HISTORY! !

Date & time of event:! ! ! Location: GCS at scene:! /15 ! (E /4, V /5, M /6) MVA Speed ______ Driver Restrained Unrestrained Death of other ! Rollover! Ejection! Trapped - duration ________ Motorcycle! Helmet! Speed ______ Pedestrian vs. _____________! ! ! CPR! ROSC ________ Fall! Distance ______! Mechanical! Witnessed! Unwitnessed Assault! ! ! ! Electrocution! Explosion/blast Other _________________________ Ambulance obs:! ! BP ____/____! HR ______! ! SpO2 ____% ! ! ! ! ! ! ! ! ADT! Pregnancy test Procedures pre-ICU: Fluid/blood products administered pre-ICU: RECORD INJURIES BELOW
HEAD Scalp Nose Ears Mouth Eyes - bruising, acuity, pupils, movement ABDOMEN Seatbelt marks Bruising Wounds Distension Tenderness Urinalysis NECK & TRACHEA

ICU TRAUMA SUMMARY

W e l l i n g t o n a t t a c h p a t i e n t l a b e l
CHEST Movement Bruising Breath sounds Drains BURNS Indicate burnt areas & thickness

I C U T R A U

PELVIS Stability Tenderness

LOG ROLL Tenderness, Crepitus Step, Wounds, Bruising

M A

GENITAL Meatal blood Priapism Bruising

RECTAL Tone Blood Prostate UPPER & LOWER LIMBS Tenderness Movement Power Reexes Sensation Pulses Crush Inspect for bruises, wounds, deformity

L
H E

E T

Wellington ICU trauma survey sheet v1.3.0 20/12/2012

alex.psirides@ccdhb.org.nz

wellingtonicu.com

RADIOLOGY

de Or

red

RESULT

o i a t i t e s n I v g

CXR Pelvic XR C-Spine XR/CT CT Brain

CT Chest

CT Abdo/ Pelvis CT Facial Bones Other

SPECIALTY

NAMED DOCTOR

Re

r fer

ed

OUTCOME

R
Spinal Precautions: Remove C-spine collar !! Does not require log-roll ! ! ! Other ________________________________________________ If NOT indicated otherwise, the patient is for FULL SPINAL PRECAUTIONS
PLEASE CONSIDER THIS PATIENT FOR ENROLMENT IN ANY CURRENT CLINICAL TRIALS
Wellington ICU trauma survey sheet v1.3.0 20/12/2012 alex.psirides@ccdhb.org.nz wellingtonicu.com