SW London & Surrey Trauma Network Trauma Documentation Pre-alert details Ambulance Call Sign: Age: Mechanism: Injury: Date: Call received by: Male / Female Time: St George s Hospital East Surrey Hospital Epsom University Hospital St Helier University Hospital Frimley Park Hospital Kingston Hospital Mayday University Hospital Royal Surrey County Hospital St Peter s Hospital Name: DOB: Hosp. No: Signs: RR: ; O 2 sats %( air/o 2 ); BP / ; Pulse ; GCS Treatment: Request from pre-hospital team: eg. Blood/Spec. team etc ETA: mins Time of arrival: Emergency Med. Team/ Major Trauma Team (Please circle as appropriate) Trauma Team Team Leader: Senior Nurse: Name Signature Specialty Grade Time attended Emerg. Med. Emerg. Med. TRAUMA Anaesthetics General Surgery Orthopaedics CHART Trauma chart completed by: Signature: Position: 1
Pre-Hospital Care Transport to Hospital: Ambulance service / HEMS (land /helicopter) / Private / Other 999 call time: Arrive at scene time: Left scene time: Arrive at hospital time: Time of incident: Incident postcode: Ambulance incident no: Mechanism Injury Signs Airway: Patent / Compromised Breathing: RR /min O2 sats % on air / oxygen Circulation: BP / mmhg Pulse /min Disability: GCS /15 (E ;V :M ) Treatment Spinal immobilisation: Non / Cervical collar / Head blocks / Spinal board / Scoop Airway adjuncts: / Oral airway / ETT (time ) Breathing: Oxygen - Yes /No Circulation: IV Access Right Left Site Size Procedure Right Left Needle thoracocentesis Chest drain(size) Thoracostomy Other Drugs: Drug Etomidate Dose Fluids given: Type: Volume: Suxamethonium Pancuronium Splints (pelvis/limbs): Propofol Ketamine Dressings: Morphine Midazolam CPR perfomed: Yes / No Time of arrest: Initial rhythm: Time CPR stopped: Return of spontaneous circulation: Yes / No Allergies: Medication: PMH: Last meal: Events (reported by patient if different from above): Tetanus: Immune / Not immune / unknown 2
Primary Survey Assessment C-spine immobilisation: / Collar / Blocks / Spinal board / Scoop / other Chest assessment Right Left Airway: Patent /Compromised Breathing: RR / min Normal Reduced air entry Flail chest Surgical emphysema O 2 Sats % on air/oxygen Circulation: BP / mm Hg Pulse /min External haemorrhage: Yes / No Abdomen: Soft / Distended / Tender FAST scan: Free fluid present / absent; Performed by at (time) Free fluid in: Hepato renal angle / Spleno-renal angle / Pericadium / Pelvis Pelvis: Obvious injury / no apparent injury Disability: GCS /15 (E ; V ; M ) Right pupil (Size /reaction) mm Yes /No Left Pupil (size /reaction) mm Yes/No Limb movement: RA / RL / LA / LL Priapism : Present / Absent Temperature: 0 C Blood Glucose: mmol/l Treatment C-spine immobilisation commenced in ED: Yes / No Collar / head blocks Airway: adjunct / oral/ nasal / ETT ( time ; size ) / Surgical airway ( time ; done by ) Breathing: Oxygen Yes / No ; I/min Procedure Right Procedure carried out by Left Procedure carried out by Needle Thoracocentesis Chest drain (size and time) Thoracotomy (time) Circulation: IV/IO access Right Left Other Other Site Size CPR performed: Yes / No Time of arrest: Time CPR stopped: Initial rhythm: Return of spontaneous circulation: Yes / No Splints: Massive haemorrhage protocol activated: Yes / No Dressings: If Yes at what time: 3
Secondary Survey 4
Secondary Survey RIGHT Dominant Hand: Left/Right Neurovascular exam of foot: Right / Left Sural Nerve Superficial Peroneal Nerve Saphenous Nerve Posterior Tibial Artery LEFT Dominant Hand: Left/Right Tibial Nerve Deep Peroneal Nerve Dorsalis Pedis Capillary Refill time: Colour: Perfusion: 5
Additional Information 6
Secondary Survey Body Region Findings Head Face Neck Chest Abdomen Pelvis Upper Limbs Lower Limbs Log roll / back Rectal ECG Other 7
Summary of Injuries Injuries Investigations completed Outstanding tasks Head Face C-spine T/L spine Chest Abdomen Pelvis Upper limbs Lower limbs Skin Other Patient handed over to Name: Grade: Specialty: Time of handover Destination Ward / ITU / HDU / 8 Team Leader s signature
Team Leader s Notes Time 9
Anaesthetic Notes Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 10
General Surgery Notes Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 11
Orthopaedic Notes Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 12
Neurosurgery Notes Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 13
Specialty Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 14
Specialty Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 15
Specialty Name(s) of doctor(s) (please print): Consultant: Time attended: Time notes written: 16
Radiology Name(s) of doctor(s) (please print): Consultant: 17
Results Time Temperature ph Hb WCC Plt INR PT APPT Na K Bic Cl Urea Creatinine Glucose Alcohol Urinalysis Blood Protein Glucose Ketones Leuc. Urinary Catheter Time of catheterisation Size of Catheter Residual volume (measure 15min after catheterisation) Place sticker here Nitrates ph Antibiotics required: Yes / No CSU sent: Yes / No Given: Yes / No B-HCG 18
Results Please attach blood gas results here 19
Miscellaneous Notes 20