: scene safety, mechanism and energy, number of patients, and any need for extrication or more resources. Sort all of it out before you touch the patient.

Where It Fits

Field triage picks the destination. The 2021 National Guideline for the Field Triage of Injured Patients sorts findings into high-risk (red) and moderate-risk (yellow). Where does a red patient go? The highest-level trauma center available within the regional system. Yellow goes to a trauma center as available, and that center does not have to be the highest level. Patients who meet only EMS-judgment criteria go to a trauma center or a hospital that can evaluate them in a timely and thorough way. Patients in extremis may need the closest hospital first, to stabilize them.

Indications

• Any injured patient, including one who looks well after a high-energy mechanism
• Any red or yellow criterion in the field triage guideline (Overview)
• Altered mental status after a reported injury, or an injury of unknown mechanism

Absolute Contraindications

There is no absolute contraindication once the patient is injured. Never withhold the survey. Its order and depth change with the scene and the patient.

Relative Contraindications & Cautions

• Unsafe scene: stay out until traffic, fire, violence or hazardous materials are under control, per agency policy.
• Ongoing resuscitation: the survey runs alongside the intervention. Don't hold an intervention for a complete exam.
• Spinal precautions: apply per protocol. Never hold up airway or hemorrhage control to finish immobilizing.

Abort / Stop Criteria

• Scene still unsafe: stop entry, request resources and wait.
• In extremis (unstable airway or severe shock)? Stabilize the bleeding and the airway, then move. Finish the rest of the survey en route.

Team Roles During the Procedure

• Assessor: leads the xABCDE sequence and calls each finding aloud.
• Hemorrhage and airway: controls bleeding and manages the airway and spinal precautions.
• Monitor and recorder: applies monitors, records vital signs, GCS and times, and tracks interventions.
• Communicator: prepares the destination, the radio report and the handoff.

Equipment

• Pulse oximeter, capnography where available, and ECG monitor
• Automated blood pressure cuff in adult and pediatric sizes
• Glucometer and penlight
• Tourniquet, pressure dressings and wound packing
• Suction, oxygen and airway adjuncts
• Cervical collar or immobilization device per protocol
• Blankets and a warming barrier for the exposed patient

Sizing

Cuff size follows the limb. Adult or pediatric, checked against the manufacturer's sizing chart. Pediatric equipment sizes live on the equipment sizing page.

Patient Positioning & Preparation

Lay the patient supine. When you use spinal precautions, keep head and neck in line. The back exam needs a log roll. Uncover the chest, abdomen, pelvis and limbs. Protect privacy and warmth.

Phase 1: Prepare

1. Confirm scene safety: enter only when hazards are controlled, per agency policy.
2. Size up the scene: note mechanism and energy (speed, height, intrusion, ejection), number of patients, and any need for extrication or more resources.
3. Form a general impression: note level of consciousness, obvious bleeding and whether the patient is moving.

Phase 2: Perform (Primary Survey, xABCDE)

4. Control exsanguinating bleeding (x): apply a tourniquet or wound packing with continuous pressure to active bleeding. Reassess and record the time.

5. Assess the airway (A): open and clear it, protect the cervical spine per protocol, and treat an obstruction before going on.
6. Assess breathing (B): count the respiratory rate and effort, inspect and palpate the chest, listen to both sides, then apply oxygen and read the SpO₂. Treat what you find: decompress a suspected tension pneumothorax (absent breath sounds, deviated trachea, distended neck veins or hypotension) by needle or finger decompression per scope and protocol; cover an open chest wound with a vented or occlusive dressing; support ventilation for flail chest or respiratory distress per protocol.
7. Assess circulation (C): check pulse and blood pressure, skin color, temperature and capillary refill. Look for hidden bleeding in the chest, abdomen, pelvis and femurs. Treat what you find: apply a pelvic binder for a suspected unstable pelvic fracture; establish two large-bore IV or IO lines per protocol; start the blood-product or tranexamic acid pathway if your system carries one (CRASH-2 found TXA beneficial when given within 3 hours of injury). Permissive hypotension applies to hemorrhage without head injury and is avoided when TBI is present. See hemorrhage control.
8. Assess disability (D): score the GCS (eye, verbal and motor), check the pupils and check blood glucose.
9. Expose and protect (E): undress the patient fully, look for hidden injury, and prevent hypothermia.

Phase 3: Confirm & Secure (Secondary Survey and Triage)

10. Examine head to toe: check each region with DCAP-BTLS (deformities, contusions, abrasions, punctures or penetrations, burns, tenderness, lacerations, swelling). Examine both sides and log roll for the back.
11. Repeat the vital signs: repeat blood pressure, pulse, respiratory rate, SpO₂, GCS and pupils. Compare with the first set; a worsening trend matters more than a single value.
12. Apply the triage criteria: match the findings to the red and yellow criteria in Overview. Red criteria go to the highest-level trauma center available; yellow criteria go to a trauma center as available (need not be the highest level).
13. Reassess after any change: repeat the primary survey after any move, change or intervention, and confirm hemorrhage control and airway status.
14. Hand off: give a structured report with mechanism, injuries, interventions and response (see Post-Procedure Care & Transport).

Primary Confirmation

Your primary confirmation is a second set of vitals and GCS, read against the survey. Hold it next to the first set. A rising heart rate while systolic BP drops, a GCS that is sliding or an SpO₂ that is sliding all mean one thing: worse. That holds even when one value still sits in range.

Secondary Confirmation

• No active bleeding through the dressing or tourniquet, with tourniquet time recorded
• Airway open, with clear or equal breath sounds and no obstruction
• Waveform EtCO₂ present when the airway is advanced and ventilated
• Pupils and GCS unchanged or improving; motor GCS 6 (obeys commands)

Ongoing Monitoring

• Vital signs, GCS and pupils: after each intervention, each move and any change; the interval follows local protocol.
• SpO₂ and capnography: continuously when available.
• Bleeding and dressings: at every reassessment and before transport.
• Temperature: check it and keep the patient warm.

Pediatrics

• Hypotension is late: kids compensate with tachycardia and vasoconstriction. Watch perfusion, capillary refill and mental status first. The Pediatric Assessment Triangle gives that look a structure.
• Age-based systolic threshold: in a child aged 0–9 y, systolic BP below 70 mm Hg + (2 × age in years) is high-risk. At 10 y the adult 90 mm Hg threshold takes over. The age-based ranges sit on the pediatric vital signs page.
• Low-level falls: a child 5 y and younger who falls low with significant head impact is an EMS judgment criterion.
• Restraint: an unrestrained child 0–9 y, or one in an unsecured seat, is a moderate-risk mechanism.
• Destination: a child who meets red criteria goes preferentially to a pediatric-capable trauma center. Local system resources set the age that defines a child.
• Equipment: cuffs and other gear are sized to the child. See the equipment sizing page.

Older Adults

• Systolic BP below 110 mm Hg at 65 y or older is high-risk. It may already mean shock.
• A low-level fall with significant head impact in an adult 65 y or older is an EMS judgment criterion. Ground-level falls can still cause severe injury.
• Anticoagulants, antiplatelets included, are an EMS judgment criterion at every age. Weigh them against the mechanism and any head injury.

Pregnancy

• Pregnancy over 20 weeks is a moderate-risk criterion. EMS judgment decides it.
• The guideline favors trauma centers that have obstetric capability. Follow your local obstetric trauma protocol.

Head Injury

• Avoid hypoxia and hypotension: each one makes the secondary brain injury worse. Keep SpO₂ at or above 90% and treat hypotension early, per protocol.
• Ventilation: no routine hyperventilation. Ventilate to the protocol target EtCO₂. Go lower only for signs of herniation: unequal or dilated pupils, posturing or a falling GCS.
• Triage is not a head-injury target: SBP below 90 mm Hg, or the age-based thresholds, is a transport trigger. Protocol sets the head-injury blood pressure goals.
• Move early: a falling GCS, a new pupil change or posturing means transport now. Don't finish the survey on scene first.

Score each component, then record the total (3–15) along with its parts. For example, E3 V4 M6 = 13. If the patient is intubated, record V as T. Teasdale and Jennett described the scale in 1974. The head-injury points above follow the 2023 prehospital TBI guideline. Numeric blood pressure and EtCO₂ targets are left to local protocol.

Spinal and Burn Injury

• New motor or sensory loss with suspected spinal injury is a high-risk pattern.
• Selective spinal motion restriction: the 2018 joint position statement from NAEMSP, ACS-COT and ACEP favors limiting motion based on clinical findings. It moves away from routine long-board and collar use. The long board is for extrication or movement when other means can't be used, per protocol. Never hold up airway or hemorrhage control to finish it.
• Burns with trauma: a trauma center with burn care is preferred. If there isn't one, a trauma center takes precedence over a burn center.

Immediate Aftercare

Pick the position, then check what rides on it. Two things have to survive every position and every turn: the airway and your hemorrhage control. Turns are log rolls under spinal precautions, per protocol. Blankets on. Patient warm.

Ongoing Maintenance

• Recheck vital signs, GCS and pupils after every move. The interval follows local protocol.
• Look at tourniquets and dressings for bleeding. Record the tourniquet time.
• Keep SpO₂ and capnography on when available.

Transport Considerations

• Destination: red goes to the highest-level trauma center available within the regional system. Yellow goes to a trauma center as available, and it need not be the highest level. In extremis, the closest hospital may come first.
• Pediatric red patients: a child who is red goes preferentially to a pediatric-capable trauma center.
• Medical control: for a moderate-risk judgment call, the guideline says call online medical control.
• Noise and motion: a moving vehicle drowns out the pulse and breath sounds. Trust the monitor, and waveform capnography once the airway is advanced.
• Reassessment: repeat the full set after every move and on any change.

Handoff & Documentation

Pearls

• Bleeding first: in xABCDE, x comes before A.
• Mechanism raises the index: ejection, a death in the same compartment, or a fall over 10 ft is moderate-risk, even with normal vitals.
• Trend, do not snapshot: Watch the line, not the dot. A falling GCS, rising heart rate or falling systolic BP across repeated sets matters more than any single value.
• Heart rate above systolic BP: the guideline uses this as a field stand-in for a shock index above 1.0, in adults and older adults.
• Look under the clothes: log roll to see the back, then check the pelvis, thighs and axillae.

Common Pitfalls

• Stopping at the first abnormal finding: finish the primary survey, then move on to the secondary.
• Trusting one normal set of vital signs: one normal set means little until you repeat it after each intervention and move.
• Calling a minor-looking scene stable: looks can fool you. Apply the mechanism criteria.
• Delaying bleeding control for spinal precautions: the bleeding gets controlled first. Immobilize per protocol after that.
• Assuming intoxication for altered mental status: check glucose, oxygenation and the head before anything else.