Trauma Resuscitation Record



Trauma Resuscitation Record

|Patient Tag/Sticker | Admit |

| |Date / / |

|Date of Birth |Patient Name |

| |Arrival Time : |

|Gender | |

| | |

|Medical Record # | |

| |Trauma Team Notification/Arrival |

| |Trauma Team Activated? Yes No Time: : |

| | Name |Time called |Time arrived|Present upon Pt |

| | | | |arrival? |

| |General Surgeon | |: |: |Yes No |

| | | |: |: |Yes No |

|Arrived via: |Pre-hospital Interventions |Pt. Medications |Past History |Allergies |

|Ambulance |Airway: | | | |

|Helicopter |Oral Nasal Intubated O2 | | | |

|Police |IV size _____ site ________ | | | |

|Self |IV #2 size _____ site ________ | | | |

| |Blood sugar _______ mg/dl | | | |

|Transfer from: |CPR LBB C collar MAST | | | |

| |Splint type __________ location ___________ | | | |

|EMS report in |Meds: | |unknown | |

|Pt chart |Morphine ______ mg Versed ______mg | |last tetanus_________ | |

| |_______________________ ______mg |unknown |last P.O.____________ |unknown |

|Mechanism of Injury |

|Motor Vehicle |Fall/Jump |Burn |Penetrating |

|Involved: |Patient was: |

|Auto |Driver |

|Light truck |Passenger-front |

|Heavy truck |Passenger-back |

|Motorcycle |Pedestrian struck |

|ATV |by auto |

|Bicycle |Bicyclist struck |

|Pedestrian |by auto |

|Watercraft |Unknown |

|Sporting _________ | |

|Airway |Patent/talking |Jaw thrust |Intubation RSI |Time:____:_____ |

| |Clear |Suction |tube size________ |BP: ______/______ |

| |Partially obstructed |Foreign object |time:____:____ |Pulse: ____________/min |

| |Completely obstructed |removal/laryngoscopy |______cm @ _________ |Resp.: ____________/min |

| |Breathing assisted |Oral airway |#attempts:______ |Temp.: ____0 C site______ |

| |Intubated |Nasal airway |Confirmed by: |SaO2: ____________% |

| |___________________ |Combitube/LMA/King |End tidal CO2 |Blood Glucose _________ mg/dl |

| | |time: ____:____ |Aspirator |Est. weight: ___________ kg |

| | | |CXR | |

|Breathing |Spontaneous |Lung sounds: |Assisted: | |

| |Labored |L R |BVM | |

| |Agonal |Present |Ventilator | |

| |No effort |Clear |Vent. Rate ________ | |

| | |Diminished | | |

| |Trachea: |Absent |Supplemental O2 | |

| |Midline |Rales |Mask | |

| |Deviated R L |Rhonchi |NC | |

| | |Wheezes |_______ l/m | |

| |Chest wall symmetry: | | | |

| |Symmetrical | | | |

| |Asymmetrical | | | |

| | | | |A |

| | | | |V |

| | | | |P |

| | | | |U |

|Disability |Glasgow Coma Scale (GCS) |Pupils |

| |Eye Opening |

|Head |Pain/tenderness | |

| |Drainage from: ears nose mouth | |

|Neck |Pain/tenderness | |

| |JVD | |

|Chest |Pain/tenderness Dyspnea | |

| |Deformity Paradoxical expansion | |

|Abdomen |Pain Tender Rigid Bowel sounds present | |

| |Soft Guarded Distended Bowel sounds absent | |

| |Emesis/gastrocult: + - | |

|Pelvis/Genital |Pain/tenderness Pelvis: stable unstable | |

| |Blood at the meatus Rectal tone: present absent | |

| |Hemocult: + - | |

|Extremities |Pain/tenderness CMS intact x4 | |

| |Moves all extremities Extremities warm and pink | |

|Back |Pain/tenderness | |

| |Deformity | |

|Ongoing Monitoring |

|Time |

|Drug/Procedure |Dose |Route |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 |: | | |

|Cricothyrotomy |: | | |

|Defib/Cardiovert |: | | |

|Foley |: | | |

|Intraosseous |: | | |

|Needle thoracotomy |: | | |

|OG/NG tube |: | | |

|RSI |: | | |

|Suture |: | | |

| |: | | |

| |: | | |

| |: | | |

|Laboratory |Radiology |

|Lab |Time Ordered |X-ray |Time Ordered |CT |Time Ordered |

|BAC |: |CXR |: |Abdomen |: |

|hCG |: |spine- Lumb/Sac |: |Pelvis |: |

|Hgb |: |spine- Thoracic |: |Spine |: |

|PT/INR |: | |: | |: |

|PTT |: | |: | |: |

|pH |: | |: |Ultrasound |Time Ordered |

|Tox. screen |: | |: |FAST exam |: |

|UA |: | |: | |: |

|Patient Disposition |

|Admitted |Transferred |

|Pt left ED |: |Ordered |: |Transfer via: |Accompanying Pt: |

| | | | | |Copy of chart |

| | | | |Helicopter |EMS report |

| | | | |________________ |X-rays/CTs |

| | | | |Ground |Lab report |

| | | | |________________ |RN______________ |

|Report called |: |Arrived |: | | |

|Admitting service: | |Pt left ED |: | | |

|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#

|Notes |

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|[INSERT HOSPITAL NAME, ADDRESS, PHONE NUMBER] |Signatures |

| |Physician | |

| |Primary nurse | |

| |Recorder | |

version 2009.1

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