WHO EMERGENCY UNIT FORM: TRAUMA □ Mass Casualty

Form to be used with WHO Reference Card. See who.int/emergencycare for more information.
Hospital Registration Number: Date: DD/MM/YY Time of Arrival: : _ _(24h)
Patient Surname: Age: ________ Arrival Mode: □Ambulance □Car/Truck (circle Private or Taxi)
First Name: □ Motorized 2/3-wheeler (circle Private or Taxi)
INF / CH / AD □ Public Transport □ Walk □ Other: __________________
Gender: □Male □Female Date of Birth:
□ Other: ___________ DD/MM/YY Weight: kg Number of prior facilities: ____
Occupation: □ Unknown Referred from:
Patient Residence (at least City and Sub-district): Sub-district where injury occurred:
□ Unknown □ Unknown
Contact Person: Phone: Relation:
CHIEF COMPLAINT: Triage Category:
INITIAL VS at : _ _ (24h) RR: ________ SpO2: _______ % on_______
Temp: ______ BP: _____ /______ Pulse: _______ Pain score (see Ref Card for details): _______ / 10 □ Dead on arrival
TREATING PROVIDER ASSESSMENT: Date: DD/MM/YY Time: : _ _ (24h)
PRIMARY SURVEY (see Reference Card for normal findings, only mark NML if all key elements are normal):
□ Angioedema □ Stridor □ Voice changes
Airway □ Oral/Airway burns
Obstructed by: □ Tongue □ Blood □ Secretions
Airway: □ Repositioning □ Suction □ OPA □ NPA □ LMA
□ BVM □ ETT
Spine stabilized: □ Not needed □ Done before arrival □ Done in EU
□ NML □ Vomit □ Foreign body (not needed = not altered, no pain or TTP, no distracting injury, no focal neuro deficit)
Spontaneous Respiratory Rate: ____________ Oxygen: _____ L Chest needle / tube (circle):
B reathing
Chest Rise: □ Shallow □ Retractions □ Paradoxical
Trachea: □ Midline □Deviated to □L □R
□NC □Mask □NRB
□BVM □CPAP/BIPAP
□ L – Size: _____ Depth: ______ cm
□ R – Size: _____ Depth: ______ cm
□ NML Breath Sounds: □ L__________ □ R__________ □Ventilator: ________ □ 3-sided dressing
Skin: □ Warm □ Dry □ Bleeding controlled (bandage, tourniquet, direct pressure)

C irculation
□ Pale □ Cyanotic □ Moist □ Cool
Capillary refill: □ <3 sec or
Pulses: □ Weak □ Asymmetric______
______ sec
Access: □IV: Loc ___________ Size _____
□CVL: Loc ______ Size _____ □IO: Loc _______ Size _____
□IVF:__________mLs □NS □LR □Other___________
□ NML
JVD: □ Yes □No □Blood ordered □Pelvis stabilized

D isability Blood glucose: ____________

Responsiveness: □ A □ V □ P □ U □Naloxone
□Glucose □ Not
Indicated
□ Not
Peritoneum: □ Negative □ Indeterminate
□ NML Available
□ Free Fluid: ___________________________
GCS: ______ (E______ V______M______) □Qualified
Chest: □ Negative □ Indeterminate
E xposure
Moves Extremities: □ LUE □RUE □LLE □RLE
Pupil: Size: L _________ R ___________
F AST
□ Pneumothorax (R/L): ___________________
□ Pleural fluid (R/L): _____________________
□ Exposed Reactivity: L _________ R ___________
□ Pericardial effusion
completely □ NML
MEDICAL HISTORY: History obtained from:
Medications: □ Anticoagulant: _____________________ □ Unknown Allergies: □ Unknown
Other:
Last Menstrual Cycle: _________________ G____P____ □ Unknown
Past Medical: □ HTN □ DM □ COPD □ Psych □ Renal Disease □ Unknown Pregnant? (circle) Yes / No □ Reported □ Testing done
Other: Last Tetanus: ________________________ □ Unknown
Substance Use: □Tobacco □Alcohol □ Drugs □ IV Drugs □ Unknown
Past Surgeries (type & date): □ Unknown Safe at home? ____________________________________________

HISTORY OF PRESENT ILLNESS: Date of Injury: DD/MM/YY Time: : _ _ (24h format)

Place of injury: First care sought:

□ Unknown Prehospital care
Activity at time of injury: □ None □ Layperson first aid □ Health care professional (EMT, medic)
□ Unknown Care given:

Mechanism of injury (select one or multiple): Other Details of Incident

□Road traffic incident: □ Driver □ Passenger □ Pedestrian □ Loss of consciousness (circle): <5 min 5-29 min 30-24 hr >24 hr
□ Airbag □ Seat belt □ Other vehicle restraint □ Helmet □ Head trauma: Y / N □ Neck trauma: Y / N
□ Extricated Patient vehicle: _____________________ Other:
□ Ejected Hit by/crashed with: _____________________
□Fall from: _____________ □Hit by falling object: _____________ Intent: □ Unintentional or accidental □ Intentional: □Self harm □Assault
□Stab/Cut □Gunshot □Sexual Assault □ Legal process, political unrest or war □ Unknown
□Other blunt force trauma (struck/hit): ________________________ Assaulted by (see Reference Card): _______________________________
□Suffocation, choking, hanging
Hours since last meal: _____________ hours □ Unknown
□Drowning: _________________________________ Life vest: Y / N
□Burn caused by: __________________________________________ Substance use within 6 hours of injury:
□Poisoning/Toxic Exposure:__________________________________ □ Unknown □ None □ Reported □ Evidence (positive test or clinical findings)
□Unknown □Other: _______________________________ □ Alcohol □ Other Substance (if known): _______________________
 !Spine Deformity
Back
PHYSICAL EXAM: (See Reference Card for normal findings. Do NOT mark NML unless all key elements are normal.) Other :

Form to be used with WHO Reference Card. See who.int/emergencycare for more information.
(Log roll)

□NML General Detail area of injury:

(D
□NML Neuro/Psych fin

□NML HEENT Tend

Bony
□NML Neck
Dislo
□NML Respiratory
Ampu
□NML Cardiac Deep
Ecchy
□NML Abdominal
Vascu
□NML Pelvis Moto
Senso
□NML GU/Rectal
Prolo
□NML MSK Pulse
Oede
□NML Skin

DIAGNOSTIC TESTS:
UPT: □ Positive □ Negative □ N/A List imaging studies with results (and check findings below):
Hgb: _______________ □ Result pending □ Pneumothorax □ Pleural Fluid
Blood type: _______________ □ Pulmonary Opacity □ Rib Fracture
□ Pelvic Fracture □ C-spine fracture
Other: □ Extremity Fracture

ADDITIONAL INTERVENTIONS:
Fluids and Medications Given Time (24h) Procedures (circle and note outcome) Time (24h):
□ IVF: ______ mLs □NS □LR □Other ________ ____:____ □ Intubation: _______________________________________ _____:_____
□ Blood products (specify number of units given): ____:____ □ Chest Tube: ______________________________________ _____:_____
_______________________________________ ____:____ □ Splinting / Reduction: ______________________________ _____:_____
□ Opioid Analgesia:_______________________ ____:____ □ Pelvic Stabilization: ________________________________ _____:_____
□ Other Analgesia:________________________ ____:____ □ Simple / Complex Laceration Repair: __________________ _____:_____
□ Sedation/Paralytics:_____________________ ____:____ □ Other:
□ Antibiotics:____________________________ ____:____
□ Tetanus: ______________________________ ____:____
□ Other:

ASSESSMENT (include summary and differential) AND PLAN (imaging; meds/interventions; consults with time called/arrived and recs):

REASSESSMENT at _ _ : _ _ (24h) □ Condition same

Temp:_____ Pulse:______ BP:____ / ____ RR:_____ SpO 2:____ % on______ Changes:_____________________________

DISPOSITION: Checklist completed: □ Y □ N ED departure (date & time): DD/MM/YY ___ ___ : ___ ___ (24h)
Diagnoses/Impressions (list all): Number of serious injuries as judged by provider (circle): 0 1 ≥2

□ Admit to: □ Ward ___________ □ ICU □ OT

VS at Dispo at: : (24h)
□ Discharge: Plan discussed with patient? □ Yes □ No
Temp:____ Pulse:____ BP:____ / ____ RR:____ SpO2:___ % on_____
□ Transfer to: ________________________________
□ Left without being seen or before treatment complete Accepting Provider: ____________________________________________
□ Died of (specify cause - NOT cardiopulmonary arrest): _______________________________________________________________________
Emergency Unit Provider Name/Title (include handovers) Signature and Date