Before We Start
Why trauma assessment needs a systematic framework
When a trauma patient arrives — a car accident victim, a fall from height, a gunshot wound — there are potentially dozens of injuries all competing for your attention at once. The natural human instinct is to focus on the most obvious injury. This is exactly the wrong approach.
The most dramatic-looking injury is not always the most life-threatening one. A patient with a compound fracture and a visible broken bone may be distracting you from a tension pneumothorax that will kill them in minutes.
ABCDEFGHI forces you to assess in the correct priority order — starting with what will kill the patient fastest and working systematically from there. It's used in emergency departments, trauma bays, and wherever rapid patient assessment is required.
💡 The Memory Trick
It's just the alphabet — A through I. Nine steps, in alphabetical order. If you know the alphabet, you know the framework. The challenge is knowing what each letter stands for and what you're actually assessing at each step.
The Nine Steps
ABCDEFGHI — every step explained
A — Airway
Is the airway open and patent?
The airway is always first. A patient with no airway is dead within minutes — nothing else matters if they can't breathe.
Assess: Is the patient talking? (Speaking = airway is open.) Is there stridor (high-pitched breathing sound)? Gurgling? Snoring? Any visible obstruction?
Intervene if needed: Jaw thrust or chin lift, suction, positioning, oral/nasal airway, or prepare for intubation. In trauma — always use jaw thrust (not chin lift) to protect the cervical spine until injury is ruled out.
💊 If the patient can speak in full sentences — their airway is open. Move to B.
B — Breathing
Are they breathing adequately?
An open airway doesn't guarantee adequate breathing. Assess the quality and effectiveness of breathing.
Assess: Rate (normal 12–20), depth, effort (accessory muscle use, nasal flaring), equality of chest rise, breath sounds bilaterally, SpO2.
Watch for: Tension pneumothorax (absent breath sounds on one side, tracheal deviation, hypotension), flail chest (paradoxical chest movement), open chest wounds.
💊 Apply supplemental oxygen to all trauma patients immediately — don't wait for SpO2 to drop.
C — Circulation
Is blood circulating effectively? Is there hemorrhage?
Circulation means both pumping (heart) and plumbing (vessels). Uncontrolled hemorrhage is the leading cause of preventable death in trauma.
Assess: Pulse (rate, rhythm, strength), blood pressure, skin color/temperature/moisture, capillary refill, visible bleeding.
Intervene: Direct pressure on bleeding wounds, IV access (two large-bore IVs), fluid resuscitation per order. Major hemorrhage → pressure + tourniquet if extremity.
💊 Control visible bleeding WHILE assessing — direct pressure doesn't require a physician order.
D — Disability
What is the neurological status?
Disability = neurological assessment. A quick, standardized neuro check that can be done in under a minute.
AVPU: Alert (awake and oriented), Voice (responds to verbal stimulus), Pain (responds to pain only), Unresponsive.
GCS: Glasgow Coma Scale — Eyes (1–4) + Verbal (1–5) + Motor (1–6) = total score out of 15. Score ≤8 = severe brain injury, consider intubation.
Pupils: PERRLA — Pupils Equal, Round, Reactive to Light, Accommodating. Unequal pupils may indicate brain herniation.
💊 A GCS of 15 is normal. A GCS of 8 or less = "intubate" — that's the NCLEX threshold to memorize.
E — Expose/Examine
Remove clothing and look for hidden injuries
You cannot assess what you cannot see. Cut off clothing if necessary — trauma shears are standard in emergency settings.
Look for: Entrance and exit wounds, bruising, swelling, deformity, lacerations, burns, tire marks (from being run over), seatbelt signs.
Important: Prevent hypothermia — expose only what you need to assess, then cover immediately. Trauma patients lose heat rapidly, and hypothermia worsens coagulopathy and outcomes.
💊 Cover the patient as soon as you've assessed each area — trauma patients are at high risk for hypothermia.
F — Full Set of Vitals
Get complete baseline vital signs
By now you've been doing spot checks — now get a complete, documented set of baseline vitals.
Includes: BP (both arms if aortic injury suspected — a difference of >20 mmHg is significant), HR, RR, Temperature, SpO2, pain score, weight (for medication dosing).
Also obtain: 12-lead ECG, urine output (Foley catheter if not contraindicated), lab draws (type and screen, CBC, BMP, coagulation studies, blood alcohol level).
💊 Blood pressure difference between arms >20 mmHg = possible aortic dissection. Report immediately.
G — Give Comfort
Manage pain and provide emotional support
Trauma is terrifying. The patient may be scared, confused, or in severe pain. Comfort is not a luxury — it's part of the assessment and affects outcomes.
Pain management: Administer ordered analgesics. Uncontrolled pain raises heart rate, blood pressure, and oxygen demand — worsening the physiological state.
Emotional support: Introduce yourself, explain what's happening, reassure the patient. If the patient is conscious, they're watching everything. Calm, competent behavior from the nurse reduces the patient's anxiety.
💊 "My name is ___. You're safe. We're taking care of you." — Three sentences that reduce patient anxiety and build trust.
H — Head-to-Toe Assessment
Systematic physical exam from head to feet
Now do a complete systematic physical examination. You've addressed the life threats — now find everything else.
Order: Head → Face → Neck → Chest → Abdomen → Pelvis → Extremities → Neurological recap
Look and feel for: Tenderness, swelling, deformity, crepitus (bone grinding), wounds, hematomas. Assess each region completely before moving to the next.
💊 Pelvis: do NOT rock the pelvis repeatedly to check for fracture — one gentle check only. Rocking a fractured pelvis causes massive internal hemorrhage.
I — Inspect Posterior
Log roll the patient and examine the back
The back is where injuries hide. Posterior injuries from high-speed trauma — spinal fractures, posterior rib fractures, kidney injuries, exit wounds — are missed if you don't look.
Log roll: Requires 3–4 people minimum. One person maintains cervical spine alignment throughout. Roll as a unit — spine straight. Examine the entire posterior surface quickly, then roll back.
Look for: Step-offs in the spine (vertebral fractures), midline tenderness, wounds, bruising over flanks (Grey Turner's sign = retroperitoneal hemorrhage).
💊 Log roll = 3–4 people minimum. One always controls the head and neck. Never compromise cervical spine alignment.
🏥 Clinical Scenario — MVC Patient
A 28-year-old male is brought in by EMS after a high-speed motor vehicle collision. He was the unrestrained driver. He is conscious but confused. You are the receiving nurse.
A
Airway: Patient is speaking — "What happened?" Airway is open. Apply cervical collar (C-spine precautions for all unrestrained MVCs).
B
Breathing: RR 24, labored. Breath sounds diminished on left. SpO2 91%. Apply 100% O2 via non-rebreather mask immediately. Notify physician — possible pneumothorax.
C
Circulation: HR 128, BP 88/60. Skin pale, diaphoretic. Capillary refill 4 seconds. Large laceration on left thigh — actively bleeding. Apply direct pressure. Start two large-bore IVs. Draw labs.
D
Disability: AVPU = Voice (responds to his name). GCS = 13. Pupils 3mm equal and reactive. No focal deficits noted.
E–I
E: Cut clothing off — large abrasion across abdomen (seatbelt sign). Cover immediately.
F: Full vitals documented. 12-lead ECG. Foley placed — output 15mL first hour (normal >30mL/hr — renal perfusion concern).
G: Morphine 2mg IV per order. Reassured patient calmly.
H: Head-to-toe reveals left rib tenderness (3–5), abdominal guarding, left thigh deformity.
I: Log rolled with 4-person team — midline lumbar tenderness noted. Physician notified.