Head-to-Toe Trauma Examination Documentation
Document Glasgow Coma Scale (specifically the motor component), pupillary size and reactivity, vital signs (maintaining systolic BP >110 mmHg), and systematically assess for life-threatening injuries following the ABCDE approach with specific attention to bleeding sources, neurological deficits, and injury patterns. 1
Primary Survey Components
Airway and Cervical Spine
- Airway patency and control status (intubation if GCS ≤8)
- Cervical spine immobilization status
- End-tidal CO2 monitoring if intubated 1
Breathing
- Oxygen saturation (maintain >90%; hypoxemia significantly worsens outcomes) 1
- Respiratory rate and pattern
- Chest wall integrity and breath sounds bilaterally
- Evidence of pneumothorax or hemothorax
Circulation
- Systolic blood pressure (maintain >110 mmHg in adults with head injury; even single episodes <90 mmHg worsen mortality) 1
- Heart rate
- Visible blood loss (on clothing, floor, drains) 2
- Skin color, capillary refill, peripheral pulses 2
- Signs of internal hemorrhage
Disability/Neurological Assessment
- Glasgow Coma Scale with all three components (Eye-Verbal-Motor), though the motor response is most critical in sedated/intubated patients 1
- Pupillary size and reactivity bilaterally 1
- Focal neurological deficits
- Limb movement and sensation
Critical pitfall: In moderate TBI (GCS 9-13), repeat neurological examination every 30-60 minutes initially, as these patients have significant risk of secondary deterioration. Any decrease of ≥2 points in GCS warrants immediate CT imaging 1.
Exposure and Environmental Control
- Temperature (active warming required to prevent hypothermia-induced coagulopathy) 2
- Complete body exposure to identify all injuries
Head-to-Toe Systematic Examination
Head and Face
- Scalp lacerations, hematomas, depressions
- Facial fractures (LeFort II/III patterns are risk factors for vascular injury) 1
- Basilar skull fracture signs: Battle's sign, raccoon eyes, hemotympanum, CSF rhinorrhea/otorrhea 1
- Facial sensation testing (cranial nerve assessment) 3
Eyes (if orbital trauma suspected)
- Vision testing and pupillary examination
- Intraocular pressure measurement
- Extraocular movements (versions, ductions)
- Signs of globe injury or enophthalmos 3
- Oculocardiac reflex signs: bradycardia, heart block with nausea/vomiting suggesting muscle entrapment requiring urgent intervention 3
Neck
- Soft tissue injuries (risk factor for vascular dissection) 1
- Tracheal position
- Jugular venous distention
- Horner syndrome (ptosis, miosis, anhidrosis—indicates carotid dissection) 1
Chest
- Rib fractures, flail segments
- Subcutaneous emphysema
- Cardiac sounds and rhythm
Abdomen
- FAST examination findings (free fluid in Morrison's pouch, splenorenal recess, pelvis, pericardium) 4
- Abdominal distention, tenderness, rigidity
- Patterns suggesting internal bleeding 2
Pelvis
- Pelvic stability
- Perineal/urethral bleeding
Extremities
- Obvious deformities, open fractures
- Neurovascular status of all limbs
- Compartment syndrome signs
Back (log-roll with spine precautions)
- Spinal tenderness or step-offs
- Posterior wounds or bleeding
Risk Stratification for Vascular Injury
Document presence of these high-risk features requiring CT angiography 1:
- Cervical spine fracture
- Focal neurological deficit unexplained by brain imaging
- Horner syndrome
- LeFort II/III facial fractures
- Basilar skull fractures
- Neck soft tissue injuries
Serial Reassessment
Document timing and frequency of repeat examinations. Any deterioration (decreased GCS ≥2 points, new focal deficits, hemodynamic instability) requires immediate re-imaging and intervention 1.
Mechanism and Context
- Detailed mechanism of injury (fall height, vehicle speed, penetrating vs. blunt)
- Time of injury
- Prehospital interventions and response
- Witness accounts if available
Common pitfall: Falls in elderly patients (especially women >57 years) are frequently misidentified during external examination and require heightened suspicion for head trauma 5. Document injury consistency with stated mechanism—inconsistencies may indicate non-accidental trauma 6.