Trauma Flow Sheet

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 Time Present upon Pt
Name called arrived arrival?
Gender
General Surgeon : : Yes No
Medical Record # ED Physician : : Yes No
Anesthesia : : Yes No
: : Yes No
Pt. Medications Past History Allergies
Arrived via: Pre-hospital Interventions
Ambulance Airway:
Helicopter Oral Nasal Intubated O2
Police IV size _____ site ________
Self IV #2 size _____ site ________
Blood sugar _______ mg/dl
CPR LBB C collar MAST
Transfer from:
Splint type __________ location ___________
unknown
Meds:
last tetanus_________
EMS report in Morphine ______ mg Versed ______mg
unknown last P.O.____________ unknown
Pt chart _______________________ ______mg
Mechanism of Injury
Motor Vehicle Fall/Jump Burn Penetrating
Involved:
Approx. height:
Auto Patient was: Seatbelt GSW
_____________ Flame
Light truck Driver Airbag caliber_________
Impact: Landing surface: Steam
Heavy truck Passenger-front Child seat distance________
Front Grass/dirt/earth Chemical
Motorcycle Passenger-back Helmet Stab
Side Stone Radiation
ATV Pedestrian struck blade length_____
Rear Concrete/brick Inhalation
Bicycle by auto Ejected Self inflicted
Rollover Tile/wood Electrical
Pedestrian Bicyclist struck Extrication Impalement
T-bone Carpet voltage:_______
Watercraft by auto Death of
Water
Sporting _________ Unknown another occupant

Primary Survey and Preliminary Interventions Initial ED Vital Signs

Intubation RSI Time:____:_____
Jaw thrust
Patent/talking tube size________
Suction
Clear time:____:____ BP: ______/______
Foreign object
Partially obstructed ______cm @ _________
removal/laryngoscopy
Airway Completely obstructed
Oral airway
#attempts:______ Pulse: ____________/min
Breathing assisted Confirmed by:
Nasal airway
Intubated End tidal CO2 Resp.: ____________/min
Combitube/LMA/King
___________________ Aspirator
time: ____:____
CXR Temp.: ____0 C site______
Spontaneous Assisted:
Labored BVM SaO2: ____________%
Lung sounds: Ventilator
Agonal
L R Vent. Rate ________
No effort Blood Glucose _________ mg/dl
Present
Clear
Trachea: Est. weight: ___________ kg
Breathing Midline
Diminished Supplemental O2
Absent Mask
Deviated R L
Rales NC A Awake and alert
Rhonchi _______ l/m V Verbal stimuli elicits response
Chest wall symmetry:
Wheezes Painful stimuli elicits response
Symmetrical P
start __:__ stop __:__ Unresponsive to stimuli
Asymmetrical U
Skin: Pulse: IVs:
Warm Pink Central pulse present Time Site Size 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. Warm IV fluids
Glasgow Coma Scale (GCS) Pupils
Eye Opening Verbal Motor
6 Obeys L R
5 Oriented
4 Spontaneous 5 Localizes pain Brisk Brisk
Disability 3 To Verbal
4 Confused
4 Withdraws from pain Sluggish Sluggish
3 Inappropriate response
2 To Pain 3 Flexor posturing Non-reactive Non-reactive
2 Incomprehensible
1 None 2 Extensor posturing _______mm _______mm
1 None/Intubated
1 None/chemically paralyzed
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: + -
Pain/tenderness CMS intact x4
Extremities
Moves all extremities Extremities warm and pink
Pain/tenderness
Back
Deformity Surface Trauma
Ongoing Monitoring
Time : : : : : : : : : : :
BP / / / / / / / / / / /
Pulse
Resp.
SaO2 % % % % % % % % % % %
GCS
0 0 0 0 0 0 0 0 0 0 0
Temp. C C C C C C C C C C C
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 :

RSI :

Suture :

Surgical Airway :

Tourniquet :

Urinary Catheter :

:
Laboratory Radiology
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 : ________________
X-rays/CTs
Admitting physician: Transferred to: Ground
Lab report
Referral hospital ________________
Expired in ED : 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 Telephone In-person
Orthopedic Surgery Telephone In-person
Other: __________________________ Telephone In-person
Notes

Signatures
Physician

[INSERT HOSPITAL NAME, ADDRESS, PHONE NUMBER]

Primary nurse

Recorder
version 2014.1