Emergency Trauma Assessment
34 M BIBA Fall from height onto concrete.
**Pre-Arrival:**
Pre arrival Notification:
Pre-hospital report indicates a 34-year-old male found at the base of a 3-storey building. GCS 10 (E3V3M4) en route. BP 90/60, HR 120, RR 24. Spinal immobilisation and two large bore IVs initiated with 1L normal saline infused.
Mechanism of Injury:
Blunt trauma. Patient fell approximately 9 meters onto concrete. No vehicle involvement. Minimal blood at scene reported by EMS. No other fatalities.
Trauma call:
Yes, activated due to significant mechanism of injury and altered mental status.
**Arrival:**
Time of Patient Arrival:
1 November 2024, 09:30
Trauma Team Activation Time:
1 November 2024, 09:25
Team Members Present:
Dr. Eleanor Vance (EM Registrar), Dr. Thomas Kelly (Consultant EM), Nurse Sarah Jenkins (Trauma Coordinator), Paramedic John Smith, Respiratory Therapist Mark Lee.
**EMS Hand-off:**
Time of Handoff Completion:
1 November 2024, 09:38
Key Findings from EMS Report:
Initial vital signs: BP 90/60, HR 120, RR 24, SpO2 92% on room air. GCS 10. Received 1L Normal Saline en route. Spinal immobilisation applied. Patient conscious but confused, complaining of severe back pain and left leg pain.
Paramedic Handover - Mechanism of Injury:
Paramedics reported the patient was found by a passerby at the base of a construction site. Witness observed patient falling from a significant height, estimated at 3 floors. Patient was initially unconscious for an unknown duration but roused to verbal stimuli.
**Immediate Life Threats Noted:**
Hemodynamic instability (hypotension, tachycardia), decreased level of consciousness, potential for significant internal haemorrhage, suspected spinal injury.
**Primary Survey (ABCDE Assessment):**
**Vital Signs:**
RR: 28
SpO2: 96%
HR: 118
BP: 85/55
MAP: 65
T: 36.8 C
GCS: 9
E: 2
V: 3
M: 4
Central Capillary Refill Time: >3 seconds, prolonged.
**Airway & C-spine:**
Patent:
Airway patent, no obstruction due to blood, vomit, or foreign bodies.
Verbal Response:
Responds to pain, moaning, unable to follow commands.
Airway Interventions:
None required immediately, airway adjuncts (OPA) at bedside for immediate use if needed. Jaw thrust maintained by nurse.
Cervical collar (Philadelphia type) in place, spine precautions maintained.
**Breathing:**
Chest Wall Examination:
Equal chest rise bilaterally. No paradoxical movement. Tenderness on palpation over posterior chest wall, particularly left lower ribs. No crepitus noted.
Trachea Position & JVD:
Trachea midline. No jugular venous distension observed.
Breath Sounds:
Bilateral breath sounds present, diminished at left lung base.
Oxygenation/Ventilation:
SpO2 96% on 10L non-rebreather mask. End-tidal CO2 not yet initiated.
**Circulation:**
External Bleeding:
Small laceration to forehead, controlled with direct pressure. No other obvious external bleeding sites.
Internal Bleeding Suspicion:
eFAST performed, positive for free fluid in Morison's pouch and splenorenal recess, concerning for intra-abdominal haemorrhage.
Blood Pressure & Pulses:
BP 85/55 mmHg. Radial pulses weak but palpable bilaterally. Dorsalis pedis pulses weak but present bilaterally.
Pelvic Stability & Intervention:
Pelvis unstable on gentle compression. Pelvic binder placed immediately due to suspected open book fracture, confirmed by X-ray.
Blood products transfused: 2 units packed red blood cells, 1 unit fresh frozen plasma initiated.
Details of vascular access established: Right antecubital 16G IV, Left femoral 14G IV. No arterial line established yet.
**Disability (Neurologic Status & Cervical Spine Status):**
Pupil Examination:
Pupils 4mm, sluggishly reactive to light bilaterally. Equal.
Extremity Movement:
Withdraws from painful stimuli in all four extremities. Decreased movement in left lower extremity, unable to assess fully due to pain.
**Exposure:**
Complete Undressing:
Patient fully exposed for assessment.
Hypothermia Prevention:
Warm blankets applied, IV fluids warmed.
Log Roll for Back Assessment:
Performed with spinal precautions. Large contusion noted over lumbar spine, no obvious step-off. No saddle anaesthesia observed.
**Assessment & Plan:**
Summary of Findings:
34-year-old male with severe blunt trauma following a 9-meter fall, presenting with hypovolemic shock (BP 85/55, HR 118) and altered mental status (GCS 9) with positive eFAST and unstable pelvis.
* Hypovolemic shock secondary to suspected intra-abdominal and pelvic haemorrhage.
* Polytrauma including suspected spinal injury (lumbar contusion), left lower limb injury, and potential thoracic injury (diminished left lung sounds).
* Head injury with GCS 9 and sluggish pupils.
Interventions Performed:
* Spinal immobilisation and cervical collar application.
* Two large-bore IVs established; 1L Normal Saline and 2 units PRBCs, 1 unit FFP infused.
* Oxygen via non-rebreather mask at 10L/min.
* Pelvic binder placed.
* eFAST performed, positive.
Pending Procedures & Investigations:
* CT head, C-spine, chest, abdomen, and pelvis.
* Orthopaedic consultation for pelvic injury and left lower limb.
* General surgery consultation for intra-abdominal haemorrhage.
* Central venous access placement.
* Arterial line placement for continuous BP monitoring.
* Further blood product transfusion based on ongoing bleeding and lab results.
Disposition:
* Operating room for exploratory laparotomy and pelvic stabilisation.
Consultations:
* General Surgery
* Orthopaedics
* Neurosurgery (on standby)
Clinician Specialty: Emergency Medicine Registrar
**Emergency Trauma Assessment**
[Patient age] [Patient gender using M for male, F for female, or X for non-binary] [BIBA if brought in by ambulance, or PW if presents via other means] [One line summary of presentation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write on a single line.)
**Pre-Arrival:**
Pre arrival Notification:
[Document pre-hospital report including mechanism of injury, field vital signs, and any pre-arrival interventions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Mechanism of Injury:
[Describe 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 a 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:
[Document 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:
[Record the 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 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:
[Record time of handoff completion] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Key Findings from EMS Report:
[Summarise findings such as vital signs, pre-hospital interventions, and mechanism of injury] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Paramedic Handover - Mechanism of Injury:
[Describe the mechanism of injury as handed over by the paramedic team] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**Immediate Life Threats Noted:**
[Describe any 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 leave blank.)
SpO2: [Oxygen saturation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
HR: [Heart rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
BP: [Blood pressure] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
MAP: [Mean arterial pressure] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
T: [Temperature with C for Celsius or F for Fahrenheit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
GCS: [Total Glasgow Coma Scale score] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
E: [Eyes score 1 to 4] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
V: [Voice score 1 to 5] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
M: [Movement score 1 to 6] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else leave blank.)
Central Capillary Refill Time: [Document capillary refill status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**Airway & C-spine:**
Patent:
[Assess airway 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:
[Record 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:
[Describe any 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:
[Document findings from inspection and palpation of the chest] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Trachea Position & JVD:
[Note any deviation or jugular venous distension] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Breath Sounds:
[Record 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:
[List oxygen saturation and end-tidal CO2 monitoring results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**Circulation:**
External Bleeding:
[Document any 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:
[Assess extended Focused Assessment with Sonography for Trauma results if performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Blood Pressure & Pulses:
[Record blood pressure and compare 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:
[Describe if a pelvic binder was placed and the 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:
[Size and reactivity, noting if pupils are equal and reactive bilaterally] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Extremity Movement:
[Document findings on motor function] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
**Exposure:**
Complete Undressing:
[Confirm patient was fully exposed for assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)
Hypothermia Prevention:
[Note use of warm blankets and 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.)
**Assessment & Plan:**
Summary of Findings:
[Summarise key injuries, Glasgow Coma Scale score, and haemodynamic status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write the initial summary on one line, then list all subsequent findings as bullet points.)
Interventions Performed:
[List interventions performed including airway management, chest tube placement, fluid resuscitation, and blood products] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as list.)
Pending Procedures & Investigations:
[List any procedures yet to be completed or investigations pending] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as list.)
Disposition:
[Document disposition including intensive care unit admission, operating room, imaging, or interventional radiology] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as list.)
Consultations:
[List specialists consulted] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as list.)
