Download Trauma Forms

Place Patient Label Here
EMERGENCY DEPARTMENT
TRAUMA INITIAL ASSESSMENT
AND RESUSCITATION
Date and Time of Incident
Location of Incident
h Trauma Team Activation:
h Pre-Hospital
h In-Hospital
h Trauma Consult/Work-up
Date and Time of Assessment
h Scene Admit h Bedline h Yes h No
Emergency Physician: ______________________
Sending Facility ____________________________
Trauma Team Leader: ______________________
Sending Physician ___________________________
Family Physician ____________________________
Pediatric Trauma Score: ______ (see reverse side)
(Check μ boxes, comment where necessary)
MECHANISM OF INJURY
MOTOR VEHICLE
Number MV:
h Single
h Multiple
Patient:
Vehicle Type: ____________________
Speed: ________ km/hr
Other
Occupants
h
h
h
h
h
Driver
Impact:
Front Passenger
Rear Passenger
Pedestrian
Cyclist
h Unknown
h
h
h
h
None
Uninjured
Injured
Died
Extrication:
h Assault
Distance __________m
Weapon(s) ____________________
Onto ________
h Stab
h Firearm
Weapon ____________________________
Size/Calibre ________________
Site ________________________________
Restraints:
h Self
h EHS
h Fire service
Time:________min
h
h
h
h
h
None
2-point
3-point
Airbag
Helmet
h
h
h
h
Ejected _______m
Thrown _______m
LOC _________min
Amnesia
BLUNT INJURY
h Occupational
h Fall From: ______________________
PENETRATING INJURY
h Head-on
h Lateral
h Rear-end
h Rollover
h Other
h
h
h
h
h
Rear Facing
Front Facing
Infant
Child
Booster
h Sports/Recreation
Type ______________________
THERMAL INJURY
h Explosion h Electrical
h Burn
h Cold
(see adult or ped % calc sheet)
Carseat:
EXPOSURE
h Radiation
h Chemical
h Hot Gas
Type ________________________
OTHER MECHANISMS
Type: __________________________
______________________________
Comments:
Child / Elder Abuse h
Concerns:
Domestic violence h
Self-Harm? Yes h
No h
Unknown h
PRE-HOSPITAL OR REFERRING HOSPITAL MANAGEMENT
Airway
Breathing
Circulation
h Own
h Assisted:
Type: __________________________
h Spontaneous
h Assisted:
h Chest Tube(s):
Type: __________________________
h R Size: ________Size: ________
h L Size: ________Size: ________
Pulse: ____________
BP: ______________
IV:
Number: __________
Size: ______________
Adjuncts
Intravenous
h
h
h
h
h
h
h
h Crystalloid: Volume __________mL
Rigid Collar (C-Spine Prec.)
Aspen Collar (Semi Rigid)
Clamshell
Spine Board
Nasogastric Tube
Urinary Catheter
X-rays
h PRBCs:
________________units
h FFP:
________________units
h Other:
h Drugs:
________________units
____________________
h Tranexamic Acid given:____________
Comments:
MEDICAL HISTORY
Past Illnesses
Special Considerations
Medications
Special Considerations
h Nil of note
h Yes
List:
h
h
h
h
h
h
h
h
h
h None
h Yes
List: ________________________
h
h
h
h
h
h
h
h
NPO: ________________
Wt: __________________kg
Emerg #18, | MAY.2013
Hepatitis h B h C
HIV
Ischemic Heart Disease
COPD
Diabetes
Renal Failure
Malignancy
Pregnancy
Chronic Disorder(s)
____________________________
Allergies
h None
h Yes List:
Part 1 - White - Chart Part 2 - Canary - Consultant Copy Part 3 - Pink - Trauma Registry
Alcohol
Narcotics: Type ______________
Beta-blockers
Steroids
Warfarin
Smoker:
________ppd
Street Drugs: ______________
Last Tetanus: ________________
Page 1 of 4
Pediatric Trauma Score
Component
Score
+2
+1
-1
Weight
>20 kg ie: > 20kg
10-20 kg
<10 kg
Airway
Normal
Oral or nasal airway
Intubated or
trachestomy
Systolic BP
>90 mm Hg
Level of
Awake
Consciousness
50-90 mm Hg
<50 mm Hg
Obtunded or any Loss
Comotose
of consciousness
Open Wounds
None
Minor
Major or penetrating
Fracture
None
minor
Open or Multiple
Total Score
9-12
6-8
0-5
<0
Minor Trauma
Potentially life threatening
Life threatening
Usually fatal
PEDIATRIC GCS
Verbal
Eye Opening
4
3
2
1
spontaneous
to speech
to pain
no response
5
4
3
2
1
coos and babbles/oriented
irritable cry/confused
cries to pain/inappropriate words
nonspecific sounds/moans to pain
no response
Motor
6
5
4
3
2
1
spontaneous/obeys
withdraws to touch/localizes pain
withdraws to pain
flexion/decorticate
extension/decerebrate
no response
Place Patient Label Here
EMERGENCY DEPARTMENT
TRAUMA INITIAL ASSESSMENT & RESUSCITATION
PRIMARY SURVEY
Airway
Breathing
Assessment
h Own, Protected
h Pharyngeal:
h Oral
h Intubated by EHS
h Unprotected
h Obstructed
h Nasal
Inspection
h Spontaneous
h Bagged
h Ventilated
Rate: ________breaths/min
Percussion
h Normal
h Dull
Hyper-resonant
Circulation
Disability
hRh L
hRh L
h Oral h Nasal ETT Size: __________ Other: ______
Drugs: __________________________________________
__________________________________________
h Surgical: ________________________
Palpation
h Normal
h Flail
h Crepitus
h Subcut. air
h Open injury
Auscultation
h Normal
h Decreased
Action
h
h
h
h
Rh
Rh
Rh
Rh
L
L
L
L
h None
h O2 _________%
h Needle Thoracostomy:
Side:______________
h Chest Tube:
Size: ______________
h Right:
Drainage_______________mL
h Left:
hRh L
Size: ______________
Drainage_______________mL
Assessment
Pulse ______________beats/min
Blood Pressure______________mmHg
Capillary Refill:
h Normal h Abnormal
Neck Veins:
h Normal h Distended h Flat
Temperature __________°C Site: h Oral
h Rectal
h Other: __________
Action
IV Access
h Peripheral
Size:____________
Site:____________
h Intraosseus
Site:____________
h Central
Site:____________
Assessment
Pupils
Imaging
Reviewed images with:
GCS (/15): ______
R____ mm h Reactive
h C-spine
X-Ray
h Radiologically Normal to T1
h Clinically Normal
h Abnormal
Comment:
Lab Results
Hgb___________
Hct___________
Plt___________
WBC___________
Troponin___________
h Chest
X-Ray
h Normal
h Abnormal
Comment:
Na___________
K___________
Cl___________
Urea___________
Creatinine___________
Glucose___________
Lipase___________
h Pelvis
X-Ray
h Normal
h Abnormal
Comment:
h FAST
h Negative
h Positive
Comment:
h Other
Comment:
Eye Opening (/4):
________
Verbal Response (/5): ________
Motor Response (/6): ________
h Seizures:
Adjuncts
Action
h None
h Intubation:
Tubes
h Nasogastric
h Orogastric
h Foley Catheter
Urinalysis
Clear
Hematuria
Specimen sent
Pregnancy: h Negative
h Positive
Emerg #18, | MAY.2013
L____ mm h Reactive
h Non-reactive
h
h
h
h
PRBC: ______________ units
FFP: _________________ units
Other: ________________ units
Tranexamic Acid given:________
Symmetry of Movement: __________________
Bloodwork
h CBC, Lytes, Lipase
h Blood Gases
h Crossmatch
h Ethanol
h Toxicology
h Troponin
h Other: ________________
h
h
h
h
h Non-reactive
Fluids Administered in ED
h Crystalloid
Volume ________________mL
pH___________
pCO2___________
pO2___________
HCO3___________
BE___________
O2 sat___________
Ethanol Level___________
Other___________
___________
h Mediastinum width:__________cm
h Site ______________________________
Part 1 - White - Chart Part 2 - Canary - Consultant Copy Part 3 - Pink - Trauma Registry
Page 2 of 4
Place Patient Label Here
EMERGENCY DEPARTMENT
TRAUMA INITIAL ASSESSMENT & RESUSCITATION
SECONDARY SURVEY
Head/Neck
Chest
Abdomen
Pelvis
Back
(Log Roll)
Extremities
Assessment
h Normal
h Laceration
h Facial Injury
h Periorbital Hematoma
h Hemotympanum
h Tracheal Deviation
h C-Spine Tenderness
Comments
Assessment
h Normal
h Contusion
h Seat belt bruising
h Heart murmur
h Cardiac dysrhythmia
h Ribs /Flesh
h Hemo Pneumo thoro
Comments
Assessment
h Normal
h Distension
h Seat belt bruising
h Tenderness
h Peritonitis
h Open wound
Comments
Assessment
h Normal
h Unstable
h Blood at meatus
h Scrotal/Labial Hematoma
Comments
Assessment
h Normal
h Tenderness
h Step Deformity
h Hematoma
h Rectal Exam Completed
h Tone/Prostate/Blood: h Normal
h Abnormal
Comments
Assessment
Upper
h Normal
h Abnormal
Comments
Lower
Vascular
CNS
Action:
h ECG:
Comments
h Normal
h Abnormal
h CT Chest:
h Normal
h Abnormal
h Arch Angiography: h Normal
h Abnormal
Action:
h CT Abdomen:
Comments
h Normal
h Abnormal
h DPL: h Negative
h Positive
h Normal
h Abnormal
Comments
h Normal
h Abnormal
Assessment
h Normal
h Abnormal
h Tone/Power/Reflexes
h Co-ordination/Sensation
Emerg #18, | MAY.2013
Comments
h Normal
h Abnormal
h CT(A) Spine: h Normal
h Abnormal
h Angiogram: h Normal
h Abnormal
h Endoscopy: h Normal
h Abnormal
h Wound exploration
Assessment
Upper
h Normal
h Abnormal
Lower
Action:
h CT Head:
Action
h CT Pelvis: h Normal
h Abnormal
h Stabilization Method: ________________
h Urethrogram Result: ________________
h Cystogram
h Pelvic angiography Result: ____________
Action:
h Spine Imaging
h T-spine X-Ray h Normal
h Abnormal
h CT Scan T-spine h Normal
h Abnormal
h L-spine X-Ray h Normal
h Abnormal
h CT Scan L-spine h Normal
h Abnormal
Action:
X-rays:
Comments
Comments
Upper:
h Normal
h Abnormal
Lower:
h Normal
h Abnormal
Action:
h Ankle Brachial Index: R ______
L ______
Comments
h Angiography h Normal
h Abnormal
Comments
Action:
h Steroids
Comments
Dose:__________________
Commenced at__________ hours from injury
Part 1 - White - Chart Part 2 - Canary - Consultant Copy Part 3 - Pink - Trauma Registry
Page 3 of 4
Place Patient Label Here
EMERGENCY DEPARTMENT
TRAUMA INITIAL ASSESSMENT & RESUSCITATION
SUMMARY
OF INJURIES
SYSTEM
MANAGEMENT PLANS
CNS/HEAD:
CRANIOFACIAL:
SPINE:
CS
TS
LS
THORACIC:
A - Abrasion
V
B - Burn
V
© - Contusion
/ - Sutures
h - Amputation
V - Crush
V
# - Deformity
V - Swelling
# - Open Fracture
S - Splint
T - Traction
- Penetrating Wound
CARDIAC:
ABDOMINAL:
➝
PELVIS:
/ - Laceration
P - Pain
EXTREMITIES:
PATIENT DISPOSITION
h Admission h Direct to OR
h ICU
h High Acuity
h Ward (Service) h Trauma
h Spine
h CVT h Plastics
h Orthopedics h Vascular h Urology
h Gynecology h Obstetrics h Pediatrics
h General Surgery h Other: __________________
h Discharged h Transfer Out h Expired: Time: __________h
Follow-up with: ______________________________
Consultations
h General Surgery
Time Called:_________h
h ICU
Time Called:_________h
h Neurosurgery
Time Called:_________h
h Orthopaedics
Time Called:_________h
h Pediatrics
Time Called:_________h
h Plastics
Time Called:_________h
h Spine
Time Called:_________h
h Vascular
Time Called:_________h
h Other: ______________Time Called:_________h
Emerg #18, | MAY.2013
Time Seen:
Time Seen:
Time Seen:
Time Seen:
Time Seen:
Time Seen:
Time Seen:
Time Seen:
Time Seen:
h Admitting Notified (Bed Requested)
h Time:______h
h Admitting Physician: (MRD) ____________________________
h Transfer Out Time________h Reason: __________________
Receiving Facility: ________________________
Receiving Physician: ______________________
____________h
____________h
____________h
____________h
____________h
____________h
____________h
____________h
____________h
Names & Signatures
Trauma Team Leader Signature:____________________________
Trauma Surgeon Staff: __________________________________
(VGH Only)
Part 1 - White - Chart Part 2 - Canary - Consultant Copy Part 3 - Pink - Trauma Registry
Page 4 of 4