EMT Template

Pediatric Trauma Assessment (Primary and Secondary Survey)

A professional EMT template for healthcare professionals.

About this template

The Pediatric Trauma Assessment template is a comprehensive tool designed for EMTs and other emergency medical professionals to conduct thorough primary and secondary surveys in pediatric trauma cases based on guidance provided by the Royal Children's Hospital in Australia. This template ensures rapid identification and management of life-threatening conditions, covering critical areas such as airway, breathing, circulation, and neurological status. It also includes detailed sections for pre-arrival preparation, radiology, and disposition planning. By using this template with Heidi, clinicians can efficiently document trauma assessments, ensuring all vital information is captured for optimal patient care and communication with the trauma team.

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Primary Survey The Primary Survey is performed to rapidly identify and manage life-threatening conditions. Priorities include: - Catastrophic Hemorrhage - Airway (with cervical spine control) - Breathing - Circulation - Disability (Neurological Status) - Exposure / Environment Control Pre-Arrival Preparation - Trauma Team Activation: The trauma team was activated based on the mechanism of injury and the patient's unstable vital signs. - Pre-Arrival Briefing: The team was briefed on the patient's condition, roles were assigned, and equipment was prepared. - Medication & Equipment Preparation: Weight-based drug doses were confirmed, and all necessary equipment was ready. - Protective Measures: Personal protective equipment and radiation protection were utilized. On Arrival - Handover: The I-MIST-AMBO handover from paramedics included the mechanism of injury, injuries sustained, signs, treatment given, allergies, medications, background, and other relevant information. - Parental Communication: Additional history was obtained from the parents, including the child's medical history and allergies. - Support for Family: Emotional support was provided to the family, and they were kept informed of the child's condition. Airway and Cervical Spine Life Threat: Airway Obstruction - Assessment: Airway was patent with no obstructions noted. No facial fractures or signs of burns were present. - Neck Examination: No tracheal deviation or other airway threats were identified. - Airway Management: The airway was maintained with positioning and suction. - Cervical Spine Management: Spinal precautions were confirmed with a cervical collar applied. Breathing Life Threats: Tension Pneumothorax, Open Pneumothorax, Massive Hemothorax, Flail Chest - Assessment: The patient exhibited increased work of breathing and decreased chest expansion on the right side. - Examination: Decreased breath sounds on the right side were noted on auscultation. - Management: Oxygen was administered, and a chest drain was inserted on the right side. Circulation Life Threat: Hemorrhagic Shock - Assessment: Heart rate was elevated, capillary refill time was prolonged, and blood pressure was low. - Sites of Bleeding: No external bleeding was noted; internal bleeding suspected in the abdomen. - Interventions: Fluid resuscitation was initiated, and blood products were prepared for transfusion. Disability (Neurological Status) Life Threat: Traumatic Brain Injury - Neurological Assessment: GCS score was 13, indicating mild head injury. - Pupillary Exam: Pupils were equal and reactive to light. - Motor Function: Limb movements were symmetrical with no deficits. - Blood Glucose: Capillary blood glucose was within normal range. - Neuroprotection Strategies: Head elevation and normothermia were maintained. Exposure and Environmental Control - Full Body Inspection: No additional life-threatening injuries were identified. - Hypothermia Prevention: Warm blankets and a warming device were used to maintain normothermia. Radiology and Imaging - Imaging Ordered: Chest X-ray and abdominal CT scan were ordered. - Findings: Chest X-ray showed right-sided pneumothorax; abdominal CT scan was pending. Secondary Survey The Secondary Survey is performed once the patient is stable, and all immediate life threats are addressed. Preparation - Communication and Reassurance: The patient was reassured, and parents were involved in the care process. - Positioning and Comfort: Pain management was provided with analgesics. Head and Face - Inspection and Palpation: No scalp lacerations or skull fractures were noted. - Eyes: No eye trauma or visual impairment was observed. - Ears and Nose: No bleeding or CSF leaks were present. - Mouth and Jaw: No oral trauma or dental injuries were found. Neck - Inspection: No neck bruising or tracheal deviation was observed. - Palpation: No vertebral tenderness was noted. Chest - Inspection and Palpation: No seat belt injuries or paradoxical movement were observed. - Auscultation: Breath sounds were decreased on the right side. Abdomen - Inspection and Palpation: No bruising or distension was noted; tenderness was present over the right upper quadrant. - Genitourinary Examination: No signs of trauma were observed. Pelvis - Inspection and Palpation: No pelvic instability or tenderness was noted. Limbs - Inspection and Palpation: No fractures or soft tissue injuries were observed. - Range of Motion: Full range of motion was present in all joints. Back - Log Roll Assessment: No tenderness or deformities were noted along the vertebral column. - Spinal Palpation: No abnormalities were detected. Urinalysis - Test Results: Urine dipstick was negative for blood. Disposition Planning - Ongoing Management: Abdominal CT scan results pending; surgical consultation requested. - Pain Management: Analgesia was administered with good patient response. - Surgical Consideration: Possible surgical intervention pending CT results. - Definitive Care Plan: Plan for ICU transfer for close monitoring. - Handover Details: The ICU team was briefed, and a formal handover was completed.

Primary Survey The Primary Survey is performed to rapidly identify and manage life-threatening conditions. Priorities include: - Catastrophic Hemorrhage - Airway (with cervical spine control) - Breathing - Circulation - Disability (Neurological Status) - Exposure / Environment Control Pre-Arrival Preparation - Trauma Team Activation: [Indicate if the trauma team was activated and based on what criteria] - Pre-Arrival Briefing: [Summarize team preparation and role allocations before patient arrival] - Medication & Equipment Preparation: [Confirm weight-based drug doses and equipment readiness] - Protective Measures: [Confirm that personal protective equipment and radiation protection were utilized] On Arrival - Handover: [Document key elements of the I-MIST-AMBO handover from paramedics] - Parental Communication: [Specify any additional history obtained from parents/caregivers] - Support for Family: [Describe any support provided to family members] Airway and Cervical Spine Life Threat: Airway Obstruction - Assessment: [Document airway patency, presence of obstructions such as blood, vomitus, or teeth, facial fractures, epistaxis, or signs of burns such as soot, singed nasal hair] - Neck Examination: [Include an anterior neck assessment for blunt or penetrating trauma, tracheal deviation, or other airway threats] - Airway Management: [Describe interventions used to maintain a patent airway, including positioning, suction, airway adjuncts, or intubation] - Cervical Spine Management: [Confirm spinal precautions and method of stabilization applied] Breathing Life Threats: Tension Pneumothorax, Open Pneumothorax, Massive Hemothorax, Flail Chest - Assessment: [Describe the work of breathing, chest expansion, respiratory effort, and any signs of injury] - Examination: [Include findings from inspection, palpation, auscultation, and any bedside imaging such as chest X-ray] - Management: [Document interventions such as oxygen administration, decompression techniques, or chest drain insertion] Circulation Life Threat: Hemorrhagic Shock - Assessment: [Describe heart rate, capillary refill time, blood pressure, and skin perfusion] - Sites of Bleeding: [Identify external and internal bleeding sources, including thoracic, abdominal, pelvic, and limb injuries] - Interventions: [Detail fluid resuscitation, use of blood products, hemostatic agents, and surgical consultation] Disability (Neurological Status) Life Threat: Traumatic Brain Injury - Neurological Assessment: [Use AVPU or GCS scale to document mental status] - Pupillary Exam: [Assess for pupil size, reactivity, and signs of neurological compromise] - Motor Function: [Describe limb movements and any neurological deficits noted] - Blood Glucose: [Record capillary blood glucose measurement] - Neuroprotection Strategies: [List measures taken to prevent secondary brain injury] Exposure and Environmental Control - Full Body Inspection: [Describe any additional life-threatening injuries identified upon full exposure] - Hypothermia Prevention: [Describe warming techniques and measures used to maintain normothermia] Radiology and Imaging - Imaging Ordered: [List initial imaging studies such as chest X-ray, pelvic X-ray, or CT scans] - Findings: [Summarize significant imaging findings relevant to trauma assessment] Secondary Survey The Secondary Survey is performed once the patient is stable, and all immediate life threats are addressed. Preparation - Communication and Reassurance: [Document patient interactions and parental involvement] - Positioning and Comfort: [Specify any measures taken to improve patient comfort, including pain management] Head and Face - Inspection and Palpation: [Assess for scalp lacerations, skull fractures, facial trauma, Battle’s sign, or periorbital bruising] - Eyes: [Describe any eye trauma, foreign bodies, visual impairment, or pupillary changes] - Ears and Nose: [Check for bleeding, CSF leaks, septal hematomas, or tympanic membrane injuries] - Mouth and Jaw: [Examine for oral trauma, dental injuries, or jaw malocclusion] Neck - Inspection: [Describe any neck bruising, tracheal deviation, or swelling] - Palpation: [Assess for vertebral tenderness or subcutaneous emphysema] Chest - Inspection and Palpation: [Assess for seat belt injuries, paradoxical movement, or tenderness] - Auscultation: [Record breath sounds, heart sounds, and any abnormal findings] Abdomen - Inspection and Palpation: [Look for bruising, distension, or tenderness over liver, spleen, or bladder] - Genitourinary Examination: [Assess for signs of trauma, such as blood at the urethral meatus] Pelvis - Inspection and Palpation: [Assess for pelvic instability or tenderness] Limbs - Inspection and Palpation: [Check for fractures, soft tissue injuries, or neurovascular compromise] - Range of Motion: [Describe any limitations in joint movement] Back - Log Roll Assessment: [Document findings from a log roll examination of the spine and buttocks] - Spinal Palpation: [Assess for tenderness or deformities along the vertebral column] Urinalysis - Test Results: [Document findings from urine dipstick or formal urinalysis] Disposition Planning - Ongoing Management: [Specify additional investigations, procedures, or specialist referrals] - Pain Management: [Document analgesia administered and patient response] - Surgical Consideration: [Indicate if operative intervention is required] - Definitive Care Plan: [Describe the plan for continued care, including inpatient admission, ICU transfer, or discharge home] - Handover Details: [State the team responsible for patient care and any formal handover process] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - 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, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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