Primary Survey - Trauma

Patient Information

[Document patient age, gender, mode of arrival (e.g., BIBA), and brief description of the incident or injury mechanism.]

Pre-Arrival

[Describe pre-arrival details including personal protective equipment used by team members, EMS notification details, mechanism of injury, and trauma activation criteria.] Example: - Personal Protective Equipment (PPE): [List PPE used] - EMS Notification: [Summarize EMS report including vital signs, interventions] - Mechanism of Injury: [Describe mechanism and scene findings] - Trauma Activation Criteria: [Specify level and reason]

Arrival

[Document time of patient arrival, trauma team activation time, and team members present.] Example: - Time of Patient Arrival: [HH:MM] - Trauma Team Activation Time: [HH:MM] - Team Members Present: [List names and roles]

EMS Hand-off

[Record time of handoff completion, key findings from EMS report, and any immediate life threats noted.] Example: - Time of Handoff Completion: [HH:MM] - Key Findings from EMS Report: [Summarize vital signs, interventions, injury details] - Immediate Life Threats Noted: [List any immediate threats]

Vital Signs

[List vital signs including respiratory rate, oxygen saturation, heart rate, blood pressure (with MAP if available), temperature, and Glasgow Coma Scale with components. Also note capillary refill time.] Example: RR: [value], SpO2: [value]%, HR: [value], BP: [value] ([MAP if available]), T: [value]C, GCS: [total] (E: [value], V: [value], M: [value]) Central Capillary Refill Time: [normal/delayed]

Airway

[Describe airway status including patency, presence of blood or secretions, verbal response, airway interventions performed.] Example: - Patent: [Yes/No], [describe any blood or obstruction] - Verbal Response: [describe] - Airway Interventions: [list interventions such as suctioning, intubation]

Breathing

[Document chest wall examination findings, trachea position, jugular venous distension, breath sounds, and oxygenation/ventilation parameters.] Example: - Chest Wall Examination: [describe bruising, deformities] - Trachea Position & JVD: [describe] - Breath Sounds: [describe] - Oxygenation/Ventilation: O2 saturation [value]%, EtCO2 [value] mmHg

Circulation

[Note external bleeding, suspicion or evidence of internal bleeding, blood pressure and pulse quality, and any pelvic stability interventions.] Example: - External Bleeding: [describe location and severity] - Internal Bleeding Suspicion: [describe findings such as E-FAST] - Blood Pressure & Pulses: BP [value], [describe pulse quality] - Pelvic Stability & Intervention: [describe]

Disability (Neurologic Status & Cervical Spine Status)

[Describe neurologic exam including pupil examination, extremity movement, cervical spine precautions, and collar placement details.] Example: - Pupil Examination: [describe] - Extremity Movement: [describe] - Cervical Spine (Status and precautions taken): [describe] - Collar: [Yes/No], [type], placed at [time]

Exposure

[Document complete undressing for assessment, hypothermia prevention measures, and findings from log roll/back assessment.] Example: - Complete Undressing: [Yes/No] - Hypothermia Prevention: [describe] - Log Roll for Back Assessment: [describe findings]