ED Primary Survey

**Emergency Trauma Assessment** [Patient age] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Patient gender: M for male, F for female, or X for non-binary] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [BIBA if brought in by ambulance, or PW if presents via other means] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [One line summary of presentation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Pre-Arrival:** Pre arrival Notification: [Pre-hospital report including mechanism of injury, field vitals, and any pre-arrival interventions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Mechanism of Injury: [Mechanism of injury including blunt versus penetrating trauma, velocity of impact, vehicle damage, presence of blood at scene, or other fatalities] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Trauma call: [State yes if trauma call was activated and document the rationale] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Arrival:** Time of Patient Arrival: [Exact time of patient arrival] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Trauma Team Activation Time: [Exact time trauma activation was initiated] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Team Members Present: [List of all team members involved in initial trauma assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **EMS Hand-off:** Time of Handoff Completion: [Time handoff completed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Key Findings from EMS Report: [Summary of findings such as vital signs, pre-hospital interventions, mechanism of injury] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Paramedic Handover - Mechanism of Injury: [Mechanism of injury as handed over by paramedic team] (Only include if explicitly mentioned in transcript during paramedic handover, else omit section entirely.) **Immediate Life Threats Noted:** [Critical findings requiring immediate intervention] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Primary Survey (ABCDE Assessment):** **Vital Signs:** RR: [Respiratory rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.), SpO2: [Oxygen saturation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.), HR: [Heart rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.), BP: [Blood pressure] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) (MAP: [Mean arterial pressure] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)), T: [Temperature with C for Celsius or F for Fahrenheit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.), GCS: [Total GCS score] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) (E: [Eyes score 1-4] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.), V: [Voice score 1-5] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.), M: [Movement score 1-6] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)) Central Capillary Refill Time: [Capillary refill status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Airway & C-spine:** Patent: [Airway assessment for obstruction due to blood, vomit, or trauma] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Verbal Response: [Patient's ability to speak and any abnormal sounds] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Airway Interventions: [Airway management steps taken] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Cervical spine status including precautions and collar type] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Breathing:** Chest Wall Examination: [Findings from inspection and palpation of chest] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Trachea Position & JVD: [Tracheal deviation or jugular venous distension] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Breath Sounds: [Presence or absence of bilateral breath sounds] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Oxygenation/Ventilation: [Oxygen saturation, EtCO2 monitoring results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Circulation:** External Bleeding: [Major bleeding sites and control measures] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Internal Bleeding Suspicion: [E-FAST results if performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Blood Pressure & Pulses: [Blood pressure and comparison of radial and dorsalis pedis pulses bilaterally] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Pelvic Stability & Intervention: [Whether pelvic binder was placed and rationale] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Blood products transfused including units of red blood cells and fresh frozen plasma] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Details of vascular access established including arterial lines and intravenous cannulas with their locations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Disability (Neurologic Status & Cervical Spine Status):** Pupil Examination: [Pupil size and reactivity, PEARL bilat if pupils equal and reactive bilaterally] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Extremity Movement: [Findings on motor function] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Exposure:** Complete Undressing: [Confirmation that patient was fully exposed for assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Hypothermia Prevention: [Use of warm blankets, fluid warmers] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Log Roll for Back Assessment: [Findings from spinal and posterior assessment including saddle anaesthesia and major bruising] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Investigations: Blood results: [Laboratory values with specific parameters and results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Venous blood gas results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Chest X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Pelvic X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) CT Trauma: [CT trauma scan findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Out of binder pelvic X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Assessment & Plan:** Summary of Findings: [Key injuries, Glasgow Coma Scale, haemodynamic status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write initial summary on one line, then list all subsequent findings as bullet points.) Interventions Performed: [Airway management, chest tube placement, fluid resuscitation, blood products administered] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Pending Procedures & Investigations: [Procedures yet to be completed or investigations pending] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Disposition: [ICU admission, operating room, imaging, interventional radiology] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Consultations: [List of specialists consulted] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)