Trauma Resuscitation Record

Admit Date / / Patient Name Arrival Time : Trauma Team Notification/Arrival Patient Tag/Sticker Trauma Team Activated? Yes No Time: : Tier 1 2 3 Prompt General Surgeon Communication? Yes No Date of Birth Time Present upon Pt arrival? Name called Gender General Surgeon : Yes No Medical Record # ED Physician : Yes No Anesthesia : Yes No : Yes No

Pre-hospital Interventions Pt. Medications Allergies Arrived via: Airway: Ambulance Oral Nasal Intubated O2 Helicopter IV size _____ site ______Police IV #2 size _____ site ______Self Blood sugar ______mg/dl CPR LBB C collar Transfer from: Meds: Dilaudid ______mg Morphine ______mg unknown unknown Ketoraloc______mg Ketamine______mg EMS report in Midazolam ______mg Ativan ______mg Pt chart Other ______mg Mechanism of Injury Motor Vehicle Fall/Jump Burn Penetrating Involved: Auto Approx. height: Patient was: Seatbelt ______Light truck Flame GSW Driver Airbag Landing surface: Heavy truck Impact: Grass/dirt/eart Steam caliber______Passenger-front Child seat Front distance______Motorcycle h Chemical Passenger-back Helmet Side Stab ATV Stone Radiation Pedestrian struck blade length_____ Rear Concrete/brick Bicycle Inhalation by auto Ejected Self inflicted Pedestrian Rollover Tile/wood Bicyclist struck Extrication Electrical Impalement Watercraft T-bone Carpet by auto Death of voltage:______Sporting Unknown Water another occupant ______

Primary Survey and Preliminary Interventions Initial ED Vital Signs

Patent/talking Jaw thrust Clear Suction Time:____:_____ Partially obstructed Foreign object Completely obstructed removal/laryngoscopy BP: ______/______Airway Oral airway Breathing assisted Nasal airway Pulse: ______/min Intubated Combitube/LMA/King Resp.: ______/min ______time: ____:____ Temp.: ____0 C site______Breathing Spontaneous Lung sounds: Labored L R SaO2: ______% Present Agonal Clear Blood Glucose ______mg/dl No effort Diminished Est. weight: ______kg Trachea: Absent Midline Rales Deviated R L Rhonchi A Awake and alert Wheezes V Verbal stimuli elicits response Chest wall symmetry: P Painful stimuli elicits response Symmetrical U Unresponsive to stimuli Asymmetrical Skin: Pulse: Warm Pink Central pulse present Warm blankets Cool Pale Peripheral pulse present Warming lights Hot Flushed No pulse Direct pressure Circulation Dry Ashen bleeding control: Moist Cyanotic Strong Diaphoretic Thready site______Capillary refill ______sec. Glasgow Coma Scale (GCS) Pupils Eye Opening Verbal Motor 6 Obeys 5 Localiz es pain 4 Withdr aws from 5 Oriented pain L R 4 Spontaneous Brisk Brisk 4 Confused 3 Disability 3 To Verbal Sluggish Sluggish 3 Inappropriate response Flexor 2 To Pain posturi Non-reactive Non-reactive 2 Incomprehensible ng 1 None ______mm ______mm 1 None/Intubated 2 Extens or posturi ng 1 None/c hemica lly paralyz ed MR# Secondary Survey Pain/tenderness Head Drainage from: ears nose mouth Pain/tenderness Neck JVD Pain/tenderness Dyspnea Chest Deformity Paradoxical expansion Pain Tender Rigid Bowel sounds present Abdomen Soft Guarded Distended Bowel sounds absent Emesis/gastrocult: + - Pain/tenderness Pelvis: stable unstable Pelvis/Genital Blood at the meatus Rectal tone: present absent Hemocult: + - Surface Trauma Pain/tenderness CMS intact x4 Extremities Moves all extremities Extremities warm and pink Pain/tenderness Back Deformity Ongoing Monitoring Time : : : : : : : : : : : BP / / / / / / / / / / / Pulse Resp. SaO2 % % % % % % % % % % % GCS Temp. 0C 0C 0C 0C 0C 0C 0C 0C 0C 0C 0C EKG

ETCO2 Pain scale /10 /10 /10 /10 /10 /10 /10 /10 /10 /10 /10 Medications Drug/Procedure Dose Route Start Time End Time Administered by Response : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved : : no change improved Fluid In/Blood Products Solution/Blood Product Time hung Size Blood unit # Time d/c’ed Amount infused : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml : ml MR# Procedures Procedure Time By Detail Cast/splint :

Central line :

Chest tube R :

Chest tube L :

Defib/Cardiovert :

Intraosseous :

Needle thoracotomy :

OG/NG tube :

Suture :

Surgical Airway :

Tourniquet :

Urinary Catheter :

: Laboratory Imaging Lab Time Ordered X-ray Time Ordered CT Time Ordered BAC : CXR : Abdomen : CBC : Pelvis : Chest : Electrolytes : Skull : Head : Glucose : Spine-Cervical : Neck : hCG : Spine- Lumb/Sac : Pelvis : Hgb : Spine- Thoracic : Spine : PT/INR : : : PTT : : : pH : : Ultrasound Time Ordered Tox. screen : : FAST exam : Type and screen : : : UA : : : Patient Disposition Admitted Transferred Pt left ED : Ordered : Transfer via: Accompanying Pt: Copy of chart Report called : Arrived : Helicopter EMS report Admitting service: Pt left ED : ______Admitting physician: Transferred to: X-rays & CTs Ground Lab report Expired in ED Referral hospital ______: notified : RN______Patient Information SSN Address Apt. #

Telephone Number City State/Province Postal Code

Ethnicity Race Pay Source Hispanic/Latino White American Indian/Alaskan Native Medicare Non-Hispanic/Latino Black Native Hawaiian/Pacific Islander Uninsured Unknown Asian Other Other ______Unknown Unknown MR# Services Consulted General Surgery Telephone In-person Neurosurgery Telephone In-person Oral Maxillofacial Surgery Orthopedic Surgery Telephone In-person Other: ______Telephone In-person Telephone In-person Notes

Signatures Physician

[INSERT HOSPITAL NAME, ADDRESS, PHONE NUMBER] Primary nurse

Recorder version 2016.1