Emergency Medicine — Trauma Evaluation Template

Trauma Activation

Date/Time: [Date] [Time]
Trauma level: Level I / Level II / Trauma consult / No activation
Trauma team leader: [Name]
Attending present: Yes / No — Time arrived: [Time]

Prehospital Information

EMS agency: [Name]
Prehospital providers: [Names/roles]
Scene information:

• Location: [Address/description]
• Time of injury: [Time]
• Extrication required: Yes / No — Duration: [Minutes]
• CPR at scene: Yes / No

Mechanism of injury: [Detailed description]

• MVC: Speed [X] mph, Restrained: Yes / No, Airbag deployed: Yes / No
• Position: Driver / Front passenger / Rear passenger
• Damage: Front / Side / Rear / Rollover
• Ejected: Yes / No
• Death at scene: Yes / No
• Motorcycle: Helmet: Yes / No, Speed: [X] mph
• Pedestrian/cyclist: Struck by [vehicle type], Speed: [X] mph
• Fall: Height: [X] feet, Surface: [Type]
• Assault: Weapon: [Type], Number of wounds: [X]
• GSW: Caliber: [If known], Number of wounds: [X]
• Stab: Weapon length: [X] inches, Number of wounds: [X]
• Other: [Description]

Prehospital vitals:

• BP: [X/X]
• HR: [X]
• RR: [X]
• GCS: [X] (E[X] V[X] M[X])
• SpO2: [X]%

Prehospital interventions:

• Airway: Maintained / BVM / Intubated / Cric
• IV access: [Sites, gauge]
• Fluids: [Volume, type]
• Medications: [Meds given]
• C-spine: Collar applied
• Splints: [Locations]
• Tourniquet: [If applicable]
• Blood products: [If applicable]

Primary Survey (ABCDE)

A - Airway (with C-spine protection)

C-spine immobilization: Collar in place / [Status]
Airway: Patent / Compromised

• Voice: Normal / Hoarse / Absent
• Stridor: None / Present
• Secretions/blood: None / Present
• Foreign body: None / Present

Intervention needed: None / Suction / OPA/NPA / Intubation / Surgical airway

B - Breathing

Respiratory rate: [X]
Effort: Normal / Labored / Agonal / Apneic
Breath sounds:

• Right: Clear / Diminished / Absent
• Left: Clear / Diminished / Absent

Chest wall:

• Symmetry: Symmetric / Asymmetric
• Crepitus: None / Present [Location]
• Instability: None / Flail segment [Location]
• Open wounds: None / [Location, size]

SpO2: [X]% on [RA / O2 at X L / Vent]
Interventions: None / O2 / BVM / Intubation / Chest tube [Side] / Needle decompression [Side]

C - Circulation

Pulse: Present / Absent

• Rate: [X]
• Quality: Strong / Weak / Thready
• Rhythm: Regular / Irregular

Blood pressure: [X/X]
Skin: Warm/dry / Cool/clammy / Mottled
Capillary refill: <2 sec / Delayed
External hemorrhage: None / Controlled / Active [Location]
Interventions: None / IV access / Fluid resuscitation / Blood products / Tourniquet / Direct pressure / REBOA
Fluid/blood administered:

• Crystalloid: [Volume]
• PRBC: [Units]
• FFP: [Units]
• Platelets: [Units]
• Whole blood: [Units]

MTP activated: Yes / No

D - Disability

GCS: [X] (E[X] V[X] M[X])

• Pre-intubation GCS: [X] (if intubated)

Pupils:

• Right: [Size] mm, Reactive / Fixed / Sluggish
• Left: [Size] mm, Reactive / Fixed / Sluggish

Motor response:

• Upper extremities: [Moves / Withdraws / Postures / None] — Symmetric: Yes / No
• Lower extremities: [Moves / Withdraws / Postures / None] — Symmetric: Yes / No

Gross neurological deficit: None / [Description]
Blood glucose: [X] mg/dL

E - Exposure/Environmental

Fully exposed: Yes / No
Temperature: [X]°F / [X]°C
Warm environment maintained: Yes / No
Obvious injuries noted: [List]

Secondary Survey

Head

Scalp: Intact / Laceration [Location, length] / Hematoma / Deformity
Skull: No deformity / [Deformity, depression]
Face:

• Midface stability: Stable / Unstable
• Orbital: [Findings]
• Nasal: [Findings]
• Mandible: Stable / Unstable / [Fracture]

Ears: No hemotympanum / Hemotympanum [Side] / CSF otorrhea / Battle's sign
Eyes:

• Vision: Intact / [Impaired]
• Pupils: PERRL / [Abnormality]
• Extraocular movements: Intact / [Deficit]
• Hyphema: None / Present [Side]

Nose: No rhinorrhea / CSF rhinorrhea / Epistaxis
Mouth: Dentition intact / [Missing teeth, loose teeth]

Neck

C-spine tenderness: None / [Level]
Trachea: Midline / Deviated [Direction]
JVD: None / Present
Carotid pulses: 2+ bilaterally / [Abnormality]
Subcutaneous emphysema: None / Present
Penetrating wounds: None / [Location]

Chest

Inspection:

• Contusions: None / [Location]
• Wounds: None / [Type, location]
• Deformity: None / [Description]

Palpation:

• Tenderness: None / [Location]
• Crepitus: None / [Location]
• Instability: None / Flail [Location]

Auscultation:

• Breath sounds: Equal bilateral / [Findings]
• Heart sounds: Normal / Muffled / [Findings]

Abdomen

Inspection: No distension / Distended / Wounds [Location]
Auscultation: BS present / Absent
Palpation:

• Tenderness: None / [Location, severity]
• Guarding: None / Voluntary / Involuntary
• Rigidity: None / Present
• Masses: None / [Description]

Pelvis: Stable / Unstable — Compress/distract: [Response]
Seatbelt sign: None / Present

Back (Log-roll)

Spine: No tenderness / Tenderness [Level(s)]

• Step-off: None / [Level]
• Deformity: None / [Description]

Flank: No ecchymosis / Ecchymosis [Side]
Wounds: None / [Location, type]
Rectal tone: Normal / Decreased / Absent
Gross blood: None / Present

Extremities

Right Upper:

• Inspection: Normal / [Deformity, wound, swelling]
• Tenderness: None / [Location]
• ROM: Full / Limited [Joint]
• Neurovascular: Intact / [Deficit]

Left Upper:

• Inspection: Normal / [Deformity, wound, swelling]
• Tenderness: None / [Location]
• ROM: Full / Limited [Joint]
• Neurovascular: Intact / [Deficit]

Right Lower:

• Inspection: Normal / [Deformity, wound, swelling]
• Tenderness: None / [Location]
• ROM: Full / Limited [Joint]
• Neurovascular: Intact / [Deficit]

Left Lower:

• Inspection: Normal / [Deformity, wound, swelling]
• Tenderness: None / [Location]
• ROM: Full / Limited [Joint]
• Neurovascular: Intact / [Deficit]

Skin

Lacerations: [Number, locations, lengths]
Abrasions: [Locations]
Contusions: [Locations]
Burns: [%TBSA, depth, location]
Penetrating wounds: [Number, locations]

Diagnostic Studies

Laboratory

• CBC: WBC [X], Hgb [X], Hct [X], Plt [X]
• BMP: [Values]
• Coags: PT [X], INR [X], PTT [X], Fibrinogen [X]
• Type and screen/crossmatch: [Status]
• Lactate: [X]
• ABG/VBG: pH [X], pCO2 [X], pO2 [X], HCO3 [X], BE [X]
• Ethanol: [X]
• Urine drug screen: [Results]
• UCG: Negative / Positive
• Troponin: [X]
• Lipase: [X]

Imaging

CXR: [Interpretation - PTX, HTX, widened mediastinum, rib fractures] Pelvis XR: [Interpretation - fractures, diastasis] FAST Exam:

• RUQ (Morison's pouch): Negative / Positive
• LUQ (Splenorenal): Negative / Positive
• Pelvis (Pouch of Douglas): Negative / Positive
• Pericardium: Negative / Positive
• Overall: Negative / Positive / Indeterminate

CT Head: [Interpretation - hemorrhage, fractures, herniation] CT C-spine: [Interpretation - fractures, ligamentous injury] CT Chest: [Interpretation - PTX, HTX, contusion, aortic injury, fractures] CT Abdomen/Pelvis: [Interpretation - solid organ injury, free fluid, fractures] Other imaging: [As applicable]

Injury Summary

1) [Injury] — [Severity/grade]
2) [Injury] — [Severity/grade]
3) [Injury] — [Severity/grade]
ISS (Injury Severity Score): [X]
RTS (Revised Trauma Score): [X]

Procedures Performed

[ ] Intubation — Time: [X], Method: [RSI, etc.], Grade: [X]
[ ] Central line — Site: [X], Time: [X]
[ ] Arterial line — Site: [X]
[ ] Chest tube — Side: [X], Output: [X] mL
[ ] FAST exam
[ ] Foley catheter — Output: [X] mL
[ ] NG/OG tube
[ ] Splinting — Location: [X]
[ ] Wound repair — Location: [X]
[ ] Other: [Procedure]

Consultations

[ ] Trauma surgery — Recommendations: [X]
[ ] Neurosurgery — Recommendations: [X]
[ ] Orthopedics — Recommendations: [X]
[ ] Other: [Service] — Recommendations: [X]

Disposition

Disposition: OR / ICU / Step-down / Floor / Transfer / Morgue

If to OR

Procedure: [Planned procedure]
Indication: [Indication]
Surgeon: [Name]
Time to OR: [Minutes from arrival]

If to ICU

Admitting service: Trauma / [Other]
Attending: [Name]
Key concerns:

• [Concern 1]
• [Concern 2]

If Transfer

Receiving facility: [Name]
Accepting physician: [Name]
Reason for transfer: [Higher level of care, specialty not available]
Mode: Ground / Air
EMTALA compliance: Transfer form completed

Trauma Team

Trauma attending: [Name]
Trauma resident/fellow: [Name]
Emergency physician: [Name]
Anesthesia: [Name]
Nursing: [Names]
Respiratory: [Name]
Other: [Names/roles]