Emergency Medicine Specialist Template

Emergency Trauma Assessment (Primary Survey Notes)

A professional Emergency Medicine Specialist template for healthcare professionals.

About this template

The Emergency Trauma Assessment (Primary Survey Notes) template is a comprehensive tool designed for emergency medicine specialists to document critical trauma assessments. This template guides clinicians through the primary survey process, including pre-arrival details, EMS hand-off, and the ABCDE assessment. It ensures thorough documentation of vital signs, airway management, breathing, circulation, neurological status, and exposure. This template is essential for accurately capturing the initial evaluation and interventions in trauma cases, facilitating effective communication and continuity of care in emergency settings.

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Patient Age: 34, Patient Gender: M, BIBA, Patient was involved in a high-speed motor vehicle collision. Pre-Arrival: - Personal Protective Equipment (PPE): Gloves, masks, and face shields worn by team members. - EMS Notification: Patient was ejected from the vehicle, sustained blunt trauma, field vitals were BP 90/60, HR 120, RR 28, SpO2 92%, pre-arrival interventions included IV fluids and oxygen. - Mechanism of Injury: High-speed motor vehicle collision, patient ejected, significant vehicle damage, presence of blood at the scene. - Trauma Activation Criteria: Level I activation triggered due to high-speed collision and ejection. Arrival: - Time of Patient Arrival: 14:32 - Trauma Team Activation Time: 14:33 - Team Members Present: Dr. Thomas Kelly (EM physician), Dr. Sarah Lee (trauma surgeon), Nurse John Smith, RT Emily Davis - EMS Hand-off: - Time of Handoff Completion: 14:35 - Key Findings from EMS Report: BP 90/60, HR 120, RR 28, SpO2 92%, IV fluids and oxygen administered, blunt trauma from ejection. - Immediate Life Threats Noted: Agonal respirations, significant external bleeding from the left leg. Primary Survey (ABCDE Assessment): Vital Signs: RR: 28, SpO2: 92%, HR: 120, BP: 90/60 (MAP: 70), T: 36.5C, GCS: 10 (E: 3, V: 3, M: 4) Central Capillary Refill Time: Delayed Airway: - Patent: Blood present, suctioning performed - Verbal Response: Incoherent sounds, stridor noted - Airway Interventions: Suctioning and intubation performed Breathing: - Chest Wall Examination: Bruising on the left side, crepitus noted - Trachea Position & JVD: Trachea midline, no JVD - Breath Sounds: Decreased breath sounds on the left - Oxygenation/Ventilation: O2 saturation 92%, EtCO2 45 mmHg Circulation: - External Bleeding: Significant bleeding from left leg, tourniquet applied - Internal Bleeding Suspicion: E-FAST positive for free fluid in the abdomen - Blood Pressure & Pulses: BP 90/60, weak radial pulses bilaterally - Pelvic Stability & Intervention: Pelvic binder placed due to instability Disability (Neurologic Status & Cervical Spine Status): - Pupil Examination: PEARL bilat - Extremity Movement: Limited movement in lower extremities - Cervical Spine (Status and precautions taken): In Cx Spine precautions - Collar: Yes, rigid collar placed at 14:34 Exposure: - Complete Undressing: Patient fully exposed for assessment - Hypothermia Prevention: Warm blankets applied - Log Roll for Back Assessment: No saddle anesthesia, bruising noted on the back

[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] (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.)

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