Emergency Trauma Assessment

**Emergency Trauma Assessment** [Patent Age][Patient Gender, "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] **Pre-Arrival:** - Personal Protective Equipment (PPE): [Specify PPE worn by team members] (only include if relevant/mentioned) - EMS Notification: [Document pre-hospital report including mechanism of injury, field vitals, and any pre-arrival interventions] (only include if EMS provided details) - Mechanism of Injury: [Describe mechanism of injury, including blunt vs. penetrating trauma, velocity of impact, vehicle damage, presence of blood at scene, or other fatalities] (only include if relevant) - Trauma Activation Criteria: [Specify whether Level I or Level II activation was triggered and document rationale] **Arrival:** - Time of Patient Arrival: [Document exact time of patient arrival] - Trauma Team Activation Time: [Record the exact time trauma activation was initiated] - Team Members Present: [List all team members involved in initial trauma assessment (e.g., EM physicians, trauma surgeons, nurses, RTs)] - **EMS Hand-off:** - Time of Handoff Completion: [Record time] - Key Findings from EMS Report: [Summarize findings such as vital signs, pre-hospital interventions, mechanism of injury] - **Immediate Life Threats Noted:** [Describe any critical findings requiring immediate intervention, e.g., agonal respirations, exsanguination] **Primary Survey (ABCDE Assessment):** **Vital Signs:** RR: [Record RR], SpO2:[Record SpO2], HR: [Record HR], BP: [Record BP] (MAP: [Record MAP] ), T: [Record temperature, Include "C" for Celcius or "F" for Farenheit], GCS: [Total GCS] (E: [Eyes score 1-4], V: [Voice score 1-5], M: [Movement score 1-6]) Central Capillary Refill Time: [Document cap refill status] **Airway:** - Patent: [Assess airway for obstruction due to blood, vomit, or trauma] - Verbal Response: [Record patient’s ability to speak and any abnormal sounds (gargling, stridor)] - Airway Interventions: [Describe any airway management steps taken, e.g., suctioning, intubation] **Breathing:** - Chest Wall Examination: [Document findings from inspection and palpation of the chest] - Trachea Position & JVD: [Note any deviation or jugular venous distention] - Breath Sounds: [Record presence/absence of bilateral breath sounds] - Oxygenation/Ventilation: [List O2 saturation, EtCO2 monitoring results] **Circulation:** - External Bleeding: [Document any major bleeding sites and control measures] - Internal Bleeding Suspicion: [Assess E-FAST results, if performed] - Blood Pressure & Pulses: [Record BP and compare radial/dorsalis pedis pulses bilaterally] -Pelvic Stability & Intervention: [Describe if a pelvic binder was placed and why] **Disability (Neurologic Status & Cervical Spine Status):** - Pupil Examination: [Size and reactivity, "PEARL bilat" if Pupils are equal and reactive bilaterally] - Extremity Movement: [Document findings on motor function] **Cervical Spine (Status and precautions taken):** [Cervical Spine status ie in Cx Spine precautions or not in Cx Spine Precautions] -Collar: (If Cervical spine collar is in situ [yes/no], type of collar & time placed in precautions) - **Exposure:** - Complete Undressing: [Confirm patient was fully exposed for assessment] - Hypothermia Prevention: [Note use of warm blankets, fluid warmers] - Log Roll for Back Assessment: [Findings from spinal and posterior assessment, include saddle anesthesia and major bruising] **Secondary Survey:** - **AMPLE History:** - Allergies: [List if known, write "unknown" if not known or "NKDA" if no known drug allergy] - Medications: [Include anticoagulants, insulin, steroids, etc. if unknown write "unknown"] - Past Medical History: [Include significant conditions, if unknown write "unknown", If none write "Nil Significant"] - Last Meal: [Time and contents, if unknown write "unknown"] - Events Leading to Injury: [Details from patient, family, or EMS, if unknown write "unknown"] - **Physical Exam:** - Head & Face: [Scalp injuries, facial fractures, hemotympanum, septal hematoma, facial asymmetry, battle sign] - Cervical Spine: [Tenderness, need for imaging] - Thorax: [Rib fractures, lung auscultation, heart sounds, if heart sounds are dual no murmurs write "HSDNM"] - Abdomen/Pelvis: [Tenderness, guarding, rebound, bruising, if the pelvis is stable/unstable and if a pelvic binder is in situ] - Extremities: [Deformities, pulse presence, sensory/motor function, Include neurovascular status of each limb and if gross sensation is intact in each limb] - Back: [Spinous process tenderness, step-offs, any large bruises, wounds or lacerations] - Digital Rectal Exam: [Only if indicated before urinary catheter placement] **Assessment & Plan:** - Summary of Findings* [Summarize key injuries, GCS, hemodynamic status] - Interventions Performed: [Airway management, chest tube placement, fluid resuscitation, blood products, etc.] - Pending Procedures & Investigations: [Any procedures yet to be completed or investigations pending] - Disposition: [ICU admission, OR, imaging, interventional radiology] - Consultations: [List specialists consulted, e.g., trauma surgery, neurosurgery] (Timestamp all major interventions and changes in patient condition. Use as many lines, paragraphs, or bullet points as needed to comprehensively document the nursing care plan. Never come up with your own patient details, assessment, plan, interventions, or evaluation—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information has not been explicitly mentioned in your output—just leave the relevant placeholder blank or omit it completely.)