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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