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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