What are the key components of a thorough initial assessment for a patient involved in a Motor Vehicle Accident (MVA)?

History of Present Illness (HPI) Components for Motor Vehicle Accident

When evaluating a patient involved in a motor vehicle accident, obtain detailed information about the crash mechanism, patient physiology, anatomical injury patterns, and response to initial resuscitation to guide triage and management decisions. 1

Mechanism of Injury Details

Document specific crash characteristics as these directly predict injury severity and patterns:

• Direction of impact (frontal, side, rear, or rollover) - side-impact crashes produce higher injury severity and multiple injuries, while frontal impacts increase risk of severe traumatic brain injury 2, 1
• Vehicle intrusion or entrapment - intrusion >12 inches at occupant site or >18 inches at any site warrants trauma center evaluation; entrapment significantly increases injury severity and multiple injuries 1, 2
• Ejection from vehicle - associated with 27.4% risk of severe injury and warrants immediate trauma center transport regardless of initial appearance 1
• Rollover with roof intrusion - intrusion of 24 inches carries 19.3% risk of severe injury 1
• Estimated speed at impact - high-speed crashes in rural areas increase risk of severe blunt trauma 2
• Auto versus pedestrian/bicyclist - document if victim was thrown, run over, or struck with significant impact 1
• Fall height (if applicable) - critical falling height threshold is 6 meters (20 feet) for major injuries 3

Safety Device Usage

• Seatbelt use and position - frontal crashes with seatbelt use are associated with blunt aortic dissection; document presence of seatbelt sign on physical exam 2, 4
• Airbag deployment - note which airbags deployed (frontal, side, curtain) 5
• Head restraint position at time of impact 5
• Child safety seat use (if pediatric patient) and whether it remained properly secured 5

Patient Position and Awareness

• Seating position in vehicle (driver, front passenger, rear passenger) 5
• Awareness of impending crash - lack of awareness affects injury patterns 5
• Body position at impact (turned, leaning, braced) 5

Immediate Post-Crash Status

• Loss of consciousness - duration if present 1
• Altered mental status immediately after crash versus current presentation 1
• Ability to self-extricate versus requiring extrication 2
• Ambulation at scene - document if patient walked or was immobilized 1

Symptom Inventory

Systematically assess for symptoms suggesting specific injury patterns:

• Chest pain characteristics - nature, onset, location, radiation, severity, associated diaphoresis or dyspnea (evaluate for cardiac injury, aortic injury, or rib fractures) 4, 3
• Abdominal pain - location, severity, associated nausea/vomiting (evaluate for solid organ injury or hollow viscus perforation) 4
• Neck pain or stiffness - S-shaped cervical spine curvature occurs in rear, frontal, and side impacts 5
• Back pain - location and radiation 5
• Headache - onset, severity, associated symptoms 1
• Dyspnea or difficulty breathing 3
• Neurological symptoms - weakness, numbness, paresthesias 5

Physiologic Parameters at Scene

• Initial vital signs from EMS - heart rate, blood pressure, respiratory rate, oxygen saturation 1
• Shock Index (heart rate divided by systolic blood pressure) - useful for predicting hemorrhagic shock 3
• Response to initial fluid resuscitation - rapid responder, transient responder, or non-responder (latter two require immediate surgical bleeding control) 3
• GCS score at scene and any changes during transport 1

Pre-Existing Conditions

Document baseline health status as this affects injury risk and recovery:

• Age - elderly patients (≥75 years) have decreased physiologic reserve and may present with atypical symptoms 1, 4
• Anticoagulant or antiplatelet therapy - increases bleeding risk 3
• Previous axial pain (neck or back pain) - though self-reporting may be unreliable, particularly in patients pursuing compensation claims 6
• Bone mineral density concerns or osteoporosis 5
• Cardiovascular disease - pre-existing conditions affect cardiac injury interpretation 4
• Frailty status in elderly patients 1

Time-Sensitive Information

• Time elapsed since injury - minimize time to bleeding control 3
• Prehospital interventions performed - airway management, IV access, fluid administration, tourniquet or pelvic binder application 1
• Transport time and destination - whether transported directly to appropriate trauma center 3

Legal and Compensation Context

• Perceived fault of the accident - patients perceiving accident as another's fault may underreport previous pain or comorbidities 6
• Whether compensation claim has been filed - 80% of patients with attorneys had undisclosed previous axial pain or comorbidities in one study 6
• Police report availability for objective crash data 2

Common Pitfalls to Avoid

• Do not rely solely on absence of external trauma - significant internal injuries occur in low-speed collisions without external signs 4
• Do not dismiss complaints in elderly patients - they have higher mortality risk and may present atypically 1
• Do not assume vehicle intrusion alone predicts injury - entrapment is more predictive than intrusion measurements 7
• Do not accept self-reported previous pain history at face value when compensation claims are involved - chart audit shows 68% deny documented comorbidities 6
• Do not overlook rear-end collisions with trucks - those without rear protection have higher mortality rates 2