Last Updated on August 19, 2026
History Taking
×History taking is part of the secondary survey. However, most of the time, we are doing work as a team. One of us will ask history from the paramedics / relatives
History taking is part of the secondary survey. However, most of the time, we are doing work as a team. One of us will ask history from the paramedics / relatives
Background
• Premorbid ADL status Especially in the case of upper limb injury May complicate resuscitation
•
Hand dominance
• Occupation
•
Comorbidities
• Staying with who?
• How patient came? Brought by ambulance? Came alone?
Trauma details
• Date & time of trauma Examples: Examples:
• Witness
• How trauma occurred?
•
Type of trauma
• MVA
• Fall
• Alleged cut by sharp object
• Burn
• Was patient under alcohol or illicit drug influence?
Motor-vehicle accident
• Type of vehicle
• Patient was the driver / passenger / rider / pillion rider ?
•
How it happened
• Avoiding a cat, subsequently motorbike skidded
• Speed
• Wearing helmet? Helmet intact?
• Did the vehicle hit anything e.g. divider?
Post-Trauma
• Pain at which site? Vomiting ≥2 episodes is a criterion for Head CT How to ask? Example: Amnesia before impact more than 30 mins is a criterion for Head CT
• Bleeding at which site?
• Abrasion wound at which site? Laceration wound at which site?
• Able to walk?
• Any headache? Any
vomiting
• Any loss of consciousness? How long it lasted?
• Any
retrograde amnesia
• What was the last thing he/she did before trauma?
Relevant History
• Co-morbidities e.g. DM, HTN,
Physical Examination
• Trauma survey – [open]
Criteria
(a) High Energy Impact
(i) Falls
• >6 meters (≈double-storey)
(ii) High-risk auto-crash
• Intrusion: >30 cm from occupant site or >46 cm from any site
• Ejection: partial / complete, from vehicle
• Death in the same passenger compartment
• Vehicle telemetry data consistent with high risk injury
(iii) Auto VS pedestrian / bicyclist
(iv) Thrown / run over, or with significant (>30 km/hr) impact
(v) Motorcycle crash >30 km/hr
(b) Canadian CT Head Rule
(c) Nexus criteria for cervical clearance
Investigations
Imaging
•
Chest X-rays
Common finding in the setting of trauma; Look for: To look for pelvic fracture, especially in high impact trauma Indication as per Canadian CT Head Rule for minor injury To look for e.g. if suspect cervical fracture when patient complained of neck pain / cervical tenderness during log roll examination
• Rib fracture
• Subcutaneous emphysema
• Pneumothorax
• Trachea deviation
• Consolidation (may indicate lung contusion, which may appear after few hours post trauma
• Pleural effusion (may indicate haemothorax, usually in the setting of rib fracture but appears late e.g. after day 1 post trauma when patient complains of SOB / desaturates
•
Pelvic X-rays
•
CT brain
• Intracranial bleed
• Fracture at e.g. skull, sinus wall fracture etc.
•
CT cervical
Related Posts
• Fall [open] Canadian CT Head Rule
•
Canadian CT Head
Open https://www.myhouseman.my/canadian-ct-head-rule/