Scene & Context
SCENE assessment before patient contact
SCENE
S
Safety — dynamic risk assessment, PPE
C
Cause / MOI — consistent with findings?
E
Environment — access/egress, weather, time of day
N
Number of patients
E
Extra resources — air support, senior clinical support, major trauma advisor
Pregnancy check: consider in all women of childbearing age (roughly 12–55) unless ruled out. If pregnancy or recent pregnancy cannot be excluded, do NOT use NEWS2 — refer to Prehospital Maternity Decision Tool.
Pregnancy possible
Excluded / N/A
<C> Catastrophic Haemorrhage
Assess BEFORE airway — life-threatening external bleeding
Arrest of external haemorrhage can be life-saving. Manage immediately if found — do not proceed to airway until controlled.
Life-threatening bleed PRESENT
None found
A — Airway
AT ALL TIMES consider C-spine and need to immobilise
Manual in-line cervical spine immobilisation should be commenced now if there is any possibility of spinal injury, and maintained throughout assessment.
Assess
Look — obvious obstruction (teeth/dentures, foreign body, vomit, blood, trauma, soot/burns/oedema)
Listen — noisy airflow (snoring, gurgling, none)
Feel — air movement
Patent / Clear
Compromised
Restraint / positional asphyxia: if patient is physically restrained (police, MHA), ensure method allows a patent airway and adequate respiratory volume at all times.
B — Breathing
Rate, depth, quality — grade 1–5
1
2
3
4
5
1 Not breathing · 2 Slow <12 · 3 Normal 12–20 · 4 Fast 20–30 · 5 Very fast >30
Feel / Look / Auscultate / Percuss
Feel for chest wall instability, depth and equality of movement
Look for chest injuries, wounds, bruising, flail segment
Auscultate air entry each side
Percuss — pitch of percussion note
TWELVE — Chest & Neck
T
Tracheal deviation
W
Wounds, bruising or swelling
E
Emphysema (surgical)
L
Laryngeal crepitus
V
Venous engorgement (JVD)
E
Excluding open/tension pneumothorax, flail segment, massive haemothorax
Open/Tension PTX
Flail Segment
Massive Haemothorax
Oxygen
100% O₂ in ALL critical trauma patients, target SpO₂ 94–98% — even with COPD risk factors.
Grade 1, 2 → BVM. Grade 5 → BVM if clinically appropriate. Grade 3, 4 → supplemental 100% O₂, monitor closely.
C — Circulation
Re-check external haemorrhage control first
Re-assess any catastrophic haemorrhage controlled at the start of assessment.
Assess
Radial & carotid pulses — rate, rhythm, volume
Central & peripheral capillary refill time
Skin colour, texture, temperature
5 Places to Check for Blood Loss
Blood on the floor — and four more:
1
External
2
Chest
3
Abdomen (palpate + observe bruising/marks)
4
Pelvis — do NOT manipulate; MOI may suggest fracture
5
Long bones — assess, don't be distracted by limb trauma
Blood loss of 1000–1500ml needed before classical shock signs appear. Signs appear later in pregnant women, patients on beta-blockers, and the physically fit. There may be little evidence of shock.
Fluid Therapy Target
Penetrating — Trunk
Penetrating — Limb
Blunt Trauma
Isolated Head Injury
Tranexamic Acid
If IV fluids required AND triggers local major trauma network criteria → TXA bolus.
TXA given — dose/time logged
Long Bone Splinting
Long bone fractures splinted en-route (if critical patient)
Pelvic Stabilisation
Apply a pelvic binder at the earliest practical opportunity when BOTH are true:
① MOI suggestive of pelvic ring fracture (high-energy transfer — RTC, pedestrian struck, fall from height, crush)
② Suspicion of active bleeding — tachycardia AND/OR hypotension AND/OR decreased level of consciousness
MOI Suggestive
MOI Not Suggestive
NEVER spring or distract the pelvis to test it — unreliable, may dislodge clots and worsen injury.
Technique: purpose-made binder preferred over improvised. Apply directly to skin if minimal handling allows. Circumferential pressure over greater trochanters, NOT iliac crests. Avoid over-reducing beyond normal anatomical position. Use scoop, not log roll — max 15° tilt.
Pelvic binder/splint applied — time noted
Oxygen — Major Pelvic Injury
High-flow O₂ at 15L/min regardless of initial SpO₂. Maintain until vital signs normalise (unlikely prehospital with unstable pelvis) — then titrate to 94–98%.
Movement minimisation: avoid log roll where possible. Lift with scoop stretcher. Stay on scoop once loaded. Longboard = extrication device only, never for transport.
Penetrating trauma with no neurology and no possible direct trauma to spinal column → do NOT immobilise.
D — Disability
Full GCS, pupils, blood glucose
GCS TOTAL—
Eyes Opening
Spontaneously4
To speech3
To pain2
None1
Verbal Response
Orientated5
Confused4
Inappropriate words3
Incomprehensible sounds2
No verbal response1
Motor Response
Obeys commands6
Localises pain5
Withdraws from pain4
Abnormal flexion3
Extensor response2
No response to pain1
Altered Mental Status
Check blood glucose to rule out hypo/hyperglycaemia.
E — Exposure & Environment
Prevent further harm from environment
Patient exposed adequately for assessment
Protected from cold/wet — foil blanket / heated environment
Frailty score considered (≥65, judgement-based, refer to CFS if applicable)
Trapped patient: consider mobilising senior clinical support early. Limit clinical care to necessary critical interventions to expedite safe extrication.
Time-Critical Decision
TIME-CRITICAL
NON-TIME-CRITICAL
Spinal Clearance
JRCALC G0590 — Figure 4.10 algorithm
Default: immobilise the whole spine until positively cleared. Immobilise the whole spine in ALL unconscious blunt trauma patients — presume SCI.
Step 1 — Mechanism Type
Blunt Trauma
Penetrating Trauma
Caution — special circumstances: restless/combative patients, raised ICP/head injury, older patients or known spinal deformity (e.g. severe kyphosis) may need a 'best possible' approach rather than rigid immobilisation. Soft collars do not limit movement and should not be used.
Secondary Survey
Head-to-toe — only if time permits / non-time-critical
Head
Airway re-assessed
Skin colour/temperature checked
Palpated for bruising/fractures
Pupil size/reactivity checked
Examined for CSF loss
Other signs of basal skull fracture assessed
Neck
Loosen collar (if applied) for proper examination
Re-assessed TWELVE (Tracheal deviation / Wounds / Emphysema / Laryngeal crepitus / Venous engorgement)
Assessed/palpated for spinal tenderness — bony tenderness specifically noted
Chest
Breathing re-graded 1–5
Felt for rib fractures, instability, surgical emphysema
Looked for contusions, seatbelt marks, flail segments
Auscultated — pneumothorax / tension PTX / haemothorax / tamponade
Assessed for pulmonary contusion
Examined front and as much of back as possible
Abdomen
Examined for open wounds, contusions, seatbelt marks
Palpated entire abdomen for tenderness/guarding
Examined front and as much of back as possible
Pelvis
Do not manipulate the pelvis.
Checked for blood at urethra / PV
Urge to urinate noted (if present)
Lower / Upper Limbs
Examine lower limbs then upper limbs. Check MSC in all four limbs.
Looked for wounds / evidence of fractures
MOTOR — movement tested, all 4 limbs
SENSATION — light touch tested, all 4 limbs
CIRCULATION — pulse + skin temp, all 4 limbs
Spinal Cord Injury Check (if immobilised / suspected)
Assess sensory/motor in MID-AXILLARY line, not mid-clavicular (T2–T4 supply nipple line). Use forehead as reference for normal sensation.
Diaphragmatic/abdominal breathing checked
Hypotension + bradycardia pattern checked (neurogenic shock)
Warm peripheries/vasodilatation with low BP checked
Flaccid muscles / absent reflexes checked
Priapism checked
Cauda Equina red flags: bladder/bowel dysfunction, saddle anaesthesia, new sexual dysfunction, bilateral leg neuro deficit/sciatica → surgical emergency, immediate conveyance.
Summary & PRF
Documentation Checklist
Vital signs + times documented
GCS components documented (not just total)
Spinal decision + rationale documented
Time-critical decision + time of decision documented
Pre-alert / ATMIST given
Drugs given — dose/route/time logged
Destination + rationale documented