Trauma Code – Physical Exam Cheat Sheet

Trauma Physical Exam Cheat Sheet

For this post, we're going to highlight a new download we just made!

So, when you walk into a trauma resuscitation, obviously you're thinking about your ABC's and the whole ATLS algorithm in general. But how does anyone else know that? By you verbalizing everything you find. It's actually a lot harder than it sounds, especially your first several (weeks) of codes. I mean, frankly, you go from being a med student who is told to stand in the corner to now (supposedly) running the show and controlling the room.

As with many things, our recommendation is to make it as automatic as possible. We rely a lot on the idea of generating scripts to help guide your work. So, what are things that you need to say?

First, you're going to check the airway so you need to describe the airway. Is it patent? Any secretions or anything you're worried about?

Breathing - do you have symmetric chest rise? Bilateral breath sounds? Is the trachea midline or deviated?

Cardiovascular - are the peripheral pulses intact? What does the heart sound like?

Seems like a lot of stuff already, but really you just knocked out the ABC's.

"Airway is patent. Symmetrical chest rise. Bilateral breath sounds. Trachea midline. Heart sounds are audible and not muffled. Peripheral pulses intact bilaterally."

Done. And guess what? There is a nurse in the corner who is ABSOLUTELY RELYING on you to say all these things and say them out loud. That nurse is marking everything down on a trauma code sheet that is going to become a part of the chart. I highly recommend that you become familiar with these so you can tailor your exam to hit everything needed.

That brings me to the new cheat sheet. It's a short, bulleted list style script. Each line is a physical exam finding that you need to call out. It also assumes that everything is normal, so of course, deviate when your exam deviates. This cheat sheet also follows the trauma code sheet in my shop. Grab one of yours because you may need to make some adjustments.

Last, after the code is done and things have settled down a bit, do two extra things. Review the trauma sheet with that nurse and ask if there is anything you forgot to verbalize. Ask them for their feedback on your performance. They are the people you're working with, so their perspective is tantamount to your improvement.