How should I take a history of a road‑traffic accident (RTA) patient?

How to Take a History of a Road Traffic Accident (RTA) Patient

When evaluating an RTA patient, immediately establish the time of symptom onset and mechanism of injury, then systematically assess for life-threatening injuries, neurological deficits, and associated trauma patterns while obtaining collateral information from witnesses or EMS personnel.

Critical Initial Information

Time-Sensitive Elements

The single most important piece of information is when the patient was last known to be at baseline or symptom-free 1, 2. For unconscious patients or those unable to provide history, this is defined as when they were last awake and functioning normally. Use creative questioning to establish time anchors:

• Check cellular phone timestamps for calls made before/after the accident
• Ask about specific activities (eating, bathroom use, driving to work)
• Obtain information from witnesses, bystanders, or EMS personnel 1, 2

Mechanism of Injury Details

Document specific crash characteristics that predict injury severity 3:

• Vehicle intrusion: Any intrusion >12 inches or roof intrusion >24 inches (associated with 19.3% risk of severe injury)
• Ejection status: Partial or complete ejection from vehicle (complete ejection carries 27.4% risk of severe injury)
• Death of another occupant in the same vehicle
• Vehicle telemetry data if available (Delta V, direction of impact, seat belt use)
• Pedestrian or motorcyclist struck by vehicle
• Falls from significant height

Structured History Components

Circumstances of the Accident

• Patient's position in vehicle (driver, front passenger, rear seat)
• Restraint use: Seat belt, airbag deployment
• Speed at time of impact
• Direction of impact (frontal, lateral, rear-end, rollover)
• Loss of consciousness at scene or during transport
• Extrication time if prolonged 4

Symptom Assessment

Document the onset and progression of symptoms from time of accident:

• Immediate pain or dysfunction versus delayed onset
• Any period of confusion, disorientation, or altered mental state 5
• Loss of memory for events before (retrograde amnesia) or after (anterograde amnesia) the accident
• Any transient symptoms that resolved 1, 2

Neurological Red Flags

Specifically ask about 1, 2:

• Focal neurological deficits: Weakness, numbness, vision changes
• Cranial nerve symptoms: Facial numbness (V2 injury in midface trauma), olfactory changes, diplopia
• Spinal symptoms: Neck or back pain, radicular symptoms, bowel/bladder dysfunction
• Cognitive changes: Confusion, difficulty concentrating, memory problems

Essential Medical History

Pre-Existing Conditions

Critical caveat: Self-reported history after trauma is often inaccurate, with approximately 50% of patients under-reporting pre-existing axial pain and 75% under-reporting comorbidities 6. When possible, obtain collateral history or access prior medical records.

Document 7:

• Cardiovascular disease: Prior MI, arrhythmias, heart failure, hypertension
• Cerebrovascular disease: Prior stroke, TIA, carotid disease
• Coagulopathy or bleeding disorders
• Diabetes mellitus and glycemic control
• Anticoagulant or antiplatelet use (critical for bleeding risk assessment) 2
• Substance use: Alcohol, illicit drugs, tobacco 7
• Psychiatric history: Depression, anxiety, prior psychological trauma

Medications

Obtain a complete medication list, prioritizing 2:

• Anticoagulants (warfarin, DOACs, heparin)
• Antiplatelet agents (aspirin, clopidogrel)
• Antihypertensives
• Diabetes medications
• Bring medication containers if available

Physical Examination Priorities

Vital Signs and Initial Assessment

• Blood pressure (including orthostatic if stable)
• Heart rate and rhythm
• Oxygen saturation
• Temperature
• Glasgow Coma Scale score 5

Trauma-Specific Examination

Head and neck 2, 8:

• Signs of head trauma (contusions, lacerations, Battle sign, raccoon eyes)
• Palpate for step-offs or crepitus in facial bones
• Assess for CSF rhinorrhea or otorrhea
• Cervical spine tenderness or deformity

Neurological examination 1, 2:

• Use standardized assessment (NIH Stroke Scale for suspected stroke, Glasgow Coma Scale for altered mental status)
• Document focal deficits systematically
• Assess cranial nerves, motor strength, sensation, reflexes, coordination

Chest and abdomen 4:

• Auscultate for cardiac murmurs, arrhythmias, decreased breath sounds
• Palpate for tenderness, rigidity, or distension
• Look for seat belt sign (abdominal wall bruising predicting intra-abdominal injury)

Extremities and spine:

• Palpate entire spine for tenderness
• Assess for deformities, open fractures, neurovascular compromise
• Document any skin findings (abrasions, contusions, lacerations)

Collateral Information Sources

Always attempt to obtain information from 1, 2:

• EMS personnel: Pre-hospital vital signs, scene findings, extrication details, initial GCS
• Witnesses: Mechanism details, patient behavior immediately after accident
• Family members: Baseline function, pre-existing conditions, medications
• Bring witnesses/family to ED when possible or obtain contact information

Common Pitfalls to Avoid

1. Accepting "unknown" time of onset without creative questioning for time anchors 1
2. Relying solely on patient self-report for pre-existing conditions, especially when litigation is possible 6
3. Missing concomitant injuries: 7-11% of maxillofacial trauma patients have cervical spine injuries 8; maintain high suspicion for multi-system trauma
4. Overlooking substance use: Directly ask about alcohol/drug use before and after accident 7
5. Failing to document restraint use and airbag deployment (critical for injury pattern prediction)
6. Not obtaining blood glucose in altered patients (hypoglycemia mimics neurological injury) 2

Documentation Essentials

Record in structured format:

• Time: Last known normal, accident time, symptom onset time
• Mechanism: Specific crash details with injury predictors
• Symptoms: Onset, progression, current status
• Examination: Systematic findings with standardized scales
• Collateral sources: Who provided information and their relationship to patient

This systematic approach ensures capture of time-sensitive information for treatment decisions while identifying injury patterns requiring immediate intervention.