5.1 Physical Assessment in the Transport Environment
Key Takeaways
- XABCDE puts exsanguinating hemorrhage before airway; finish that primary survey before SAMPLE or OPQRST.
- Breath sounds are unreliable in a loud vibrating cabin—use SpO2, ETCO2, chest rise, and ultrasound if available.
- Serial neurologic checks and a pain/comfort exam belong in the transport assessment, including after every move and altitude change.
- Packaging hides injuries; do a hands-under-the-package exam before takeoff and again after landing.
- Trend numbers, not snapshots; Dalton's law means a falling SpO2 on climb may be lower inspired oxygen tension until you raise FiO2 or the cabin.
A flight assessment is not a hospital primary survey performed at 3,000 feet. Domain 1.E of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests physical assessment because noise, vibration, packaging, and Dalton's law degrade skills that work in a quiet intensive-care unit (ICU). Finish a flight-adapted primary survey before takeoff, then treat every move and every cabin-altitude change as a new exam.
XABCDE before SAMPLE
The primary survey
Exsanguinating hemorrhage, Airway, Breathing, Circulation, Disability, Exposure (XABCDE) is the order that fits a roadside scene and a hangar ramp. X comes first. A femoral or junctional bleed empties the tank while you open a mouth. On scene, tourniquet, pack, or bind the pelvis before a long airway debate. On an ICU-to-ICU hop, X still means lifting the sheet for a saturated dressing or a chest-tube chamber that just doubled.
Airway is patency plus security: confirm an endotracheal tube (ETT) with a continuous end-tidal carbon dioxide (ETCO2) waveform, not a single color-change disc. Breathing is chest rise, work of breathing, pulse oximetry (SpO2), ETCO2, and—if trained and equipped—point-of-care ultrasound (POCUS). Circulation is pulse quality, skin, obvious bleeding, and a blood-pressure trend, not one cuff number on a bouncing litter. Disability is a rapid Alert, Voice, Pain, Unresponsive (AVPU) screen, then a Glasgow Coma Scale (GCS) with pupils and laterality. Exposure is last: see the back, the perineum, and every puncture site, then cover and warm. Cabin air is cold.
History after X is controlled
Only after XABCDE is controlled do you take a Signs/symptoms, Allergies, Medications, Past history, Last oral intake, Events (SAMPLE) history and an Onset, Provocation/palliation, Quality, Radiation, Severity, Time (OPQRST) pain history. Those mnemonics do not outrank hemorrhage you have not found.
What you cannot auscultate
A working helicopter is commonly 90–110+ decibels. Breath sounds, bowel sounds, heart sounds, and subtle wheezes are unreliable. Do not write "clear bilaterally" after you heard the main rotor. Use tools that survive the cabin:
- Continuous SpO2 with a usable plethysmograph waveform
- Continuous ETCO2 with a square waveform you can trend
- Visible chest rise, symmetry, and work of breathing
- POCUS for pneumothorax, hemothorax, and cardiac activity if you are trained
- Serial inspection of the chest wall, neck veins, and trachea when lighting allows
| Finding you want | Why the cabin fails you | Transport surrogate |
|---|---|---|
| Breath sounds | Rotor noise and vibration drown the stethoscope | SpO2, ETCO2, chest rise, ultrasound |
| Soft Korotkoff sounds | Vibration scrambles noninvasive blood pressure (NIBP) | Arterial line, or repeated NIBP plus pulse quality |
| Subtle wheeze or crackle | Same noise floor | Peak airway pressure, ETCO2 shape, work of breathing |
Prefer an arterial line for shock or vasoactive drips. Treat one odd cuff reading as artifact until you feel a pulse. Heart tones and bowel sounds are equally useless; use pulse, ultrasound, gastric output, and girth.
Serial neuro, pain, and hidden injuries
Serial neurologic checks are not one GCS copied from the sending note. Recheck AVPU or GCS, pupils, motor laterality, and any external ventricular drain after packaging, loading, climb, and every stretcher-to-litter transfer. A "GCS 14" who will not open eyes after a roll has a new problem until you prove sedation, seizure, or hypoxia.
Pain and comfort sat under resuscitation on the 2021 outline. They still belong in the transport exam. Vibration, cold, and an expanding air-filled splint change pain; score it, treat it, and reassess after climb. Unexplained agitation may be hypoxia or a missed compartment.
Packaging hides injuries. A vacuum mattress, pelvic binder, burn sheet, or well-taped ETT can conceal a hematoma, a cold pulseless foot, a saturated groin pack, or a rising abdomen. Do a hands-under-the-package check before takeoff and again after landing.
Trends, Dalton, and when to look again
Numbers that move
Point-of-care (POC) glucose, hemoglobin, lactate, blood gas, and a sliding-lung ultrasound on the ramp beat a two-hour-old printout. One number is a snapshot. Trending is the skill: a mean arterial pressure of 68 mm Hg matters only if it stays 68 after loading and at 6,000 feet. A rising lactate, falling ETCO2, or drifting SpO2 on a steady fraction of inspired oxygen (FiO2) is the real assessment.
Dalton's law changes how you read SpO2. Oxygen stays about 21 percent of dry air, but the partial pressure of inspired oxygen (PIO2) falls as barometric pressure falls. An unpressurized climb from 800 to 7,000 feet can drop a nonrebreather saturation from 96 to near 90 percent without a new infiltrate. Raise FiO2 or request a lower cabin and recheck before blaming the oximeter or diagnosing pneumonia. Falling saturation plus rising work of breathing plus changing ETCO2 is a patient problem; a modest drop that corrects with extra oxygen is altitude physiology.
Reassess after every move and every altitude change. Loading, a door slide, climb, descent, and cabin-altitude step-downs all dislodge tubes and change gas volumes. That focused re-exam is the secondary survey in the air.
Scene versus ICU-to-ICU
A scene assessment starts with mechanism, hemorrhage, and a short primary survey you own. An ICU-to-ICU interfacility assessment starts with a chart and a nurse who already knows the patient—that is the trap. Confirm every line, drain, and setting yourself. Convert the hospital exam into a transport exam: what you can trend in noise, what expands under Boyle's law, and what you recheck after climb.
A flight nurse loads an intubated scene patient into a running helicopter. Rotor noise makes auscultation impossible. What is the most reliable immediate way to confirm the patient is being ventilated?
An unpressurized helicopter climbs through 7,000 feet mean sea level. SpO2 falls from 96 percent to 90 percent on the same oxygen device. Work of breathing and ETCO2 are unchanged. What is the best first interpretation?
Compared with a scene pickup, what is the most important assessment trap on an ICU-to-ICU interfacility flight?