1. Initial Approach (Safety & Primary Survey)
- Scene safety: How did the injury occur? Any ongoing danger?
- Primary survey: Airway, Breathing, Circulation, Disability, Exposure (ABCDE)
- Mechanism of injury (MOI): Blunt vs penetrating? High vs low impact?
2. Presenting Complaint
- What is hurting the most right now?
- Location of injury or pain
- Was there immediate or delayed pain?
3. History of Present Injury
- Onset: When did the injury happen?
- Mechanism: Fall? MVC? Assault? Crush? Burn?
- Positioning: What position were they in when injured?
- Force dynamics: Speed? Height? Weight? Object used?
- Immediate symptoms: Loss of consciousness? Bleeding? Weakness?
- Progression: Improving or worsening?
4. Pain Assessment (SOCRATES)
- Site, Onset, Character, Radiation
- Associated symptoms
- Timing
- Exacerbating/relieving factors
- Severity
5. Associated Symptoms to Ask
- Bleeding / swelling / deformity
- Numbness or tingling
- Loss of movement or weakness
- Shortness of breath (chest trauma)
- Headache, vomiting, seizures (head trauma)
- Abdominal pain, distension (abdominal trauma)
6. Past Medical History
- Bleeding disorders
- Bone disease (osteoporosis)
- Previous fractures or injuries
- Chronic illnesses (e.g., diabetes, heart disease)
- Medication use (e.g., anticoagulants)
7. Social & Functional History
- Alcohol/drug use (risk for falls, complications)
- Baseline mobility level
- Occupation (relevant for work injuries)
8. Red Flags
- Severe uncontrolled bleeding
- Loss of consciousness
- Chest pain or difficulty breathing
- Paralysis or inability to move limbs
- Open fractures or major deformity
- Signs of shock (cold, clammy, weak pulse)
9. Important Triage Notes
- High-energy MOI → treat as high-risk even if stable
- Always immobilise spine if in doubt
- Address airway & bleeding before detailed history
- Check for hidden injuries (back, scalp, perineum)